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Section On Ophthalmology, Baltimore Medical Society
SOCIETY PROCEEDINGS Reports for this department should be sent at the earliest date practicable to Dr. Harry S. Gradle, 22 E . Washington St., Chicago, Illinois. These reports should present briefly scientific papers and discussions, include date of the meeting and should be iigned by the Reporter or Secretary. Complete papers should not be included in such reports; but should be promptly sent to the Editor as read before the Society.
S E C T I O N ON O P H T H A L M O L OGY. B A L T I M O R E M E D I CAL SOCIETY.
perglycemia nor acetonemia could cause the retinal lesions. T h e diabetes of elderly persons has been ascribed to arteriosclerosis, but the case is not absolutely clear, for there are many arterioclerotics without diabetes. Obesity, he thought, is a very important factor in the etiology of diabetes. In diabetic retinitis he felt the arteriosclerosis was the important element, the diabetes secondary. Diabetic retinitis is not an ominous symptom as regards the prognosis of diabetes. I t can be taken as a valuable index of the general vascular condition, but the diabetes in these cases can usually be expected to be mild. Equally, the control of the diabetes can hardly be expected to have any direct influence on the course of the retinal disease. Nevertheless, cases with retinitis should be subjected to specially careful medical care, including the best antidiabetic treatment for the development of the arteriosclerosis may be somewhat retarded and while the retinal lesions rarely recede, their extension can sometimes be stopped.
October 23, 1924. Symposium on Diabetic Retinitis. DR. JESSIE W . DOWNEY,
discussing
the subject from the viewpoint of the ophthalmologist, stated that most text books dealt with diabetic retinitis in a very dogmatic way. T h e matter is by no means so clear as their statements would indicate. Recent studies, especially by Wagener and Wilder, and by Benedict, had brought up the question as to whether diabetic as distinct from arteriosclerotic retinitis actually exists. Juvenile cases of diabetes, even in the most severe instances fail to develop retinitis. T h e metabolic disturbance alone does not seem responsible for the picture. On the other hand, typical retinitis punctata centralis is but occasionally seen in cases of arteriosclerosis showing no signs of diabetes. These cases, however, are extremely rare as compared with true diabetic retinitis, and if it is to be assumed that the arteriosclerosis alone is responsible for the retinitis in diabetics, it is difficult to understand the rarity of the picture in a condition as frequent as arteriosclerosis without diabetes. It would seem that both factors must be operative in the usual case of diabetic retinitis. T h e whole subject is much complicated by the fact that neither diabetes nor diabetic retinitis are single disease entities, tho our knowledge of the distinction between diifferent subgroups is as yet imperfect. Some light may be had from a careful correlation of the ocular and general condition and from pathologic studies.
Formerly, high protein diets were used in the treatment of diabetics. This was bad for the arteriosclerosis, for the kidneys and for the retinal lesions. In the modern Woodyatt diet, how^ever, little protein is used and this is the best treatment for the retinitis as well as the diabetes. Insulin is rarely needed in these cases in which the diabetes is relatively mild. DR.
DR. EUGENE LEOPOLD, speaking from
the that was the and
JONAS
S.
FRIEDENWALD
dis-
cussed the pathology of diabetic retinitis. Surprisingly little is ¡known about this condition. Pathologic studies have been made on very few cases, and these have shown little beyond the hemorrahages. Special study of the blood vessels has been reported in one case without any significant findings. The white spots are supposed to be similar to those seen in albuminuric retinitis, and are said to
viewpoint of the internist, said the arteriosclerosis of diabetics of the usual senile type and that retinitis occurred only in elderly arteriosclerotic cases. Neither hy61
SECTION, BALTIMORE MEDICAL SOCIETY
62
contain cholesterol, but this too is unproven. Dr. Friedenwald had studied pathologically the eyes of two dia betics, but no lesions were found nor had there been any retinitis visible ophthalmoscopically in these cases. Perhaps some light may be thrown on the relation between diabetes and arteriosclerosis in the causation of ret inal lesions when we know more about arteriosclerosis. At present we diag nose arteriosclerosis without question ing whether the larger or the smaller vessels are involved; tho variations in the localization of the lesions may result in quite different clinical pictures. T h e lart played by changes in the capilaries in the production of different forms of retinitis has as yet not been studied. Discussion. DR. C . A. CLAPP said that the question of the etiology of di abetic retinitis had aroused attention as far back as the seventies. Nettleship and others of his generation en gaged in a lively discussion as to whether diabetic retinitis existed as a separate entity distinct from nephritic retinitis. The youngest case reported by Mr. Foster Moore was 39 years old.- Dr. Clapp had, however, seen a typical di abetic retinitis in a patient aged 34. Since the publication of the work of Wagener and Wilder, he had studied with special interest a series of cases from the metabolic clinic at Hopkins. Typical retinitis was very rare, but punctate retinal hemorrhages, especial ly in the peripheral parts of the fundus, were relatively common. This was contrary to the general teaching that the seat of the lesion is usually cen tral. T h e part that might be played by lesions of the capillaries was inter esting. Zellers has maintained that the conjunctival capillaries are dilated in diabetes. DR.
