The Reflexes of the Fundus Oculi

The fundus reflexes reveal, in a manner not yet completely understood, the texture and contour of the reflecting surfaces and the condition of the underlying tissues. In this way they may play an important part in the biomicroscopy of the eye. The physiological reflexes are seen at their best in the eyes of young subjects, in well-pigmented eyes, with undilated pupils and with emmetropic refraction. Their absence during the first two decades, or their presence after the forties, their occurrence in one eye only, their appearance, disappearance or change of character should suggest the possibility of some pathological state. The investigation and interpretation of the reflexes are notably assisted by comparing the appearances seen with long and short wave lights such as those of the sodium and mercury vapour lamps, in addition to the usual ophthalmoscopic lights. Most of the surface reflexes disappear in the light of the sodium lamp, sometimes revealing important changes in the deeper layers of the retina and choroid. The physiological reflexes, chiefly formed on the surface of the internal limiting membrane, take the forms of the familiar watered silk or patchy reflexes, the peri-macular halo, the fan reflex in the macular depression and the reflex from the foveal pit. The watered silk or patchy reflexes often show a delicate striation which follows the pattern of the nerve-fibre layer, or there may be a granular or criss-cross texture. Reflexes which entirely lack these indications of “texture” should be considered as possibly pathological. This applies to the “beaten metal” reflexes and to those formed on the so-called hyaloid membrane. The occurrence of physiological reflexes in linear form is doubtful, and the only admittedly physiological punctate reflexes are the so-called Gunn's dots. Surface reflexes which are broken up into small points or flakes are pathological, and are most frequently seen in the central area of the fundus in cases of pigmentary degeneration of the retina or after the subsidence of severe retinitis or retino-choroiditis. A mirror reflex from the layer of pigmented epithelium or from the external limiting membrane is sometimes recognizable in normal eyes, especially in the brunette fundus. In such, it forms the background to a striking picture of the fine circumfoveal vessels. Pathological reflexes from the level of the pigmented epithelium or of the external limiting membrane are also observed, and these often present a granular, frosted or crystalline appearance. They may indicate a senile change, or result from trauma or from retino-choroidal degeneraion. Somewhat similar reflexes may sometimes be present as small frosted patches anterior to the retinal vessels. Linear sinuous, whether appearing in annular form, as straight needles, as broader single sinuous lines, as the tapering, branched double reflexes of Vogt, or in association with traction or pressure folds, in the retina, are probably always pathological. By the use of selected light of long and short wave lengths, it can be shown that intraretinal or true retinal folds may exist with or without the surface reflexes which indicate a corresponding folding of the internal limiting membrane. On the other hand, superficial linear reflexes of various types may occur without evidence of retinal folding. Annular reflexes usually accompany a rounded elevation of the retina due to tumour, hæmorrhage or exudate, but may indicate the presence of rounded depressions; traction folds occur where there is choroido-retinal scarring, or in association with macular hole or cystic degeneraion at the macula; pressure folds in cases of orbital cyst, abscess or neoplasm; and the other linear reflexes in association with papillo-retinal œdema, for example, in retrobulbar neuritis, in hypertensive neuro-retinitis, in contusio bulbi and in anterior uveitis. Punctate reflexes, other than Gunn's dots, are also pathological. They may occur as one variety of “fragmented” surface reflexes, or as evidence of the presence of some highly refractile substance, such as cholesterin or calcium carbonate, in a retinal exudate or other lesion. It is characteristic of the pathological reflexes that they come and go and change their character according to the progress of the pathological condition. The linear reflexes in particular may change from one from to another, and may be finally transformed into surface reflexes of physiological character.