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Hole in the Macula Due to Syphilis
NOTES, CASES, INSTRUMENTS
the size of an almond and promised to sup purate. The right eye and gland were normal. Sodium-sulfathiazole ointment and cold com presses were again prescribed. In addition, however, aureomycin capsules (250 mg.) were given every four hours. This time the eye and gland conditions were cured, the latter without suppuration. I regret that I did not take cultures of the pus from the right preauricular gland when I incised it, and also from the left eye, but I failed to realize at the time how rare the condition was. 1765 Sherman Street. H O L E IN T H E MACULA DUE T O SYPHILIS REPORT OF A CASE W. A. MANSCHOT,
M.D.
Rotterdam, The Netherlands AND C. H. O. M. VON W I N N I N G ,
M.D.
The Hague, The Netherlands Formation of real holes in the macula is caused by: (1) A coalescence of cystoid spaces gradually leading to a complete break down of the tissue, and (2) retinal rupture due to shrinkage and traction of scar tissue in its vicinity (Zeeman 1 ). The latter cause of macular holes has been neglected in the more recent literature and Verhoeff,2 for instance, states that a macular hole is always preceded by cystic degenera tion. The following case report shows a typical specimen of a macular hole caused by shrink age and traction of nearby fibrous tissue. Moreover, the case is the first to be described in the literature, in which a macular hole is due to a syphilitic process. REPORT OF A CASE
A 44-year-old sailor (a Negro from Madagascar) complained that his right eye had become blind during his last journey. Ophthalmic examination showed the left eye to be without any abnormality. Vision
261
Fig. 1 (Manschot and von Winning). Reproduc tion of drawing showing hole in macula due to syphilis.
was 5/5 in the left eye and 1/300 in the right eye. The right eye showed no anomalies in the anterior segment but fundus exami nation disclosed a local periarteritis of the first large branch of the inferior temporal artery in the area just below the macula. The fire part of the artery showed no abnormalities, except for a bright reflex, but very near its origin, the branch was covered by a white coat of fibrous tissue from which a branch pointed upward in the direction of the macula (fig. 1). A little more peripherally the branch divided into two smaller branches and the periarteritic process ended just before this division. The whole length of the periarteri tic process was no longer than two times the diameter of the disc. The peripheral part, of the branch after the division showed no anomalies; the lumen had not been narrowed and the artery-wall was, except for its re flex, not visible. In the macular region, a large, dark-red hole was visible, measuring almost one half of the diameter of the disc. The edges of the hole were clear, distinct, and within the hole some bright, white points of different sizes could be seen. The retina showed radiating folds con verging to the mass of fibrous tissue below the macula. Between the hole and the end of the branch of fibrous tissue that pointed to the macula, a semicircular dark line was
NOTES, CASES, INSTRUMENTS
262
visible. Examination with the slitlamp re vealed that this semicircular line was the expression of a local retinoschism. General examination. The first heart sound was muffled and the second aortic sound was accentuated. The liver and the spleen were not palpable. Some inguinal lymph nodes were found. No scars of framboesia were visible. The blood-pressure was 170/105 mm. Hg. The heart was not enlarged radioscopically but the shadow of the ascending aorta was too wide and too dark. Laboratory studies revealed a 100-percent positive Wassermann test and a strongly positive Meinecke test. The rate of blood sedimentation was 28 mm. within the first hour and 42 mm. within two hours. The urea content of the blood was 450 mg./l. COMMENT
There can be no doubt that syphilis was the cause of the retinal periarteritis in our case. This is proven by the highly positive blood tests and by the clinical aspect of the periarteritis. Both Igersheimer3 and Haab 4 state that the syphilitic periarteritis is
marked by its local character. Even when the artery is enclosed by a thick layer of connective tissue, its lumen is not totally closed. The peripheral aspect of the artery always becomes more normal. Moreover, there can be no doubt that the hole in the macula is a consequence of the shrinkage and traction of the periarterial fibrous tissue. This traction also appears in the radiating folds in the retina, converging to the mass of fibrous tissue, as well as in the retinoschism between the edges of the macular hole and the end of the branch of fibrous tissue that points to the hole. One question still must be solved, namely, the nature of the white points at the bottom of the macular hole. These white points are represented in many pictures of macular holes, for instance in the atlas of Wilmer, in the atlas of Haab, and in a recent article of Croll and Croll.5 Wilmer states that these points resemble accumulations of cholesterin, but in the entire literature we could not find an anatomic study in which the nature of these points is properly described. 157 Nieuwe Binnenweg. 47 Josef Israelstraat.