HARRY FRIEDENWALD said that
in the last eight years he had seen in his private practice 16 cases of diabetic retinitis. T h e average age of these cases was 61 years. All cases but one were of the central punctate type; one was of the nephritic type. Marked di sease of the retinal vessels was noted in many, high blood pressure in
some, two cases were complicated by chronic glaucoma, and several by cat aract. T h e diabetes alone cannot cause the retinal changes, as is shovvn by the absence of these changes in young diabetics. However, the dia betes must play a definite part in the production of these lesions, otherwise it is not possible to explain the rela tive rarity of this ophthalmoscopic picture in arteriosclerosis without di abetes. DOCTOR GOLDBACIÍ said "the lesions in diabetic and advanced arterioscle rotic retinitis are somewhat similar, and it is dfficult to say definitely whether the diabetic or the cardiovascular con dition is the greater factor as the underlying cause of the retinitic changes." DR. FLECK told of a case in which there \vas much debate as to whether the retinal lesion was of the diabetic or nephritic type. Finally the urine was examined and both albumin and sugar found. In concluding, Dr. Leopold men tioned the cases of transient amblyopia at the beginning of antidiabetic treatment. These had been attributed to acidosis, but such cases had come about even under the Woodyatt meth od of treatment, in which no acidosis was produced. Indeed, he had seen a case in a diabetic with marked acidosis who developed transient amblyopia when both his glycosuria and acetonuria were disappearing. JONAS S . FRIEDENWALD,
Secretary. OMAHA AND COUNCIL B L U F F S OPHTHALMOLOGICAL AND OTO-LARYNGOLOGICAL SOCIETY. October 21, 1924. DR.
CLARENCE
RUBENDALL,
presiding.
The program was taken up large y with reports on the recent meeting of the American Academy, at Montreal. The ophthalmologic reports were made by Dr. Nora M. Fairchild and Dr. F . W . Dean; the oto-laryngologic reports by Drs. Uren, Haney, Wherry, and Rubendall.
S E C T I O N ON O P H T H A L M O L OGY. B A L T I M O R E M E D I CAL SOCIETY.
perglycemia nor acetonemia could cause the retinal lesions. T h e diabetes of elderly persons has been ascribed to arteriosclerosis, but the case is not absolutely clear, for there are many arterioclerotics without diabetes. Obesity, he thought, is a very important factor in the etiology of diabetes. In diabetic retinitis he felt the arteriosclerosis was the important element, the diabetes secondary. Diabetic retinitis is not an ominous symptom as regards the prognosis of diabetes. I t can be taken as a valuable index of the general vascular condition, but the diabetes in these cases can usually be expected to be mild. Equally, the control of the diabetes can hardly be expected to have any direct influence on the course of the retinal disease. Nevertheless, cases with retinitis should be subjected to specially careful medical care, including the best antidiabetic treatment for the development of the arteriosclerosis may be somewhat retarded and while the retinal lesions rarely recede, their extension can sometimes be stopped.
October 23, 1924. Symposium on Diabetic Retinitis. DR. JESSIE W . DOWNEY,
discussing
the subject from the viewpoint of the ophthalmologist, stated that most text books dealt with diabetic retinitis in a very dogmatic way. T h e matter is by no means so clear as their statements would indicate. Recent studies, especially by Wagener and Wilder, and by Benedict, had brought up the question as to whether diabetic as distinct from arteriosclerotic retinitis actually exists. Juvenile cases of diabetes, even in the most severe instances fail to develop retinitis. T h e metabolic disturbance alone does not seem responsible for the picture. On the other hand, typical retinitis punctata centralis is but occasionally seen in cases of arteriosclerosis showing no signs of diabetes. These cases, however, are extremely rare as compared with true diabetic retinitis, and if it is to be assumed that the arteriosclerosis alone is responsible for the retinitis in diabetics, it is difficult to understand the rarity of the picture in a condition as frequent as arteriosclerosis without diabetes. It would seem that both factors must be operative in the usual case of diabetic retinitis. T h e whole subject is much complicated by the fact that neither diabetes nor diabetic retinitis are single disease entities, tho our knowledge of the distinction between diifferent subgroups is as yet imperfect. Some light may be had from a careful correlation of the ocular and general condition and from pathologic studies.
