TRAUMATIC HEMORRHAGES 
IN THE REGION OF THE 
MACULA LUTEA. 
WITH A REPORT OF CASES. 
BY 
S. C. AYRES, M.D., 
CINCINNATI. 
A Paper read before the Academy of Medicine 
of Cincinnati, February 9, 1891. 
FROM 
THE LANCET-CLINIC, 
March 28, 1891. TRAUMATIC HEMORRHAGES 
IN THE REGION OF THE 
MACULA LUTEA. 
A Paper read before the Academy of Medicine 
of Cincinnati, February 9, 1891, 
BY 
S. C. AYRES, M.D., 
CINCINNATI. 
The importance of preserving cen- 
tral vision makes all injuries involving 
the macula region assume a serious 
aspect, until the blood has cleared up 
sufficiently to allow of an inspection by 
the ophthalmoscope. 
The following cases are reported to 
show how rapidly and completely eyes, 
otherwise healthy, recover from appar- 
ently severe injuries involving the 
yellow spot and its immediate vicinity. 
The anatomical construction of the 
macula lutea is such that we might 
reasonably expect it to suffer from con- 2 
HEMORRHAGE IN REGION OF 
tusions and injuries of the eye-ball 
more than other portions of the retina. 
Stricker says " the fragile and tran- 
sitory nature of the substance of the 
yellow spot, is explained by the circum- 
stances that the more delicate nervous 
elements here greatly outnumber the 
elements of the connective substance, 
which, in other portions of the retina 
occupy a much more considerable space." 
The macula being surrounded by deli- 
cate capillary loops, seems to offer a 
point of less resistance than other por- 
tions of the retina. Intra-ocular hemor- 
rhages occur quite frequently from in- 
juries and contusions of the eye-ball. 
After the vitreous has cleared up, it is 
not always possible to tell the point at 
which the hemorrhage occurred. It 
might have been from the anterior por- 
tion of the eye ball; from the ciliary 
region, in which case it would be im- 
possible to locate the lesion. If from 
the posterior portion of the globe, the 
point of hemorrhage can frequently be 
located if the eye is examined before MACULA LUTEA, AYRES. 
3 
the blood is entirely absorbed. In an 
otherwise healthy eye, traumatic intra- 
ocular hemorrhages are absorbed very 
rapidly. Hemorrhages in the vicinity 
of the macula lutea are very liable to 
be followed by impairment of vision. 
Central vision may be entirely des- 
troyed, or a condition of permanent 
metamorphopsia may remain. 
Case I.-Injury of Eye by a Ball. 
Intra- Ocular He m or r h age , and 
Hemorrhage in Mac til a Lutea Re- 
gion; Metamorphopsia; Changes in 
Refraction of the Eye; Recovery. 
C., aet. eighteen, gave the following 
history of an accident which he received 
five days ago: 
He was playing ball, and was 
struck by the ball in the left eye. 
There was immediate loss of vision, 
and the eye was considerably painful 
for the rest of the day. Cold appli- 
cations were applied, and two days 
later he began to see light. The follow- 
ing day he could dimly see large objects 
in the room. 
I saw him on the fifth day after the 
injury, on the 24th of May, 1888, and 4 
HEMORRHAGE IN REGION OF 
by that time he was able to count 
fingers at four feet. The pupil was 
dilated almost ad-maximum, and fixed, 
and presented an elongated appearance. 
He was required to keep quietly at 
home in a darkened room, and a weak 
solution of eserine was used twice a 
day. There was a hemorrhage in the 
region of the macula lutea, somewhat 
irregular in shape, but distinctly in- 
volving that region. 
May 29. V 0.3. Blood absorbing. 
He has now metamorphopsia in the 
horizontal meridian. Horizontal lines 
appear broken, and irregular in the 
centre. 
The case progressed very favor- 
ably, and by June 14 vision had in- 
creased to 0.7. He now appeared 
slightly myopic, and with 0.75; his 
vision was 0.9. The pupil still remains 
somewhat dilated, but not so much as 
at first. 
June 19. V 0.9. Sees better with 
am. 0.75; ax. o. 
July 6. V 0.9, ah 0.25, ax 90, V 1. 
Vertical lines wavy, horizontal correct. 
July 23. V 1. 
September 7 his refraction was 
tested under homatropine with the re- 
sult of discovering that he had hyper- opic astigmatism, in moderate degree, 
in both eyes. 
MACULA LUTEA, AYRES. 
5 
Case II.-Injury of the Eye by Rubber 
Sling Shot. Extensive Intra-Ocu- 
lar Hemorrhage, and Hemorrhage 
in Region of Macula Lutea voith 
(Edema of Retina; Recovery. 
G. B., set. fifteen, was hit, on the 
6th of March, 1889, in the eye with a 
shot thrown from a rubber sling, which 
struck the eye ball just below the 
cornea. The blow was followed by 
almost instant loss of sight. This con- 
tinued for two days, when it began to 
clear up. The vision slightly improved, 
so that in the course of three or four 
days he could see objects around the 
room. 
I saw him first ten days after the 
injury. At that time vision was 0.4. 
There was no external evidence of an 
injury. The central portion of the 
retina, around the macula, presented 
a stippled appearance, as if there were 
minute hemorrhages collected together. 
