CHAPTER XVI THe PAPILLA (Part 2)

A hyperzmia of the papilla with dilated retinal vessels is met with in general plethora, in fevers, and after overindulgence in liquor, but may be caused also by accommodative efforts in hypermetropia and pres- byopia, by any traumatism to the eyeball, by an inflammation any- where in the eye, by glare and heat, by an examination with the ophthalmoscope, by obstruction to the general circulation, as in some forms of heart disease and when the great vessels are compressed, by certain disorders of the brain, and is seen in some types of in- sanity. In addition it may be a symptom of an inflammation of the middle ear, or of the accessory sinuses of the nose, but, as a rule, it is only when other symptoms lead us to look for an optic neuritis, a choked disk, or a glaucoma, that a hyperemia of the papilla is important as the first ophthalmoscopic sign of such a condition. If the patient has a purulent otitis media a hyperemic disk surrounded by an oedematous retina leads us to fear an intracranial complica- tion, probably sinus thrombosis. When a papilla looks redder than it should and has margins that are more or less obscured, we must note its shape and level, the con- dition of the retinal vessels, the clearness or obscuration of the periphery of the fundus, test the vision and the fields, and sometimes measure the refraction, to ascertain whether the appearance is due to an affection of the optic nerve or not, and if so whether the nerve head is inflamed or engorged with lympk. A beginner may be troubled because the entire disk appears to be hazy, and be inclined to suspect an optic neuritis when the truth is that the papilla is not quite in focus. He must ascertain whether 334 DIAGNOSIS FROM OCULAR SYMPTOMS this is the case by moving his head back and forth slowly, if he is using the indirect method, or by interposing lenses in the ophthal- moscope, if he is looking at the upright image, until he has obtained the clearest picture possible. If this persists in remaining hazy he jmust learn whether the haziness extends to the periphery of the fundus or not before he can say there is trouble in the nerve head, for when we see a red papilla that shines as it were through a cloud which spreads over the adjacent retina so as to render all of the details indistinct, and cannot be dissipated by focussing, we have to determine whether the picture is caused by a diffuse opacity of the refractive media, by a pseudoneuritis, or by an optic neuritis. The vision is impaired in all of these conditions. If the periphery of the fundus is just as hazy as the center, we are trying to see through a diffuse opacity of the media, for the obscuration associated with an optic neuritis, or a choked disk, ex- tends outward only a short distance from the papilla. Inspection will inform us whether the opacity is in the cornea or the lens, and if it is in neither of these it must be in the vitreous. Still it is quite pos- sible for an optic neuritis to coexist with a diffuse opacity of the media, so we have not finished by finding the latter. We look to see whether the retinal veins are unusually broad and tortuous, and whether any hemorrhages or white spots can be seen in the retina, for if we can find any of these things we know that an optic neuritis is present. Otherwise such a diagnosis is rendered probable only by the detection of a central scotoma. If the details in the periphery of the fundus are clear we con- clude that there is no diffuse opacity of the media, and next consider the possibility of a pseudoneuritis. Should the papilla appear to be remarkably oblong in shape, while the obscuration of its margins does not seem to extend out into the retina, where we can find no hemorrhages or white spots, and should the visual field be normal, we suspect that the appearance of the disk is caused by a high de- gree of hypermetropic astigmatism, usually compound, even though the vessels may look as though they were engorged and tortuous, and the surface of the papilla seem to be elevated a little. This suspicion becomes certainty if we find that by slowly adding stronger and stronger plus lenses in the ophthalmoscope two opposite margins of the disk are caused to become distinct, together with the vessels that run in the same direction, and that by continuing to change the lenses these edges and vessels are caused to fade away while others THE PAPILLA 335 come into view until those which are at right angles to the ones first seen are distinct. The refractive error can be measured in this way if the observer’s own accommodation is under perfect control. After these conditions have been excluded we have to determine whether we have to deal with an optic neuritis or a choked disk. Many excellent writers and observers confound these two conditions, and make no distinction between an inflammation in which the papilla is exceptionally swollen and an engorgement of the papilla with lymph. This seems to be because it is customary to speak of the height of the swollen papilla as the distinctive characteristic of a choked disk, although the effect produced on the vision seems to be of more value in the differentiation. A choked disk may be low in its early stage, or during involution, and its maximum height is no greater than that which is observed occasionally in optic neuritis, but in the former the vision is apt to remain good for a long time in spite of the formidable appearance of the lesion. After viewing an enormously swollen papilla, with its engorged and tortuous’ blood vessels, we may be amazed to find the vision normal, but more com- monly we find it somewhat reduced, with temporary attacks of blindness or