A CASE 
OF 
SUDDEN MONOCULAR AMAUROSIS, 
PRESENTING 
UXUSUAL DIFFICULTIES IX DIAGNOSIS. 
BY 1/ 
HENRY B. SANDS, M.D., 
SURGEON TO THE NEW YORK EYE AND EAR INFIRMARY, ETC. 
Read before Ihe American Opbthaimological Society, June, 1S63, 
NEW YORK: 
JOHN MEDOLE, PRINTER, 193 PEARL STREET 
I 860. SUDDEN MONOCULAR AMAUROSIS. A CAS E 
or 
SUDDEN MONOCULAR AMAUROSIS, 
PRESENTING UNUSUAL DIFFICULTIES IN DIAGNOSIS. 
It is now fifteen years since the invention of the ophthal- 
moscope. Few persons not practically familiar with its use 
can realize the influence which its employment, during this 
brief period, has had in modifying previously existing views 
regarding the pathology and treatment of the diseases of the 
eye. By enabling the surgeon to examine the crystalline lens 
and vitreous with a degree of minuteness hitherto unattainable, 
and by rendering distinctly visible the parts constituting the 
fundus oculi, which had previously been concealed from direct 
observation during life, it naturally led to the adoption of an 
entirely new system of classification of the more deeply seated 
ocular diseases—one in which vague conjecture was replaced 
by scientific precision. By the joint labors of a multitude of 
earnest investigators, a great variety of morbid appearances 
were soon detected and described, and their true nature made 
evident in the light of pathological anatomy. In the descrip- 
tion and diagnosis of disease, refinements so nice as to excite a 
feeling of ridicule in the minds of the uninitiated found their 
justification in facts capable of easy and convincing proof. 
The gain to science was immense, and few persons at the 
present day will be found willing to dispute it. 
As has happened before; however, in the case of the stetho- 
scope, the microscope, and other valuable inventions, the new 4 
instrument failed to afford all the information that was de- 
manded of it, and we are yet compelled to retain the unsatis- 
factory and unmeaning term “ amaurosis” in the nosology of 
ophthalmic medicine. This is not owing to any defect in the 
instrument itself, but simply to the fact that its application is 
restricted to the interior of the eyeball; consequently important 
lesions affecting the sense of sight may exist in the optic nerve, 
or in the brain, which the ophthalmoscope is unable to reveal. 
Yet even here the more deeply seated disease generally leads 
to ultimate changes in the optic papilla and the retina, the 
observation of which, by the aid of the ophthalmoscope, is 
often sufficient, if taken in connection with the history of the 
case, to establish a correct diagnosis. 
These remarks may appear trite, but they seem naturally to 
precede the narration of a case in which the evidence afforded 
by the ophthalmoscope, although valuable, proved insufficient 
to explain all the symptoms presented by the patient under 
observation. 
On the 13th of November, 1865, I was consulted by a med- 
ical friend, who told me that while dressing himself a few 
hours previously he had suddenly felt his left eye “ dazzled” 
by the light of the sun. Presently he noticed that the sight 
of that eye was obscured, but supposing that the dimness would 
soon pass off, he immediately bathed his eyes in tepid water. 
Within fifteen minutes, however, from the time he first dis- 
covered the imperfection of his sight, vision of the left eye was 
entirely abolished. No pain attended the attack. He was 
certain that both eyes had been normal until that morning, 
as during the two or three days immediately preceding he 
had used the affected eye in looking through the microscope. 
The patient was twenty-seven years of age, and, with the ex- 
ception of an attack of haemoptysis, which had occurred eight 
years previously, he had enjoyed uninterrupted good health. 
He had never suffered from rheumatism. 
On examination I found as follows: Right eye, normal in 
external appearance; vision perfect. Left eye, pupil consider- 
ably dilated when both eyes arc exposed to the light, and 
greatly so when the right eye is closed; feeble contraction 
takes place only when light is admitted into the sound eye. 6 
Perception of light almost entirely absent, although patient 
can just discern the concentrated light thrown into the eye by 
means of the ophthalmoscope; tension normal. 
