Diseases Of The Vitreous | Operating Microscopes

Diseases Of The Vitreous.
By FLEMMING CARROW, M. D.,
OF ANN ARBOR, MICH.

Hyalitis (Inflammation of the Vitreous). This disease appears in two forms one characterized by suppuration suppurative hyalitis), and the other by either fixed or floating opacities.

Etiology. All opacities seen in the vitreous, however, are not to be regarded as the result of pathologic conditions peculiar to that body, for they are usually dependent upon some structural change in the uveal tract or retina. On account of the absence of blood vessels and nerves in its structure the vitreous was at one time supposed to be incapable of inflammation, but recent investigation has developed the fact that idiopathic or spontaneous inflammation may occur without change of a textural character in any other part of the eye. It is true, however, that hyalitis of the suppurative variety is generally a secondary disease, being caused by an injury (penetrating wound) to some adjacent structure, or by previously existing choroidal disease which had its origin, primarily, in consequence of some operative procedure upon some other part of the eve (as after cataract extraction).

Suppurative hydrates may also be due to microbic invasion of old operative scars of several years' standing, to exhaustion following any lengthy debilitating disease, especially the continued fevers, relapsing fevers, the exanthem or may result from metastatic choroiditis after inflammation of the umbilical cord in new born children.

Symptoms. Since suppurative hyalitis is usually secondary to disease of other structures, we will find evidences of the presence of this primary affection in adhesions of the pupillary margin to the anterior capsule of the lens, and a history of iritis and cyclitis. Pus once having formed in the vitreous (the cornea and media being clear), it is readily seen with the ophthalmoscope occupying a circumscribed area (pseudo glicoma), while the rest of the vitreous may appear perfectly clear and healthy. This condition closely resembles a true glioma of the retina ; but the history of the case, with the symptoms of iritis and diminished tension, will serve to distinguish them (see also page 356).

The disease may remain confined to some peripheral portion of the vitreous bod , but usually the suppurative process extends until the entire y vitreous becomes involved, and through a resulting panophthatmitis the eye is lost. The history of some pre existing eye disease and the ophthalmoscopic appearances will sufficiently indicate the location and gravity of the affection
Prognosis and Treatment. The result of suppurative inflammation of the vitreous is usually not only the loss of the affected eye, but the atrophied globe after panophthalmitis may be a source of menace to the sound eve. Should the health of the sound eye be threatened at any stage of the disease, enucleation of the affected organ must be at once performed.

During the course of any lengthy debilitating disease, should suppurative hyalitis supervene, it may be possible to save the eye with some degree of vision by vigorous tonic treatment. Intraocular injections of chlorin water have been recommended on experimental grounds (Berry).'

Opacities of the Vitreous. That variety of inflammation of the vitreous characterized by the formation of fixed or movable opacities may be either acute or chronic.

Etiology. As this form of vitreous disease, like the suppurative variety, is secondary to affections of other portions of the eye, the refraction of the eye and the condition of the lens, of the ciliarv body, choroid, and retina, must be examined for its cause. High degrees of myopia associated with posterior staphyloma constitute a frequent cause of this trouble. Again, in choroiditis, and especially in the specific variety, a fine dust like mist (hyalitis punctata) can be detected, through which there are distributed larger flake like opacities of irregular shape, which give individuality, to the primary disease which caused them.

Exhaustion of the general system from long continued fevers, gout, constipation, anemia, interference with the function of the liver by congestion, irregular menstruation, syphilis, and the action of drugs (arsenic), all may, and often do, produce opacities in the vitreous. Injuries to the eye causing choroidal hemorrhage will also result in the formation of opacities, and, if extensive, may lead to suppuration.

Benson has described a form of opacity in which the vitreous is filled with minute, light colored spheres (asteroid hyalitis). The condition is congenital, and does not interfere with normal visual acuity.

From the foregoing statements it is evident that opacities in the vitreous are generally the result of some pre existing disease of some other part of the eye, although there may be a primary inflammation of this body to which they owe their origin.

Symptoms. Patients readily see opacities of the vitreous, either as fixed or movable black spots, and are quite able to describe their situation, size, and shape. There may be no diminution of vision, although central vision may be entirely lost if there is a large centrally situated fixed opacity. Should there be pain or evidences of external inflammation, it must be taken for granted that the vitreal disease is complicated by some other affection, and probably the result of it.

The ophthalmoscope offers the one certain method of making a positive diagnosis if the media are clear. The patient is directed to move his eye quickly in all directions, and then to hold it quite still. The floating opacities are then seen to move in the vitreous, and gradually to sink to the lower portion of the chamber. Not only can the size of the opacities be correctly estimated in this manner, but a very good idea of the degree of fluidity of the vitreous can be obtained. It will be noticed, when the interior of the eye is illuminated by reflected light and the patient directed to move his eye, that these opacities move in a direction opposite to the movement of the eye: when the eye is turned to the right, the opacities move toward the left, and in this way they can be distinguished from opacities in the lens or cornea, which, being fixed, move with the movements of the eye. Fixed opacities in the vitreous may be discovered by using a strong convex lens (+ 16) behind the ophthalmoscope, the observer holding his eye quite close to that of the patient (see also pp. 178, 179, 183).

