seat of a malignant growth and that the hope of saving life is extremely small, if not non- existent, whether the tumor be a glioma, a sarcoma, or a tuber- culoma. Im a little child the chances are rather in favor of its being a glioma, but the differentiation had best be left to the pathologist.
<Callout type="warning" title="Be Cautious with Young Patients">In children, transient retinal detachments can occur due to kidney disease.</Callout>
DETACHMENT OF THE RETINA When a patient tells us that he has scintillations, sparks, flashes, or balls of fire before his eyes, we know that his retina is irritated. When he says that objects appear to be bent, broken, or jagged, we suppose that the rods and cones are slightly displaced. Such symptoms lead us to think of a commencing detachment of the 400 DIAGNOSIS FROM OCULAR SYMPTOMS retina as a possible cause, the probability of which is increased if hemeralopia has developed recently, and if blue objects appear to be green. But such prodromal symptoms often escape notice, and the first intimation the patient receives that anything is wrong may be the sudden appearance of a dark cloud before his eye. This cloud may obscure a portion of whatever object he happens to look at, and sometimes is observed to wave with the movements of the head, or it may render the eye either practically or totally blind. Such a history as this, taken together with a defect in the field that corresponds to the cloud when the vision is sufficiently good to en- able us to detect it, a deep anterior chamber, and minus tension, leads us to expect to find a bullous detachment of the retina.
In another case the history may be one of a gradual impairment of vision, perhaps with the development of a similar cloud that mav or may not have changed its position When the media are clear we perceive readily with the ophthal- moscope a gross change in the fundus, but there is no lesion of the eye in which a systematic use of this instrument is more imperative if we are to get anything like an accurate idea of the actual condi- tion present. The important details cannot be brought out at any one step in the examination, for we are obliged to see a part at a time and to group these parts together mentally so as to get a com- posite picture of the whole. This is why we never see anything exactly like the illustrations in the textbooks, which necessarily are composite and represent the conditions as they are, rather than as they appear in either the upright or the inverted image at a given focus.
After the pupil has been dilated we look for the red reflex and observe it while the patient turns his eyes in various directions. This reflex should be bright and clear from all parts of the fundus, so if we see dark spots float across it, which we recognize as caused by opacities in the vitreous, and its color changed to a bluish or a greenish gray in one or more places, we know that we have to deal with either a detachment of the retina, a tumor of the choroid, or a dense exudate into the vitreous. If the red reflex is blotted out, or is replaced by a grayish one, we have to determine whether this is due to a large detachment, a large tumor, or a hemorrhage into the vitreous. A hemorrhage usually can be differentiated by the history and by a dark red reflex obtained by oblique illumination.
Frequently this is all that we can learn in this way, but sometimes <Callout type="important" title="Use Sachs Transilluminator">we are able to get an approximate idea of the size and site of the discoloration</Callout>, and occasionally we can see in the latter crooked black lines, as well as whitish bands that alternate with darker ones and change slightly so as to give the impression of a wavy movement. When we see this picture we know that the waviness must be caused by a fluctuating bullous detachment.
Next we introduce a convex lens a few inches in front of the eye and use the indirect method of examination, by which we can definitely exclude an exudate by the absence of its characteristics and the presence of dark retinal vessels running over the surface of the discoloration. An exudate is excluded likewise if there is no history and no sign of a previous inflammation of the eye that might have been a uveitis. We can also determine at this time the size of the discolored area, its relations to the papilla, whether its mar- gins flatten out into normal retina or seem to overhang the latter, and whether its elevation is slight or great, sufficiently at least to inform us whether it is flat or bullous. When it is bullous we may be able to see the surface wave, or fluctuate when the patient moves his eye, which assures us of the presence of serous fluid.
Frequently an aperture can be seen through which the markings of the choroid are visible, usually in the upper peripheral part of the discoloration, which we recognize to be a laceration of the retina. Instead of such a picture as this we may see a wavy, fluctuating gray mass with crooked black lines running over it, or perhaps we see the papilla at the bottom of a gray funnel, particularly in a case in which we were unable to obtain a red reflex, and then we know that we have to deal with a total bullous detachment of the retina. If there is no such mass visible, but the entire fundus is of a bluish gray with white bands here and there over which the dark retinal vessels ‘bend, the case is one of a total flat detachment.
The papilla may be perfectly normal, but if the detachment approaches it closely its margins are likely to be obscured so as to cause us to think of an optic neuritis, but this lesion is excluded by the size of the retinal vessels, which is about normal, though they are dark, tortuous, and without light streaks. A similar condition that affects only a part of the retina is a partial flat detachment.
An cedema of the retina which is sufficiently pronounced to be taken into consideration is of a grayish white rather than a bluish or greenish gray, is associated with some such lesion as an optic neuritis, a choked disk, or an occlusion of a retinal vessel that decides its nature, and the vessels behave differ- ently. A carcinoma of the choroid may induce a detachment that is rather flat, but this is attended by hemorrhages in the retina, and is almost invariably secondary to carcinoma elsewhere in the body.
