ONTARIO MEDICAL ASSOCIATION. 
Report of the Committee on 
Ophthalmology, 
I882. 
TORONTO : 
Dudley & Burns, Colborne Street, 
1882. REPORT ON OPHTHALMOLOGY.* 
A. M. ROSEBRUGH, M. D. TORONTO. 
Chairman of Committee. 
The ophthalmoscope was invented in 1851. Von 
Grsefe commenced his brilliant career the same 
year, or the year previous. In 1854 Von Grsefe 
and Donders established the “Archives fftr 
Ophthalmologie,” and in i860 Prof. Donders pub- 
lished his great work on “ Accommodation and 
Refraction.” About the same time Snellen con- 
structed his “Test Types.” In 1865 Von Grsefe 
discovered that iridectomy will relieve intraocular 
pressure in glaucoma; and in 1867 he gave the 
world the modern operation for hard cataract. 
The invention of the ophthalmoscope, then, may 
be said to mark the commencement of a new era in 
ophthalmic medicine and surgery. We will not 
pause even to enumerate the pathological con- 
'Head before the Ontario Medical Association, June, 1882. ditions that may be observed with the eye mirror. 
We may say in general terms, however, that, with 
the exception of the ciliary processes, and a narrow 
zone of the anterior expanse of the retina, all the 
structures of the inner eye, with the aid of the 
ophthalmoscope, are brought under the eye of the 
observer. Except in a few cases where the disease 
has no ocular expression, the ophthalmoscope 
enables us to find a cause for all forms of blindness 
formerly called amaurosis and amblyopia. The 
ophthalmoscope is also a valuable aid in diagnosing 
diseases of nervous centres, as, for instance, coarse 
disease of the brain ; and quite recently the oph- 
thalmoscope has been recommended as a means 
of diagnosing diseases of the inner ear. 
The treatise of Prof. Donders, of Utrecht on the 
optical defects of the eye, which appeared in Hol- 
land in i860, and which was afterwards translated 
and published by the New Sydenham Society, is 
still a standard text-book. In the choice of spec- 
tacles, Donders’ great work is the foundation of 
our therapeutics. Donders was enabled to elimin- 
ate the variable from the fixed refraction of the eye, 
and discovered, first, that presbyopia is not a 
refractive error, but is simply a gradual lessening 3 
of the focal adjusting power, or accomodation of 
the eye, and usually commences as early as at the 
age of 15 years ; secondly, that in the original 
structure of the globe, the antero-posterior diameter 
of the eye may be elongated or shortened, causing 
(practically) excessive or deficient refraction, and 
called respectively myopia and hyperopia ; thirdly 
that the refraction of the different meridians of the 
eye may be unequal. Thus, in the vertical meridian, 
for instance, the refraction may be normal, while 
the horizontal meridian may be either myopic or 
hyperopic, and that this condition called astigmat- 
ism, may be simple, or it may be complicated with 
myopia or hyperopia. For paralyzing the accom- 
modation, Bonders dropped into the conjunctival 
sac a few drops of a solution of atropine, 4 grs. to 
the ounce. He also demonstrated that errors of 
refraction are factors in the causation of strabismus, 
—that fully 75 per cent, of cases of convergent 
strabismus are caused by hyperopia, that a large 
number of cases of divergent strabismus are due to 
myopia, and that the developement of the strab- 
ismus may be arrested by the early correction of 
the optical defect by the use of suitable spectacles, 
and also that after a tenotomy has been performed the wearing of the spectacles is often necessary to 
prevent a relapse of the deformity. More recently, 
it has been satisfactorily demonstrated that the 
irritation arising from uncorrected errors of refrac- 
tion may cause various eye troubles, such as 
phlyctenular inflammation of the cornea, or con- 
junctiva, blepharitis marginalis, neuro-retinal con- 
gestion, &c. 
