W^CRI PTION 
OF A 
CASE OF EMBOLISM 
OF THE 
Left Central Retinal Artery. 
By CHARLES A. OLIVER, M.D., 
Of Philadelphia. 
[From Transactions of American Ophthalmological Society, 1888.] 
HARTFORD, CONN.: 
Press of The Case, Lockwood & Brainard Company. 
1889. (From Transactions American Ophthalmological Society, 1888.] 
DESCRIPTION OF A CASE OF EMBOLISM OF THE 
LEFT CENTRAL RETINAL ARTERY. 
By CHARLES A. OLIVER, M.D., 
OF PHILADELPHIA. 
The present case is added to ophthalmic literature, not as 
might be conjectured, to offer in any way another opportunity 
from which to further discuss the mooted question of differen- 
tial diagnosis of thrombosis, embolism, or thrombosis and em- 
bolism of the retinal vessels by ophthalmoscopic appearances 
alone, which, as is well known, must remain sub judice and only 
answerable post mortem, until better differential points can be 
evolved by means of finer instruments of precision and more 
delicate methods of study, - but that a clinical picture which 
has been deemed sufficiently valuable to interest the student in 
such work, might be given for furtherance of researches in this 
direction. The title has been limited to that of embolism be- 
cause the details of the eye-ground, when carefully read over, 
will be found to contain much more of the true significance and 
meaning of this type of disease than of thrombosis. 
On the third of October, 1887, a young man aged twenty 
years, a weaver by occupation, came to me with the history of 
sudden failure of vision of the left eye twenty-six hours pre- 
viously, unaccompanied by any ocular pain, phosphenes, or head- 
aches ; this having come on while the patient was slowly walk- 
ing down a shaded road. He denied any previous serious ill- 
ness, and to all appearances was a healthy and hearty man. 
Upon examination it was found that the vision of the eye 
was reduced to very doubtful feeble light-perception in the outer 
field, while that of the right eye equaled full ift. Upon double 
exposure both pupils were about two-thirds dilated, but that of 
the left side became more so when its fellow was shaded. The 
left iris was not so freely responsive to light-stimulus as the 
right, with seemingly no reflex to monocular efforts for accom- Oliver : Description of a Case of 
2 
modation for objects placed in the field remnant. Tension of 
each was normal. Ophthalmoscopic examination of the left 
eye without the use of a mydriatic, showed that the media were 
clear. The disc was seven by eight diameters in apparent mag- 
nitude, the long axis being at ninety degrees; the nerve sub- 
stance itself was decidedly grayed in its tint. The edges were 
everywhere hidden by a fine and almost imperceptible thickening 
and marked oedema of the retinal fibres; this being less pro- 
nounced at the temporal side, where a faint trace of blackish 
pigment could be dimly seen through the oedematous swelling. 
The swelling of the retina extended for two or three diameters 
beyond the nerve entrance in all directions, and passed far out 
into the outer retinal periphery, embracing the entire macular 
region, where it seemed the densest and the thickest, giving 
the invaded region a grayish film-like appearance. All of the 
retinal arteries were reduced in size, especially the upper tem-' 
poral, and held thin stationary columns of very pallid blood. 
Throughout the area of swelling the veins were contracted, 
becoming more and more so as they approached the nerve- 
entrance, but appeared more tortous, nearer normal in size, and 
seemingly holding darker colored blood in the untouched peri- 
pheral area. Both sets of vessels were frequently lost to view 
in the swollen retina on the inner side of the ground. The 
small macular twigs so ordinarily seen in healthy eye-grounds, 
were invisible. Upon careful focusing, an extremely slow and 
sluggish current of broken bead-like segments of blood in the 
superior temporal vein could be plainly seen flowing continu- 
ously toward the disc, this being beautifully shown upon a bend 
of the vessel as it passed over the corresponding artery. No 
blood current or pulsation could be provoked in the arteries by 
artificial increase of intra-ocular pressure. The characteristic 
cherry-spot in the macular region was plainly seen, it being small 
in size and irregularly horizontal oval in shape. It was bounded 
by a fine network of minute branching vessels, which appeared 
to have no connection with any of the main stems. About two 
and a half disc diameters up and out from the disc, just above 
the first bifurcation of the superior temporal artery, there was 
a small hemorrhage; immediately below this there appeared a Embolism of the Left Central Retinal Artery. 