By the direct method we then measure the height of the eleva- tion, and trace the courses of the vessels as they pass over it, and interpose successively stronger plus lenses in the ophthalmoscope, while at the same time we observe its individual features. If the detachment is flat we go farther in determining whether it has or has not been caused by a carcinoma by observing the presence or absence of a yellowish color and of spots of pigment.
In rare cases we may in this manner first perceive a detachment of the retina by a clear serous fluid that produces no discoloration, by observing that the retinal vessels bend forward, lose their light streaks, and mount upward in a tortuous manner into the vitreous, where they seem to be without any support. When the discolored area has a high elevation the most important question for us to answer is whether it has been caused by a sub- retinal effusion, or by a tumor of the choroid.
If it is known to have started above and to have gravitated downward, the retina reattaching above as it became detached below, and particularly if it has left a laceration above through which the markings of the choroid can be seen, it is a simple detachment, but in many cases we do not have the advantage of such a history, and we may not be able to find a laceration. Folds in and fluctuation of the surface indicate the presence of serous fluid, but do not exclude the possibility of tumor, while their absence, leaving a smooth, nodular swell- ing, leads us to suspect tumor strongly, especially when new vessels or hemorrhages are present, or the tension of the eyeball is increased, but this is not a positive indication.
The most reliable means of differentiation now at our disposal is a test of the translucency of the swelling. We may place an electric light in the mouth of the patient and observe whether the swelling appears to be light or dark in comparison with the rest of the fundus; if it is light we as- sume that the detachment is due to the presence of serous fluid, but if it is dark we know that either a tumor or a hemorrhage lies be- neath the retina. A better way is to use a Sachs transilluminator. We place its tip against the sclera beneath the swelling and observe whether the pupil becomes illuminated or not when the light is turned on; if it does we conclude that the detachment has been caused by serous fluid, if it does not that the light has been intercepted by THE RETINA AND CHOROID 403 either a tumor or blood. We may infer that a hemorrhage has taken place if the eye has been subjected to traumatism recently, if there is evidence of vascular disease, or if glaucoma existed in the eye previously, otherwise we feel confident of the presence of a tumor.
The differentiation between a simple detachment of the retina and a tumor of the choroid may be made perfectly in the majority of the cases in which the media are clear, yet it is hard to speak with absolute certainty. Some years ago I enucleated a hard, painful, blind eye that contained a smooth, nodular, bluish protru- sion into the vitreous, which showed no signs of fluctuation on its surface, and was dark on transillumination. The diagnosis of tumor of the choroid, probably sarcoma, seemed to be positive, but the pathologist reported it to be a simple detachment.
Occasionally we meet with a case in which there is no discolored area in the fundus, and the only objective evidence of the trouble is an abrupt arching forward of the retinal vessels into the vitreous, where, dark and without light streaks, they seem to hang, branch, and curve without support. This is a simple detachment in which the retina and the serous fluid are so transparent as to transmit the red reflex from the fundus beneath them. It has been referred to already as the form in which we may first recognize the nature of the lesion when we examine the eye by the direct method.
Detachment of the retina occurs rarely in children, and when it does its diagnosis is usually attended with no more difficulty than in adults, but a couple of possible peculiarities may be mentioned. As a rule, a detachment lasts a considerable time before it becomes re- attached spontaneously, but a few cases have come to my knowledge of puzzling transient detachments in children who were suffering from kidney disease, and in at least one of them a very serious renal lesion was not discovered until after several of these had occurred, so the suggestion may be in place that the kidneys of any child should be investigated in whom a detachment occurs spontaneously, especially if it is transitory.
The other pecularity is one that was met with by de Schweinitz and Shumway in a child in whom the retina was so yellow from degeneration that a glioma was counter- feited clinically, and the correct diagnosis could not be made. Thus far we have been considering cases in which the refractive media were clear, but the diagnosis of a detachment of the retina, and still more its differentiation from a tumor of the choroid, be- comes very difficult whenever the lens, or any other of the refractive 404 DIAGNOSIS FROM OCULAR SYMPTOMS media, is too opaque to allow us to see into the eye. Sometimes we can infer the presence of a detachment from a faulty projection as- sociated with a minus tension, but we have to exclude all other diseases that may destroy a part of the field of vision.
Detachment is excluded if the field is contracted concentrically. A nasal con- traction with normal or plus tension directs our suspicions in the direction of glaucoma, though it is possible for a detachment or a tumor to occupy the temporal portion of the retina. If the field can be taken accurately enough to show that a half or a quadrant of the field is wiped out in both eyes, with the blind part delimited by a fairly straight line, we look for a cranial lesion that has caused hemianopsia.
It is only when the defect in the field seems to be rounded or irregular, light is projected in erroneous directions, and the tension is minus, that we feel pretty sure of the presence of a detachment. When the tension is plus we think of a tumor of the choroid, and sometimes Sachs’s transilluminator is of great assistance when it is used in a dark room, provided that the opacity of the media is not too dense to permit the passage of some light from within outward.
We move the tip about from place to place on the sclera, and if we find that the illumination of the pupil is cut off when the tip is at a certain point we feel fairly sure that a tumor is present. The diagnosis and the differentiation must be made in nearly every case through the weighing of every particle of evidence that can be obtained.
