Glaucoma

“ Returning to the 17 cases in which the angle of the chamber was closed, and to certain other eyeballs in which it seemed probable that glaucoma had at some time been present, we found that in every one of them one or other of the accepted causes of secondary glaucoma was revealed when looked for; in some, more than one such cause was discoverable. We shall content ourselves with enumerating these factors. ”

“ Glaucoma.—According to Elliott glaucoma is very much more common in the East than in Europe. He states that simple chronic glaucoma is extraordinarily common in India. Often the only symptoms are retraction of the field, cupping of the disc and at a later stage impairment of the central visual acuity. He notes that the advancement of the disease is often as unobtrusive as it is relentless. These patients often only present themselves at the clinic in the late stages of the disease ”

“ Certain forms of glaucoma may be inherited, and children whose parents have had this disease should watch their own eyes very carefully, since, if taken in time, the progress of this disease, in certain forms, may be arrested. Persons who see rings around the lights should heed the danger signal and see an oculist. ”

“ The early pain may be ascribed (1) to injury to the nerves of the ciliary body and iris, especially when the laceration of those structures is considerable, as our clinical experience and our specimens alike show it sometimes is; (2) to hæmorrhage from the vessels of the ciliary body, the iris, the choroid or the retina: such hæmorrhage may produce pain in two ways— (a) by dissecting up sensitive structures, and (b) by increasing the tension of the eye; and (3) to the rapid production of early glaucoma. There are several ways in which we may conceive that such a glaucoma might be produced. ”

“ At this point he stopped the treatment against my advice, and I have not seen him since. He was greatly helped by the universal swing, which he practiced all day. The truth about glaucoma is that it is a functional neurosis caused by strain, and as such is curable. You can produce hardness in a normal eye by having the patient strain to see (see page 2) , and you can soften a glaucomatous eyeball by relief of strain. These changes are so rapid that no change in the contents of the eyeball could account for them. ”

“ Glaucoma is in every case incurable. Suffusion may indeed be cured, but not always. We may try to cure suffusion before the disease is completely formed, by taking blood from the arm, by purging and acrid clysters, such as those made from the decoction of centaury, or of the bitter cucumber, and by keeping the bowels for some time in a loose state. Cupping instruments with scarifications may be applied to the hind-head; the patient must drink water during the whole regimen, take attenuant food, and, in process of time, masticatories may be used for a few days with advantage. ”

“ Gaps occur in the elastic membrane which become covered by endothelium. Some cloudiness may be seen in the corneal lamellae adjacent to these fissures, in some cases due evidently to the filtration of aqueous humor through defective endothelium. Prolonged high intra-ocular tension may be accompanied, particularly in cases of secondary glaucoma, by vesicular and bullous keratitis.
In acute glaucoma the sclera appears to be edematous and slightly thickened. As the disease progresses the sclera becomes denser than normal. ”

“ Since then I have used the same treatment in many cases, and I have never seen one in which the pain and tension could not be relieved in a few minutes by palming, while permanent relief was obtained by more prolonged treatment.
One of the worst cases of glaucoma I ever met with came to me on Feb. 2, 1920. The patient was sixty years of age, and his vision in the right eye or better eye was only 20/100, with marked contraction of the field on the nasal side. In the left he had only light perception. ”

“ I believe that in the management of a case of glaucoma, whether it be chronic or chronic with sub-acute exacerbations, the greatest care with the aid of an expert clinician must be exercised to find out exactly what mean pressure of the arterial and venous system best conforms with the patient's general welfare, and I am bitterly opposed, and I think with right, to the sudden reduction of tensions, except in emergencies, without a perfect understanding of the facts I have ventured to indicate. ”

“ Only a few years ago the literature of glaucoma was big with discussions of the comparative value of the surgical and non-surgical treatment of glaucoma, and especially of the chronic types of this disease. Now, thanks to the achievements of Lagrange, Fergus, Herbert and Elliot, the value of a filtering cicatrix, although known for a long time, has attained increased importance, due to the improvement and elaboration of operative technic, and the medical journals of the day are weighted with [Pg 62] opinions and experiences from all over the world as to these surgical measures. ”

“ A rise of the general vascular tension alone will not cause glaucoma, because any alteration in intra-ocular pressure resulting would be purely a temporary change, easily taken care of by the extensive access of aqueous to the intra-ocular venous system. ”

“ Glaucoma, another potentially blinding eye disease, can be controlled when detected early. Approximately 3 million Americans suffer from this disease, which strikes silently often without pain or noticeable symptoms. Especially at risk are African Americans age 40 and older and all people age 60 and older. ”

“ A characteristic of this condition is increase of the intra-ocular tension, which has a deleterious effect on the optic nerve end and its ramifications in the retina. The cause of the rise of tension is partly congestive, partly mechanical. The effect of glaucoma, when untreated, is to cause ever-increasing loss of sight, although the time occupied by the process before it leads to complete blindness varies within such extraordinary wide limits as from a few hours to many years. ”

“ Where the iris tissue lies in contact with the cornea, the stroma of the iris almost totally disappears. In some cases the iris becomes totally adherent to the cornea.
Ciliary Body and Chorioid. In acute glaucoma there is congestion of the entire uveal tract, the congestion partaking more of a venous stasis than of an active or arterial congestion. The vessels of the [Pg 46] ciliary process, which are larger and more tortuous in adults of advanced years than in the young, become enormously distended, causing almost complete obliteration of the perilental space. ”

“ All are agreed as to the essential feature of the malady, namely, increased tension of the eye ball, but every case of increased tension of the bulb is not recognized as glaucoma, and the true cause of the persistent and progressive increase of pressure in cases recognized as glaucoma is not absolutely settled. ”