of obscuration, and with various faults in the field, but rarely if ever with a central scotoma, while in nearly if not quite every case of optic neuritis the vision becomes bad early in its course, and frequently a central scotoma can be demonstrated. OPTIC NEURITIS When a patient complains of a recent great impairment of vision, and we see a papilla that is redder at its center than at its margins, while the latter are obscured by a gray or reddish cloud that shades off into the surrounding retina, or see a disk that looks like a red sun seen through a fog, or one that is so blotted out that we can locate it only by the convergence of its blood vessels, we do not hesitate to pronounce the case one of optic neuritis if the veins are broad and tortuous, the arteries are normal, and hemorrhages or white spots are visible elsewhere in the fundus. The surface of the papilla may be on a level with the retina, in which case the physio- logical excavation almost certainly is filled up, but, as a rule, it is elevated. The hemorrhages and white spots may be found on or about the papilla as well as elsewhere, and are particularly apt to occur about the macula. When the papilla is greatly swollen the 336 DIAGNOSIS FROM OCULAR SYMPTOMS veins are very broad, distended and tortuous, dipping in and out of the cloudy tissue, hidden in some places, appearing in others as dis- connected pieces, while the arteries may be so buried as to appear smaller than normal, and the gray cloudiness may have radiating striations, so that the picture is exactly the same as that presented by a typical choked disk. The impaired vision, the central scotoma if one can be detected, and the discovery of the etiology settle the diagnosis. An optic neuritis may be simulated more or less closely by in- accurate focussing, by a pseudoneuritis, by a supertraction crescent, by an occlusion of the central artery, by a flat detachment of the retina, and by a traumatic cedema of the retina. The first two have been dealt with. A supertraction crescent is differentiated by the normal vessels and the presence of a myopic conus or staphyloma; an occlusion of the central artery by the sudden blindness, the broad gray expanse in the retina, and the cherry red spot in the fovea; a flat detachment by the local elevation of the retina, the absence of the light streaks on the vessels that pass over it, the discoloration of this area, and a corresponding defect in the visual field; a traumatic oedema by the history of traumatism, the normal vessels, and the rapid recovery. CHOKED DISK When in spite of good vision we find a reddish gray papilla that is enormously swollen and elevated and has precipitous sides, with arteries that are smaller than normal, and veins that are very broad, dark, and tortuous, has a great many small vessels on its surface, and has its base surrounded by an opacity with radiating lines that covers its margins and extends out so as to make the papilla appear to be abnormally large, we diagnose a choked disk. The height of the swelling usually is 1 mm., 8 diopters, or more, though it may be much less. Its surface, as well as that of the opaque retina in its immediate vicinity, has a striate, reddish white appearance that corresponds to the*courses of the bundles of nerve fibers. The retinal arteries are quite small, while the broad veins bend about in great loops. Often the great vessels can scarcely be seen in the center of the papilla, but come into view in its sides, or at its margins. The veins may be accompanied by white stripes along their sides. In children and young people we frequently see THE PAPILLA 337 small, brilliant white spots, or fine brilliant white lines, on or outside of the papilla, while hemorrhages and white spots are present almost invariably in both the disk and the retina. In the early stage of a choked disk the entire papilla may be swollen to a less degree, or only a part of it may be swollen. Oc- casionally the periphery may be seen to protrude above the center. Its size may seem to be increased by the cedema that obscures its margins and infiltrates the adjacent retina. It may have a clear appearance, the vessels may be only slightly changed, and the retina may appear to be normal, except for a narrow rim about the papilla, even when the top of the swollen disk is two thirds of a millimeter above its proper level. The differentiation from an optic neuritis in such a case and at this time, is made much more easily through the disproportion of the swelling to the retinal changes, the dis- proportionate sizes of the arteries and veins, and the presence of good vision. Finally the vision fails, the redness of the papilla is replaced by pallor, the swellmg subsides, and a neuritic atrophy supervenes. The subsidence may affect only one part of the papilla at first, just as one part may be the first to swell. Exceptionally a choked disk of short duration subsides without inducing atrophy. Diagnostic Value of an Optic Neuritis Optic neuritis is not a disease, it is only a symptom, and our real diagnosis has not been made until we have discovered its cause. It may be due to a malformation of the skull, to an inflammation in the orbit, or in the accessory sinuses, to disease of some of the in- ternal organs of the body, including the vascular and central nervous systems, to an acute infectious disease, to a disturbance created by irregular or suppressed menstruation, lactation, or loss of blood, to poisoning, or to sympathetic inflammation. The only cases in which an optic neuritis may be said to be a pathological entity are the very rare ones in which it attacks a large proportion of the male members of a family about the age of