KOLLOCK: Case of Atrophy of the Optic Nerve.
215
brane of the choroid, which, as we know, consists of variouslyshaped small projections from this structure. Colloid excrescences were first described as senile changes,* but they may occur in young subjects, as, for example, in the cases herewith presented, and are often unaccompanied by impairment of visual acuity. Dimmert gives a good account of the pathological anatomy of these bodies and a r6sume of the various theories which have been advanced to explain their origin, his own belief being that they may arise from cells, which become filled with a homogenous substance, gradually coalesce and form the colloid projections; in other words, the process is similar to simple colloid degeneration. Based upon microscopic studies,4 I have expressed the opinion that colloid excrescenses of the lamina vitrea and drusen in the nerve-head are not analogous lesions, an opinion also held by a number of other observers.
A CASE OF ATROPHY OF THE OPTIC NERVE. BY CH'ARLES W. KOLLOCK, M.D., CHARLESTON, S. C.
Six years ago this summer Miss L , while riding a tricycle, fell off on her head, but apparently was not injured nor rendered unconscious. The next day her vision began to fail rapidly, but prior to this accident she had noticed that she did not see quite as well as formerly. She was at the time away from home, and a physician whom she consulted advised her to hasten home, as loss of vision was likely to follow. The prognosis was correct, for very soon she was almost entirely blind. She was for two or three years under the care of one or more physicians, but became gradually worse, and they gave up the * An instructive chromo-lithograph representing senile degeneration of the macula, suggestive of this change, is given by Caspar (Monatsbl. f. prakt. Augenheilk., I892, p. 284), who considers his case identical with the* changes described by Nagel as " hyaline growths and crystalline deposits of lime on the inner surface of the choroid." + Arch. of Ojhthalmology, Vol. XIV, p. 65. $ Trans. Amer. OOhth. Soc., 1892.
2I6
KOLLOCK: Case of Atrophy of the Optic Nerve.
case as incurable. She was brought to me in August last, just five years after the fall which preceded the loss of vision. Upon examination both pupils were found to be partially dilated and responded sluggishly to light. The right eye could only see light; the left had 4/cc vision, with fair color perception and a good field, considering the amount of vision. The ophthalmoscope showed gray atrophy of both optic nerves, the right whiter and cupped, and the vessels much contracted. The left disc was not so light in appearance and its vessels not as small, but there was some cupping. The ophthalmoscope also showed a myopia of 2 D., but no glass improved the vision. Tension was normal, and at no time had there been any pain. On account of the size of the vessels, the field of vision, and the good color perception, it seemed that some improvement might follow trealnent, but my prognosis was, of course, unfavorable, as she had been in this condition for five years. Iodide of potassium was prescribed in ascending doses, beginning with ten grains three times a day. She came to me once a week, and after a time it was noted that the pupils were becoming smaller and reacted more quickly to light. Vision improved slowly, and in the course of two months she could see 15/cc. It then struck me that as some tendency to improvement existed, that regular exercise of the retina and nerve might be beneficial. Certainly it could do no harm. She was accordingly told to see everything that she could, to use her eye as much as possible every day upon surrounding objects. Before this she was listless and without hope; the advice gave her occupation, and she entered, heart and soul, into xny plan, puzzled over objects, made them out, walked without assistance on the streets (she had been habitually led), read signs, etc. She began to write, and found after a little practice that she could write in parallel lines, and, though she could not read her writing - which was legible enough to others - she could see sufficiently to know when the ink ceased flowing from a fountain pen which she used. The iodide was gradually increased until she took over three hundred grains a day, and the vision became with - 2 D. I5/c. Strychnine was next tried in ascending doses, but without improvement. In fact, she seemed to thrive
KOLLOCK : Case of A trophy of the Optic Nerve.
217
better on the iodide. Before beginning treatment the hearing was very dull, and there were constant noises in both ears and flashes of light in the eyes. The hearing has not materially improved, but the noises and flashes of light have almost ceased.' Some time before the accident she had trouble with both eyeteeth, which necessitated their being filled, and subsequently an abscess formed at the root of one, which left an enlargement. This entirely disappeared while she was taking the iodide. No history of syphilis could be obtained, though the patient has somewhat of a scrofulous appearance. The mother is in good health; the father, who was myopic, is dead. The patient continues to recognize objects better and better, and at times recognizes persons whom she does not expect to meet. She readily detects colors i cm. square at i5 inches. I believe in this case that the improvement has been due not only to the large doses of iodide, but to the constant exercise of the retina. Constant use of the eye causes more blood to flow into it, and in atrophy there is a lack of blood. Why, therefore, should not exercise that improves paralyzed limbs not help to strengthen an atrophic optic nerve if some life is left ? As to the cause of this atrophy there is doubt. The failure of vision before the accident may have been due to the myopia which she inherited from the father. This failure had not interfered with her duties as a school teacher. Glaucoma may be excluded by the conditions of the field, the color perceptions, lack of increased tension, and absence of pain. It is scarcely possible that there could have been a fracture at the base of the skull and through the orbit, for she was not rendered unconscious by the fall, nor did she suffer from pain. The improvement under the large doses of iodide would seem to indicate a specific cause. I do not expect much further improvement, but think that, considering her condition at the time treatment was begun, and the length of- time (five years) that she had been in this condition, the result is, to say the least, gratifying.
