The Early Eye-Symptoms 
. In Chronic Alcoholism. 
BY 
CHARLES H. MAY, M.D., 
NEW YORK. 
REPRINTED FROM 
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for March, 18$ 2. Reprinted from the American Journal of Inebriety for April, 1891, and the Northwest- 
ern Medical and Surgical Journal for March, 1892. 
THE EARLY EYE SYMPTOMS IN CHRONIC ALCOHOLISM. 
By Charles H. May, M.D., 
Chief of Clinic, Eye Department, Vanderbilt Clinic; Instructor in Oph- 
thalmology, College of Physicians and Surgeons, New York ; Assist- 
ant Surgeon, New York Ophthalmic and A ural Institute, etc. 
As is well known, the organ of vision, like so many other 
parts of the body, suffers insidiously from excessive use and 
long-continued over-indulgence in alcoholic beverages ; it 
is the purpose of this paper to point out the early symptoms 
referable to the eye, which occur at a stage of chronic alco- 
holism when the amblyopia alcoholica has not yet become 
very marked. Such observations can best be made in the 
cases of private patients and among the better class of dis- 
pensary patients, since the lower classes are very apt to 
neglect seeking medical aid until vision has become very 
much impaired. 
The eye symptoms produced are quite constant and are 
sufficiently well marked to be observed in quite an early 
stage of the condition which we call chronic alcoholism—a 
condition which may be defined as one in which the quantity 
of alcohol habitually and repeatedly taken exceeds that 
which can be assimilated, and which results in producing 
toxic effects of greater or lesser intensity, after a longer or 
shorter period. 
It is commonly stated and usually accepted that the max- 
imum daily quantity of alcohol which, if properly diluted, 2 
can be indulged in every day without causing evil effects 
eventually is an ounce and a half. This would represent 
about three ounces of whiskey, about nine ounces of sherry, 
about a pint of light wine (claret, rhine wine, etc.), and 
about two or three pints of beer. But as is the case in the 
effects upon other parts of the body, much larger quantities 
are taken regularly by persons who never complain of 
symptoms referable to the eye, and who would not present 
any such symptoms if functionally examined ; and, in like 
manner, the time during which alcoholic excesses can be 
indulged in before eye symptoms show themselves also 
varies. The frequent indulgence in small non-intoxicating 
doses seems to favor the occurrence of amblyopia alcoholica 
much more decidedly than does the drinking of Large, in- 
toxicating quantities at longer intervals. Whiskey certainly 
causes the majority of cases in this country. In the great 
majority of cases the condition occurs in the male sex ; 
this is, as we would most naturally expect, considering the 
much greater frequency with which men acquire the alcohol 
habit than do women. Almost always both eyes are af- 
fected, though the symptoms may present variations in de- 
gree of severity in the two eyes. 
The symptoms are : 
Conjunctivitis. 
Injection of the ocular conjunctiva. 
Congestion of the iris. 
Spasm of accommodation. 
Contraction of the pupil. 
Photophobia. 
Nyctalopia. 
Glimmering sensation in bright light. 
Scotomata (color and white). 
Amblyopia. 
Partial (temporal) atrophy ofjdie optic nerve. ] 3 
The conjunctivitis is of the catarrhal variety, and is of very 
common occurrence in chronic alcoholism. It is peculiar 
in its “ irritative” nature. Its severity is subject to changes 
from day to day, according to the quantity of alcohol in- 
dulged in. The injection of the ocular conjunctiva is not 
merely a part of the conjunctivitis ; it may exist indepen- 
dently of the latter, presenting a marked appearance and 
sometimes accompanied by congestion of the iris j there will 
then be found a well-marked ring of circumcorneal redness 
—the condition indicating an implication of the ciliary re- 
gion in the vascular disturbance. As is the case with the 
conjunctivitis, these two symptoms depend largely upon the 
immediate effects of the quantity of alcoholic drink taken, 
so that they are especially marked after a debauch. 
Spasm of accommodation is not infrequent in alcoholic sub- 
jects, and becomes noticeable especially because male adults 
are rarely otherwise subject to it. The amount of spasm 
seems largely to depend upon the quantity of drink on the 
same or the previous day ; it may interfere materially with 
a functional examination of the eye in testing for errors of 
refraction, and may therefore necessitate the use of atropine 
or of homatropine before the accommodation becomes re- 
laxed. 
The pupils are apt to be smaller than ‘usual in chronic 
alcoholism ; during intoxication or after a debauch the 
dilated pupils of acute alcoholic poisoning are observed. 
