Diabetic Affections of the Eye. WILLIAM OLIVER MOORE, M. D., BT PROFESSOR OF DISEASES OF THE EYE AND EAR IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. REPRINTED FROM JEije Weto York J&rtucal Journal for March 31, 1888. Reprinted from the New York Medical Journal for March 31, 1888. DIABETIC AFFECTIONS OF THE EYE.* PROFESSOR OF DISEASES OF THE EYE AND EAR IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. WILLIAM OLIVER MOORE, M. IX, “ What says the doctor to my water ? “ He said, sir, the water itself was a good, healthy water, but for the party that owed it, he might have more diseases than he knew for.”—King Henry IV, Part 11. The only excuse I can offer for presenting this subject to your attention is, that during the past ten years I have seen an unusually large number of diabetic affections of the eye as compared with the number of such cases re- ported in the practice of older physicians. This is to be accounted for by my especial interest in this class of pa- tients and my solicitation of diabetics for ophthalmoscopic examination from general practice, thus having sought for the cases before they sought the ophthalmic physician. What I may say will contain nothing new, but will be rather a report of my own cases, together with a resume of the subject as it at present is understood, with the hope uppermost that a full discussion will be evoked and some interesting facts brought out that have hitherto been latent. * Head before the Section in Ophthalmology and Otology of the New York Academy of Medicine, February 20, 1888. 2 DIABETIC AFFECTIONS OF THE EYE. Celsus was probably the first to clearly describe diabe- tes, and Galen (131 to 210 a. d.) to first call it by that name. In 1674 Willis first associated the presence of sugar with the disease, discovered by the sweet taste of the urine. Other observers succeeded in separating the sugar, and Rollo in 1787 began the dietetic treatment by withholding vegetable food. It is not a rare disease, is more common now than formerly. This fact is probably due to the frequent and more accurate examination of the urine. In the United States census for 1880 there are reported 1,443 deaths from diabetes, or OT9 per cent, of deaths from all causes, against OT7 per cent, in 1870. Report of Deaths from, Diabetes in New York City. From the Rec- ords of the Board of Health.* DEATHS FROM DIABETES. DEATHS FROM ADD CAUSES. Total. Over 15 years Total. Over 15 years ms 42 41 27,008 13,174 1879 37 36 28,342 14,075 1880 44 43 31,987 15,684 1881 43 43 38,624 18,250 1882 46 43 37,924 18,264 1883 68 64 34,011 18,451 1884 68 67 35,034 18,184 1885 63 62 35,682 18,787 1886 82 78 37,351 19,566 1887 105 104 38,933 20,303 Total deaths in ten years from diabetes, 598. Total deaths from all diseases in ten years, 344,846, or 1 diabetic in every 577 deaths. * I am indebted for the foregoing to Dr. Roger S. Tracy, Register of Vital Statistics. DIABETIC AFFECTIONS OF THE EYE. 3 In 1867-69 the ratio of deaths from diabetes to the total number of deaths was 1 to 1,-379. In 1877—79 there were 123, an increase of 74, which is out of proportion to the population increase. In 1867-69 there were 49 deaths from diabetes. It is more common between thirty and forty years of age, but does occur, as seen, in early life, although the older writers did not so consider. Prout states that of 700 cases of diabetes, he had met with “but one instance of it in a child five years old, and only twelve in young persons between the ages of eight and twenty.” Ilanner has re- ported the case of an infant twelve months old. G. M. Smith (1), M. D., reports one twenty-three months old, and W. H. Deane (2), M. D., of Blanford, Mass., one, a fe- male, one year and three weeks old. Of cases treated at the New York Post-graduate School and Hospital, there were only three in the first 10,000. In the Vienna Poly- clinic Romberg found the same ratio to exist. I am quite sure that the disease is more prevalent in private practice than is usually conceded, and that the reason we do not find records of such in hospitals and dispensaries is on ac- count of the carelessness of examinations and the improper signing of death certificates. That there is also a great disproportion between the diabetic affections of- the eye seen in private and those seen in hospital practice, owing to the loose way of making diagnoses, I make this sweep- ing statement from my recent efforts to obtain evidence as to this point in the principal ophthalmic hospitals of this country. The statistics of these institutions are utterly use- less. Hirschberg (3) remarks upon the much greater fre- quency of diabetes in private than hospital ophthalmic practice, and reports, of 1,638 private patients, 17 suffering from diabetes, while of 10,000 at his clinic 3 only had su- 4 DIABETIC AFFECTIONS OF THE EYE. gar in the urine. During the past ten years I have exam- ined 97 diabetic subjects, and of this number 21 had ocular affections. Amblyopia (without ophthalmoscopic change) 4 Cataract 4 Retinitis (glycosuric) 5 Haemorrhages and floating bodies in vitreous 4 Paralysis of accommodation 3 Iritis (diabetic) 1 Total 21 Dufresne (14), out of 162 diabetics, had 20 with various ocular affections. In 1798 Rollo first called attention to eye trouble in di- abetes, although Blankaard in 1688 mentioned a case of blindness from this disease, in which, however, it was sub- sequently found that both the diabetes and the blindness were due to a tumor of the brain. Dr. Front and Mr. France long since called attention to this association. The most common ocular symptoms usually are, first, affections of the muscular system, paralysis or loss of accommodation, and paralysis of the extrinsic muscles of the eye, usually the abducens. Then the vascular system becomes affected and we observe haemorrhages into the vitreous, also floating bodies, the result of improper nutrition of that body. As a result of the serious changes in the vascular system, retinal haemorrhages take place, and at the same time we find them in the vitreous usually associated. Cataract and amblyopia are found in the later stages of the disease. Iritis and keratitis are rarely seen, but have been very admirably de- scribed by Leber (16), Schirmer (17), and Wiesinger (19). It is quite natural that the first ocular symptoms noticed occur as the result of general muscular weakness. I have seen in many diabetics a temporary loss of accommodation, DIABETIC AFFECTIONS OF THE EYE. 5 which would last during a few days to a few weeks, when more than the usual amount of sugar was being voided from the system, which would give way on a proper treat- ment being adopted. The cases where the accommodative disturbance wras hut transitory I have not counted, and will relate only the three where it remained permanent. Case I.