215
brane of the choroid, which, as we know, consists of variouslyshaped small projections from this structure. Colloid excrescences were first described as senile changes,* but they may occur in young subjects, as, for example, in the cases herewith presented, and are often unaccompanied by impairment of visual acuity. Dimmert gives a good account of the pathological anatomy of these bodies and a r6sume of the various theories which have been advanced to explain their origin, his own belief being that they may arise from cells, which become filled with a homogenous substance, gradually coalesce and form the colloid projections; in other words, the process is similar to simple colloid degeneration. Based upon microscopic studies,4 I have expressed the opinion that colloid excrescenses of the lamina vitrea and drusen in the nerve-head are not analogous lesions, an opinion also held by a number of other observers.
A CASE OF ATROPHY OF THE OPTIC NERVE. BY CH'ARLES W. KOLLOCK, M.D., CHARLESTON, S. C.
Six years ago this summer Miss L , while riding a tricycle, fell off on her head, but apparently was not injured nor rendered unconscious. The next day her vision began to fail rapidly, but prior to this accident she had noticed that she did not see quite as well as formerly. She was at the time away from home, and a physician whom she consulted advised her to hasten home, as loss of vision was likely to follow. The prognosis was correct, for very soon she was almost entirely blind. She was for two or three years under the care of one or more physicians, but became gradually worse, and they gave up the * An instructive chromo-lithograph representing senile degeneration of the macula, suggestive of this change, is given by Caspar (Monatsbl. f. prakt. Augenheilk., I892, p. 284), who considers his case identical with the* changes described by Nagel as " hyaline growths and crystalline deposits of lime on the inner surface of the choroid." + Arch. of Ojhthalmology, Vol. XIV, p. 65. $ Trans. Amer. OOhth. Soc., 1892.
2I6
KOLLOCK: Case of Atrophy of the Optic Nerve.
case as incurable. She was brought to me in August last, just five years after the fall which preceded the loss of vision. Upon examination both pupils were found to be partially dilated and responded sluggishly to light. The right eye could only see light; the left had 4/cc vision, with fair color perception and a good field, considering the amount of vision. The ophthalmoscope showed gray atrophy of both optic nerves, the right whiter and cupped, and the vessels much contracted. The left disc was not so light in appearance and its vessels not as small, but there was some cupping. The ophthalmoscope also showed a myopia of 2 D., but no glass improved the vision. Tension was normal, and at no time had there been any pain. On account of the size of the vessels, the field of vision, and the good color perception, it seemed that some improvement might follow trealnent, but my prognosis was, of course, unfavorable, as she had been in this condition for five years. Iodide of potassium was prescribed in ascending doses, beginning with ten grains three times a day. She came to me once a week, and after a time it was noted that the pupils were becoming smaller and reacted more quickly to light. Vision improved slowly, and in the course of two months she could see 15/cc. It then struck me that as some tendency to improvement existed, that regular exercise of the retina and nerve might be beneficial. Certainly it could do no harm. She was accordingly told to see everything that she could, to use her eye as much as possible every day upon surrounding objects. Before this she was listless and without hope; the advice gave her occupation, and she entered, heart and soul, into xny plan, puzzled over objects, made them out, walked without assistance on the streets (she had been habitually led), read signs, etc. She began to write, and found after a little practice that she could write in parallel lines, and, though she could not read her writing - which was legible enough to others - she could see sufficiently to know when the ink ceased flowing from a fountain pen which she used. The iodide was gradually increased until she took over three hundred grains a day, and the vision became with - 2 D. I5/c. Strychnine was next tried in ascending doses, but without improvement. In fact, she seemed to thrive
KOLLOCK : Case of A trophy of the Optic Nerve.
217
better on the iodide. Before beginning treatment the hearing was very dull, and there were constant noises in both ears and flashes of light in the eyes. The hearing has not materially improved, but the noises and flashes of light have almost ceased.' Some time before the accident she had trouble with both eyeteeth, which necessitated their being filled, and subsequently an abscess formed at the root of one, which left an enlargement. This entirely disappeared while she was taking the iodide. No history of syphilis could be obtained, though the patient has somewhat of a scrofulous appearance. The mother is in good health; the father, who was myopic, is dead. The patient continues to recognize objects better and better, and at times recognizes persons whom she does not expect to meet. She readily detects colors i cm. square at i5 inches. I believe in this case that the improvement has been due not only to the large doses of iodide, but to the constant exercise of the retina. Constant use of the eye causes more blood to flow into it, and in atrophy there is a lack of blood. Why, therefore, should not exercise that improves paralyzed limbs not help to strengthen an atrophic optic nerve if some life is left ? As to the cause of this atrophy there is doubt. The failure of vision before the accident may have been due to the myopia which she inherited from the father. This failure had not interfered with her duties as a school teacher. Glaucoma may be excluded by the conditions of the field, the color perceptions, lack of increased tension, and absence of pain. It is scarcely possible that there could have been a fracture at the base of the skull and through the orbit, for she was not rendered unconscious by the fall, nor did she suffer from pain. The improvement under the large doses of iodide would seem to indicate a specific cause. I do not expect much further improvement, but think that, considering her condition at the time treatment was begun, and the length of- time (five years) that she had been in this condition, the result is, to say the least, gratifying.
