The white patches occur mostly in the deeper layers of the retina, as proven by the fact that the retinal vessels may usually be seen passing over them, but may be partially or completely covered by the patch at some places.
Haemorrhages are almost universally found in albuminuric retinitis, but unlike the white patches just described, are not especially pathognomonic of this disease. They may occur in great numbers and of various sizes and shapes, from large, dark- red extravasations to small, round or linear-shaped spots scattered throughout the fundus. Haemorrhages occurring in the nerve fibre layer are striated in appearance. The extent of the haemorrhages is considered to be somewhat indicative of the severity of the disease.
COURSE-When due to pregnancy, diphtheria, or scarlet fever, is comparatively short, but when dependent upon the contracted kidney it is very chronic. Albuminuric retinitis may either gradually or suddenly pass into a neuro-retinitis resembling very closely the choked disc from cerebral causes. The ophthalmoscope picture of retinitis albuminurica (See Chromo-Lithograph, Plate II, Fig.6) may remain unaltered for a long time, the haemorrhages and white patches slowly disappearing, while new ones at the same time may make their appearance. The white plaques at the macula are always the last to disappear, and, may never, according to some authorities. As the secondary changes go on the optic disc becomes discolored and atrophied, the retinal vessels become contracted and pigment changes in the retina result.
CAUSES-Renal retinitis may occur with any form of kidney disease, but is especially found with the contracted kidney. It is also quite frequently seen associated with the albuminuria of pregnancy, and more rarely with post scarlatinal nephritis. A few cases have also been reported associated with functional albuminuria. Both eyes are as a rule involved, although it may occur in but one.
DIAGNOSIS-The ophthalmoscopic appearances are always quite characteristic of this disease, and the presence or albumin in the urine would at once confirm the diagnosis. Diabetic and leukaemic retinitis both present appearances of the fundus very similar to those found in this disease, and an examination of the urine will be necessary to clear up the diagnosis. A neuro- retinitis resulting from intra-cranial disease, especially if it be complicated by albuminuria, would present great difficulty in the differential diagnosis and a very careful study of the general symptoms would be required. The white spots in choroidal affections would differ from this by presence of more or less pigment and by the different location and shape of the white patches. Opaque optic nerve-fibres resemble somewhat closely the snow-bank appearance around the papilla, but in opaque nerve- fibres the white patches extend out from the disc in a fan-shaped manner, it is unaccompanied by any change in the macula or oedema of the retina and the vision is but little or none affected.
PROGNOSIS-In albuminuric retinitis the prognosis must necessarily cover two points; first, as to vision, and second, as to the life of the patient. The prognosis as to vision should always be unfavorable, excepting in the slighter cases and particularly those occurring in pregnancy. The appearance of albuminuric retinitis in all cases, excepting when associated with pregnancy, is always a most unfavorable symptom as regards the life of the patient. It is extremely rare for recovery to take place in cases of kidney disease after the retina has become involved, and in the majority of cases a fatal termination will ensue inside of two years.
In the retinitis albuminurica of pregnancy the prognosis depends chiefly upon the period of gestation, and secondly upon the extend of the disease. Some cases of very extensive haemorrhages, with marked patches of infiltration of the retina and almost complete loss of vision, when only occurring in the last weeks of pregnancy, may recover, after confinement at full term, with almost complete restoration of vision. On the other hand, slight changes in the earlier months of pregnancy, which have a tendency to increase in spite of treatment, may prove very serious both o vision and the life of the patient as w3ell, if allowed to go on to full term, The longer the disease exists the greater are the degenerative changes which may take place, and it is on this account that the appearance of the disease in the last weeks of pregnancy proves far less serious than when occurring early. Induction of premature delivery in these cases becomes then a question of grave importance. The presence of albuminuric retinitis, when of a high degree and accompanied by loss of sight, denoting advanced degeneration of the kidneys, together with the face that the uraemic condition of the blood, threatens the life of both mother and foetus, to us argues in favor of interference. Howe draws the conclusion that ” The induction of labor is warrantable when the retinitis appears in the early stage of pregnancy and persists in spite of -proper treatment, but is not warrantable in the last few weeks, in spite of the greater case with which it is accomplished, unless the inflammation is unusually severe.”