—Male, aged* thirty, lawyer, first consulted me in 1879, complaining of difficulty in reading. On examination, Y. = |£, em. No ophthalmoscopic changes; pupils normal; ac- commodation, however, faulty, so that newspaper type could be seen only at eighteen inches. Convex glasses were ordered for reading (+ ■£%) and near vision was restored. This patient subsequently had opacities in the vitreous, and died eighteen months later from phthisis. Case ll.—Female, aged thirty-six, has had sugar in the urine for the past two years. Has never had any trouble in the eyes until three months since, when she had to put the book farther away than usual. The normal range of vision was re- stored only by the wearing of convex glasses. The fundus and media were normal. Any slight effort caused accommodative asthenopia. The refraction was hyperopic. This patient had V. = for distance, and after prescribing glasses was lost sight of. Case lll.—Male, aged twenty-nine, single, butcher, has had sugar in urine for the past six months, passing nine pints with ten grains of sugar to the ounce; specific gravity, TO4O. Gen- eral muscular weakness; first noticed failure of sight in reading two weeks before my examination, October 15, 1886. Y. = |f, hyperopia = This patient was a friend, and I had previ- ously examined the refraction before any diabetic symptoms had made their appearance, when emmetropia was present. Since the diabetes the hyperopia and paresis of accommodation have appeared. With the decrease in the sugar in the urine the hyperopia and accommodation also diminished. This change in the refraction of the eye is due to the change in the specific 6 DIABETIC AFFECTIONS OF THE EYE. gravity of the blood. Convex glasses gave relief to this patient. He died of carbuncle of the back, March 3, 1887. Next to failure of accommodation, the muscular system shows its weakness in the paresis of the abducens (or sixth nerve). I have never seen this affection as a result of dia- betes, or, if so seen, it has not been recoginzed. Gut- mann (20), in 1883, reports a case occurring in the person of a physician, aged fifty-three, thought to be suffering from tabes, but who was found to have diabetes. He was seen by Hirschherg, who found paralysis of the right abducens, with normal pupillary reaction and accommodation. The paralysis of the abducens was complete ; the patient retired to Carlsbad, and after a sojourn of two months the sugar diminished and finally disappeared, and with it the diplopia produced by the affected muscle. The sixth nerve taking its deep origin from the floor of the fourth ventricle, the portion of the brain usually affected in diabetes, is sup- posed to be the reason why this particular muscle is para- lyzed, as the other ocular muscles get their innervation from other parts more remote from this region. Iritis and keratitis from diabetes have been noticed, and Leber and Wiesinger in 1885 report such cases, most of which occurred in the Gottingen Clinic. In 1857 von Leudet, in the “Gazette medicale,” relates the case of a female diabetic, aged thirty-two, with keratitis of the left eye; this patient, however, had paralysis of the third and fifth nerve of the same side, and at the autopsy a tumor, syphilitic in character, was found in the brain, so that this case was not diabetic, but neuro-paralytic in origin. In 1830 Hiraby speaks of keratitis in connection with dia- betes, but the cases are not clearly defined. Panas (21), Galezowski (22), Bellouard, Coundouris, and others have reported cases of diabetic keratitis, and in most every case it has been of the purulent form, and the inflammation of a DIABETIC AFFECTIONS OF THE EYE. 7 very passive character. One of Galezowski’s cases was not diabetic, but rather due to the cerebral tumor which caused the diabetes; the two other cases reported by him were, without doubt, due to the general loss of nutrition produced by the diabetes. Most of the cases reported terminated in complete leucoma, and some in leucoma adhserens. From what literature I have had access to, it would seem that keratitis from diabetes alone is a rare affection. Iritis seems to be more common. The first case reported, so far as I can learn, was in 1 863, by Marchal de Calvi (23), that of a female diabetic, aged fifty, who had an irido-chorioiditis, and died shortly after from the general affection. In 1868, at the American Oph- thalraological Society, Dr, H. D. Noyes (24) reported a case of retinitis haeraorrhagica occurring in a diabetic woman, aged sixty, who had had, some months previous to coming under his observation, double iritis, the posterior synechue showing this at the time of the examination for the retinitis. This case is reported by Noyes for the intra- ocular affection, and only incidentally are the results of the iritis mentioned, he evidently not at that time considering the iritis due to diabetes. It, however, belongs to that class. Wickersheimer (25), in 1874, reports a patient, male, aged thirty-seven, with irido-chorioiditis. Galezowski, 1879 and 1883, relates the case of a male, aged sixty, with iritis in the left eye and synechue in both. For two years the right eye had been the seat of iritis, he having been a diabetic since 1866. The left eye in three months improved. Aladie, in the same year, reports a similar case. Umman (26), 1881, reports the case of a priest, sixty- nine years old, with purulent iritis. Qoundouris reports also a case of a male of a diabetic family, having iritis. 8 DIABETIC AFFECTIONS OF THE EYE. Leber reports nine cases of iritis, with full and complete histories. I have seen only one case of iritis in a diabetic, and it occurred only two months before the death of the pa- tient. Case IY.—Male, aged thirty-five, laborer, for two years has lost flesh and grown weaker; March 1. !Sbs, passing seven pints of urine daily, and eleven grains of sugar to the ounce. Has never had any trouble with his eyes; two weeks before seeking advice first noticed cloudiness of vision in R. E., fol- lowed in six days by failure of vision in the L. E. When seen by me the R. E. bad Y.=|£, L.=fs. Right iris inflamed and one or two small syneohiae showing aqueous cloudy and small amount of hypopyon, slight injection of the eyeball, and not much pain. L. E.. pupil clear, though slowly responding to light; circumcorneal injection, slight pain, and no fear of light. The ophthalmoscope shows media clear in the eye. Four days later each eye has hypopyon and more marked signs of iritis. The cornea of the R. E. is slightly cloudy in the outer quadrant. A careful diet wras prescribed, and the usual local measures for iritis were adopted. The patient recovered with a few' adhesions remaining in the R. E. and some in the L. E. after an inflam- mation of six weeks’ duration. The cornea remained cloudy till the time of death. I have, in a number of diabetics, noticed a want of clear- ness in the vitreous where no opacity could really be de- termined, which would vary with the excretion of the sugar in the urine, and 1 suppose is to be explained by the vary- ing conditions of the blood in these cases. I will, however, only record cases where an actual change could be distinctly seen. Case Y.