Ophthalmoscopic Examination, 12, M., five hours after the 
attack. Right eye, normal. Left eye, media transparent; 
branches of central artery very small, being scarcely traceable 
beyond the papilla; veins hardly, if at all, diminished in size; 
at centre of macula lutea a circular disk, of a deep red color, 
sharply outlined, having about one-third the diameter of the 
optic papilla; the latter very pale and anaemic, contrasting 
strongly with that of the healthy eye; between the optic pa- 
pilla and the macula lutea another deep red spot, resembling 
the first, but of nearly double the size, and having an irregu- 
larly oval shape, the long diameter situated in the horizontal 
median plane. The appearances thus described were also seen 
by my friends, Drs. Noyes and Althof. Careful auscultation of 
the chest failed to discover the least sign of cardiac disease, 
the presence of which, indeed, there was no good reason to 
suspect. The patient was directed to remain quiet, in a dark 
room, and to have six leeches applied to the left temple. 
At 7 p.m. I saw him again, in consultation with Prof. 
Schweigger, of Berlin. Meanwhile, and, according to the 
patient’s statement, before the application of the leeches, a 
decided improvement in vision had taken place, and he was 
able to count fingers at 2' in several parts of the visual field. 
The latter, however, showed various interruptions, and central 
vision was absent. Ophthalmoscopic examination: Arterial 
vessels of the retina restored to their natural size; veins 
slightly turgid; retina gray and cloudy, especially around the 
macula lutea, where the red spot formerly mentioned still ex- 
ists. The larger red spot near the nerve also remains the 
same. Patient ordered to have the eyes bandaged. 
Nov. 15. Hardly any change. The visual field exhibits, 
beside other interruptions, a large central scotoma, about 7" 
in diameter, at 1' from the eye. Latterly, patient counts fin- 
gers at 3', except when held above and to the right side. 
Ophthalmoscopic appearances nearly the same. The whole 
retina, however, is more decidedly cloudy, and conceals the 
choroid from view. The cloudiness is most marked in the 6 
neighborhood of the macula lutea, toward which numerous fine 
vessels are seen to converge. The two red spots still quite 
distinct. 
Nov. 17. No change. Ordered potass, iodid. gr. v., ter in 
die. 
Nov. 21. Vision a little improved, the central scotoma 
being smaller. The ophthalmoscope shows a nearly trans- 
parent retina, and also, for the first time, a swollen, reddish, 
infiltrated and dirty looking optic nerve, the contour of which 
is hazy and ill defined. Removed bandage from the eyes, and 
substituted smoke glasses. 
Nov. 24. Still slight improvement in vision. Central 
scotoma a little smaller, extending principally to the right side 
of the centre of the visual field. Ophthalmoscopic examination: 
Retina nearly transparent; red spots less distinct; optic papilla 
still red and indistinct. Allowed patient to walk out, wearing 
the glasses. Iodide of potassium to be continued. 
Dec. 5. Signs of neuritis disappearing, the nerve looking 
abnormally white, with irregularly notched margin. It is 
needless to give further dates of examination, except such as 
relate to the projection of the visual field. The accompanying 
Limit of central obscuration, Dec. 5, 1865. 
Limit of central obscuration, Dec. 18, 1865. 
figures represent the form and relative size of the central ob- 
scuration, which, it will be observed, diminished up to Decem- 
ber 26; subsequently it again grew larger, and now has nearly 
its original form and dimensions. Its longest diameter, when 
measured upon a (blackboard held at the distance of twelve 
inches from the eye, is seven inches. 7 
Within the dark spot vision is wholly absent; eccentric vi- 
sion, however, does not seem to be materially impaired. An 
ophthalmoscopic examination made a few days ago revealed 
the ordinary signs of atrophy of the optic nerve, which had a 
whitish, fibrous, glistening appearance, but was slightly, if at 
all, depressed. Both the arteries and veins were greatly re- 
duced in size, the former being scarcely perceptible. Nothing 
special was seen at the macula lutea. 
The case above detailed is the only one of the kind that has 
come under my observation, and possesses a singular interest, 
I think, from the obscurity which attended the diagnosis. I 
have preferred giving at first a simple statement of facts, re- 
serving until now the reflections which they suggest. 
Limit of central obscuration, Dec. 26, 1865. Limit of central obscuration, May 1, 1866. 