Formerly, high protein diets were used in the treatment of diabetics. This was bad for the arteriosclerosis, for the kidneys and for the retinal lesions. In the modern Woodyatt diet, how^ever, little protein is used and this is the best treatment for the retinitis as well as the diabetes. Insulin is rarely needed in these cases in which the diabetes is relatively mild. DR.
DR. EUGENE LEOPOLD, speaking from
the that was the and
JONAS
S.
FRIEDENWALD
dis-
cussed the pathology of diabetic retinitis. Surprisingly little is ¡known about this condition. Pathologic studies have been made on very few cases, and these have shown little beyond the hemorrahages. Special study of the blood vessels has been reported in one case without any significant findings. The white spots are supposed to be similar to those seen in albuminuric retinitis, and are said to
viewpoint of the internist, said the arteriosclerosis of diabetics of the usual senile type and that retinitis occurred only in elderly arteriosclerotic cases. Neither hy61
SECTION, BALTIMORE MEDICAL SOCIETY
62
contain cholesterol, but this too is unproven. Dr. Friedenwald had studied pathologically the eyes of two dia betics, but no lesions were found nor had there been any retinitis visible ophthalmoscopically in these cases. Perhaps some light may be thrown on the relation between diabetes and arteriosclerosis in the causation of ret inal lesions when we know more about arteriosclerosis. At present we diag nose arteriosclerosis without question ing whether the larger or the smaller vessels are involved; tho variations in the localization of the lesions may result in quite different clinical pictures. T h e lart played by changes in the capilaries in the production of different forms of retinitis has as yet not been studied. Discussion. DR. C . A. CLAPP said that the question of the etiology of di abetic retinitis had aroused attention as far back as the seventies. Nettleship and others of his generation en gaged in a lively discussion as to whether diabetic retinitis existed as a separate entity distinct from nephritic retinitis. The youngest case reported by Mr. Foster Moore was 39 years old.- Dr. Clapp had, however, seen a typical di abetic retinitis in a patient aged 34. Since the publication of the work of Wagener and Wilder, he had studied with special interest a series of cases from the metabolic clinic at Hopkins. Typical retinitis was very rare, but punctate retinal hemorrhages, especial ly in the peripheral parts of the fundus, were relatively common. This was contrary to the general teaching that the seat of the lesion is usually cen tral. T h e part that might be played by lesions of the capillaries was inter esting. Zellers has maintained that the conjunctival capillaries are dilated in diabetes. DR.
HARRY FRIEDENWALD said that
in the last eight years he had seen in his private practice 16 cases of diabetic retinitis. T h e average age of these cases was 61 years. All cases but one were of the central punctate type; one was of the nephritic type. Marked di sease of the retinal vessels was noted in many, high blood pressure in
some, two cases were complicated by chronic glaucoma, and several by cat aract. T h e diabetes alone cannot cause the retinal changes, as is shovvn by the absence of these changes in young diabetics. However, the dia betes must play a definite part in the production of these lesions, otherwise it is not possible to explain the rela tive rarity of this ophthalmoscopic picture in arteriosclerosis without di abetes. DOCTOR GOLDBACIÍ said "the lesions in diabetic and advanced arterioscle rotic retinitis are somewhat similar, and it is dfficult to say definitely whether the diabetic or the cardiovascular con dition is the greater factor as the underlying cause of the retinitic changes." DR. FLECK told of a case in which there \vas much debate as to whether the retinal lesion was of the diabetic or nephritic type. Finally the urine was examined and both albumin and sugar found. In concluding, Dr. Leopold men tioned the cases of transient amblyopia at the beginning of antidiabetic treatment. These had been attributed to acidosis, but such cases had come about even under the Woodyatt meth od of treatment, in which no acidosis was produced. Indeed, he had seen a case in a diabetic with marked acidosis who developed transient amblyopia when both his glycosuria and acetonuria were disappearing. JONAS S . FRIEDENWALD,
Secretary. OMAHA AND COUNCIL B L U F F S OPHTHALMOLOGICAL AND OTO-LARYNGOLOGICAL SOCIETY. October 21, 1924. DR.
CLARENCE
RUBENDALL,
presiding.
The program was taken up large y with reports on the recent meeting of the American Academy, at Montreal. The ophthalmologic reports were made by Dr. Nora M. Fairchild and Dr. F . W . Dean; the oto-laryngologic reports by Drs. Uren, Haney, Wherry, and Rubendall.