—Floating Bodies in the Vitreous and Opacities in the Lens in a woman aged fifty, Mrs. 0. This patient first showed the signs of diabetes four years before. About six months before coming under the writer’s notice she complained of dimness of DIABETIC AFFECTIONS OF THE EYE. 9 vision, with “ specks before her eyes.” These symptoms gradu- ally increased, and when seen by me, 1884, she had vision=|£ each eye, pupils normal, field of vision normal; the ophthalmo- scope showed very many floating bodies in the vitreous, and some small fresh haemorrhages; the appearance was about alike in each eye; the retina and optic nerve seemed normal. The lens showed a few striae in the peripheral portions. At this time the patient could read with correcting glasses for a short time ouly. Much sugar was being voided. Whenever the quan- tity of sugar diminished in the urine the vision improved. During the remainder of her life the eyes gave annoyance, and on two occasions—for a period of five wreeks, during which time the diabetic symptoms were more pronounced than usual —vision was so bad that reading could not be indulged in. On these two occasions the opacity of the lens was much increased, and the lens, in fact, generally cloudy. On the disappearance of the severe diabetic symptoms the lens gradually cleared, the floating bodies in the vitreous remaining, but the vision improv- ing so that she could read for a short time. This case would seem to he one like that reported by Nettleship, where cataract disappeared on the subsidence of the severe diabetic symptoms. The patient died in diabetic coma in December, 1887, with no increase in the opacity of lenses or vitreous. The patient was the wife of a physician of this city, and was very carefully treated. Case YI. Floating Bodies in the Vitreous, and a Small Opacity in the Right Lens.—W. H. R., male, aged twenty-nine, seen by rne in January, 1888. Y.=■£•s, Em. Seen by Dr. Sat- terthwaite. Reads Jaeger Ho. 3 with + from Bto 18 inches. Has floating bodies very small and fine in vitreous of each eye, and opacity of the right lens, outer and lower quadrant. Has bad diabetes for past year; has become emaciated and otherwise shown marked debility. Is an artist and can do work only for a short while at a time. This patient is still under observation. Case Yll.—Female, aged forty-seven, married, has had fail- 10 DIABETIC AFFECTIONS OF THE EYE. ing vision and “ spots before her eyes ” for the past eight months, has emaciated during the past year, and has passed large quan- tities of urine with a specific gravity of 1-040 to 1-045, containing sugar. Examination of eyes showed V.=f| each ; ophthalmo- scopic picture showed lens clear, but the vitreous filled with numerous fine floating bodies and ten small fresh haemorrhages. The retina and optic nerve wTere normal. Each vitreous had a similar appearance except the haemorrhages. This patient had recurring haemorrhages until her death, January 17, 1886, from diabetic coma. At no time were there haemorrhages into the retina. Case Ylll.—Male, aged thirty-eight, for two years before coming under observation had had diabetes, passing 8 pints of urine daily, with 20 grains of sugar to the ounce. When first seen, March, 1885, marked emaciation was noticed, with much muscular weakness. R. Y.=-f!, L. Y.=|-2-. Ophthalmoscopic examination showed many floating bodies in the vitreous, and several small haemorrhages. The fundus was normal. This patient, under careful and systematic treatment, improved, so that only 10 grains of sugar to the ounce was voided, and with this improvement the vision also increased. The patient, how- ever, died soon after December, 1885, in an attack of pneu- monia. Cataract.—Opacity of the crystalline lens has from very early times been considered as one of the most common affections of the eye in diabetes mellitus, and it is only re- cently that the text-books speak of other diabetic affections of the visual apparatus. According to Roberts, it occurs once in 45 ; according to Bouchardat, once in 38 diabetics; while Griesinger, out of 225, found cataract to exist in 20. In the St. George’s Hospital it occurred once in 28 cases; Frerichs found 19 out of 400; and Graefe asserts that he has found them present in one quarter of all diabetics. In 858 diabetics col- lected from various sources already reported, together with my own, I find that diabetic cataract occurs once in every DIABETIC AFFECTIONS OF THE EYE. 11 17 whose glycogenic function is disturbed. In regard to the frequency of diabetic cataract to other forms of lenticu- lar opacity it is difficult to say, as in the various hospitals the diagnosis is not accurately made, the special kind being rarely recorded—e.g., of 8,933 cases of soft and hard cata- ract, n on-traumatic and not congenital, recorded in the prin- cipal eye hospitals of New York, Brooklyn, Philadelphia, Boston, and Baltimore, only 4 are recorded as of diabetic origin, or 1 diabetic cataract in every 2,223 opacities of the lens. 1 am quite sure that this ratio is far too small. Badal, out of 20,000 patients with eye diseases, found 62 with diabetic affections of the eye, and of the latter number 13 were cataract. It occurs in advanced cases, yet it also happens that at- tention is first directed to the diabetes by the disturbance of vision, more especially by the rapid formation of the cataract. As a rule, both eyes are attacked, though the maturing is not usually equal. The origin of cataract in diabetes was formerly attrib- uted to the withdrawal of water, from the experiments made by Kunde in 1856, who produced an opacity of the lens in frogs by desiccation or the introduction of substances hav- ing a strong affinity for water, such as salt and sugar under the skin ; these experiments were afterward confirmed by Weir Mitchell and others. Yon Graefe, on the contrary, pointed out that such lenses (diabetic) did not, like those of frogs, lose their opacity by being laid in water, and that they did not, like the latter, show any formation of vacuoles in their interior. The non- appearance of cataract in diabetes insipidus also tells against its origin in mere deprivation of water. In view of the fact that several cases of spontaneous disappearance of cata- ract on the improvement of the diabetic symptoms and the decrease in the sugar voided, as reported by Seegen, Nettle- 12 DIABETIC AFFECTIONS OF THE EYE. ship, and others, and as seen in Case Y of our series, it would seem more probable that the abnormal constitution of the blood, its saccharinity, as well as that of the other fluids, favored the formation of cataract. Sugar has been detected in the lens and in the aqueous and vitreous humors, as shown by Liebreich, Knapp, and Lohmeyer. In my own practice I have seen four diabetic cataracts, or 1 in 14 of the diabetics examined. Case IX.—Male, aged forty-six, laborer, came to the New York Eye and Ear Infirmary, March 18, 1881, complaining of failure of vision in each eye, more marked in the left—E.=^°u, L.