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Annular Scotoma
NOTES, CASES, INSTRUMENTS ANNULAR SCOTOMA ALSTON CALLAHAN,
Vicksburg,
M.D.
Mississippi
Annular scotoma is a characteristic fea ture of disease of the outer retinal layers and is prominent in syphilitic chorioretinitis and in retinitis pigmentosa. Ac counts of this defect are reported in the foreign literature and in our own, follow ing such various factors as administration
buhdle defects due to damage to the inner retinal layers from the associated disease of branches of the central retinal artery; nevertheless, the exact modus operandi of this peculiar abnormality has never been established. A few years later, Gonin2 and Nettleship 3 reported a few cases and expressed the hypothesis that the cause was neurogenic in origin, and since that time various authors have veered from one assumption to the other.
Fig. 1 (Callahan). Central visual fields charted April 17, 1939, 1/2° target, showing complete ring scotoma in the left eye and partial ring in the right eye.
of quinine, excessive use of tobacco, phototraumatism, and like conditions. In these cases, the defect is usually per sistent. As a rule, in retinitis pigmentosa, which most of the older observers thought to be the only etiological agent, the ring widens with the loss of the peripheral field. In 1895, Ole Bull,1 in his classic, "Perimetrie," called attention to the complete or partial, sometimes irregular, winglike or crescentic arcuate or annular scotomata, which he regarded as practically pathognomonic of syphilis. A certain number of these are probably nerve-fiber-
During the past three decades very little has appeared on this subject. Claiborne, 4 ' 5 in 1915, reported a case of ring scotomata from chorioretinitis syphilitica, but no field studies were made, and the diagnosis of syphilis was not established. Favory, 6 in 1928, mentions a case in re lationship to several others, but presented no detailed consideration and omitted all but several conclusions. CASE REPORT
A white man, aged 42 years, presented himself on April 17, 1939, complaining of poor vision and headaches of increas-
NOTES, CASES, INSTRUMENTS
ing severity. Vision was especially poor at night, and he had difficulty in walking down the dimly lit hallway of his home. His wife stated that he drank alcohol and beer immoderately, and they both believed
197
orthophoria, and the tension of each eye was 20 mm. Hg. Manifest refraction showed the impossibility of improving the vision with lenses. Ophthalmoscopic ex amination revealed the f undus of the right
Fig. 3 (Callahan). Improvement in central visual fields following specific treatment, April 20, 1939, 1/2° target.
that he needed glasses; he denied venereal infection. Vision in the right eye was 20/80 and in the left eye 20/25. The external appear ance of both eyes was normal; the pupils reacted quickly to accommodation and sluggishly to light. Muscle tests showed
eye to be hazy; the nasal portion of the disc was slightly blurred. The appearance of all vessels was normal, and there was no evidence of abnormality in the left eye. The central fields were charted (April 17, 1939) and a complete ring scotoma was found to be present in the left eye;
198
NOTES, CASES, INSTRUMENTS
an incomplete ring in the right eye (fig. 1). Visual fields when charted the next morning were found to be contracted to almost 30 degrees in each eye (fig. 2 ) . Complete physical examination, includ-
was corroborated by the central fields (fig. 3 ) . A strongly positive Wassermann reaction was reported later in the same day, and on April 24th, 0.45 ex. of neoarsphenamine i.v. and 1 c.c. of thio-
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Fig. 4 (Callahan) above. Further improve ment of visual fields, as of April 24, 1939. Fig. 5 (Callahan) left. Remnant of scotoma, y2° target, in left and right eyes.
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ing neurological studies, failed to disclose any etiological factor; blood for a Wassermann test was taken but before results were reported, on April 19th, 0.3 gr. neoarsphenamine was given i.v. and 1 c.c. of bismuth i.m. was administered. Two days later, the patient reported himself to be vastly improved, and this
bismol i.m. were given. The peripheral fields on that day (figs. 4, 5), showed marked enlargement with considerable re duction in the size of the scotoma. By April 26th, they had almost disappeared. On May 1st, the visual acuity had im proved to 20/40— in the right eye, 20/20 in the left. On May 8th, 0.6 gm. of neo-
NOTES, CASES, INSTRUMENTS
199
Fig. 6 (Callahan). Visual fields as of May 22, 1939.
arsphenamine i.v. and 1 c.c. of thiobismol were administered and continued
four
Fig. 7 (Callahan). Central field showing blind spots small and eccentrically placed, August 2, 1939. Visual acuity, left eye, 20/20.
at weekly intervals. By May 22d, the limits of the peripheral field had returned and were almost normal (fig. 6 ) ; by August 2d, the blind spots were small and eccentrically placed and the acuity was 20/20 in the right eye, 20/20 in the left (fig. 7). The patient has continued the antisyphilitic treatment without in terruption until the present time, and the headaches and ocular symptoms have long ■since disappeared. Discussion. The rapidity and manner with which the scotomata disappeared and the visual fields enlarged must un questionably be related directly to the cir culatory system of the eyes, and cannot plausibly be explained in any other fashion. This would seem to exclude the possible tenancy of the theory that syphi litic scotomata are due to a degenerative lesion of the neurones. First National Bank Building.
REFERENCES 1
Bull, Ole. Perimetrie. Bonn, 1895. Gonin. Ann. d'Ocul., 1901. Nettleship. Royal London Hosp. Rep., 1906. ' Claiborne, J. H. Persistent ring scotoma. Arch, of Ophth., 1915, v. 43, pp. 516-517. Ring scotoma from chorioretinitis syphilitica. Virginia Med. Semi-Mo., 1920, v. 18, p. 298. ' Favory, Albert. A propos du scotome annulaire. Clin. Opht., 1928, v. 32, pp. 3-8. !
1
Vicksburg,
M.D.