3 
curious small dark red swelling, apparently in the vessel itself. 
The fundus of the right eye was normal. Careful physical ex- 
amination failed to reveal any other organic lesion. Ten grains 
of iodide of potassium three times daily were ordered. 
On the following day all light perception had gone, although 
the oedema seemed less and the cherry spot was not so marked. 
The lower macular artery had become patulous, and carried a 
slow beaded current of bright colored blood, while the current 
in the upper temporal vein had become quicker in motion. The 
veins appeared slightly fuller than the arteries. 
On the next day a slow broken current could be distin- 
guished at the primary bend of the inferior temporal vein on the 
disc, which was somewhat slower in movement than in the up- 
per vein. The small swelling in the upper temporal artery had 
partially disappeared, and the vessel began to carry a broad bead- 
like current of bright blood. Both macular twigs became visible, 
enlarged, and carried interrupted blood currents. Color of the 
cherry-colored macule had faded to a brownish hue. The den- 
sity and area of the oedema had markedly increased; the outer 
edges of the disc being much more hazy. Vision still remained 
absolutely nothing. 
One day later (the fourth day of the attack) the cherry-col- 
ored macule had almost gone, and the surrounding vessel twigs 
had nearly disappeared. The area of the oedema was increased 
on the inner side, and the disc edges were entirely hidden. 
The inferior nasal vein began to carry a broken current of blood 
which, as it slowly passed over a bend just before its passage 
into the main inferior stem, did not fill the lumen of the canal. 
Two small fresh blood extravasations in the fibres of the retina 
upon the disc along side of the macular vessels, and one small 
fresh blood massing on or in the substance of the disc above 
the primary distribution of the upper nasal vein, manifested 
themselves. A fine cholesterin crystal, about pin point in size, 
could now be seen in the oedematous retina, immediately above 
the upper macular artery, between the disc and macula. The 
bead-like blood columns could be observed in all of the vessels 
except the upper nasal artery, which still remained impervious; 
the currents in the arteries being at times hidden by the Oliver: Description of a Case of 
4 
oedema, and again reappearing before being lost to view in the 
peripheral endings of the vessels. At this time the veins ap- 
peared very much larger than the arteries. The oedema now 
gained its utmost height, being 2.50 D to the inner side of the 
macular region, in contradistinction to 1 D, the level of the 
normal eye-ground in the periphery, while its color, especially 
about the macular region, had assumed a greenish tinge (gas- 
light illumination). No vision whatever could be obtained by 
the strongest light stimulus. 
Three days afterward the lower vessels were carrying full 
columns of blood, though no pulsation whatever could be ob- 
tained by pressure. The hemorrhages had almost disappeared. 
The macular region had become more irregular in outline and 
seemed filled with almost imperceptible grayish massings. The 
retina was still markedly oedematous, though the macular 
region appeared to be depressed from the general oedematous 
level. The two macular arteries still remained enlarged and 
were visible almost directly up to the macula itself, but the vas- 
cular circle seen primarily surrounding it, had entirely gone. 
The eye still continued blind. 
Four days later (the eleventh day) the blood currents were 
all re-established with the appearance of two fresh hemorrhages 
upon the lower temporal artery and lower temporal vein. Nerve 
substance rapidly undergoing degeneration, this being mostly 
marked to the outer side, while the retinal oedema was becom- 
ing striated, corrugated, and flattened in places. Eye still 
remained "black-blind." 
One month later (six weeks from when first seen) the nerve 
substance had greatly shrunken - to such an extent that the 
scleral rings could be plainly seen, both to the nasal and the 
temporal sides of the disc, with blackish pigment groupings 
beyond. The oedema had almost gone, there being but a few 
faint traces of the swelling left, its position being occupied by 
numerous small cholesterin crystal studdings. The macular 
region was converted into a large irregular degenerative area. 
Vision remained nil. 
During the entire time the patient had persistently used 
the iodide of potassium. The physical examination was kindly Embolism of the Left Central Retinal Artery. 
5 
made by Dr. James H. Hutchinson, of Philadelphia, and the 
eye-grounds were seen by Drs. George C. Harlan and William 
F. Norris.