Treatment. While treatment is not generally effective in entirely removing opacities of the vitreous, much may be done for the relief of the patient. If myopia is found to be their cause, its correction to the full degree of the error should be ordered. Irregularities of the menstrual function, disorders of the liver, or exhaustion from protracted illness of any kind must be corrected. For syphilitic varieties the mercurial preparations employed in the form of intramuscular injections promise more than when given in any other way. The protiodid of mercury, combined with iron, also gives excellent results, as do iodid of potassium and sodium. Gout, constipation, and anemia should be treated for the share they may have had in the production of the disease. Diaphoresis with pilocarpin hydrochlorate (gr. fto 16 hypodermically) is of service, and, according to de Schweinitz and Spaulding, small doses of the same drug, even when sweating is not produced, are valuable. Electricity in the form of galvanism has been reported to be of use.

Various medicinal agents, such as the soluble mercurial salts, solutions of potassium iodid, and carbolic acid, have been injected into the vitreous chamber in the hope that absorption of vitreous opacities and other effused inflammatory products might follow. The writer does not believe that such treatment is warranted, except where vision has been reduced to a mere quantitative perception of light, which no remedy, however severe, can make worse, for disorganization and dense opacity of the vitreous body are almost certain to follow its use. Furthermore, the hyaloid and retina become affected, and panophthalmitis usually results.

A large fixed and more or less central membranous opacity may be divided by passing a discission needle into the vitreous in front of the equator of the eve, entering it just below the lower border of the external rectus muscle, care being exercised to watch the movements of the instrument with the ophthalmoscope.

Pseudo glioma, so called from its resemblance to glioma of the retina, is a circumscribed suppurative inflammation of the vitreous, generally occurring in the periphery of the chamber near the ciliary region.

With the ophthalmoscope a yellowish white reflex can be seen, but as there are abundant evidences of a pre existing irido choroiditis, there can scarcely be excuse for mistaking this for a true glioma of the retina. Diminished tension, followed by shrinking of' the globe, sometimes with subsequent ossification of the choroid, marks the distinction between this and true glioma.

The treatment is to be directed to the primary disease standing in a causal relation to this affection (see also page 355).

Volitantes. Myodesopsia. There are in the vitreous certain ameboid cells, most abundant at its periphery, which are of normal occurrence, and are not disturbing to vision, as they are transparent and readily transmit light. On account of their constant presence the mind usually disregards them, but occasionally, when looking at some white surface, as the page of a book, and while there are no other retinal images with which to compare them, they force themselves upon the notice of the patient and cause more or less distress. They may be seen entoptically by closing the eyelids and turning the face toward a bright light. They appear as fine threads and specks of various size, which float across the field of vision when the eve is being moved, but do not in any way disturb visual acuity. Occasionally they assume curiously fantastic shapes.

Treatment. As most patients annoyed by musca volitantes have some error of refraction, this should be corrected with suitable lenses. At the same time, they should be assured that the presence of these floating opacities has no clinical or pathological significance.'

Hemorrhage into the Vitreous. This most frequently follows a rupture of some of the vessels of the choroid at its anterior portion where the retina is thinnest, thus allowing a freer extravasation than would be the case should a vessel rupture at its posterior part, where the retina is thicker. Schweigger doubts if extravasation of blood into the vitreous can occur as the result of' a rupture of the vessels of the retina, because, owing to the arrangement of its connective tissue fibrille and the strength of its internal limiting membrane, hemorrhage front it would generally extend toward the choroid and not toward the vitreous. However this may be, we are able to see with the oplithalitioscope, if the hemorrhage is slight, a bright red reflex indicating the seat of the extravasation, or a red veil if the blood is thinly distributed over a considerable extent of the vitreous.
Spontaneous hemorrhage into the vitreous may occur, particularly in the case of young male adults who are subjects of irregularities of the circulation (Eales) and of gout (Hutchinson). Such hemorrhagic effusions are not, as a rule, entirely absorbed, but leave opacities in the vitreous very damaging to vision if centrally situated.

If the hemorrhage is extensive, the sight is immediately lost, and it is impossible to obtain a view of the interior of the eye. After absorption of the effused blood, and when the vitreous has become clear, numerous fixed and floating opacities may be seen, which become less and less distinct as absorption goes on, only to be followed by other extravasations, and perhaps finally by detachment of the retina. Permanent opacities are usually left behind, even in those cases where the hemorrhages do not recur, and Vision is always very considerably impaired.

Treatment. The mercurial preparations, iodid of potassium, pilocarpin, and the saline mineral waters are indicated in the treatment of these cases. Ergot may also be employed, especially early in the disease. Abadie has directly galvanized the vitreous, passing a platinum needle in the chamber, in a case of chronic vitreous hemorrhage. This procedure is of doubtful value.