Ophthalmology has been wonderfully advanced 
by the adoption of Standard Test Types. The 
average acuteness of vision in the visual line—that 
is, at the fovea centralis retinae is taken as of a 
degree. Capital letters, varying in size from to 
4 inches in length, printed on a large card are so 
constructed that the diameter of the perpendicular 
stroke of each series of letters shall subtend an angle 
equal to of a degree, when viewed from a fixed 
distance designated: thus, No. 15 should be seen 
distinctly at 35 feet, No. 20 at 20 feet. No. 100 
at 100 feet, and so on. When a patient can dis- 
tinguish, say No. 20 at 20 feet, his vision is con- 
sidered normal, and it is indicated by the fraction 
f or unity. If, however, he can only distinguish 
No. 10 at 200 feet, his vision would be expressed by 
the fraction r^0T — that is, the distance at 
4 which the letters are actually seen divided by 
the distance at which the letters might be seen 
with normal vision gives the fraction of acuity of 
vision. In modern ophthalmology, in addition to 
making a careful record of the acuteness of vision 
in the visual line, note is also made of the field of 
vision. This may be clouded or completely 
obliterated in certain directions, and may be caus- 
ed by detachment of the retina, haemorrhagic 
effusions, tumours, &c. Before giving a favourable 
prognosis in cataract cases, the extent of the visual 
field is carefully examined. In certain cases 
colour tests are also used, as it has of late been 
demonstrated that colour blindness may be an 
acquired lesion. In tobacco amaurosis, for in- 
stance, a seaman or a railroad man may be able to 
attend to his ordinary duties, but fail to distinguish 
between a red and a green signal. Hence such 
persons should be examined periodically for colour 
blindness. 
5 
We are indebted to Von Grsefe for the modern 
treatment of glaucoma. He had noted the fact 
that iridectomy reduces the normal tension of the 
eye. When, therefore, it was subsequently dis- 
covered, by the combined aid of the ophthalmos- 6 
cope and pathological examination, that glaucoma 
is caused by excessive intraocular pressure, Von 
Grsefd immediately tried the effect of iridectomy 
in relieving the intraocular pressure, and gave to 
the world a cure for an hitherto incurable disease. 
During the last 15 or 20 years, a complete 
revolution has taken place in the treatment of 
cataract. By the combined use of the ophthal- 
moscope and oblique illumination, the different 
varieties of cataract can be differentiated, and the 
state of the development of the opacity accurately 
ascertained. With facilities for making an accurate 
diagnosis, improved operative procedures, and 
with the judicious adaption of the operation in 
each case, the results of treatment are at least as 
satisfactory as in any other class of surgical cases. 
Statistics have been collected of 11,000 cases of 
hard cataract treated by the old “ flap ” operation 
previous to 1868 ; and of 11,000 cases treated by 
the modern operation,—showing that with the 
former there was a total loss of sight in 16.7 per 
cent, of the cases, and with the latter operation the 
total loss was 6.5 per cent.; still further that of 
1,000 cases of hard cataract operated upon by 
Von Grsete between 1865 and 1869, the total loss 7 
was less than 3 per cent. In the modern operation, 
for which we are indebted to Von Grsete, the 
triangular Beer’s Knife and the semicircular cor- 
neal flap are discarded, and a narrow knife and a 
straighter and more peripheral cut substituted. 
The cut is made more nearly in the direction of a 
great circle of the globe, and a sector of the iris is 
removed, so as to facilitate the extrusion of the 
lens, and prevent prolapse of the iris. This oper- 
ation of Von Graefe—called the “ modified linear ” 
—is considered the classic operation for the ex- 
traction of hard cataract, but it is more or less 
modified according to the individual preference of 
the operator. Some, like Dr. Wecker, make the 
flap wholly in the sclero-corneal margin, make a 
very small iridectomy and divide the capsule only 
at the periphery, or even remove the lens and 
capsule entire. Dr. Coleman, of St. John, N.B., 
makes an iridectomy two or three weeks before the 
extraction, and subsequently divides the capsule 
with the corneal knife simultaneously with making 
the corneal section. It is, prehaps, almost un- 
necessary to state, that the old operation of “couch- 
ing,” or pushing the lens back into the vitreous, 
has been completely abandoned, as it was found 8 
that fully 50 per cent, of the cases thus treated were 
ultimately lost from destructive inflammation. 
The treatment of strabismus and paralysis of 
ocular muscles in late years has been modified and 
improved. By the operation called “ layering for- 
ward,” the insertion of a weakened muscle is 
advanced nearer the cornea. Tenotomy of a con- 
tracted muscle is performed subconjunctivally. A 
conjunctival suture is used to modify the effect of 
an operation, and prismatic spectacles are used to 
relieve diplopia and muscular strain. In treating 
paresis of ocular muscles it is now recommended 
to perform an early tenotomy of the secondarily 
contracted antagonist before electricity to 
the paretic muscle. 
