The objective appearances with the ophthalmoscope are best seen by an examination by the direct method and there is then noticed, in place of the normal red reflex from the fundus, a green or bluish-gray (See Chromo-Lithograph, Plate III., Fig.2) membrane which is thrown up into folds and extending forward into the vitreous. The detached retina as a rule is seen to oscillate on part appear darker and often smaller than normal. Movements of the detached retina are seen when the underlying substance is fluid and the amount of motion depends upon the consistency of the vitreous and is not seen when there is a solid substance, as a tumor, beneath. At the borders of the detachment, which are usually sharply defined from the normal fundus, the retinal vessels pass out of focus and a change of focus is always necessary on passing from a detached portion of the retina.
The retinal vessels, as they rise over the separated portion, lose their light streak and appear dark and tortuous as they course up and down over the furrows of the detachment. There may often be seen a rupture at some portion of the detached retina. The size and position of these rents vary in different cases. Diminished tension is found in all cases that have existed for some time and when not due to a tumor. The detachment may occur in any part of the fundus, though usually above, and extends gradually to the lower part from a sinking of the fluid, the upper portion of the retina sometimes becoming again re-attached. detachments may be complete or only partial, and when the latter, may appear as a small line or furrow or may be more or less circular in shape.
COURSE-Detachment often develops within a few hours, but it may gradually take place during one or two weeks. Every detachment has a tendency to extend and become total. Idiopathic detachment is frequently found in both eyes, but rarely occurs in both eyes simultaneously, the second eyes being involved often only after many years.
CAUSES-Separation of the retina is most frequently found in myopic eyes, and is more apt to occur in very high degrees of myopia. It seems to occur more frequently in men than in women and in about one-half of the cases in those upward of fifty years of age. It results from traumatism, haemorrhages, intra-ocular tumors, cysticerci and from diseased conditions of the such as retinitis, cyclitis, irido-cyclitis.
The mechanism of a detachments has been the subject of extended investigation, and the researches of Leber and Nordenson would indicate that it is due to a shrinking of the anterior portion of the vitreous which, by dragging upon the retina, causes a rupture and that the fluid of the vitreous passes in behind the retina through the rupture and fills up the space left by the membrane. The diffusion theory supported by Raehlmann Archiv. Fur Ophthal., xxvii, Part I, p. I. is that, owing to some chemical change in the vitreous the diffusing “vitreous salts” cause an albuminous fluid to collect behind the retina, this diffusion of fluid behind the retina going on it is pushed more and more inward until it finally gives away. The primary cause, therefore, seems to be due to some change in the vitreous which may perhaps be due to some senile change or to some disease of the choroid or ciliary body whereby the nutrition of the vitreous has become altered.
DIAGNOSIS.- In the majority of cases the ophthalmoscopic appearances present such a perfect picture that no trouble is found in recognizing a detachment. The only difficulty occurs in small or transparent detachments and these will usually be revealed by a careful examination with the aid of a mydriatic. The most important point in the diagnosis is to determine whether it is due to an intra-ocular tumor, and the most valuable sign rests on the tension, which is plus in tumor and minus detachment.
PROGNOSIS.- This as a rule, is unfavorable, for the detachment, when of any size will usually extend and become total, no matter what care or treatment is followed. A detachment of the upper part of the fundus will usually extend to the lower, from a sinking of the sub-ret and fluid. cataract frequently occurs in cases of detached retina. Spontaneous re-attachment may take place after a longer or shorter interval, and, when it occurs early the vision may be greatly restored and no ophthalmoscopic signs be seen that any detachment has taken place.
TREATMENT.- If the patient comes under treatment a short time after the detachment has occurred, or even in six months afterward, he should be confined to his bed for from four to six weeks at least, chiefly upon his back, with the eyes bandaged. This is of great importance in aiding recovery. If it is impossible to confine the patient to his room he must be warned to avoid all use of the eyes and to keep as quiet as possible. If he must be out in the light the eyes should be protected by darkly colored glasses. In many cases the constant use of Atropine is of advantage, as it prevents accommodation and thus keeps the eye and tissue more quiet.