Synchisis Corporis Vitrei (Fluidity of the, Viti cous). During the progress of certain diseases of the eye, notably retinitis, choroiditis, and very high degrees of myopia, the nutrition of the vitreous is so seriously impaired that its proper framework is destroyed, and it loses its normal consistency and becomes a straw colored liquid. !it extracting a cataractous lens we frequently have to guard against this condition, which has been developed by a previously existing disease of sot tie other part of the eye. There are always diminished tension, and frequently a tremulous condition Of the iris. Treatment is of no avail.

Synchisis Scintillations (Cholesterin Crystals in the Utreou8). Tlie presence of minute crystals of cholesterin and tyrosin in the vitreous produces a very interesting ophthalmoscopic picture, but does not interfere with vision if that body is otherwise healthy. The crystals are seen in the eyes of the aged, usually in connection with vitreal opacities. They are not of frequent occurrence. They appear as small luminous bodies which reflect the light from. the ophthalmoscope in the form of a shower of sparks, and do not yield to treatment.

Blood vessel Formation in the Vitreous. Observation with the ophthalmoscope has occasionally revealed the formation of new blood vessels in the vitreous, and their presence is presumptive evidence of a previously existing inflammation of that body or of former hemorrhages. Becker relates that lie observed them in a case of purulent infiltration of the vitreous, while Hirschberg has seen them it) connection with specific disease of the eye. They start from the nerve head, which they partly obscure, and pass forward into the vitreous as a more or less well formed veil of freely communicating capillaries, without, however, having any connection with the vessels of the, retina (Fig. 256).
Entozoa in the Vitreous. Two distinct parasites have been found in the vitreous of the human eye the cysticercus cellulose and the filaria sanguinis¬ hominis (Manson)

The former, while rare, has been seen most frequently in North Germany. It is the scolex of the tenia solium, the eggs of which, having obtained entrance into the stomach, find their way into the blood channels, whence they are carried to the eye and deposited under the retina. In the course of its development it is provided with hooklets, by means of which it perforates this tunic and is set free in the vitreous. Here it may appear encysted in a membrane which will mask its distinctive characteristics and prevent a correct diagnosis. If, however, it is quite free, it is of a pale, greenish blue color, having a short neck surmounted by a round head ornamented with minute suckers I which may be seen to move in undulating lines.

Von Graefe attempted the removal of a cysticercus through an incision, following his method of the extraction of a cataractous lens. After delivery of the lens he passed a blunt hook into the vitreous, and by alternately ad it toward the entozoon and then withdrawing it, he succeeded in delivering the parasite, without, however, restoring vision.

The filaria sanguinis hominis in the human eye is of such rare occurrence that it requires only passing mention.

of the Vitreous. The vitreous is subject to degenera changes which produce a shrinkage in its volume, thus removing it from direct contact with, and support of, the limiting membrane of the retina. As is readily seen, this condition is followed by detachment of the retina and loss of vision. The author has enucleated a painful atrophied eyeball in which this condition was beautifully illustrated. The vitreous bad shrunken to half its size, and was closely enveloped by the retina, and consisted of bands of connective tissue stretching from the nerve head to the posterior surface of the lens. This condition results from inJury to the vitreous, followed by choroiditis and hemorrhage, or from extensive posterior staphyloma. The treatment is enucleation.

Fatty Degeneration of the Vitreous. Under this heading Dr. D'(Ench and Dr. Valk have reported cases the diagnostic features of which seem to resemble those described by Iwanoff and called by him fatty degeneration of the stroma and cells of the vitreous.

The ophthalmoscope furnishes a picture of' numerous white, glistening spots very evenly distributed throughout the vitreous, and having slight motion when the eye is moved not, however, an independent motion, but one, seeming to depend upon the quivering or tremulousness of the normal vitreous when the eye is quickly moved in any particular direction. Iwanoff does not regard this condition as a pathologic change, but a quasi physiologic state due to senile decay. The vision is slightly reduced, but not to an extent requiring special treatment, further than the correction of any existing error of refraction.

Persistent Hyaloid Artery. The hyaloid artery (an extension of the central artery of the retina) during fetal life passes from the optic nerve head forward across the vitreous body, sometimes terminating in the vitreous and sometimes extending as far forward as the posterior surface of the lens. It occupies a canal (the canal of Cloquet), which, with the artery, shrivels tip and disappears about the sixth month of gestation. (See page 24.)

In exceptional cases, however, it remains, and, according to De Beek, may be seen floating in the vitreous in one of the following forms: a filamentous strand attached to the disk, the free end floating in the vitreous; a strand attached to the lens, and the end floating in the vitreous; a strand attached to the disk, and a like strand to the posterior surface of the lens, each terminating in the. vitreous a strand passing across the vitreous and attached to the disk and the lens a distinct vessel containing blood, passing entirely across the vitreous ; and the canal of Cloquet, not containing any vessel.

The remains of this artery are also sometimes seen as irregular minute bodies on the surface of the disk, and its vestigial remains doubtless produce that variety of congenital cataract called posterior capsular cataract (page 389) when situated on the posterior surface of the lens. (Consult Figs. 137, 138 on pages 190, 191.)

Back to Resources