– Whole Men. Women.
Number.
Spinal cord…………………. 59 55 4
Brain……………………….. 41 23 18
Simple progressive…………… 22 16 6
After neuritis optica……….. 17 13 4
Sudden embolism of arteries……. 8 3 5
Disease and accident in orbit….. 8 3 5
Dementia paralytica…………… 7 6 1
Loss of blood……………….. 4 0 4
Alcoholism…………………… 4 4 0
Lead poisoning……………….. 2 2 0
Hereditary…………………… 3 2 1
Injury………………………. 3 2 1
Epilepsy…………………….. 2 2 0
Nephritis……………………. 1 0 1
Railway spine………………… 1 1 0
Congenital, with hydrophthalmia.. 1 0 1
183 132 51
In addition to this table, which only includes causes outside of the eye, could be added many other causes, such as syphilis, diabetes, menstrual disturbances, colds, malaria, etc., while, from within the eye, inflammatory atrophy may follow from an inflammation of the nerve, retina, choroid, etc. Examination of Uhthoff’s table shows a preponderance of cases resulting from lesions of the brain and spinal cord, and this fact has been frequently noticed by other observers, and, hence, examination of the eye is always important in suspected lesions of these structures.
DIAGNOSIS.-In well-marked cases of optic nerve atrophy, the diagnosis presents no difficulties, but in the earlier stages, or where there is but slight paleness of the nerve, it often requires a careful consideration of all the symptoms detailed, with special attention paid to the field and color perception. As this disease, in the great majority of cases, is due to some disease of the brain or spinal cord it is often necessary to consult the neurologist for a thorough examination of these structures. The differential diagnosis between optic nerve atrophy and glaucoma will be considered under the latter disease.
PROGNOSIS.-In all forms of atrophy of the nerve the prognosis should always be guarded, for, as a rule, it is unfavorable. In some cases, where the originating cause has been controlled or but transient, as in meningitis-especially when occurring in young subjects-more or less complete recovery has taken place. Other cases will be met with in which there is a remarkable preservation of the sight, as judged from the appearance of the disc and the circulation. In estimating the prognosis, the field of vision should be carefully watched, as it is considered to be more unfavorable where there is a regular concentric limitation than in the irregularly notched field.
TREATMENT.-In true atrophy of the optic nerve very little can be done to restore vision, though we are often able to check its progress by the selection of appropriate remedies as indicated by general symptoms.
The general health requires most careful attention. The diet should be nutritious and light, while tobacco and all liquors must be prohibited. Mental and physical fatigue must not be allowed.
The hypodermic injection of Strychnia has proved efficacious in some instances, though its internal administration is usually more satisfactory.
Favorable results have been reported from the use of galvanism, and it seems as though, when properly and persistently used, it should be of value in checking the progress of the disease at least.
Nux vomica- Has been followed by more favorable results in this condition than any other remedy.
Argent. nitr., Arsen., Veratrum vir. and others have been used with advantage.
Injury of the Optic Nerve.-This may result from a fracture of the orbital wall, or of the base of the skull, or from the penetration into the orbit of a foreign body, and it results in an atrophy of the nerve.
Tumors of the Optic Nerve.-Very cases of tumors of the optic nerve are on record, and those reported have been of the fibroma, sarcoma, glioma and myxoma type.
SYMPTOMS.-There is simply a very slow, gradually increasing exophthalmos, with defective vision. The growths are usually very slow and painless, and the movements of the eye are generally unaffected. There is seen upon ophthalmoscopic examination symptoms of papillitis, the veins are engorged, the papilla oedematous and congested, and later there will be a shrinking of the vessels and white atrophy of the nerve.
TREATMENT.-Removal of the tumor is of course, the only remedy. This should be done, if possible, without removal of the eyeball; but in most instances enucleation has been necessary. The nerve should be served as far back as possible, so as to include the whole tumor.