=-g-§~o; ophthalmoscope showed a cataract in each, of a soft variety and progressive in character; fundus normal, so far as could be seen. This failure of vision came on three months before coming under observation, and has rapidly increased. Examination of the urine by Fehling’s test gave evidences of sugar. Patient voiding eight pints of urine daily. The patient was put on antidiabetic diet, and the amount of the sugar dimin- ished. The vision, however, gradually decreased, and percep- tion of light only remained. After three months’ careful treat- ment for the constitutional disease, the lens of the L. E. was extracted, and, save a mild form of iritis, no serious difficulty was experienced in the healing pi’ocess. The patient was oper- ated on at his home, and lived two years after the operation, dying of pneumonia on December 28, 1883. Case X.—Female, aged forty-eight, widow, sewing-woman. First noticed failure of vision in January, 1888, and three months previously had noticed an increase in the quantity of urine voided. The increase in urine came on shortly after a severe sorrow, since which time she has lost weight and become verv 7 • * melancholy. Examination revealed double soft cataract, K.Y. = rolV) L. Y.=fs. Fundus normal; antidiabetic treatment was directed, and rigidly adhered to for two months, when the quantity of sugar in the urine diminished, and with it a general improvement in the patient’s physical and mental condition. The eyes, tested again at this time, showed R. Y.=|£, L. Y.= |-$. The patient, becoming tired of the prescribed method of DIABETIC AFFECTIONS OF THE EYE. 13 diet and treatment, went back to the former ways of living, and four months later the vision was as when first examined. Shortly after this the patient went to a distant Western town, and I have not since learned of the result. Case Xl.—Male, aged fifty-three. First seen by me at Bur- lington, Yt,, in May, 1886. Previous to April, 1885, his health had been very good, but about that time he was affected with a great thirst, passed large quantities of urine, and gradually lost strength and flesh. When first seen by me he bad large quan- tities of sugar in the urine, which had a specific gravity of 1-035. Failure of vision rapidly supervened, and, when exam- ined, cataract of a bluish-white luster was observed in each eye, though more marked in the right. The fundus was nor- mal. R. Y.=t L. Y.=fs. Constitutional treatment was prescribed and the patient advised to report in a few months. The patient, however, did not report, and after a lapse of eight months I learned, by inquiry, that the patient had died of ex- haustion on December 14, 1886, the vision being so that he had only perception of light. Case Xll.—Male, aged sixty-one, merchant, seen in my pri- vate practice, April 18, 1885, with the history of failing vision for the past four months, associated with increase in the quantity of urine passed, containing much sugar. Specific gravity l-040. No gout or rheumatism, or anything of impor- tance in the family history. Examination of the eyes revealed in R. E. incipient cataract, with striae in many places, having the usual appearance of senile cataract; in the L. E. the lens looked more like the soft variety, and was more opalescent. The fundus was normal—R. V.=fs, L. Y.=fs. This patient was placed on a careful diet, and iodide of potassium prescribed. This method of treatment was kept up for seven months faith- fully, and with the result of improving very much the general condition, and with some effect on the opacities in the lenses. One year after the first examination the vision was, R.=T^-, T —2O TO- The patient died of diabetic coma three years after the first appearance of the general disease without an operation for the cataract. 14 DIABETIC AFFECTIONS OF THE EYE. Besides these four cases seen by me, I know of one in the practice of Dr. E. Gf. Loring where he extracted a cata- ract in a diabetic subject with very excellent results and without any reaction ; also of one case in the practice of Dr. Thomas R. Pooley. We are to make a distinction between cataract occur- ring in diabetic subjects from ordinary senile changes and those coming from the loss of nutrition produced by the disturbance of the glycogenic function. For we may, I think, extract with freedom those lenses occurring in old people having sugar in the urine, whereas in the young dia- betic we may have serious inflammation and necrosis of the cornea following the operations for the removal of the cata- ract. I should not hesitate to operate upon any case of cataract in a diabetic after a few weeks’ treatment of the general disease by proper remedies, and think that the poor results previously reported were due to the infection of the parts, the lowered vitality having less power to resist the germs, and that if proper antiseptics had been employed better results would have been obtained. The spontaneous disappearance of cataract as above men- tioned gives us a point in the treatment to by all means try and diminish the quantity of urine voided, and especially to look for syphilis as a cause of the diabetes, and when it is found, iodide of potassium will be found to have most ex- cellent effects. The use of Carlsbad waters is said to have caused diabetic cataract to disappear or to greatly diminish the opacity. Diabetic Retinitis.—We next come to the deep-seated affections of the eye, in which the long-continued derange- ment of the glycogenic function causes changes in the vas- cular system generally, and when haemorrhages are prone to occur in any part of the body, as the brain, retina, or spleen. According to Artigalas (30), whatever the symptoms DIABETIC AFFECTIONS OF THE EYE. 15 associated with retinal haemorrhages, it is always dependent upon the fibrous degeneration of the arteries, and that if the degenerative process continues, cerebral haemorrhage is very apt to follow. Mauthner in 1868, in his work on ophthalmoscopy, says : Eduard Jaeger (28) found retinitis in a person with diabetes raellitus; others have since then declared it possible (Nagel, Virchow), and by Martin and Galezowski it is positively asserted. Jaeger’s case was that of a male, aged twenty-two. No record is given of the quantity of the urine, or sugar in it. Bouchut (29), Desmarres, Martin, and others report similar cases, and seem to be unable to distinguish it from albuminuric retinitis. Noyes, at the American Ophthalmological Society in 1868, reports the case of a woman, aged sixty, diabetic for several years, and who in the previous year had double iri- tis, resulting in posterior synechia. When seen by the re- porter, R. V. = L. = |£. In the retina of each were found specks like fatty degeneration, with a few haemor- rhages. In the right eye the vitreous was noticed to be hazy. He says the appearances are absolutely identical with what he has often seen in cases of chronic renal dis- ease, and the case was at first so considered. Minute and careful records of the urine passed and tested were kept, and sugar only without albumin discovered. In concluding the history of the case he says : “ Pure glycosuria is capa- ble of causing retinitis, and that the ophthalmoscopic ap- pearances can not be distinguished from those which be- long to albuminuric retinitis.” I am of the opinion that retinitis occurring in diabetes before the kidneys are diseased can be diagnosticated as such, and that it has distinctive characters. That, however, when the kidneys are diseased, as so frequently happens in the latter part of diabetes, we get a mixed form of retinitis, 16 DIABETIC AFFECTIONS OF THE EYE. which is indeed difficult to determine from the ophthalmo- scopic picture. Lagrange (32) gives the following points in differentiation between retinitis from Bright’s disease and diabetes : Diabetic Retinitis. 