Mississippi
Annular scotoma is a characteristic fea ture of disease of the outer retinal layers and is prominent in syphilitic chorioretinitis and in retinitis pigmentosa. Ac counts of this defect are reported in the foreign literature and in our own, follow ing such various factors as administration
buhdle defects due to damage to the inner retinal layers from the associated disease of branches of the central retinal artery; nevertheless, the exact modus operandi of this peculiar abnormality has never been established. A few years later, Gonin2 and Nettleship 3 reported a few cases and expressed the hypothesis that the cause was neurogenic in origin, and since that time various authors have veered from one assumption to the other.
Fig. 1 (Callahan). Central visual fields charted April 17, 1939, 1/2° target, showing complete ring scotoma in the left eye and partial ring in the right eye.
of quinine, excessive use of tobacco, phototraumatism, and like conditions. In these cases, the defect is usually per sistent. As a rule, in retinitis pigmentosa, which most of the older observers thought to be the only etiological agent, the ring widens with the loss of the peripheral field. In 1895, Ole Bull,1 in his classic, "Perimetrie," called attention to the complete or partial, sometimes irregular, winglike or crescentic arcuate or annular scotomata, which he regarded as practically pathognomonic of syphilis. A certain number of these are probably nerve-fiber-
During the past three decades very little has appeared on this subject. Claiborne, 4 ' 5 in 1915, reported a case of ring scotomata from chorioretinitis syphilitica, but no field studies were made, and the diagnosis of syphilis was not established. Favory, 6 in 1928, mentions a case in re lationship to several others, but presented no detailed consideration and omitted all but several conclusions. CASE REPORT
A white man, aged 42 years, presented himself on April 17, 1939, complaining of poor vision and headaches of increas-
NOTES, CASES, INSTRUMENTS
ing severity. Vision was especially poor at night, and he had difficulty in walking down the dimly lit hallway of his home. His wife stated that he drank alcohol and beer immoderately, and they both believed
197
orthophoria, and the tension of each eye was 20 mm. Hg. Manifest refraction showed the impossibility of improving the vision with lenses. Ophthalmoscopic ex amination revealed the f undus of the right
Fig. 3 (Callahan). Improvement in central visual fields following specific treatment, April 20, 1939, 1/2° target.
that he needed glasses; he denied venereal infection. Vision in the right eye was 20/80 and in the left eye 20/25. The external appear ance of both eyes was normal; the pupils reacted quickly to accommodation and sluggishly to light. Muscle tests showed
eye to be hazy; the nasal portion of the disc was slightly blurred. The appearance of all vessels was normal, and there was no evidence of abnormality in the left eye. The central fields were charted (April 17, 1939) and a complete ring scotoma was found to be present in the left eye;
198
NOTES, CASES, INSTRUMENTS
an incomplete ring in the right eye (fig. 1). Visual fields when charted the next morning were found to be contracted to almost 30 degrees in each eye (fig. 2 ) . Complete physical examination, includ-
was corroborated by the central fields (fig. 3 ) . A strongly positive Wassermann reaction was reported later in the same day, and on April 24th, 0.45 ex. of neoarsphenamine i.v. and 1 c.c. of thio-
VWP / ^ s ^ t o
^<^\
V i t
ISO//
/
/^v
/
\
J^, 50
Fig. 4 (Callahan) above. Further improve ment of visual fields, as of April 24, 1939. Fig. 5 (Callahan) left. Remnant of scotoma, y2° target, in left and right eyes.
■
\
^
^/aaa
ZBS^.
e+o^s^
/
\
^*£?^iai
ing neurological studies, failed to disclose any etiological factor; blood for a Wassermann test was taken but before results were reported, on April 19th, 0.3 gr. neoarsphenamine was given i.v. and 1 c.c. of bismuth i.m. was administered. Two days later, the patient reported himself to be vastly improved, and this
bismol i.m. were given. The peripheral fields on that day (figs. 4, 5), showed marked enlargement with considerable re duction in the size of the scotoma. By April 26th, they had almost disappeared. On May 1st, the visual acuity had im proved to 20/40— in the right eye, 20/20 in the left. On May 8th, 0.6 gm. of neo-
NOTES, CASES, INSTRUMENTS
199
Fig. 6 (Callahan). Visual fields as of May 22, 1939.
arsphenamine i.v. and 1 c.c. of thiobismol were administered and continued
four
Fig. 7 (Callahan). Central field showing blind spots small and eccentrically placed, August 2, 1939. Visual acuity, left eye, 20/20.
at weekly intervals. By May 22d, the limits of the peripheral field had returned and were almost normal (fig. 6 ) ; by August 2d, the blind spots were small and eccentrically placed and the acuity was 20/20 in the right eye, 20/20 in the left (fig. 7). The patient has continued the antisyphilitic treatment without in terruption until the present time, and the headaches and ocular symptoms have long ■since disappeared. Discussion. The rapidity and manner with which the scotomata disappeared and the visual fields enlarged must un questionably be related directly to the cir culatory system of the eyes, and cannot plausibly be explained in any other fashion. This would seem to exclude the possible tenancy of the theory that syphi litic scotomata are due to a degenerative lesion of the neurones. First National Bank Building.
REFERENCES 1
Bull, Ole. Perimetrie. Bonn, 1895. Gonin. Ann. d'Ocul., 1901. Nettleship. Royal London Hosp. Rep., 1906. ' Claiborne, J. H. Persistent ring scotoma. Arch, of Ophth., 1915, v. 43, pp. 516-517. Ring scotoma from chorioretinitis syphilitica. Virginia Med. Semi-Mo., 1920, v. 18, p. 298. ' Favory, Albert. A propos du scotome annulaire. Clin. Opht., 1928, v. 32, pp. 3-8. !
1