Operations to allow the escape of the fluids have been reported with some success. Sutphen Trans. Amer. Ophthal. Soc., 1888. reports three cases of detachment of the retina treated by puncture, with one success and two failures. Bull plus Trans. Amer. Ophthal. Soc., 1891. reports five cases treated by Schoeller’s method of injecting tincture of iodine into the vitreous in front of the detached retina to tear the shrinking or contracting bands in the vitreous and to produce an adhesive retinitis. In all of these cases the results were unfavorable. Yet successes have been reported by the authors of both these methods.
Gelsemium.- One of the most prominent remedies for serous infiltration beneath the retina dependent upon injury or myopia Especially indicated if accompanied by choroiditis, with haziness of the vitreous and some pain. A bluish haze or wavering is often observed.
Aurum.- Has been used successfully in amotio retinae. The symptoms under Aurum which suggests its use is as follows: “Under half of vision as if covered by a black body; lower half visible.” The choroid, or retina is usually inflamed, and opacities are seen in the vitreous giving rise to the “blacks” complained of by the patient.
Apis.- Fluid beneath the retina. Passive pain in the lower part of the ball with flushed face and head. Stinging pains through the eye. OEdematous swelling of the lids.
Arnica.- Traumatic detachment of the retina.
Digitalis.- Adapted to the general pathological condition and has this common symptoms of detachment of the retina: ” As if the upper half of the vision were covered by a dark cloud evenings on walking.” Benefit has been seen from its use.
Ars, Bry, Hepar, Kali iod., Merc and Rhus may also be thought of for this condition.
Ischaemia Retinae (Anaemia of the Retina).- This term has been applied to a peculiar condition of the retinal circulation which has seen or recorded a few times.
It consists in a great reduction in the size of the retinal vessels, especially the arteries, which appear as very fine threads, and in one case recorded by Knapp Archiv. Ophthal., vol. iv., p. 448, 1875. could not be found at all in one eye. This was a case of sudden blindness during whooping cough, the optic nerves nerves were white and the vessels were all very fine and thread-like while no arteries could be could be discerned in the right eye. No other lesions were present. Vision improved and there was an increase in the size of the vessels after paracentesis was made.
The reduction in the size of the arteries, as a rule is the only ophthalmoscopic appearance present, although the optic disc may be pale and its outlines indistinct. There is usually total blindness, and the attack may come on suddenly or gradually and last from a single moment to several weeks. The trouble has been supposed to be due to reduced heart’s action and by von Graefe attributed to some obstructive cause within the optic sheath.
TREATMENT.- When the anaemic condition of the retina is complete (Vision entirely lost) paracentesis or iridectomy, to diminish the intra-ocular tension, becomes necessary. Inhalation of Nitrite of Amyl will be of service. We sometimes observe a partial anaemia of the optic nerve and retinal associated with and dependent upon general anaemia. These cases should be treated by the general condition of the patient as Calc, China, Ferrum, phos., Pulsatilla, etc.
Agaricus has cured cases accompanied by a tendency toward chorea.
Embolus of the Arteria Centralis Retinae.- An embolus may become lodged in the central artery of the retina, or in any of its branches. It is only rarely that the circulation becomes completely stopped. As the retinal has an independent circulation of its own with no provision for collateral circulation in cases of obstruction its nutrition ceases at any stoppage of the central artery.
SYMPTOMS.- There is nearly always sudden loss of sight with out pain or external symptoms. Occasionally there is slight giddiness and headache, flashes of light and some uncertainty of vision preceding the sudden onset of blindness. The field of vision in complete obstruction, is lost in all directions as there may be even no perception of light in these cases. If one of the branches is involved there may be simply a loss of the field of vision in one direction. The pupil may be somewhat dilated and will not respond to light. The tension may be either increased, decreased or normal.
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.