Photophobia and nyctalopia exist not infrequently ; and a 
glimmering sensation, especially in bright light, is also some- 
times complained of. The photophobia may depend upon 
the conjunctivitis, to which, in some cases, the congestion 
of the iris and injection of the ocular conjunctiva are addi- 
tional factors. The principal cause, however, is probably 4 
hypercesthesia of the retina—a condition which is held respon- 
sible for the nyctalopia. The latter symptom may be de- 
fined to be the ability to see better by dim light than by 
bright illumination—a condition resembling what has been 
described as retinitis nyctalopica. While these patients may 
occasionally really have an increase in the acuteness of 
vision when the illumination is less intense, as a rule there 
is no increase, but rather a slight diminution in the acute- 
ness of vision with a less bright light ; so that the improve- 
ment is merely apparent, and not real. But these patients 
feel very much more comfortable in a subdued light, and 
hence imagine they see better. The influence of diminished 
illumination is quite often marked, and many such patients 
acquire the habit of wearing smoked glasses, often resort- 
ing to these without the advice of any oculist, because the 
eye feels more comfortable with them. 
Quite early the existence of central scotomata can be dem- 
onstrated ; that is, a small part of the centre of the field of 
vision will be defective in its appreciation of color or even 
of white. This symptom usually exists quite early, but it 
may require careful testing in order to be found. The 
portion of the field which will be defective is almost always 
a small oval, with its long axis placed horizontally, extend- 
ing from the point of fixation to the blind spot and partially 
or entirely including the latter. At first these scotomata 
exist only for green and red ; later there may be a scotoma 
for purple and then also for white ; that is, there will be 
no sight at all over this small oval area. These scotomata 
whether for colors or white are almost always negative or rel- 
ative—not apparent to patient ; they may, however, be abso- 
lute, and thus appear as constant spots before the eyes, just 
as in certain diseases of the retina. They are, however, al- 5 
most always central. The patient may be conscious of color 
defect, but usually the color perception is good excepting 
this central scotoma. If in this early stage he is tested for 
color blindness, as by Holmgren’s colored skeins, he will 
not be found defective, and will match colors well. A 
number of such cases have, however, complained to me that 
everything appeared less bright to them than it had for- 
merly, though they could distinguish colors quite readily. 
Even though these central scotomata for colors or white 
are found, there may be no diminution in the acuteness of vi- 
sion; but commonly some amblyopia becomes manifest when 
the symptoms already mentioned are found. This reduc- 
tion in the acuteness of vision, again, is almost always cen- 
tral, so that the circumference of the field of vision is not 
usually affected, and peripheral vision remains good. The 
amblyopia does not, as a rule, advance rapidly ; very often 
in the early stages |JJ or will represent the patient’s sight. 
Even in advanced stages total blindness from amblyopia 
alcoholica is uncommon, though this is probably because 
the patient has sought medical advice before such an ex- 
treme result has occurred, and has reduced or stopped his 
alcoholic excesses. There is no constant relation between 
the amount of amblyopia and that of color scotoma. It is 
quite interesting to observe how quickly the amblyopia 
will respond to changes in the habit of the patient, and 
how, after a few weeks of abstinence from alcohol, the vi- 
sion can be brought up to, say, ,o to 3“; and how quickly also 
there is a response in the opposite direction when the alco- 
holic excesses are resumed. 
In most cases of amblyopia alcoholica (60 to 70 per cent) 
the ophthalmoscope reveals a well-marked picture. In the 
very early stages no abnormalities of the fundus may be 6 
seen, or, perhaps, only a little hyperaemia of the disk, or a 
slight swelling at its margins, with, perhaps the appearance 
of white striae along the blood vessels, especially near the 
margins of the disk. But even before an advanced period 
there is apt to be a well-marked and characteristic picture 
—a pallor of the temporal portion of the disk, due to partial 
atrophy—to. a wasting of the fibres constituting this seg- 
ment. This pallor must not be confounded with a certain 
amount which is physiological, and is found in a certain 
percentage of normal eyes examined with the ophthalmo- 
scope ; there may, therefore, be cases in which it will be dif- 
ficult to draw the line between the physiological pallor and 
the appearance of the pathological atrophy. But usually 
no such difficulty will be met with, and the ophthalmoscopic 
picture will be a characteristic one. 
For a long time nothing was known concerning the pa- 
thological anatomy of "this condition ; this was first ex- 
plained by Samelsohn and by Vossius in 1882, confirmed 
by Nettleship and by Burge in 1884, and by Edwards and 
Uhthoff in 1886. All these investigators found an intersti- 
tial neuritis—proliferation of connective tissue and secon- 
dary degenerative descending atrophy of those fibres of the 
optic nerve which pass from the temporal side of the disk 
to supply the macula lutea. The atrophy affects chiefly 
the nerve fibres of the fasciculus cruciatus ; these spread 
from the temporal part of the disk to the region of the 
macula lutea, hence the occurrence of central scotoma and 
the form of the latter (oval horizontally). 
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