In the first place, there can be no doubt that the loss of sight 
was sudden, as the patient not only remembered to have used 
the affected eye a day or two previously in microscopical ex- 
aminations, but had also observed, within the space of a quar- 
ter of an hour, the change from mere dimness of vision to total 
blindness. In the next place, it may be fairly assumed that, 
when one eye is sightless and the other perfect, the lesion must 
be situated either in the eyeball itself or at some point between 
the latter and the commissure of the optic nerves. Any lesion 
involving the commissure, the optic tracts, or the tubercula 
quadrigemina, would, for anatomical reasons, necessarily affect 
both eyes at the same time. A similar statement may be 
made in regard to sudden blindness coming on after sexual 
excesses, long fasting, exhausting diarrhoea, sudden and copi- 8 
ous hemorrhage, etc.; in all these instances both eyes are; 
simultaneously involved. Among the causes of sudden blind- 
ness situated within the eyeball itself, if we exclude cases of 
injury to the cornea, iris, and crystalline lens, the most fre- 
quent are detachment of the retina and hemorrhage into the 
vitreous, either from the vessels of the ciliary processes, or of 
the choroid and retina. Here, too, the diagnosis is easy, and 
the difficulties are at once cleared up by the ophthalmoscope. 
Finally, we meet with instances in which the refractive media 
are entirely transparent, and in which the retina shows no 
structural alteration sufficient to account for the total and 
almost instantaneous loss of sight. To this category belongs 
the case now under discussion. 
In 1856, Virchow1 gave the results of a post mortem exam- 
ination of two women, who had died of puerperal fever, in 
each of whom he discovered evidences of acute disease of the 
interior of the eyeball, depending upon the presence of emboli 
in the arterial vessels; and he then predicted that many cases 
of amaurosis, occurring in connection with valvular disease of 
the heart, would find their true explanation in this occurrence. 
It was not long before his prediction was verified, for in 1859 
von Graefe detailed, with great minuteness, the particulars of 
a case in which the diagnosis of embolus of the central artery 
of the retina seemed fully established. Subsequent post mor- 
tem examination proved the accuracy of this opinion, and some 
among us have been fortunate enough to see the beautiful spe- 
cimen prepared by Dr. Schweigger, in which the embolus can be 
distinctly seen, completely occluding the central artery of the 
retina, just behind the plane of the lamina cribrosa. Since the 
date of von Gracfe’s publication, at least ten2 additional cases 
1 Gesammelte Abhandiungen, pp. 539, 711. 
2 Blessig. Archiv. fur Ophthalmologic, Bd. 8, Ab. 1, S. 210. 
Schneller. Ibid., S. 271. 
Liebreich. Deutcher Klinik., No. 50, 1861. 
Pagenstecher. Mithcilungen aus der Augenheilanstalt zu Wiesbaden, No. 
2, p. 275. 
Just. Klinische Monatsbliitter, Juni, 1863. 
Saemisch. Ibid., Janv., 1866. 
Hirschmann. Ibid. 
Quaglino. Ophthalmic Review, April, 1866. 
Quaglino. Ibid. 
Pano. Annales d’Oculistique, t. lii., p. 239. 9 
liave been recorded in foreign journals, in which the diagnosis 
of embolus was pretty clearly made out. The symptoms of 
the disease arc tolerably uniform. Sudden blindness, with sub- 
jective luminous sensations, announce the invasion of the dis- 
order. At this period, on ophthalmoscopic examination, the 
media are found to be transparent, the optic papilla pale, and 
both the arteries and veins of the retina reduced to an extreme 
degree of tenuity. After the lapse of some days or weeks, 
the vessels may partially regain their previous size, especially 
towards the periphery, probably from the development of a col- 
lateral circulation. The retina exhibits an opalescent opacity, 
especially near and at the macula lutea, the centre of which, 
however, is usually marked by a deep red spot, which, by some 
observers, is looked upon as an extravasation of blood, while 
by others it is ascribed to the natural color of the choroid, 
seen through the retinal substance (which, in this situation, is 
•exceedingly thin), and contrasting with the grayish opacity of 
the surrounding infiltrated retinal tissue. The final result is 
usually atrophy of the optic nerve and retina, with nearly total 
loss of sight; and when vision is partially restored, it is gen- 
erally limited to the eccentric parts of the visual field. 
