AN OPHTHALMOSCOPIC STUDY OF A CASE OF HEMORRHAGIC NEURO- RETINITIS. BY CHARLES A. OLIVER, A.M., M.D., One of the Attending Surgeons to the Wills Hospital; one of the Ophthalmic Surgeons to the Philadel- phia and Presbyterian Hospitals; Honorary Member of the Milwaukee Medical Society, etc. Reprinted from the International Medical Magazine for May, 1896. Plate I. Appearance of eyeground during hemorrhagic stage. Aate II. Appearance of eyeground during stage of degeneration. AN OPHTHALMOSCOPIC STUDY OF A CASE OF HEM- ORRHAGIC NEURORETINITIS.1 The accompanying phototypes represent the ophthalmoscopic appear- ances of an extremely interesting case that the writer has had the privilege to study during his terms of service in the ophthalmic wards of the Phila- delphia Hospital. On the 2d of April, 1895, M. McF., a sixty-year-old man, formerly employed as a dyer, gave the following brief history of his ocular condition : Three years previously, Dr. George M. Gould, the writer's immediate predecessor as one of the ophthalmologists to the hospital, removed the right eye for gumma of the ciliary body. Some four years previous to this, as also shown by the hospital records, the case was under the care colleague, Dr. George E. de Schweinitz, who treated him for a double iritis, which rapidly became gummous in type, in the right eye. At that time, the left eye showed a diffused retinitis, and had a visual power of but When the patient was first seen by the writer, he stated that the vision of the left eye had been steadily failing for three months' time, objects appearing as if they were seen through a mist, or as if they were placed in a cloud. Direct vision for form was reduced to an uncorrectable JL. The visual 5 0 fields for white and red, which were carefully taken by Dr. Wm. T. Shoe- maker, one of the writer's friends and assistants, showed a decided excentric contraction, the greatest diminutions being in the upper and the lower nasal quadrants. The pupil was ovoid, with its long diameter of two and one-half milli- metres, situated at seventy-five degrees. The iris responded fairly well to light-stimulus and to efforts for accommodation. The anterior scleral veins 1 Sketches of case exhibited before the January, 1896, meeting of the Section on Ophthalmology of the College of Physicians of Philadelphia. 2 CHARLES A. OLIVER, M.D. were full and intra-ocular tension was normal. Extra-ocular muscle move- ment appeared good in all directions. Oblique examination made plainly evident the marks of an old iritis upon the anterior capsule of the lens. With the ophthalmoscope, a most interesting and typical picture of hemorrhagic neuro-retinitis, with a just commencing glaucomatic cup, could be seen through the clear media. The details of fundus are so fairly shown in the first of the accompanying phototypes, which have been reproduced from two most excellently and faithfully painted water-color sketches, made by Margaretta Washington, of this city, that an extended verbal description is rendered unnecessary. Here the irregular and unequal recession of the swollen tissues on and around the optic nerve-head; the just beginning pathological sinking of the outer half of the disk-substance, allowing the lamina cribrosa to be seen through the superjacent translucent structures ; the immense fresh hemor- rhage, about the size of the disk, with its upper edges and central portion showing the first effects of rapid absorption ; the irregular line of degenera- tion and atrophy extending up and out from the large blood extravasation into a second much fainter hemorrhagic area ; the clump-like blood-massings in the macular and supramacular regions; the flame-shaped extravasations into the fibre layer of the retina immediately above the disk edge; and the slightly oedematous condition of the peripapillary area, can all be fairly recognized in the details of the first of the two plates. On the 17th of September, 1895, the patient was again seen by the writer. At this time, the ophthalmoscopic picture was so different that a new water-color drawing was made by Miss Washington. As the additional data found in the notings taken at this time by the writer will serve to give a better idea of the conditions seen than the mono- tint can alone, they are here given directly as written in the writer's case- book. The nerve-head preserves the same red-gray tint, especially to the outer side, as at the previous examination. The retina appears much more degen- erate, this being markedly seen in the temporal region and in and around those portions that have been previously occupied by the deeper-seated hemorrhages. The smaller retinal twigs appear more disturbed in their lateral curvings, this probably being caused by irregular retinal shrinkage and cicatrization. The lumen of the retinal vessels and the relative tints of their contained currents, do not seem to be altered in any way. The ectasia left by the large hemorrhagic mass extends in places directly through to the sclera, and is bordered by irregular aggregations of pigment which are more OPHTHALMOSCOPIC STUDY OF HEMORRHAGIC NEURO-RETINITIS. 3 dense to its outer edges, though more extensive to its nasal portion. The whitish band, extending over to the second and more peripheral area of degeneration, is more plainly evident, and the faintest superficial haze and somewhat irregular linings remain as the only vestiges of the large periph- eral mass with which the great hemorrhage was connected. The excentric cupping of the nerve-head, though somewhat deeper than before, does not appear to be any more extensive than when previously studied.1 At this time vision was reduced to the ability to see to count fingers in a small central field at one metre's distance. The case is here presented from an ophthalmoscopic stand-point only, as offering an interesting example of the peculiarities of retinal, choroidal, and optic nerve-changes, that are produced from low-grade, inflammatory, and degenerative action, and that can be seen only by repeated and careful study of existent objective conditions. 1 At the meeting in which these drawings were exhibited, Dr. de Schweinitz showed a third sketch of the ophthalmoscopic appearance made for him by Miss Washington. In this drawing, made but one month later, the retina in the region of the second large and more peripheral hemorrhage had become finely granular, , and was flecked with minute whitish points; a remarkable change for soZ/ZzzzS period of time. International Medical Magazine. AN ILLUSTRATED MONTHLY DEVOTED TO MEDICAL AND SURGICAL SCIENCE. edited, under the supervision of JOHN ASHHURST, JR., M.D., AND JAS. T. WHITTAKER, M.D., LL.D., BY HENRY W. 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