puberty for several generations, and results in hereditary optic atrophy, but our knowledge of these is slight. When an optic neuritis occurs during the course of one of the acute infectious diseases, such as measles, scarlet fever, diphtheria, whooping cough, typhoid fever, influenza, pneumonia, facial ery- 338 DIAGNOSIS FROM OCULAR SYMPTOMS sipelas, gonorrhea, malaria, polyneuritis, or acute articular rheuma- tism, we are justified in ascribing it to the disease itself, but later it may be due to a sequel, like nephritis, or an inflammation of the accessory sinuses, or to a different infection, like syphilis. It is said to have followed catching cold, and exposure to severe weather, but such a cause as this cannot be accepted until every other one has been excluded. . We can never infer the cause with any certainty from the oph- thalmoscopic picture, although in some cases it is quite suggestive; no matter what suspicions the appearance may engender, they must be confirmed or disproved by a searching investigation of the or- ganism. Occasionally we may be guided toward a diagnosis of syphilis when a wide area of the retina about the papilla is occupied by a dense cedema with radiating hemorrhages, with or without white spots, there is a diffuse central opacity of the vitreous, or patches of disseminated choroiditis are to be seen in the periphery of the fundus, but these signs are wanting in many cases of luetic neuritis. When the patient is a child a glance at the conformation of the skull may inform us of a probable malformation of the orbit, and it is well to inquire into the family history in search of a hereditary predisposition, but the chances are that an optic neuritis in a child is tuberculous. We must search for other clinical symptoms of tuberculosis, especially in the lymphatic glands, and observe the effect produced by the tuberculin test. Sometimes when the patient is very sick we may see small, roundish, elevated, yellowish white spots in the fundus, or an elevated white mass in the papilla, which we take to be tubercles and render the diagnosis almost certain. When the patient presents symptoms indicative of meningitis, abscess of the brain, or sinus thrombosis, the optic neuritis is ex- plained, but we still have to learn the cause of the intracranial trouble. If there is considerable cedema of the retina about the papilla with vessels that are very slightly changed, our attention is directed to the middle ear. Exceptionally a disseminated choroiditis, or tubercles in the choroid, suggest syphilis, or tuberculosis. If the retina contains many small hemorrhages and white spots, especially about the macula, we suspect nephritis, or ascribe it to diabetes if the patient is in a late stage of this disease. No one pic- ture can be said to be characteristically produced by either of these diseases. The retinitis usually predominates over the neuritis, but the opposite may be the case and the swelling of the papilla may be THE PAPILLA 339 so great as to simulate in almost every respect a choked disk, and as this is met with most frequently in cases of nephritis the condition is commonly known as albuminuric choked disk. At the same time the many small hemorrhages and white spots, even in their so-called characteristic grouping, have been observed in neuro- retinitis from other causes. One symptom, which is quite suggestive of diabetes rather than of nephritis, when it is detected in these cases, is a very small central scotoma. An optic neuritis in an old person may be due to arteriosclerosis, but this form presents no characteristic signs, unless we have the opportunity to watch its development, which is very slow. Occasion- ally the swelling of the papilla is enormous when it resembles very closely an albuminuric choked disk. An optic neuritis in only one eye generally is due to an inflamma- tion in the orbit. A wound, a cellulitis, or a periostitis of the walls near the apex, gives rise to symptoms that attract attention prior to the examination of the fundus, but this is quite apt not to be the case when it is caused by inflammation of the posterior ethmoidal cells, or of the sphenoidal sinus. These accessory sinuses should be in- vestigated in every case in which the cause of an optic neuritis, a disease of the papillomacular bundle, or a choked disk, is doubtful, whether it is present in one or in both eyes, but especially when it is confined to one, because inflammation there may ruin the eyes before it excites any other subjective symptom. ‘We should also take note of any persistent dropping of a watery fluid from the nose. When an eye has been wounded at some previous time and is tender to the touch, an optic neuritis that develops in the other may be of sympathetic origin. This diagnosis is confirmed if we can find little yellowish spots in the periphery of the fundus, and some signs of a uveitis, such as diffuse opacities in the vitreous, deposits on Descemet’s membrane, or evidences of iritis. Diagnostic Value of Choked Disk A choked disk of only one eye ordinarily indicates a lesion that compromises its optic nerve, while one of both eyes is an evidence of increased intracranial pressure. In the majority of cases of unilateral choked disk signs of trouble in the orbit have attracted attention before the discovery of the condition of the papilla, and 340 DIAGNOSIS FROM OCULAR SYMPTOMS furnish a sufficient explanation. An abscess or a tumor in the frontal portion of the brain may break through into the orbit and produce the same local symptoms, which are not always accom- panied by those of brain trouble. If the orbit is normal we must remember that a single choked disk is sometimes, though quite