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Late Traumatic Detachment of Retina, Psychic Blindness
N O T E S , CASES A N D I N S T R U M E N T S
516
A TYPICAL CASE OF OBSTRUC TION OF CENTRAL RETINAL ARTERY. J.
R O S E N B A U M , MONTREAL,
M.D.
CANADA.
The interesting features in this case were the absence of a cherry red spot in the macula, and the absence of a history of heart disease. A. B., aged 17 years, called to see me about 9 o'clock on the morning of Sep tember 1st, 1923, complaining of sud den loss of vision of the right eye, com ing on while helping to wash his father's car. No previous history of illness of any kind. External appear ance of the eye was normal. The pupil was widely dilated and did not react to light, accommodation, convergence, or consensually. The tension was normal. Ophthalmoscopic examination re vealed a white cloudiness of the retina especially marked in the neighborhood of the macula; with the exception of an area between the disc and the macula supplied by a cilioretinal ves sel, which looked unchanged and had the appearance of the normal color. Surrounding this area there was a zone of opacity about 1 mm. wide. The vessels were of normal caliber. Vision: fingers at 2 feet—eccen trically. Physical examination by Dr. R. Hardisty of the Royal Victoria Hospi tal showed only a slight systolic mur mur at the apex. Other findings were negative; that is, x-ray of teeth, sinuses, Wassermann, kidneys, and tuberculin reaction. In the course of a few days the cloudiness was noted to disappear and in the central area numerous fine white exudations made their appearance. The rest of the retina resumed a normal tint. The disc, however, began to show signs of pallor, and the capillaries on it were seen with difficulty. About three months later the disc was definitely atrophic, bluish white in appearance, and the white spot in the macula cleared up. Vision then: 20/200, and it remained so, unchanged for two years. Field of vision showed con
traction to about 5°, to the temporal side of the fixation point. CONCLUSION. In seeking an explana tion for the absence of the cherry red spot in the macula, the writer is in clined to believe that the cause was due to the edema and infiltration of the retina; which involved not only the entire rim of the macula, but also en croached on to the entire fovea, pre venting, therefore, the contrast of the choroid from being visible. 206 Bishop Street. LATE T R A U M A T I C DETACH MENT OF RETINA, PSYCHIC BLINDNESS. C L . \ R E N C E E . I D E , A.B., M.D., F.A.C.S. TUCSON,
ARIZONA.
Mrs. F. L., aged 68, came August 11, 1925, complaining that a fortnight ago, she found, on covering her left eye, that the vision of the right eye was almost nil. P. H. Ten months ago, on turning suddenly, the right frontotemporal re gion came violently in contact with the edge of a door. Ecchymosis over frontal, temporal and malar regions and swelling of the lids resulted. At tendance at "movies" has fatigued eves, headache and insomnia resulting. 'Examination: V. R. 1/50; L. 6/15. Ophthalmoscope (with euphthalmin my driasis) shows right lens somewhat opacified, equatorial spicules coming in from the periphery; nervehead shows decided physiologic excavation. Up ward and outward there is a detach ment of the retina, sagging over the macula. Treated by rest in bed, sub conjunctival injection of Hg. Cn.,, with dionin and novocain; free drink ing of water, bland diet. 8, 17, V. R. 4/50; L. 6/6. The oph thalmoscope shows the lens clearer, the general opacity being less, which renders the dense areas of opacity bet ter defined. The field of vision is re stricted below, from the blind spot downward and outward to the per iphery, also from 10 degrees below the macula downward and inward to the periphery, there being a clear area be tween the two scotomas (Stereocampimeter).
N O T E S , CASES A N D I N S T R U M E N T S
8, 2 2 . Ophthalmoscope shows the retina settled back against the choroid. There are three small pigmented areas at the seat of the detachment, with fainter pigmentation surrounding them. Also four small white areas of degeneration. Subconjunctival injec tion repeated. 8, 2 7 . Lens clearing. V . 4 ^ / 5 0 . Subconjunctival injection Na. CI. with dionin. V . = 6 / 7 0 on illuminated cabi net. 0.1 Landolt chart. Retinoscopy resulted in this prescription at final test: R. -I- 0 . 3 7 with -f- 1. at 1 2 0 ° = 2 / 1 0 ; L. -f- 0.25 with - f . 5 0 at 1 6 5 ° = 6/6.
