26 A. f. O., xxiv., 2, pp. 37-70.
27 In clinical lecture reported by Angelucci, Klin. Monatsblätter f. Augenheilkunde, 1880, p. 23.
28 Graefe und Saemisch, vol. v. p. 531.
29 Gaz. méd. de Paris, 1879, p. 217.
Retinal hemorrhage is of frequent occurrence. It is often associated with inflammation in cachectic conditions of the system, as in the various forms of symptomatic retinitis, but is also found where there is not any demonstrable constitutional disease. Here, as in the other tissues of the body, apoplexies are favored by disease of the coats of the vessels, by alteration in the state of the blood, and by increased intravascular pressure. Anatomical examination has shown in the most common form of disease in the retinal vessels fatty degeneration of their walls, with calcareous deposits in them, and a condition (denominated sclerosis) in which the coats become thickened, homogeneous, and of a higher index of refraction. In this hardened tissue there is a condition similar to amyloid degeneration, but no reaction is to be obtained from iodine (Leber). No ruptures can be seen with the ophthalmoscope, but the vessels appear to pass on in contact with the hemorrhage without change of course or calibre. These circumstances have led Leber30 to suppose that most retinal hemorrhages are due to diapedesis, and not to rhexis. When the blood escapes into the fibre-layer of the retina, it frequently diffuses itself along the course of the fibres and between them, and gives rise to linear and striated hemorrhages, while in the deeper layers its progress is barred by the connective-tissue elements—notably by the radiating fibres of Müller—and forms irregular masses which appear as more or less rounded clumps when looked at by the ophthalmoscope. Such extravasations of blood are frequently absorbed, or, again, they may leave black spots of pigment as the only marks of their presence. At other times they produce yellowish-white masses which disappear slowly, and often leave connective-tissue cicatrices behind them, dragging upon and displacing the retinal elements. When the hemorrhage is considerable, it may cause primary distortion of the images and impairment of vision by pressure on the rods and cones. At times it breaks through the limitans interna into the vitreous, giving rise to floating opacities, more rarely spreading itself out in a layer between the vitreous and the retina. The writer well remembers such an instance in the case of an apparently healthy woman about forty years of age, who, while sitting quietly in church, noticed that objects looked red and that a dense cloud came before the eye. Examination with the ophthalmoscope showed a large hemorrhage which covered the entire region of the macula and extended far beyond it, overlapping the temporal edge of the disc. This hemorrhage was slowly absorbed, and four years later the patient had a vision of 20/xx, and no trace of hemorrhage was visible in the entire eyeground. Liebreich31 gives a good illustration of a similar case in a woman of forty-five years of age who, after suppression of the menses, had a similar state of affairs. Leber32 has seen several such cases, in one of which the hemorrhage was changed into a brilliant white mass. This was entirely absorbed, leaving only a small pigmented stripe at its lower border as the sole trace of the previous large extravasation of blood. Occasionally retinal hemorrhage ushers in glaucoma. Retinal apoplexies, like extravasations of blood in the conjunctiva of the eyeball, often come without apparent cause. In many cases they are finger-posts pointing to grave disease of the vessels in other parts of the body. The writer recalls a patient of seventy years of age who believed himself in perfect health until alarmed by a retinal hemorrhage, which a few months later was followed by a cerebral apoplexy which caused his death.
30 Graefe und Saemisch, vol. v. p. 554.
31 Atlas, Table viii. Fig. 2 (1863 ed.).
32 Graefe und Saemisch, v. p. 553.
Aneurism of the central retinal artery is of excessively rare occurrence. Sous of Bordeaux quotes33 the elder Graefe and Scultetus as having anatomically demonstrated the existence of the lesion, and Mackenzie refers34 to a pathological specimen in the collection of Schmidler of Friburg where there was an aneurism of the central artery of each retina. Sous was the first who recognized it with the ophthalmoscope, and describes it as a red egg-shaped, pulsating dilatation of one of the main branches near the disc. Vision was so far destroyed that the patient was unable to recognize the largest letters. Martin describes35 a similar case, while Magnus records what he supposed to be an arterio-venous aneurism following severe contusion of the eyeball, and Mannhardt a case of rupture of the choroid with a gray pulsating mass in the disc, which was also supposed to be aneurismal in nature. Schirmer has recorded36 a case of widely-spread congenital telangiectasis of the face with a similar condition of the retinal veins of one eye. Liebreich37 has pictured curious bead-like dilatations of the veins in a glaucomatous eye. Jacobi38 gives three woodcuts of varix-like tortuosities of the retinal veins. Offsets extending from the retinal vessels forward into the vitreous have been observed during life and described by Coccius,39 Becker,40 Jaeger,41 Samelsohn,42 Jacobi,43 and Norris.44 They probably occur to some extent in many severe inflammations of the eye, and have been not unfrequently found and described in anatomical examinations of that organ; but their development is usually attended with so much cloudiness of the media as to prevent accurate ophthalmoscopic examination.
33 Annales d'Oculistique, 1865, pp. 241-243.