Ossification of the Choroid.-True bone may, in the course of time, be found in the choroid. It is usually found in the inner layers of atrophied balls and more especially in eyes that have been lost by irido-choroiditis. The plate of bone generally assumes a more or less spherical shape, although some spiculae or growths may be found upon it. The diagnosis is made by feeling a hard body which ends at the ciliary region, as ossification never takes place in the ciliary body. The principal danger seems to be that of exciting sympathetic irritation and the treatment should be enucleation.
Haemorrhages in the Choroid are the result of some diseased condition of the blood-vessels. The exciting cause may be from injuries, operations, coughing, etc. The haemorrhage may be slight or extensive and it may extend forward between the choroid and retina, producing detachment of the retina, or more frequently it will extend outward between the choroid and sclera and may cause a separation of the choroid from the sclera. The diagnosis between haemorrhage in the choroid and haemorrhage in the retina is uncertain, when occurring in the outer layers of the retina; but when in the inner, or nerve-fibre layer of the retina, the haemorrhage has a striated or flame-shaped appearance, while that in the outer layer of the retina or in the choroid is not striated. Haemorrhage into the retina usually corresponds to the retinal vessels-that is, it usually occurs along the course of the vessels and is apt to cover the vessels slightly. If there are no retinal vessels near the haemorrhage, it is more likely to be in the choroid. If the haemorrhage is in the retina, its color is more of a bright red and its outlines are well defined; while if in the choroid it appears of a darker red and the outlines are ill-defined. Choroidal haemorrhages interfere somewhat with the vision by causing scotoma. On absorption of a haemorrhage there is left behind an atrophic spot surrounded by pigment.
TREATMENT.-Haemorrhage is the most common symptom that demands our attention in the treatment of a rupture of the choroid, though we may have haemorrhages arising spontaneously or from inflammatory changes, etc.
The remedies chiefly for will be Arnica, Belladonna, China., Crotal., Hamamelis, Lachesis, Mercurius Corr., or Phosph.
For special indications refer to Retinitis Haemorrhagica.
If there is hyperaemia or inflammation of the choroid present, our treatment will be guided by the rules laid down under choroiditis.
Detachment of the Choroid from the sclera may occur from an injury, from an effusion of blood or serum, or from a tumor. Its diagnosis is always difficult and uncertain. The ophthalmoscopic examination gives an appearance similar to that of a tumor-a dark mass, like that seen in sarcoma, but more often at the lower part of the eye ball. In detachment the tension is decreased, while in tumor of the choroid it is increased. Groenouw Archiv. Ophthal., vol. xviii., 3, 1889. reports two cases of detachment of the choroid, after cataract extraction, with spontaneous recovery. As these simulate choroidal tumor, he cautions against enucleation until after watching the case for two weeks at least, as the apparent tumor may disappear spontaneously. Eyes have been enucleated for choroidal tumor which have proven to have been a detachment of the choroid. The tension is, however, diminished and it differs from retinal detachment by having none of the wavy appearance on moving the eye, and it has a dark red or black appearance instead of the bluish-green color of a detached retina.
Rupture of the Choroid.-This condition is of comparatively frequent occurrence. It is usually found after a blow on the eye, and we may find associated with it, from the same injury, a rupture of the retina, a separation of the iris, or a dislocation of the lens, but often the rupture of the choroid occurs alone. It is generally accompanied by a haemorrhage that often conceals the rupture at first. The location of the rupture is almost always at the posterior pole of the eye, and is more frequently seen between the optic nerve and the macula. Rupture occurs at this point, because the choroid is here more closely attached to the sclera and does not so easily give to the impact of the blow. It is generally vertical and in the shape of a curved line, the concavity being directed toward the optic nerve; it is most frequently a single line, with occasionally one or more bifurcations, although two distinct ruptures may occur.
The ophthalmoscopic appearances vary. In the early stage it may be completely obscured by the haemorrhage. Later it is seen as a yellowish-red line, and as the blood becomes absorbed and the swelling and haziness of the retina pass off, it gradually assumes a more and more white appearance, until it finally looks like a clear white line, possibly bordered by a little pigment. The pigment layer of the retina is always ruptured, and usually the layer of rods and cones is also involved. The loss of vision depends upon the amount of destruction in the retina and its nearness to the macula. It causes a scotoma, more or less large, according to the size of the rupture.
PROGNOSIS.-Should be guarded, because in the atrophic stage, the vision may decrease after it has first improved. When the retina is involved we never find the retinal vessels passing over the ruptured choroid as they may in an uncomplicated case.
Coloboma of the Choroid.-This is a congenital anomaly, often hereditary, due to an arrest of development in foetal life and is usually associated with a coloboma of the iris, but may be found alone and may be present in one or both eyes. Other evidences of arrested development, such as harelip and cleft palate, are sometimes met with, together with the ocular defect. The usual location of a coloboma of the choroid is downward or downward and inward, and may extend from the iris through the ciliary body and choroid to the optic nerve, which may also be involved. Coloboma may vary greatly in shape in different cases. It is, however, generally more pointed or narrow at the optic nerve, be-coming wider toward the equator. The appearance with the ophthalmoscope is that of a white, glistening patch, with the retinal vessels seen coursing over it and occasionally masses of pigment may be found here and there upon it, the edges of the coloboma appear distinct, clear cut and often pigmented. In all cases the retina is either imperfectly developed or absent, and in consequence, a scotoma corresponding to the coloboma is usually present. The sclera may also be to some extent affected; that is, it is thinned and may be staphylomatous. In place of the choroid over the region of the coloboma there is to be found a thin connective tissue membrane which corresponds to both the choroid and retina, as the vessels of both are found in it. Cases of so-called coloboma, in which the defect is confined to the region of the macula alone, have been rarely reported, but these may possibly have been the result of degenerative changes following some in- flammatory condition in intra-uterine life. Johnson Archiv. Ophthal., vol. xix., i, 1890. gives a thorough description of extra papillary colobomata, illustrated by drawings and chromo- lithographs. He believes that coloboma may occur in any part of the fundus and are more frequent than generally diagnosed. They differ from atrophic changes due to disease in that their margins are always sharply defined, they are always surrounded by healthy tissue, the pigment is in front and never behind the retinal vessels, the appearance of the coloboma always remains the same, the floor of the coloboma being of a dazzling whiteness, or sometimes covered by a layer of connective tissue looking like mother-of-pearl.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.