9, 12. Same appearance with oph thalmoscope. 9, 17. V . R. 0.2 Landolt chart with glasses. Subconjunctival injection Na. CI. with dionin. Lens clear enough to
617
permit good view of fundus. Spicules of opacity of lens, barely visible with plus 2 0 in aperture. Faint posterior opacity seen with ophthalmoscope at a distance. Subconjunctival injection of Na. CI. with dionin. 10, 13. V . R. 0 . 1 5 Landolt at 5 meters. Fundus appears as before. After making this much improvement the patient began to complain that she could see practically nothing. Exami nation revealed no changes. A con sultant could find no change. The con clusion reached, therefore, was that mental depression resulting from fear of loss of vision had brought about that condition which we know as psychic blindness. The lens had cleared decidedly, there were no new areas of pigmentation or of degenera tion. Physicians' Bldg.
SOCIETY PROCEEDINGS R O Y A L SOCIETY OF MEDICINE. LONDON. Section of Ophthalmology. March 11, 1927. MR.
ERNEST C L A R K E ,
Presiding.
Exophthalmic Goitre with External Ocular Paresis. MR.
R.
FOSTER
MOORE exhibiteo
a
woman with exophthalmic goitre and paresis of external ocular muscles. He saw the patient five years ago, at which time she had exophthalmic goitre of severe degree. Part of the thyroid gland was removed. At that time she had very definite proptosis and most of the ocular muscles were paralysed, except the internal branches. Seen now, there was still ocular palsy, and in reading she had to move her head from side to side so as to follow the lines. He regarded it as a mus cular condition. Her general health was not much better. Chronic Ophthalmoplegia and Ptosis. Miss ROSA FORD showed a girl, aged 17, who, except for this condition, seemed quite healthy. The first sign of anything being amiss dated seven
years back, when, on looking at any thing she closed one eye with her hand, due, no doubt, to diplopia, which was still present. She felt so little in convenience that advice was not sought until four years later, the oc casion being her rejection on an ap plication to enter the Civil Service. Now, there was partial ptosis, and al most complete ophthalmoplegia in both eyes. The right eye was the more prominent, the left being a little divergent. In the right eye the vision was 6 / 6 , in the left 6 / 9 partly. The fundi looked normal except for some pallor at the outer halves, and there was slight cupping—probably physi ologic—of the outer half of the right disc. Pupil reaction to accommoda tion on both sides was sluggish. She was able to do her work, that of typ ing, without difficulty. Some 4 7 cases of the kind had now been collected from the literature, but no cause for the condition had yet been assigned. Messrs McMullen and Hine, in their paper on the subject, seemed to incline to the view that it owned a nuclear origin, believing that there existed a congenital weakness of nerve centers leading to premature decay.
516
A TYPICAL CASE OF OBSTRUC TION OF CENTRAL RETINAL ARTERY. J.
R O S E N B A U M , MONTREAL,
M.D.
CANADA.
The interesting features in this case were the absence of a cherry red spot in the macula, and the absence of a history of heart disease. A. B., aged 17 years, called to see me about 9 o'clock on the morning of Sep tember 1st, 1923, complaining of sud den loss of vision of the right eye, com ing on while helping to wash his father's car. No previous history of illness of any kind. External appear ance of the eye was normal. The pupil was widely dilated and did not react to light, accommodation, convergence, or consensually. The tension was normal. Ophthalmoscopic examination re vealed a white cloudiness of the retina especially marked in the neighborhood of the macula; with the exception of an area between the disc and the macula supplied by a cilioretinal ves sel, which looked unchanged and had the appearance of the normal color. Surrounding this area there was a zone of opacity about 1 mm. wide. The vessels were of normal caliber. Vision: fingers at 2 feet—eccen trically. Physical examination by Dr. R. Hardisty of the Royal Victoria Hospi tal showed only a slight systolic mur mur at the apex. Other findings were negative; that is, x-ray of teeth, sinuses, Wassermann, kidneys, and tuberculin reaction. In the course of a few days the cloudiness was noted to disappear and in the central area numerous fine white exudations made their appearance. The rest of the retina resumed a normal tint. The disc, however, began to show signs of pallor, and the capillaries on it were seen with difficulty. About three months later the disc was definitely atrophic, bluish white in appearance, and the white spot in the macula cleared up. Vision then: 20/200, and it remained so, unchanged for two years. Field of vision showed con
traction to about 5°, to the temporal side of the fixation point. CONCLUSION. In seeking an explana tion for the absence of the cherry red spot in the macula, the writer is in clined to believe that the cause was due to the edema and infiltration of the retina; which involved not only the entire rim of the macula, but also en croached on to the entire fovea, pre venting, therefore, the contrast of the choroid from being visible. 206 Bishop Street. LATE T R A U M A T I C DETACH MENT OF RETINA, PSYCHIC BLINDNESS. C L . \ R E N C E E . I D E , A.B., M.D., F.A.C.S. TUCSON,
ARIZONA.