With the modern improved methods of preparing 
tissue for the microscope, there has been an 
advance in our knowledge of the normal and 
pathological histology of the eye, but we cannot 
stop to particularize. Quite recently the extraord- 
inary discovery has been made that in the living 
retina there is secreted a photo-chemical matter, 
called “visual purple,” which is bleached in a bright 
light, and re-secreted in the dark. It is said to be 
an albuminoid secretion, confined to the layer of 9 
rods, and is believed to be a conservative element 
which enables the eye, in conjunction with the iris, 
to adapt itself to variations in the intensity of the 
light. 
An advance has been made in our knowledge of 
the etiology of glaucoma. The prominent symp- 
tom in glaucoma is excessive intraocular tension. 
The eye is hard and unyielding. Until recently, 
this condition was supposed to depend upon hyper- 
secretion of the choroid. It is now known that 
this is not necessarily the case, and that the loss of 
equilibrium of intraocular pressure may be caused 
by any interference with exosmosis or fi tration from 
the eye, that pressure from the peripheral part of 
the iris against Fontana’s spaces and Schlemm’s 
canal—at the so-called “ iritic angle,”—causes 
glaucoma, not from any increase in the secretion 
from iris or choroid, it is claimed, but by mechani- 
cally interfering with exosmosis or filtration through 
the trabeculae of the anterior scleral ring. Iridec- 
tomy, or the removal of about \ of the iris, was 
supposed to relieve the intraocular pressure by re- 
moving a large secreting surface, but its action is 
now believed to depend partly upon the removal of 
pressure at the iritic angle, and partly upon filtra- tion being favoured by the cicatrix, in the anterior 
scleral ring. 
The construction of the ophthalmoscope has been 
greatly improved of late years. The form now in 
gene al use is Knapp’s and Loring’s. A disc is 
secured behind the mirror which can be rotated, 
and which carries a series of very small convex and 
concave lenses behind the central aperture of the 
mirror. By this convenient arrangement any 
optical defect either in the eye of the observer, or 
in the eye under observation, is counterbalanced. 
By suspending the accommodation and rotating the 
lenses behind the mirror, the latter being brought 
close to the eye under observation, the refract- 
ion can be, at least approximately determined, and 
by this method alone it is possible to prescribe the 
proper correcting spectacles; but this method of ex- 
amination is rather resorted to for the purpose of 
confirming the result of the examination made with 
the test types and trial glasses,—with or without 
paralyzing the accommodation. 
Among the operative procedures which may be 
said to be on trial may be mentioned optico- 
ciliary neurotomy as a substitute for enucleation; 
sclerotomy as a substitute for iridectomy in certain forms of glaucoma, and Loring’s discission of the 
iris for closed pupil after cataract operation as a 
substitute for Dr. Wecker’s scissors-operation (irit- 
omy). 
Eserine is being substituted for atropine in con- 
nection with cataract operations, and in the after 
treatment of extraction, the eye is now less inter- 
fered with than formerly. If there is no oedema of, 
or discharge from between the eyelids, it is now 
advised to keep the eye closed for about seven days 
after the operation. For the removal of chips of 
iron or steel from the interioi of the eye, the per- 
manent magnet is giving place to the more powerful 
electro-magnet. 
Antisepsis, which has proved a boon in general 
surgery, has been tried in ophthalmic surgery, but 
not with encourging results ; and, moreover, the 
practical difficulties in the way of carrying out 
strictly antiseptic treatment in ordinary eye opera- 
tions, seem to be almost insurmountable. The eye 
is, however, sponged with antiseptic solutions before 
and after important operations, all instruments before 
use are made absolutely clean, or even dipped 
in an antiseptic solution, and caution is used to 
prevent the infection of wounds from blenorrhoea 12 
of the lachrymal sac, the discharges from trachoma, 
&c., and where atropine or eserine is used continu- 
ously for some time, it is considered advisable that 
these salts (which, by-the-way, should be quite 
neutral) should be dissolved in a two or three per 
cent, solution of boracic acid. Boracic acid solu- 
tion are also used in cases where there is purulent 
discharge, and boracic acid in powder has recently 
been used, and apparently with good effect, in 
cases of purulent conjunctivitis. 