<Callout type="tip" title="Use Ophthalmoscope for Clear Media">For clear media, use an ophthalmoscope to measure height and trace vessel courses.</Callout>
DETACHMENT OF THE CHOROID A few days after a cataract extraction we frequently find the eye quite soft, the anterior chamber shallow or empty, although the wound has not reopened, and we can see, either by oblique illumina- tion or with the ophthalmoscope, a yellowish or brownish mass be- hind the iris that has no folds and does not fluctuate. Sometimes several such masses are to be seen. We need not be worried about such a case, the choroid has become detached, but the prognosis is good and we can confidently expect it to return to its normal posi- tion in a few days.
After a contusion of the eye we can sometimes see by the curved courses of the vessels that a part of the retina has been elevated, although it retains its normal appearance in general, and function- ates perfectly perhaps, because its relations with the choroid are maintained. In such a case we may suppose that the choroid has been detached from the sclera by a hemorrhage, though the latter is not visible unless the fundus is albinotic.
Detachment of the choroid may be caused also by a great loss of vitreous, or by the contraction of cicatricial tissue in a blind eye which has been the seat of a very severe intraocular inflammation, but on the whole, with the exception of the last mentioned class of cases, it is of much less serious importance than detachment of the retina, and is apt to escape observation. It is usually recognized through a protrusion of normal retina into the vitreous in an eye which is soft and has a shallow anterior chamber.
TUMORS OF THE CHOROID Every distinct elevation of the surface of the retina leads us to think of a possible tumor. If the patient is a young child, the sur- face of the swelling is smooth or lobulated, and its color is yellowish, the tumor may be a glioma of the retina, or a tuberculous growth of the choroid, both of which have been discussed already, while if the color is bluish or greenish we have to determine whether it is a detachment of the retina, or some tumor, probably a sarcoma, of the choroid. Whether the patient is a child or an adult the cases are few in which we can definitely determine the nature of a tumor of the choroid, or even whether it is benign or malignant, prior to the enucleation of the eyeball, but while it is possible for us to meet with a gumma, an angioma, or possibly some other neoplasm, such benign tumors are extremely rare, while sarcoma is common, and the differentiation very seldom can be made clinically.
We may suspect a growth in the choroid to be a gumma when the patient has tertiary syphilis, and prove it to be such by watching it melt away under appropriate treatment, or the presence of other vascular anomalies might go far to convince us that a certain protrusion was caused by a congenital angioma, but in the great majority of cases the demonstration of a tumor of the choroid is equivalent to a diag- nosis of sarcoma.
A tumor of the choroid needs to be differentiated from a cyst of the retina, or of the vitreous, on rare occasions, when we see a bluish white growth with semitranslucent walls, especially when it is some- what obscured by fine, membranous opacities in the vitreous. We suspect such a growth to be a cyst if it has a generally translucent 406 DIAGNOSIS FROM OCULAR SYMPTOMS appearance, and this diagnosis is positive if it has a slightly tremu- lous movement, or if we can see a small white spot within it.
When the history given by the patient is that of a slow, painless impairment of vision, that may or may not have culminated sud- denly in the blindness of one eye, and we find a more or less globular,
Key Takeaways
- Recognize retinal detachment symptoms like scintillations and flashes.
- Use the ophthalmoscope for clear media to measure height and trace vessel courses.
- Differentiate between tumors of the choroid and retinal detachments using Sachs transilluminator.
- Be cautious with transient retinal detachments in children due to kidney disease.
Practical Tips
- Regular eye check-ups can help detect early signs of retinal detachment, especially for those at higher risk.
- Maintain a healthy lifestyle and manage chronic conditions like diabetes to reduce the risk of ocular complications.
- Be aware of sudden changes in vision or floaters, which could indicate an emergency situation.
Warnings & Risks
- Do not delay seeking medical attention if you experience sudden vision loss or other concerning symptoms.
- Misdiagnosis can lead to permanent blindness; seek a second opinion if unsure about the diagnosis.
- Avoid self-treatment with eye drops or ointments without consulting an ophthalmologist.
Modern Application
While much of this chapter focuses on historical techniques, modern ophthalmology has advanced significantly. Techniques like the use of the ophthalmoscope and transilluminator are still crucial but now supported by digital imaging and faster diagnostic tools. Understanding these principles remains vital for recognizing ocular emergencies in a timely manner.
Frequently Asked Questions
Q: What are the symptoms of retinal detachment?
Symptoms include scintillations, flashes of light, floaters, and sudden vision loss. Objects may appear bent or broken, and there might be a dark cloud obscuring part of your vision.
Q: How can I differentiate between a retinal detachment and a tumor of the choroid?
Use an ophthalmoscope to measure height and trace vessel courses. A Sachs transilluminator can help determine if the swelling is due to serous fluid, a tumor, or blood.
Q: What should I do if I suspect retinal detachment in a child?
Seek immediate medical attention as children may experience transient detachments associated with kidney disease. Regular eye check-ups are crucial for early detection.