1. Tendency to marked atrophy of the optic nerve. 2. Haemorrhages multi- ple, disseminate, and alone. 3. Extensive alterations of fundus throughout. 4. Haemorrhages not con- tinuing throughout. 5. Exudations small in amount and scattered. 6. Changes frequently. Albuminuric Retinitis. 1. Less marked, and the nerve not becoming entirely atrophic. 2. Haemorrhages equally multiple, but mostly in pos- terior part of fundus. 3. Mostly in the macula lutea and optic nerve. 4. Remaining through- out. 5. Exudations white, fat- ty in character, with much infiltration of retina and nerve. 6. Remains a long time the same. One symptom is, however, more characteristic—namely, haemorrhages into the vitreous are common in diabetic retinitis, and not so in retinitis from kidney lesions. This is to me an important point in diagnosis, and is a clinical fact which has been noticed by several observers. Why they should occur in this affection and not in Bright’s dis- ease is probably due to the more marked changes in the vascular system in diabetes. As regards the frequency of the retinal affection, Badal, in 52 diabetic affections of the eye, found retinitis 17 times, and in our 21 diabetic affections of the eye, 5 retinitis with haßinorrhages, or some over one fourth of the cases. DIABETIC AFFECTIONS OF THE EYE. 17 In the eye infirmaries of this country for the past ten years I find no recorded cases of the disease. That it does occur is certain, but the diagnosis is not made. Case Xlll.—Male, aged forty-three, clerk, first seen by me on March 18, 1888, when the following history was obtained: For two years past has had a desire for sweet things to eat, and has voided much urine; emaciation has occurred, and great muscular weakness. Ten days before first noticed a failure of vision in the R. E., which for twenty-four hours increased, then remained as at the time of examination, when vision in R. E,=fs, L. E.=f§; no refractive error. Ophthalmoscope showed haemorrhages into the vitreous and into the retina, the optic nerve was not swollen, and there was no infiltration of the retina. The haemorrhages were minute and scattered over all parts of the fundus. 25th.—R. E.=t2/7; more retinal haemorrhages and some signs of exudation in its tissue. Examination of the urine at this time showed sugar in the urine, seven pints being voided daily, and with a specific gravity of l-038, and seventeen grains of sugar to the ounce. Bromide of arsenic and a careful diet prescribed, and this treatment rigorously ad- hered to. April 25th, one month later, R. Y.=|£, and the ophthal- moscopic picture found to be changed. Vitreous haemorrhages absorbed, and only a few opacities now remaining. Retinal hasmorrhages absorbing, and in some places entirely absent, a slight staining showing the site of the former extravasation. Urine and sugar diminished in quantity, voiding now only three pints daily, and only a trace of sugar. This treatment continued for another month with good re- sult as to the quantity of urine and sugar voided, hut with no further improvement in the vision. The patient left the city for the sea-side, and after bathing in the surf contracted pneumonia, and died, September 18, 1883, of catarrhal phthisis. The vision remained the same as at last reported, so I learned from the family. Case XIV.—Male, aged thirty-nine, residing in Jamaica, 18 DIABETIC AFFECTIONS OF THE EYE. L. 1., sent to me, May 2, 1884, with the history of gradual ema- ciation and loss of muscular weakness for the past year, and sudden loss of vision in both eyes one week before. Examina- tion revealed Y.=f-§- in each eye. No improvement by glasses? can not read the largest test-letters of Jaeger’s. Ophthalmoscope shows haemorrhages into each vitreous, which are fresh and abundant, and in the retina, scattered throughout, are fine punctate extravasations in the macular re- gion and also distant from it; optic nerve hypersemic but not infiltrated; no exudations into the substance of the retina; the blood-vessels are about normal in appearance. No albumin or casts found in the urine, although many examinations were made. Sugar by the fermentation test was present; the specific gravity was D 034, and the quantity eight pints daily. The cause of the diabetes in this case was supposed to be due to an injury received in falling from an ice-boat the previous winter, as the health began to decline from this out. The field of vision for sight and color appeared to be normal. Bromide of arsenic, diet, and rest were ordered, and followed for six weeks, when it was found that no improvement had taken place either in the general condition or the eyes, the latter being the same as regards vision ; the interior, however, showed some different arrangement of haemorrhages. lodide of potassium was prescribed, and three weeks later specific gravity was DO2B, sugar less, and the.quantity of urine also; no albumin. R. E.=fg-, L. E.=f£ (as before). Vitre- ous and retinal haemorrhages absorbing, and less hyperaemia of optic nerve. This treatment was continued until August, when the patient went to California, where he died, December, 1885, as I learn, from exhaustion, the eyes remaining always bad, but so that he could read large type. Case XV.—Female, aged forty-three, seen by me while in the office of Dr. E. Gr. Loring. In the summer of 1885 the pa- tient, while in the Catskills, noticed failure of sight in one eye, her attention being called to it by the annoyance of seeing ob- jects floating in front of the eye. This gradually increased until she sought advice. On examination, it was found that vision in R. +), DIABETIC AFFECTIONS OF THE EYE. 19 the other being normal. Ophthalmoscope revealed numerous htemorrhages into the vitreous and also in the retina, some in- filtration of the retina, and only a few exudations. The optic nerve slightly congested, the retinal haemorrhages were scat- tered throughout the fundus. The appearance of the retinal picture, together with the vitreous haemorrhage, led me to ask in reference to the quantity of urine voided, when it was brought out that the quantity was in excess, although the patient, an intelligent woman, had not given it much concern. She had also a great desire for sweetmeats. Examination of the urine revealed sugar in large quantity and no albumin. Under treat- ment by two different physicians, who regulated the diet, she improved, and the retinal appearance changed the vision in power to fs. The restricted diet prescribed being irksome, the patient relinquished it, and, on returning to ordinary diet, the dia- betic symptoms reasserted themselves, the eye symptoms again becoming worse by the recurrence of fresh haemorrhages. The patient is still living and under the care of Dr. Loring, to whom I am indebted for the use of his notes. Case XVl.