REFERENCES
1. 2. 3. 4. 5.
Zeeman, W. P. C.: Arch. f. Ophth., 79:259, 1911. Verhoeff and Grossman: Arch. Ophth., 18 :S61,1937. Igersheimer, J.: Syphilis und Auge. Berlin, Springer, 1918. Haab, O.: Festschrift fur Helmholtz, 1891. Croll, L. J., and Croll, M.: Am. J. Ophth., 33:248,1950.
MEMORY AID FOR T H E PARALLAX T E S T JOSEPH I. PASCAL, M.D. New York
The cover-and-prism test for detecting and measuring heterophoria has its subjec tive counterpart in Duane's parallax test. As the occluder is passed from one eye to the other, while the patient fixes a target, the target seems to move one way or the other depending upon the kind of heterophoria present. It is a very delicate test and will disclose, in a good observer, an error of a fraction of a prism diopter. It is especially
efficient for uncovering small amounts of hyperphoria. There are several rules given for inter preting the kind of heterophoria from the direction of apparent movement of the tar get. These rules are easily forgotten. The simplest way to remember the relationship is to remember that both eyes always move like the target. Thus, for example, as the occluder (which may be a simple business card) is passed from the right eye to the left eye the target seems to move to the left, then both eyes have moved to the left during the process. If the target seems to move to the right, then both eyes have moved to the
the size of an almond and promised to sup purate. The right eye and gland were normal. Sodium-sulfathiazole ointment and cold com presses were again prescribed. In addition, however, aureomycin capsules (250 mg.) were given every four hours. This time the eye and gland conditions were cured, the latter without suppuration. I regret that I did not take cultures of the pus from the right preauricular gland when I incised it, and also from the left eye, but I failed to realize at the time how rare the condition was. 1765 Sherman Street. H O L E IN T H E MACULA DUE T O SYPHILIS REPORT OF A CASE W. A. MANSCHOT,
M.D.
Rotterdam, The Netherlands AND C. H. O. M. VON W I N N I N G ,
M.D.
The Hague, The Netherlands Formation of real holes in the macula is caused by: (1) A coalescence of cystoid spaces gradually leading to a complete break down of the tissue, and (2) retinal rupture due to shrinkage and traction of scar tissue in its vicinity (Zeeman 1 ). The latter cause of macular holes has been neglected in the more recent literature and Verhoeff,2 for instance, states that a macular hole is always preceded by cystic degenera tion. The following case report shows a typical specimen of a macular hole caused by shrink age and traction of nearby fibrous tissue. Moreover, the case is the first to be described in the literature, in which a macular hole is due to a syphilitic process. REPORT OF A CASE
A 44-year-old sailor (a Negro from Madagascar) complained that his right eye had become blind during his last journey. Ophthalmic examination showed the left eye to be without any abnormality. Vision
261
Fig. 1 (Manschot and von Winning). Reproduc tion of drawing showing hole in macula due to syphilis.