COMPLICATIONS-Detachment of the retina and haemorrhage into the vitreous are the most frequently seen complications, although other conditions, such as glaucoma, extravasations into the choroid and embolism have been recorded as occurring with this disease.
TREATMENT-The principal treatment should be directed to the kidneys, the seat of the primary disease, and such hygienic and dietetic measures adopted as are recommended for Bright’s disease. Benefit has sometimes been derived from keeping the patient quiet in bed and upon a low or skim-milk diet. The use of stimulants should be avoided.
Mercurius corr-Has been more extensively used in albuminuric retinitis than any other remedy. The fatty degeneration, extravasation of blood from the weakened vessels and all the pathological changes in the eye as well as in the kidney point to Mercury as the remedy, even though no characteristic subjective symptoms are present. The results are especially favorable when pregnancy appears to be the exciting cause of the difficulty.
Apis-If associated with oedematous swelling of the lids and general dropsical condition. Patient very drowsy, with little thirst and scanty urine.
Arsenicum-If the patient is restless, especially at night after midnight, with great thirst for small quantities. Urine scanty and albuminous.
Gelsemium-Retinitis albuminurica occurring during pregnancy. White patches and extravasation of blood in the retina. Dimness of vision appears suddenly. Serous infiltration into the vitreous, making it hazy, may be observed. The patient is thirstless, and albumen is found in the urine.
Kalmia-Nephritic retinitis accompanied by much pain in the back, as if it would break.
Hepar, Kali iod, Plumb and phosph. have either been used or are highly recommended for this condition of the eye. In fact, any remedy applicable to the disease of the kidney will often prove of service in the eye complication.
As haemorrhages are usually found in the retina in this form of inflammation, compare the remedies recommended for Retinitis Haemorrhagica.
Retinitis Diabetica (Retinitis Glycosurica)-The appearance and general features of this form of retinitis are particularly the same as already described under albuminuric retinitis, with the exception that in diabetic retinitis there is, as a rule, less exudation or white patches and usually more haemorrhages. Opacities in the vitreous, probably due to haemorrhage, are frequently found. The white spots are apt to be smaller in size and not grouped at the macula or around the disc in the manner so characteristic of albuminuric retinitis, although cases have been reported in which the appearance was absolutely identical. Retinitis occurring with diabetes is quite rare and usually makes its appearance only after the diabetes has existed for a long while. It is more frequently found existing in both eyes, although it may occur in one eye alone. The pathological changes are the same as those occurring in albuminuric retinitis.
As this form of retinitis is especially characterized by haemorrhages into the retina, compare the remedies recommended for Retinitis Haemorrhagica and Albuminurica. In addition to which Secale is suggested, though the chief attention must be directed to the diabetes.
Retinitis Leukaemia (Splenic Retinitis)-This is an extremely rare form of retinal inflammation, which, m in its earlier stages, resembles a simple retinitis, but later it develops a characteristic appearance, the essential features of which are the peculiar color of the fundus and of the blood in the retinal vessels. The fundus becomes of a peculiar orange hue, due to an alteration in the elements of the blood of the choroidal vessels, and presumably the same changes in the blood exists in all the vessels of the body. Loring Text-Book of Ophthalmoscopy, Part II., p. 154. says this orange tint is by no means constant and that he has more frequently seen the color as a pale grayish-pink, and in some case there is no deviation from the normal color of the fundus. The retinal veins are of a bluish-pink, while the arteries have the same orange color; the veins are enormously distended; he arteries are less distended. so that the normal proportionate relation between the vessels seems exaggerated. The optic disc may be somewhat paler than normal, and its outlines slightly illdefined. Haemorrhages are especially prone to occur in this disease, and are generally found in the anterior half of the retina. These haemorrhages may disappear rapidly and fresh ones appear in different parts of the focus. The diagnosis should depend upon a microscopical examination of the blood-corpuscles and an increased proportion of white. The treatment should of course be directed to the general disease, as the retinal complication may be looked upon as merely a symptom of the disease.
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.