—Female, aged sixty-three, first seen by me at the Post-graduate Hospital, December, 1886. Patient a hard-work- ing woman, coming for defective vision in each eye, R. = L. = Ophthalmoscopic examination showed well-marked haemorrhages into each vitreous and each retina. Those in the vitreous were large and those in the retina small and scattered throughout the whole fundus, and not, as in retinitis albuminuri- ca, in the macular region. This patient was not emaciated, and the only symptom complained of beside the dimness of vision was a strange sensation in the region of the heart. She was referred to Dr. W. H. Porter, who found albumin in the urine and a sound over the heart, which he thought to be due to an opening in the aortic valve, congenital, and not as the result of disease. Later, sugar was discovered in the urine and the al- bumin disappeared. She was put on the iodide of potassium treatment and she gradually improved, the sugar remaining in the urine but greatly diminished in quantity. The vision improved so that she could go to and from the hospital, where at first she had to be led. When seen by me, Janu- 20 DIABETIC AFFECTIONS OF THE EYE. ary, 1887, R. = fs, L. = f£, and she could read Jaeger No. 4 with correcting-glasses. The ophthalmoscope showed optic nerve of the right eye pale on the outer half, and in nu- merous points on the retina stainings showing the former position of the haemorrhages. The vitreous and lens were both clear. Visual field not contracted nor any change in that for color. The patient is still under the care of Dr. Porter for the gen- eral disease. He considers that the diabetes was the cause of the albumin in the urine when first seen, and that its disap- pearance is due to the less work the kidneys have to do owing to the diminished quantity of urine voided. Case XVll.—Male, aged fifty-two, clerk, seen first Octo- ber 9, 1885, when he complained of failure of vision for three weeks past, more rapidly during the past two days. Has not been in good health for one year, being weak and irritable; has lost twelve pounds in weight in as many months. Passed eight pints of urine daily and has great thirst. R. E. = T L. =|g. Ophthalmoscope shows vitreous and retinal haemorrhages, more abundant in the former, and small and punctate in the retina and scattered in all parts. Optic nerve has red look and outline somewhat indis- tinct. No exudations into the retina save one or two points near one vessel near the macular region. Examination of the urine revealed large quantity of sugar; no albumin or casts. Specific gravity, DOB 9, and ten grains of sugar to the ounce. Diet, iodide of potassium, and Windsor water were prescribed, and the patient carefully adhered to it for two months, when the R. V. =|g, and decrease and ab- sorption of the intra-ocular haemorrhages to a considerable de- gree, though some remained in the vitreous and retina. The restricted diet becoming unbearable, he returned to ordinary fare, and with it an increase in all the diabetic symptoms; and again failure of vision in each eye, R. = and L. = |s, thus for the first time showing vitreous and retinal haemorrhages. While under the careful treatment the sugar and urine de- creased, and he had to only follow the injunction laid down in DIABETIC AFFECTIONS OF THE EYE. 21 the “Code of Health of the School of Saleroom” (1), which says: “ At least six times in every fleeting day Some tribute to the renal function pay.” This patient passed from under my observation, having re- turned to Ireland, and I have not been able to learn of the final issue of the case. It will be noticed that in all these live cases reported by me vitreous haemorrhages were present, and I consider this of much importance in arriving at the diagnosis of glyco- suric retinitis from the ocular symptoms alone. I have en- deavored to ascertain how frequently this affection occurs in private practice, and have asked many of my friends, and have found, as a rule, that it is exceedingly rare, or if seen it is not so recognized, but rather attributed to some other cause. Dr. Pooley has furnished me with the notes of two cases taken from his private case-book. I woidd urge the more careful system of indexing diseases in private prac- tice, so that when statistics are wanted they can be had ac- cess to and thus much labor saved the compilei'. Amblyopia in Diabetes.—There can be no doubt, in the light of our present knowledge, that diabetes produces am- blyopia, which is central, and in which the visual field is not interfered with, but in which there is usxxally a central scotoma for red and green, and occasionally for blue; that the defect improves with diminution of, and increases with the quantity of, sugar in the urine ; that it comes on rather suddenly, and increases, then varying according to the diabetic condition ; that it rarely produces blindness, but may result in partial atrophy of the optic nerves. This class of cases may vexy easily be mistaken for the amblyopia ex abusu, unless care is taken to examine the urine for sugar, as the symptoms are much the same, and, as most men 22 DIABETIC AFFECTIONS OF THE EYE. smoke, it is very easy to conclude that that is the cause of the amblyopia. Galezowski was probably the first to point out this resemblance, and, according to him, the diagnosis is very difficult without examination of the urine. The most important distinction drawn by him is that amblyopia ex abusu usually occurs in both eyes ; that in diabetic am- blyopia one eye may escape. This has not been our expe- rience ; from the cases observed by me all have been affected in each eye ; this has been also the experience of Mr. Nettleship. It is ray firm conviction that the amblyopia occurring in smokers having diabetes is due to the loss of nutrition produced by that disease, and not to the effect of tobacco on the system. Since the invention of the ophthalmoscope much has been written on amblyopia in diabetes, without cataract, and without retinal haemorrhages or other visible lesions. And it is this particular form of ocular affection that is ex- tremely interesting. A very careful exposition of this sub- ject is presented by Mr. Nettleship and Dr. Walter Ed- munds, of London, in the “ Transactions of the Ophthal- mological Society of the United Kingdom ” (4), 1882, and from this we have made frequent use; In 1858 Desmarres (5) records the case of a woman, emaciated by diabetes, passing much sugar, with the sight so bad