In the macula region there was a 
little grayish spot, which seemed to be 
slightly prominent. The retina, for 
some distance around the macula, was 
oedematous. Four days later vision was 6 
increased to 0.8, and on March 21 vision 
was 0.9. The stippled appearance 
around the macula gradually subsided. 
Later I saw him again and vision was 
perfectly restored, and no trace of the 
injury could be seen. 
HEMORRHAGE IN REGION OF 
Case III.-Hemorrhage in the Region 
of the Macula while Stooping down 
to Drink out of a Stream. (Eedema 
of the Retina; Central Scotoma; 
Recovery. 
October 25, 1888, E. H. N., aet. 
twenty-four, gave the following history 
of the amblyopia of his right eye: 
He says that two weeks ago, while 
out hunting, he stooped down to drink 
out of a stream, and when he arose he 
noticed some dark clouds before that 
eye, and dimness of vision. This in- 
creased during the day, and by evening 
his sight was so imperfect that he could 
not count fingers, and could only see 
motions far downwards. There was 
no pain, and no inconvenience except 
from loss of vision. This remained 
nearly the same until the present time. 
The ophthalmoscope showed marked 
alterations in the region of the macula. 
There is a hemorrhage, irregular in 
shape, and a greyish cloud, which MACULA LUTEA, AYRES. 
7 
partly covers it, probably due to oedema 
of the retina. 
He remained under treatment for a 
short time, and when he left his vision 
had increased to o. i; but the scotoma 
still involved the inner and central 
portion of his field of vision. He went 
home under strict instructions and re- 
turned in a month, and vision had 
improved to 0.6. He was seen Feb- 
ruary 7, 1889, about four months after 
the injury, and vision in this eye was 
perfect. The field of vision was com- 
plete, but he says there is the thinnest 
possible scotoma, which can still be 
detected in the central portion of the 
field; it does not, however, interfere 
with his acuity of vision. 
In the first case there was a well- 
marked mydriasis, with a fixed con- 
dition of the pupil, and later on some 
interesting changes in the refraction. 
First, he saw best with a concave lens, 
then with a concave cylinder, later 
with a convex cylinder; and when his 
refraction was tested, he was found to 
have hyperopic astigmatism. 
Berlin, in speaking of the eye, says 8 
" that it is very probable that hemor- 
rhages, in the immediate vicinity of the 
lens, can influence the shape, and even 
under certain circumstances the position 
of the latter, and thus cause a disturb- 
ance of vision in conjunction with the 
spastic contraction of the sphincter 
iridis through irregular astigmatism." 
In this case the concussion of the heavy 
ball, coming with considerable velocity, 
would very probably cause hemorrhage 
in the anterior portion of the eye. It 
was probably in the ciliary region, and 
in sufficient quantity to influence the 
action of the ciliary on the lens, and 
especially when associated with my- 
driasis. 
In the proceedings of the Ophthal- 
mological Society of the United King- 
dom, March, 1888, Mr. Lang reported 
a case of retinal hemorrhage in the 
region of the yellow spot. It recovered 
with perfect vision, and, in his judg- 
ment, the hemorrhage occurred be- 
tween the layers of the retina or in 
the. choroid. 
HEMORRHAGE IN REGION OF MACULA LUTEA, AYRES. 
9 
At the same meeting, Mr. Nettle- 
ship showed diagrams of two cases of 
large, semi-circular hemorrhages at 
the yellow spot. The inferior macular 
artery, which traversed the blood patch, 
was found to be obliterated in one case, 
and greatly altered in the other. This 
condition offered a very plausible ex- 
planation of the hemorrhage, and 
showed that it was from a retinal vessel. 
It seems, also, more probable that com- 
plete recovery might take place when 
the hemorrhage was from the retina 
and immediately underneath the hy- 
aloid, than where it was from the 
choroid. If from the latter, it would 
probably cause such an amount of 
cicatrization in the chorio-capilaris as 
to influence the rods and cones, and 
result in a limited scotoma or in per- 
manent metamorphopsia. 
In the second case there was an 
oedematous condition of the retina, 
which extended for some distance 
around the macula, but it all dis- 10 
HEMORRHAGE IN REGION OF 
appeared, and there was no visible 
trace of the injury left. 
Berlin says he has observed the 
retina assume a grey, cloudy opacity, 
in a defined area, after injuries of the 
eye with a blunt body. 
Arlt, in his work on injuries of the 
eye, says that experiments on rabbits 
proved that blows on the sclerotic 
caused an opacity in the immediate 
vicinity of the injuries, and also at 
a point nearly corresponding on the 
opposite side of the eye. He says that 
this oedema of the retina is due to 
hemorrhages between the choroid and 
the sclerotic. 
In the third case the hemorrhage 
was not strictly traumatic. He had 
become heated while walking, and 
stooped down to drink. It was not 
apoplectic, in the general acceptation 
of the term, as it was not due to 
a disease of the coats of the blood- 
vessels. It was traumatic, in the sense 
that the retinal vessels were engorged, and their return to the heart impeded 
by his constrained and unnatural po- 
sition. Here, also, there was oedema 
of the retina, as in the previous case. 
There was a central scotoma, and 
vision was long in returning. It is 
probable that there was a hemorrhage, 
not only between the retina and the 
hyaloid membrane of the vitreous, but 
into the substance of the retina itself. 
MACULA LUTEA, AYRES. 
11 
FROM 
THE LANCET-CLINIC, 
March 28, 1891.