“ Any process that increases the volume of the contents of the vitreous chamber, as hemorrhage, neoplasm, profuse serous or plastic exudation, may by pushing iris and lens forward produce an attack of acute glaucoma.
Buphthalmos. Reis (Graefe's Arch. f. Ophth. V. LX. 1905) states that there is always obliteration of the anterior scleral venous channels (Schlemm's canal) in buphthalmos. Seefelder (Graefe's Arch. V. LXIII. 1906) mentions the abnormal position and abnormal narrowing of Schlemm's canal and the imperfect and insufficient differentiation of the cornea-scleral junction. ”

“ At the public library he collected a half-dozen books treating of blindness, and selected his particular malady. He picked out glaucoma, and for his purpose it was admirably suited. For, so Jimmie discovered, in a case of glaucoma the oculist was completely at the mercy of the patient. Except to the patient the disease gave no sign. To an oculist a man might say, "Three nights ago my eyesight played me the following tricks," and from that the oculist would know the man was stricken with glaucoma ”

“ Panas and Duvigneaud have assumed rightfully that “If the nervous mechanism of intra-ocular secretion or, to speak without hypothesis, the action of the nervous system on intra-ocular tension can be known, the pathology of glaucoma will be cleared up, iridectomy will be explained, and perhaps a new and scientific basis for the treatment of glaucoma will be established.” Many observers have sought to solve the problem. Donders attributed the hypertension to a neuro-secretory cause and believed 261the trigeminus to be the agent of excessive secretion. ”

“ The chief lymph stream flows from the posterior chamber past the margin of the lens, through the zonula of Zinn, beneath the iris, through the pupil into the anterior chamber, thence through the tissue at the junction of the iris and sclera into the circular canal of Schlemm and from this space into the external lymph channels. Obstruction to the steady escape of the intra-ocular fluids at any point in this drainage system or any undue increase of the fluids themselves may [Pg 103] produce glaucoma. ”

“ Experimentally the eyeball can be made to burst by tying all the venous outlets from it. I have seen very high intra-ocular tension develop in a few hours after general thrombosis of the orbital veins. The absence of the canal of Schlemm is noted in congenital buphthalmos. The enlargement of the anterior perforating veins is an old symptom of chronic glaucoma. ”

“ The arrangement of the arteries at the disc, passing out as they do from the nasal side, of necessity make the vessels that pass to the temporal part of the retina longest and of less caliber. These vessels and their terminals are first to suffer marked diminution in size; death of the perceptive elements supplied with nutrition by these vessels follows. For this reason the nasal part of the field of vision is more often the first to disappear. In [Pg 49] congestive (inflammatory) glaucoma, the typical field of vision shows most marked contraction on the nasal side. ”

“ She said that I had worked a miracle; but I explained that when she used her imagination she had to relax enough to relieve the strain in her eyes, and that had stopped the pain.
We often hear the remark, "This person makes me sick," or "That person makes me nervous," but it remained for my glaucoma patient to make me realize that these observations are literal statements of fact. ”

“ After needling the lens in young people I have seen a rise of intra-ocular tension to 50 and 60 mm., maintained for many days, with considerable general deep hyperemia, and soreness of the globe, followed by gradual return to normal tension, and no permanent impairment of vision or the visual field.
One other type may be mentioned. That of an elderly patient with marked vascular disease, often renal involvement, and distinctly impaired nutrition. There may be renal retinitis or retinal hemorrhages. The case may easily become one of hemorrhagic glaucoma. It may run a very chronic course. ”

“ In glaucoma of long standing the veins of the retina bend round the margin of the optic disc, and if the margin be unusually prominent they are lost sight of for some distance. This causes the portions of the veins in the optic disc to appear as if they were not the continuations of those in the retina. ”

“ About one-half of those who are blinded by injuries lose the second eye by sympathetic ophthalmia. It is a constant source of danger to those who retain an eye blinded by Sympathetic inflammation. injury. Blindness from this cause can be prevented by the removal of the injured eye, but unfortunately the proposal often meets with opposition from the patient.
Glaucoma is a disease which almost invariably leads to total Glaucoma. blindness; but in most cases it can be arrested by a simple operation if the case is seen sufficiently early. ”

“ Wood's system of therapeutics gives rise to an hypothesis as to why disease of the nasal accessory sinuses may be a factor in producing increased intra-ocular tension and why treatment directed toward obtaining free drainage from the sinuses gives good results in so many cases, especially if the relationship is recognized sufficiently early. "Glaucoma proper is essentially a damming or blocking of the drainage from the interior of the eye. ”

“ A point that we must never lose sight of is that the very great majority of these patients are in the glaucoma period of life, and with a certain number of them very little alteration of the status quo is required to precipitate an attack of pathological high tension. If we take all these factors into account, and especially if we bear in mind the great variability that different patients present in their sensibility to pain, we shall have little difficulty in understanding that couching may sometimes be followed within the first few hours by great suffering attended with vomiting. ”

“ VOLUNTARY PRODUCTION OF EYE TENSION A SAFEGUARD AGAINST GLAUCOMA It is a good thing to know how to increase the tension of the eyeball voluntarily, as this enables one to avoid not only the strain that produces glaucoma, but other kinds of strain also. ”

“ The increased tension is supposed to be due to an excess of fluid in the eyeball, and this is commonly attributed to an impeded outflow. The aqueous humor, which is secreted very rapidly, is supposed to escape at the angle formed by the junction of the iris with the cornea, and in glaucoma it is believed that the iris adheres to the cornea so that the angle is obstructed. ”