that she could no longer read. Also, a male, aged twenty-five, passing large quantity of sugar, with vision so bad that lie can neither read nor write. After seven months’ treatment, health im- proving; the vision was so much better that No. 8 Jaeger, with glasses, could be read. Begbie, 1861, writing in the “Edinburgh Medical Journal,” says he was familiar with a form of “ diabetic amaurosis,” com- ing on earlier than cataract, advancing gradually, and remaining permanent. He cites no cases. The same yearLecorch6, in an elaborate paper on “ Diabetic Amblyopia,” says the cause will probably be found to be a par- DIABETIC AFFECTIONS OF THE EYE. 23 tial or general atrophy of the optic nerve, occurring independ- ently of changes in any part of the brain. The suggestion that some cases of diabetic amblyopia were due to cerebral cause had been previously made by von Graefe (7), who had reported several cases of various forms of eye disease in diabetes. Seegen, 1870, reports a case of a male, aged thirty-eight; amblyopia, with no ophthalmoscopic changes ; vision improved under treatment. Another author (9) reports the case of a male, aged forty- two ; one eye nearly blind from old injury, with diabetic symp- toms for six months; passing daily one pound of sugar; vision in the only eye failing for a month before coming under obser- vation. The ophthalmoscope revealed disc somewhat pale, but no other changes. Vision and refraction not stated. Leber (10) reports three cases, one of which, probably, does not belong to this class, but the other two may be considered. Male, aged forty-three, passing sugar, but no albumin; am- blyopia of R. E., V. =i; field normal for vision and colors. L. E., high amblyopia; shadows at center of tield, and fingers at five feet in outer part; inner half of field absent almost. Final recovery with both, on improvement in the general symptoms. Four years later the vision is reported as being good. A scotoma for white and colors at the central and outer central part of the field was left. No ophthalmoscopic changes. Male, aged fifty, double equal amblyopia, with central scotoma for colors, but no contraction of the visual field ; V. = No ophthalmoscopic changes. He was treated as a case of amblyo- pia ex abusu, and vision improved to each eye. Two months later, R. E. again became bad ; V. = ; scotoma still present in both. Urine now examined, and found to contain sugar. Under treatment for the diabetes the vision improved. Forster (11), female, aged sixty two, having diabetes, in whom the discs became pale, and subsequently showed signs of atro- phy. The field in this case was normal. Galezowski (12), in 1878-’Y9, reports the case of an officer in the French array, aged forty-eight, passing one hundred and fifty grains of sugar daily. No contraction of the visual field, but 24 DIABETIC AFFECTIONS OF THE EYE. vision so imperfect that he could not discern faces at nine feet. No ophthalmoscopic changes. With diminution of sugar, some improvement in the amblyopia. Albumin, later, was found in the urine. He also reports the case of clergyman, aged forty- four, V. =£ ; nomal color perception ; visual field normal; no ophthalmoscopic changes; much sugar in urine. Eales (13), of Birmingham, England, reports a case of a dia- betic with amblyopia, male, aged fifty, without ophthalmoscopic changes, having a scotoma for red, green, and blue. This patient died shortly after being seen. Bresgen (13), in 1881, reports the case of a male, aged twenty- four, diabetic, with symmetrical amblyopia, Y. = with central scotoma for red and green, and with no contraction of the visual field or ophthalmoscopic changes. With an increase in the quantity of sugar voided the amblyopia increased to and the color scotoma increased also in size. Mr. Lang, Mr, Nettleship .(4), Dr. S. Edmunds, and Dr. Lan- ford, of London, have reported similar cases, Nettleship has reported the case of a female diabetic suffering from amblyopia. In this case there was no question of smoking. I have myself seen four cases having central amblyopia, all having each eye affected; two were males and two were females; all had perfect visual fields, and all scotomata for red and green; the men smoked moderately, and the women not. The accompanying fields of vision are shown, giving the scotoma area, the blind spot, and the visual field. The histories of these cases are as follows : Case XVIII.—W, A. S., male, aged thirty-nine, sent to me by Dr. Galer, of Newtown, N. Y., in 1880; the patient had been suffering from diabetes for two years, and most of that time passing sugar. One month before his visit to me he first noticed trouble in his eyesight; this gradually increased until such time that he could not see to read. When first seen he had R. L. Y.=fs. No ophthalmoscopic changes. On testing the visual field, it was found to be normal; the color DIABETIC AFFECTIONS OF THE EYE. 25 field showed a scotoma for red and green, as shown in the figure marked No. 1. At this time the patient was passing fifteen Fig. 1. grains of sugar to the ounce of urine. The media were clear, and the eyes looked perfectly normal. Three weeks after the first examination the R. as before, and the L. V.=ff. A more rigorous treatment was adopted, the sugar diminished in quantity, and the amblyopia improved, but there was no change in the scotoma. The patient died one year later in diabetic coma. No autopsy; Case XlX.—Female, aged forty-nine, married. Mother of three children. Sent to me by Dr. Fassit, of St. Albans, Yt., with the history of having had diabetes for the previous six Fig. 3. 26 DIABETIC AFFECTIONS OF THE EYE. months. One week before coming under my observation she noticed failure of vision, which came on suddenly, and so much so as to give her much alarm. She was at this time passing 150 ounces of urine daily, with much sugar. Vision, each eye, equal to //j, no limitation of the visual field", but central scoto- ma for red and green, as seen in Fig. 2. No change in the fundus was noticed save, perhaps, a slight pale color to tem- poral half of the disc. The vision in this case never became worse and did not improve. The patient died two years and seven days after, from exhaustion. No autopsy. Case XX.—Male, aged forty-eight, seen by me at the Post- graduate Medical School Clinic, Decembers, 1887, with the his- tory of failing vision for the three months preceding. Exami- nation of eyes revealed V.=f-g- each; no ophthalmoscopic change; visual fields intact, but color scotoma for red and green was found in the central part of the visual field. (See Fig, 8.) This patient was voiding nine pints of urine daily, with large quantities of sugar. The patient was treated by the ad- ministration of iodide of potassium; the sugar was diminished, yet the amblyopia continued as before. The patient died eight months later, from asthenia. The eyes were examined repeat- edly, but no ophthalmoscopic change could be discerned. Fi«. 