As removal of a tumor of the optic nerve without enucleation of the eyeball has only been successfully made in a very few instances, the following successful operation made by Dr. Geo. S. Norton, and reported by the writer in the Archives of Ophthalmology, July, 1892, is worthy of record and is reported as taken from his case records:
“Miss J_____, age 30, was first seen on September 25, 1890, and gave the following history : The right eye began to protrude ten or twelve years ago, and has steadily increased ever since. For five years she had much sharp pain in the eye, extending to the back of the head and down to the stomach. Examination shows O. D. V. = 1/200, O. S. V.= 15/15, a protrusion of the right eye directly outward of twenty-two centimetres, which varies at different times, being greater on some days than others and greater during menstruation, and she says that the vision seems to be better when the eye is small. The ophthalmoscope showed the retinal vessels contracted and optic nerve atrophic. The movements of the eye were as good as could be expected from the amount of the protrusion. Is very nervous and would not allow of deep pressure to determine the nature of the growth.
“October 7th.-Eyeball protrudes directly forward so that the posterior portion of the globe is just even with the outer border of the orbit. No pulsation could be detected. Patient very nervous, had a fainting spell with retching just before being put on the table for operation, but recovered after taking some whisky. Ether given and well borne throughout the operation until after the tumor was removed, when the pulse became so much weakened that a hypodermic of brandy was given. Palpation, after she was under ether, showed a soft, elastic tumor behind the eyeball and connected with it. Aspirating needle inserted at the outer canthus drew out a drop or two of serum. An incision was then made between the superior and internal recti muscles of sufficient size to permit of the finger being passed down to the tumor. Using the finger as a guide, the tissues around the tumor were severed, back to the optic foramen. The nerve was then divided at the optic foramen and afterward severed close to the eyeball. Tumor at once appeared at the opening and was removed. By rotating the eye the cut end of the nerve could be seen, and it appeared clear and white. The socket was washed out with 1 to 4,000 solution of the bichloride of mercury, the eyeball replaced and covered with the lid. There was but moderate haemorrhage throughout, yet some infiltration of blood underneath the conjunctiva and into the lids was noticed, so that protrusion appeared about the same as before the operation; a compress bandage was applied, the ice-bag used locally and Aconite given.
“Oct. 21 st.-The day after the operation the temperature was 99 1/2, pulse 102. The ice was used for three or four days. Patient has had no pain at any time. The eyeball protruded greatly for three or four days, caused by the infiltration of blood into the orbit and the lids, extending even to the other eye. There was quite extensive chemosis below, so that the conjunctiva protruded greatly, appearing between the lids. Upper lid greatly swollen, but covered the eyeball. This swelling gradually subsided, so that about the sixth or seventh day the lid retracted, leaving the eyeball exposed and the cornea hazy. The eyelid was drawn over the eyeball and held in place by adhesive strips, which were kept on for four or five day’s. Today there is considerable haziness of the cornea, but it has diminished greatly. The eye has sunken back into the orbit nearly as much as the other eye. Eye is, however, nearly immovable, especially outward and inward, and stands somewhat outward. The conjunctiva still protrudes between the lids, but is diminishing, and with but slight discharge. No pain or unpleasant sensation.
“Nov.20th.- Still swelling at the inner canthus, moderate discharge, cornea little hazy below, but clearing. MUch better movements of the eye.
“Dec. 10th.-Optic disc very white,, but from its centre are seen two small vessels running upward for about the distance of the diameter of the optic disc. There are also seen slight choroidal changes. Much less redness of the eye movements much better.
“May 3,1892-Eighteen month after the operation there is little, if any, perceptible protrusion of one eye more than the other. The movements of the eye are a trifle limited in all directions, but the eye perfectly straight. An oblique illumination of the cornea shows a very slight opacity. The pupil is slightly dilated. but not as much as one year ago. In fact, the general external appearance of the eye is not noticeably different from the other, and the eye operated upon could only be told by a close examination. The ophthalmoscope shows the optic papilla to be of an extremely white glistening appearance, with faint line showing the position of the central vessels; at the upper part of the papilla there appears a leash of small vessels. There are some choroidal changes a short distance from the disc. The fundus appears normal and in the lower part of the field there is seen two sized retinal vessels.
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.