Mrs. F. L., aged 68, came August 11, 1925, complaining that a fortnight ago, she found, on covering her left eye, that the vision of the right eye was almost nil. P. H. Ten months ago, on turning suddenly, the right frontotemporal re gion came violently in contact with the edge of a door. Ecchymosis over frontal, temporal and malar regions and swelling of the lids resulted. At tendance at "movies" has fatigued eves, headache and insomnia resulting. 'Examination: V. R. 1/50; L. 6/15. Ophthalmoscope (with euphthalmin my driasis) shows right lens somewhat opacified, equatorial spicules coming in from the periphery; nervehead shows decided physiologic excavation. Up ward and outward there is a detach ment of the retina, sagging over the macula. Treated by rest in bed, sub conjunctival injection of Hg. Cn.,, with dionin and novocain; free drink ing of water, bland diet. 8, 17, V. R. 4/50; L. 6/6. The oph thalmoscope shows the lens clearer, the general opacity being less, which renders the dense areas of opacity bet ter defined. The field of vision is re stricted below, from the blind spot downward and outward to the per iphery, also from 10 degrees below the macula downward and inward to the periphery, there being a clear area be tween the two scotomas (Stereocampimeter).
N O T E S , CASES A N D I N S T R U M E N T S
8, 2 2 . Ophthalmoscope shows the retina settled back against the choroid. There are three small pigmented areas at the seat of the detachment, with fainter pigmentation surrounding them. Also four small white areas of degeneration. Subconjunctival injec tion repeated. 8, 2 7 . Lens clearing. V . 4 ^ / 5 0 . Subconjunctival injection Na. CI. with dionin. V . = 6 / 7 0 on illuminated cabi net. 0.1 Landolt chart. Retinoscopy resulted in this prescription at final test: R. -I- 0 . 3 7 with -f- 1. at 1 2 0 ° = 2 / 1 0 ; L. -f- 0.25 with - f . 5 0 at 1 6 5 ° = 6/6.
9, 12. Same appearance with oph thalmoscope. 9, 17. V . R. 0.2 Landolt chart with glasses. Subconjunctival injection Na. CI. with dionin. Lens clear enough to
617
permit good view of fundus. Spicules of opacity of lens, barely visible with plus 2 0 in aperture. Faint posterior opacity seen with ophthalmoscope at a distance. Subconjunctival injection of Na. CI. with dionin. 10, 13. V . R. 0 . 1 5 Landolt at 5 meters. Fundus appears as before. After making this much improvement the patient began to complain that she could see practically nothing. Exami nation revealed no changes. A con sultant could find no change. The con clusion reached, therefore, was that mental depression resulting from fear of loss of vision had brought about that condition which we know as psychic blindness. The lens had cleared decidedly, there were no new areas of pigmentation or of degenera tion. Physicians' Bldg.
SOCIETY PROCEEDINGS R O Y A L SOCIETY OF MEDICINE. LONDON. Section of Ophthalmology. March 11, 1927. MR.
ERNEST C L A R K E ,
Presiding.
Exophthalmic Goitre with External Ocular Paresis. MR.
R.
FOSTER
MOORE exhibiteo
a
woman with exophthalmic goitre and paresis of external ocular muscles. He saw the patient five years ago, at which time she had exophthalmic goitre of severe degree. Part of the thyroid gland was removed. At that time she had very definite proptosis and most of the ocular muscles were paralysed, except the internal branches. Seen now, there was still ocular palsy, and in reading she had to move her head from side to side so as to follow the lines. He regarded it as a mus cular condition. Her general health was not much better. Chronic Ophthalmoplegia and Ptosis. Miss ROSA FORD showed a girl, aged 17, who, except for this condition, seemed quite healthy. The first sign of anything being amiss dated seven
years back, when, on looking at any thing she closed one eye with her hand, due, no doubt, to diplopia, which was still present. She felt so little in convenience that advice was not sought until four years later, the oc casion being her rejection on an ap plication to enter the Civil Service. Now, there was partial ptosis, and al most complete ophthalmoplegia in both eyes. The right eye was the more prominent, the left being a little divergent. In the right eye the vision was 6 / 6 , in the left 6 / 9 partly. The fundi looked normal except for some pallor at the outer halves, and there was slight cupping—probably physi ologic—of the outer half of the right disc. Pupil reaction to accommoda tion on both sides was sluggish. She was able to do her work, that of typ ing, without difficulty. Some 4 7 cases of the kind had now been collected from the literature, but no cause for the condition had yet been assigned. Messrs McMullen and Hine, in their paper on the subject, seemed to incline to the view that it owned a nuclear origin, believing that there existed a congenital weakness of nerve centers leading to premature decay.