Atlas of rare ophthalmoscopic conditions : and supplementary plates to the atlas of ophthalmoscopy / by J. Oeller ; the text translated into English by Thos. Snowball.

  • Oeller, Johann Nepomuk, 1850-1932.
Date:
1904
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Licence: In copyright

Credit: Atlas of rare ophthalmoscopic conditions : and supplementary plates to the atlas of ophthalmoscopy / by J. Oeller ; the text translated into English by Thos. Snowball. Source: Wellcome Collection.

Provider: This material has been provided by UCL Library Services. The original may be consulted at UCL (University College London)

    14/42 (page 6)
    The colour of the fundus is by no means characteristic, but corresponds merely to that of a light-coloured person. A striking condition, however, is met with in a limited area below, and below and internal to, the optic disc. About 'I2 disc's breadth below the papilla there begins a peculiar coarse speckling of the fundus, which it is impossible to confuse with the normal fine stippling. This speckling is made up of numerous, small, yellowish-white, round spots without much lustre, that are scattered about quite irregularly, at all events without any relation to the course of the retinal vessels: they lie partly discrete, partly collected into small patches, many even confluent but never forming large plaques. Most of them are sharply defined iji outline, only a few having ill- defined margins. No pigment can be observed either at the edge of these spots or between them. A fine tesselated appearance is present over the rest of the fundus, but is absent in the area occupied by these spots. Towards the equator the speckling disappears again altogether. During the period of over 6 months under observation no change had occurred in the ophthalmoscopic condition, except that the small spots just described increased slightly in numbers, while some of those already present had increased in size. The colour of the fundus described by Liebreich and Becker as characteristic for leucaemia is not confirmed by our case, which presents simply the appearances of a light-coloured fundus. Of course one cannot deny the possibility that, before the disease began, the colour might have been darker. That a change in tlie red of the fundus may possibly take place in very advanced cases is a very natural thing to suppose. Since the red colour of the fundus is determined by the blood contained in the choroid, it may be influenced merely by the abundance of white blood-corpuscles in that layer. In certain eases a further factor influencing the colour comes into account, viz. that the choroid may be diffusely infilt- rated with leucocytes. A very strong analogy may be observed in those certainly extremely rare cases of shell-like tumours of the choroid (metastatic carcinoma) when the retina is still adherent to it: the colour of the fundus is then very light ochre yellow. Now although the lighter colour of the fundus is absent in our case, yet a condition is present that is very characteristic for leucaemia, viz. the lighter colour of the veins, as well as their abnormal dilatation and tortuosity. This sign is undoubtedly depen- dent on the alteration in the composition of the blood and the mechanism of the blood-stream. If in normal circumstances the peripheral stream of the white blood-corpuscles is 10—12 times slower that the axial stream of the red, then this difference must be considerably increased with the enormous disproportion between the red and white corpuscles in leucaemia. A tliick layer of leuco- cytes must collect along the vessel walls in such a way that with the viscidity of these cells the side-stream is retarded very considerably. In a similar case of leucaemia with choked disc Grunert') was able to observe a distinct blood-stream in the enormously distended veins. As a consequence of the stasis of the white blood-corpuscles in the peripheral stream, there must in time ensue a stretching and tortuosity of the veins even without any trace of inflammatory symptoms, so that from this condition alone one can make the diagnosis of leucaemia. Of course the distension and tortuosity of the veins will necessarily be specially great when symptoms of inflammation in the retina or optic nerve supervene, which are very liable to come on in leucaemia. Obviously, however, these processes are to be traced to the impoverishment of the blood in red blood-corpuscles and a consequent chronic ferment- intoxication in the same way as the similar changes in severe cases of anaemia and other constitutional diseases. By far the greatest number of fundus changes in leucaemia that come under observation comprises the well-known leucaemic retinitis or papillitis almost exclusively with retinal haemorrhages. A papillitis with so slight ') Grunert: Manifest blood-circulation in the retinal veins in leucaemia. Centralblntt for Augenheilkundo. 26«' Year, 1901. August, p. 225. implication of the surrounding retina and without haemorrhages, as there is in this case, is surely a very rare occurrence. In view of such a case the dea might well arise that this might possibly be a simple, instead of an inflammatory, oedema of the papilla pro- duced by the pressure of the unyielding lamina cribrosa on the over-distended veins and an exudation due to the blocking of the circulation. Apart altogether from the question whether oedema of the papilla could arise at all in this way, the disc would have to retain its transparency in spite of its swelling, so that the rings surrounding it and the point of exit of the vessels on it would necessarily remain visible. The opaque swelling of the papilla in our case with its ill-defined margins and the obliterated optic cup points to its inflammatory nature. Moreover, the inflammatory in- filtration of the optic nerve is a condition in keeping with the various cases that have been examined microscopically. The peculiar vulnerability of the optic nerve through the various noxious sub- stances in the circulation is a certain fact of clinical experience. Another very singular point in our case is that in the com- plete absence of haemorrhages there are present those peculiar, numerous, small, round, yellowish spots chiefly below the optic disc, the position of which in the choroid or retina one cannot at first glance determine. From their shape they might well be taken for colloid bodies of the lamina vitrea. But quite apart from the fact that these bodies are mostly senile changes or occur in degenerative processes of the choroid and retina, e.g. in retinitis pigmentosa, they are also mostly slightly smaller than the spots we are con- sidering, whiter and more glistening, and often even with dark margins. Then the colloid bodies are most usually situated round the disc or at the extreme periphery. Still less can these spots be taken for nests of nerve-fibres that have undergone fatty degener- ation, as the latter never appear by themselves in so great numbers, they are always larger than the spots in question, and possess the well-known white silken sheen. The dull, yellow colour of the spots also prevents them from being mistaken for patches of fatty granular cells. The most probable view, therefore, is to consider them as leucaemic formations, as clumps of leucocytes. Such clumps are found in the retina as well as in the choroid. In the retina, however, they appear to be dependent on previously existing haemorrhages '), while in our cases haemorrhages could never be seen in all the long period of observation although we looked for them. On ex- amination too one most certainly receives the impression that these clumps cannot be situated in the retina Although it may often be very difficult to locate pathological changes in the fundus to one particular layer yet by practice one acquires such ability in estim- ating the smallest differences in depth that in most cases one is able to determine accurately with the ophthalmoscope the position of the various ophthalmoscopic changes. I believe, therefore, I can with certainty locate the small spots above described in the choroid. They are undoubtedly small clumps of white blood-corpuscles. In the same way that in leucaemia the choroid may become more or less diffusely infiltrated with leucocytes, so these corpuscles may be collected into small circumscribed clumps or lymphomata. In all cases of leucaemia examined microscopically it could be demon- strated that it was the vessels of the choroid that are crammed with mostly white blood-corpuscles, and that even outside the vessels leucocytes are met with in large numbers, which have obviously passed through without red corpuscles. Nevertheless I do not con- sider it altogether precluded that a few clumps possibly also deve- loped inside the vessels themselves by the formation of miliary aneurisms of their walls, which could then be filled out with white blood-cells (Deutschnmnn, Murakami). These whitish-yellow spots appear in some measure to be specific for leucaemia and to have a certain analogy to the nodular deposits described by Friedliinder in the white and grey matter of the brain. ') Back; On ocular clianges in leucaemia. Zeitschrift fiir Augenheilkunde. Vol. I. 1899; p. 234. *.