was 5/5 in the left eye and 1/300 in the right eye. The right eye showed no anomalies in the anterior segment but fundus exami nation disclosed a local periarteritis of the first large branch of the inferior temporal artery in the area just below the macula. The fire part of the artery showed no abnormalities, except for a bright reflex, but very near its origin, the branch was covered by a white coat of fibrous tissue from which a branch pointed upward in the direction of the macula (fig. 1). A little more peripherally the branch divided into two smaller branches and the periarteritic process ended just before this division. The whole length of the periarteri tic process was no longer than two times the diameter of the disc. The peripheral part, of the branch after the division showed no anomalies; the lumen had not been narrowed and the artery-wall was, except for its re flex, not visible. In the macular region, a large, dark-red hole was visible, measuring almost one half of the diameter of the disc. The edges of the hole were clear, distinct, and within the hole some bright, white points of different sizes could be seen. The retina showed radiating folds con verging to the mass of fibrous tissue below the macula. Between the hole and the end of the branch of fibrous tissue that pointed to the macula, a semicircular dark line was
NOTES, CASES, INSTRUMENTS
262
visible. Examination with the slitlamp re vealed that this semicircular line was the expression of a local retinoschism. General examination. The first heart sound was muffled and the second aortic sound was accentuated. The liver and the spleen were not palpable. Some inguinal lymph nodes were found. No scars of framboesia were visible. The blood-pressure was 170/105 mm. Hg. The heart was not enlarged radioscopically but the shadow of the ascending aorta was too wide and too dark. Laboratory studies revealed a 100-percent positive Wassermann test and a strongly positive Meinecke test. The rate of blood sedimentation was 28 mm. within the first hour and 42 mm. within two hours. The urea content of the blood was 450 mg./l. COMMENT
There can be no doubt that syphilis was the cause of the retinal periarteritis in our case. This is proven by the highly positive blood tests and by the clinical aspect of the periarteritis. Both Igersheimer3 and Haab 4 state that the syphilitic periarteritis is
marked by its local character. Even when the artery is enclosed by a thick layer of connective tissue, its lumen is not totally closed. The peripheral aspect of the artery always becomes more normal. Moreover, there can be no doubt that the hole in the macula is a consequence of the shrinkage and traction of the periarterial fibrous tissue. This traction also appears in the radiating folds in the retina, converging to the mass of fibrous tissue, as well as in the retinoschism between the edges of the macular hole and the end of the branch of fibrous tissue that points to the hole. One question still must be solved, namely, the nature of the white points at the bottom of the macular hole. These white points are represented in many pictures of macular holes, for instance in the atlas of Wilmer, in the atlas of Haab, and in a recent article of Croll and Croll.5 Wilmer states that these points resemble accumulations of cholesterin, but in the entire literature we could not find an anatomic study in which the nature of these points is properly described. 157 Nieuwe Binnenweg. 47 Josef Israelstraat.
REFERENCES
1. 2. 3. 4. 5.
Zeeman, W. P. C.: Arch. f. Ophth., 79:259, 1911. Verhoeff and Grossman: Arch. Ophth., 18 :S61,1937. Igersheimer, J.: Syphilis und Auge. Berlin, Springer, 1918. Haab, O.: Festschrift fur Helmholtz, 1891. Croll, L. J., and Croll, M.: Am. J. Ophth., 33:248,1950.
MEMORY AID FOR T H E PARALLAX T E S T JOSEPH I. PASCAL, M.D. New York
The cover-and-prism test for detecting and measuring heterophoria has its subjec tive counterpart in Duane's parallax test. As the occluder is passed from one eye to the other, while the patient fixes a target, the target seems to move one way or the other depending upon the kind of heterophoria present. It is a very delicate test and will disclose, in a good observer, an error of a fraction of a prism diopter. It is especially
efficient for uncovering small amounts of hyperphoria. There are several rules given for inter preting the kind of heterophoria from the direction of apparent movement of the tar get. These rules are easily forgotten. The simplest way to remember the relationship is to remember that both eyes always move like the target. Thus, for example, as the occluder (which may be a simple business card) is passed from the right eye to the left eye the target seems to move to the left, then both eyes have moved to the left during the process. If the target seems to move to the right, then both eyes have moved to the