Now, in the case I have recited, although many of the symp- 
toms above mentioned were present, I think we must reject the 
diagnosis of embolus for the following reasons: 1st. The ab- 
sence of any evidence of cardiac disease. This alone, how- 
ever, would not be decisive, provided all the other symptoms 
were present. 2d, and principally, because the phenomena 
ef the retinal circulation, as revealed by the ophthalmoscope, 
cannot be reconciled with the theory of complete and perma- 
nent arterial obstruction, such as would be caused by an em- 
bolus. In every reported example of this affection, it has 
been noticed that both the arteries and the veins of the retina 
were greatly reduced in size. This is what we should expect, 
a ■priori, seeing that an embolus, while it would prevent the 
blood from entering the central artery and its branches, would 
in no way interfere with the return of the blood through the 
veins, which would, consequently, also be empty. But in the 
present case, the arterial branches alone were * anaemic, while 
the veins were filled with blood. Furthermore, if the tw& red 10 
spots above described are to be regarded as extravasations, it 
may be inferred that the hemorrhages were the result of in- 
creased pressure on the walls of the veins, due to their conges- 
tion. That the red spot at the macula was hemorrhagic in 
character is, to my mind, evident, not only from its appear- 
ance, but also from the fact that throughout the whole course 
of the disease the total absence of central vision pointed 
strongly to the existence of a lesion at the yellow spot. The 
other and larger red spot had also exactly the appearance of 
an extravasation, and its situation was such that it could 
hardly be regarded as the effect of contrast. Finally, it is to 
be observed that the symptoms of arterial obstruction were of 
but few hours’ duration. The arteries which, at noon of the 
day of attack, were almost invisible, at 7 o’clock in the even- 
ing of the same day were seen by Dr. Schweigger and myself 
to be of their normal size. This fact would be difficult to ex- 
plain upon the supposition of embolism. 
The theory which appears to me to explain most satisfacto- 
rily the morbid phenomena in question, is that which assumes 
the primary lesion to have been an extravasation of blood 
into the sheath of the optic nerve, between the globe and the 
optic commissure. Such a lesion has not, so far as I am 
aware, been demonstrated by dissection, but several instances 
have been recorded in which the symptoms rendered its ex- 
istence highly probable.1 Hemorrhages in the substance of 
the retina and at the base of the brain are by no means 
rare, and it is quite possible that the same lesion may occur in 
that commissure which we call the optic nerve. My own solu- 
tion of the present case would be as follows: at first, hemor- 
rhage within the sheath of the optic nerve, compressing sud- 
denly the nerve fibres, the central artery and vein. Hence, 
the empty state of the arteries, the fullness of the veins, and the 
general oedematous infiltration of the retina. Hence, also, 
total blindness, due partly to insufficient arterial supply, 
and partly to a diminution in the conducting power of the 
optic nerve fibres. Next, hemorrhages into the retina, owing 
1 Hutchinson. Ophthalmic Hosp. Keports, vol. iv., p. 237. Pagenstecher. 
Op. cit., H. 1, p. 54. 11 
to mechanical congestion of its veins. Later in the day, diffu- 
sion of cxtravasated blood, in consequence of which, the press- 
ure being lessened, the arteries again filled with blood, and 
the retina again resumed its function, except centrally, where 
vision remained absent in consequence of hemorrhage at the 
macula lutea. Lastly, inflammation of the optic nerve, with 
its usual termination in atrophy. During the progress of the 
neuritis, I thought that the red discoloration of the optic pa- 
pilla might be owing to the presence of extravasated blood, 
which had found its way along the sheath to the surface; but 
I was not certain that I saw any thing more than the simple 
redness of liyperaemia. 
I have spoken of hemorrhage within the sheath of the optic 
nerve, because if blood had been effused external to the sheath 
in sufficient quantity to have caused the symptoms mentioned, 
it would necessarily, at the same time, have exerted pressure 
upon the other nervous filaments traversing the orbit, and 
would have given rise to pain, strabismus, and other morbid 
phenomena, which were not present.