Among the new remedies recently introduced 
into ophthalmic practice, duboisia and homatropine 
dilate the pupil, while eserine and pilocarpine con- 
contract it. Duboisia can be substituted for 
atropine in the exceptional cases where the latter is 
found to irritate the conjunctiva. Atropine is the 
most reliable for dilating the pupil in plastic iritis. 
It also acts as an anodyne to the sensitive nerves of 
the iris and cornea. But it is contra-indicated where 
there is a tendency to glaucomatous complications, 
or in serous iritis, on account of its tendency to 
increase intraocular tension ; in the latter case, 
homatropine is substituted for the atropine. In 
cases where it is simply desirable to dilate the 
pupil temporarily, as, for instance, for an ophthal- 13 
moscopic examination, homatropine, used in a 
weak solution, will dilate the pupil without paralyz- 
ing the accommodation,and its effect upon the pupil 
is more transitory than that of atropine. Used in 
stronger solutions, say 5 or 6 grains to the ounce, 
homatropine will paralyze the accomodation, 
and the paralysis is not nearly so persistent as it is 
after using atropine solutions. This is an advan- 
tage in favour of homatropine in treating anomalies 
of refraction. Eserine is used both for contracting 
the pupil and relieving intraocular tension. It is a 
valuable adjunct in the treatment of glaucoma, and 
in some cases may alone ward of an inflammatory 
attack. By relieving intraocular pressure, it is a 
valuable remedy in suppurative and ulcerative dis- 
eases of the cornea. Pilocarpine is not so power- 
ful a myotic as eserine, and is not so much used as 
a local application. Used hypodermically, how- 
ever, in or Yi grain doses, it acts beneficially 
upon scleral and episcleral disease, and is recom- 
mended for sub-retinal effusion and opacities of the 
vitreous. 
In cases of complete paunus of both cornse and 
as a last resort, purulent inflammation is artificially 
induced by inoculation with blenorrhoeal matter, preferably from a case of benign ophthalmia nean- 
atorum. Good results are obtained in many cases 
but the procedure is not a perfectly safe one, and 
it is moreover very difficult to obtain the matter 
from a healthy patient. It is now proposed to 
use an infusion of the seeds of Jequerity obtained 
from Brazil, where it is used for exciting purulent 
inflammation in cases of trachoma or true granular 
conjunctivitis. In using Jequerity the degree of 
inflammation produced, it is claimed, is more under 
the control of the surgeon. 
Electricity is used with advantage in ophthalmic 
practice. The faradic current is used in hysterical 
amblyopia, in muscular asthenopia and muscular 
paresis, in photophobia and twitching of the eye- 
lids and for promoting absorption of opacities of 
the vitreous. The galvanic current is used for 
paresis of occular muscles, phlyctenular and ulcer- 
ative keratitis and in incipient atrophy of the optic 
nerve, retina and choroid, as well as in chronic 
retinitis and choroiditis. Electricity is also used 
to relieve neuralgic pains in and around the orbit. 
Pagenstecher thinks massage occupies a very 
important place in ocular therapeutics. He uses 
either circular or radial friction of the eye with the 15 
finger against the closed lid, making very light and 
rapid motion. It is recommended in old corneal 
opacities, in pustular conjunctivitis, in scleritis and 
episcleritis. Pagenstecher prefers combining the 
massage with the use of oxide of mercury ointment, 
but claims very satisfactory results from the massage 
alone. 
The interest now taken in ophthalmology is 
quite remarkable. An International Ophthal- 
mological Association, which meets every four 
years, was established about twelve years ago, and 
many vigorous local societies are nowin operation. 
The American Ophthalmological Society numbers 
over 75 active members, and quite a large volume 
of transactions is published annually. There are 
now over one dozen journals devoted either exclus- 
ively or very specially to the advancement of this 
department of medical science. But, as we some- 
times say, “It never rains but it pours.” During 
the past 12 months four treatises on diseases of 
the eye were issued by the American press alone— 
one written by Dr. Noyes, of New York, one by 
Dr. Williams, of Boston, one by Dr. Schell, of 
Philadelphia, and onej.by Dr. Mittendorf, of New 
York.