3. Case aged fifty-one, widow, first noticed an increase in her urine in 1882, in the early part of the year, after having received a severe fall on the back; eight months after DIABETIC AFFECTIONS OF THE EYE. 27 this she noticed a failure of vision in the R. E. and then in the L. E.; it finally became so bad that she could not read. When seen by me at my office, in December, 1882, she had Y.=|£ each, not improved by glasses, and with normal pupils and no oph- thalmoscopic change except, perhaps, a slight dirty look to the optic disc. No albumin in urine, but sugar in abundance. The visual fields, as usual, were normal, and green scotoma centrally placed; red was with great difficulty and inaccurately seen. Six months later the patient was examined again, and vision of each eye equal to and scotoma for red and green still pres- ent in the L. E.; ring scotoma. (See Fig. 4.) Sugar in urine more than before. Patient died December 8, 1883, of gangrene of the right foot. No autopsy. Fig. 4. In each of these cases I regret that an autopsy was impossible, for it would have been interesting to make an examination of the optic nerves in these cases. Dr. Walter Edmunds and Dr. J. B. Lawford, of London, made such an examination in the case of a patient aged twenty- nine. The optic nerve showed marked changes throughout the whole length of the orbital part of the nerve; in the diseased area was found thickening of the trabeculse and of the walls of the nutrient vessels; the libers in the nerves seem to have been destroyed, and to be replaced by an 28 DIABETIC AFFECTIONS OF THE EYE irregularly granular structure, in which there is a large number of staining nuclei. Mr. Nettleship reports, also, the post-mortem appear- ances of the optic nerve in a similar case: Microscopical examination of the optic nerve showed changes in the orbital portion of the nerve; the portion posterior to the optic foramen was not examined. Longitudinal sections were made of the nerve, and transverse sections at various points. The longitudinal sections showed no changes anterior to the lamina cribrosa. Posterior to the lamina, on one side of the nerve, was a tract with well-marked pathological changes, atrophic nerve-fibers, increase of nuclei, thickening of the con- nective tissue, trabecula), and of the walls of the small vessels. The thickening of the walls of the vessels was most marked in front of the point of entrance of the central artery of the retina. On a transverse section the atrophic patch appeared wedge- shaped; and from the relation of this diseased part to the cen- tral artery, at its entrance, it was certain that the change was chiefly in the temporal half of the nerve. In Samelsohn’s case both optic nerves were examined and symmetrical changes were found. Deutschraann (15) also reports similar appearances mi- croscopically. These post-mortem examinations would lead us to conclude that we have a subacute retro-bulbar neuritis and a subsequent atrophy of the optic nerve-fibers. That the cause of this neuritis is the poison in the blood pro- duced by the derangement of the glycogenic functions. That not only the optic nerves are affected, but also the sciatic and others throughout the system. Sachs (18), in an elaborate paper on central scotoma, finds the same appearances as above described, and as shown in the accompanying diagram (Fig. 5). From this clinical picture of the affections of the eye occurring in diabetes it will be seen how varied and howT DIABETIC AFFECTIONS OF THE EYE. 29 numerous are the ways the poison of the disease shows itself in the same organ, and how we may, from the eye symptoms alone, make a diagnosis of unsuspected diabetes. In conclusion, the following practical points may he summar- ized. 1. In view of the recorded facts, shall we not urge the exami- nation of the urine for sugar in every obscure ocular affection ? 2. Cataract occurring in a dia- betic may be extracted without danger if the patient is previously treated for the general disease. 3. Retinitis occurring in dia- betes is usually associated with vitreous haemorrhages, and that this is a point in favor of the disease rather than retini- tis from kidney affection. 4. Diabetic amblyopia is usually associated with cen- tral color scotoma for red and green, with visual fields in- tact, and does occur independent of amblyopia from tobacco and alcohol, as shown by our cases. And, further, diabetes can be diagnosticated by amblyopia when no diabetic symp- toms exist. 5. All the diabetic affections of the eye are the result of poor nutrition produced by the disturbance of the glyco- genic function, and that the more marked the disturbance, the more profound and more deep-seated the ocular affection. 6. The changes occurring in the eye are also taking place in other tissues of the body at the same time. “ To man’s short reach of mind and scanty powers, How much is dubious in the things he sees, How much eludes his sight! ” Fig. 5.—Transverse section of the optic nerve, showing wedge-shaped atrophic spot to the outer side of the nerve (after Sachs). “ Archiv f. Augenheil.,” Bd. xviii. 30 DIABETIC AFFECTIONS OF THE EYE. 1. Smith, G. M.—“Trans, of the N.Y. Acad, of Medicine,” vol. iii, part xi. 2. Deane. ST. Y. “Medical Record,” vol. xxxiii, Yo. 4, p. 97. 3. Hirschberg.—“ Oentralblatt f. prakt. Aug.,” July, 1880. 4. “Transactions of the Ophthal. Soc. of the United King- dom,” vols. i, ii, iii, et seq. 5. Desraarres.— “Traits,” 1858, t. iii. 6. Lecorche.—“Gazette hebd.,” 1861, 521, 717. 7. Yon Graefe.—“ Archiv f. Ophth.,” iv, ii, 230, 1858. 8. Seegen.—“Der Diabetes Mellitus,” Leipsic, 1870. 9. 0. E. Fitzgerald.—“ Dublin Quarterly Journal of Med. Sei.,” vol. 1, p. 226, 1870. 10. Leber, Graefe.—“Archiv f. Ophth.,” xxi, 3, 206. 11. Forster, Graefe, und Saemisch.—“ Handbuch,” vii, 187. 12. Galezowski.—“ Receuil d’ophthal.,” 1878-’79. 13. Bresgen.—Hirschberg’s “Central, f. Augenheil.,” 1881, Ah. xxxi. 14. “ Wood’s Reference Hand-book of the Medical Sciences,” vol. ii, p. 420. 15. Deutschmann.—“ Graefe’s Archiv f. Ophth.,” Bd. xxxiii, Ab. ii. 10. Leber.—“Graefe’s Archiv f. Ophth.,” Bd. xxxi, Ab. iv, 1885. 17. Schirmer.—“Klin. Monatsbl. f. Augenh.,” April, 1887. 18. Sachs.—“Archiv f. Augenheil,,” Bd. xviii, p. 21. 19. Wiesinger.—“ Graefe’s Archiv f. Ophthal.,” 1885, Ab. iv. 20. Gutmann.—“Oentralblatt f. prakt. Augenhlk.,” October, 1883. 21. Panas.—“Logons sur les keratites,” Paris, 1876, p. 158. 22. Ooundouris.—-“Th&se de Paris,” 1883, p. 48. 23. Marchal de Calvi.—“Nouvelle th6orie du diab&te,” p. 414. 24. Yoyes, H. D.—“Trs. of the Americ. Ophthal. Soc.,” 1868, p. 71. 25. Wickersheimer.—“These de Paris,” 1874. Bibliography. DIABETIC AFFECTIONS OF THE EYE. 31 26. “France m&licale,” 188 L 27. Jaeger.—“ Beitriige zur Pathologic des Anges,” p. 33. 28. Mautliner.—“ Lehrhuch der Ophthal.,” 1868, p. 375. 29. Bouchut. “Da diagnostic des maladies dn systhme nerveux par I’ophthal.,” p. 442. 30. Artigalas.—“ Ann. d’ocul.,” May-June, 1884. 31. Noyes.—“ Trans, of the Am. Ophthal. Soc.,” vol. i, p. 71. 32. 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