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diff --git a/23544.txt b/23544.txt new file mode 100644 index 0000000..a60f23d --- /dev/null +++ b/23544.txt @@ -0,0 +1,2894 @@ +The Project Gutenberg EBook of Glaucoma, by Various + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Glaucoma + A Symposium Presented at a Meeting of the Chicago + Ophthalmological Society, November 17, 1913 + +Author: Various + +Editor: Willis O. Nance + Wesley Hamilton Peck + +Release Date: November 19, 2007 [EBook #23544] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK GLAUCOMA *** + + + + +Produced by Bryan Ness, Martin Pettit and the Online +Distributed Proofreading Team at http://www.pgdp.net (This +book was produced from scanned images of public domain +material from the Google Print project.) + + + + + + +GLAUCOMA + +A SYMPOSIUM PRESENTED AT A MEETING OF THE +CHICAGO OPHTHALMOLOGICAL SOCIETY, +NOVEMBER 17, 1913. + +EDITED BY + +WILLIS O. NANCE, M.D., + +PRESIDENT CHICAGO OPHTHALMOLOGICAL SOCIETY (1913); OPHTHALMIC +SURGEON, ILLINOIS CHARITABLE EYE AND EAR INFIRMARY; FORMER +OCULIST AND AURIST, COOK COUNTY HOSPITAL; EDITOR +JOURNAL OF OPHTHALMOLOGY AND OTO-LARYNGOLOGY, + +AND + +WESLEY HAMILTON PECK, M.D., + +PRESIDENT CHICAGO OPHTHALMOLOGICAL SOCIETY (1914); FORMER +PROFESSOR OPHTHALMOLOGY, CHICAGO EYE, EAR, NOSE AND +THROAT COLLEGE; ASSISTANT SURGEON, ILLINOIS +CHARITABLE EYE AND EAR INFIRMARY; +OPHTHALMIC SURGEON, OAK +PARK HOSPITAL. + +1914 +CHICAGO MEDICAL BOOK COMPANY +CHICAGO + + +COPYRIGHT 1914 +BY +CHICAGO MEDICAL BOOK COMPANY + + + + +CONTRIBUTORS + +EDWARD JACKSON, A.M., M.D. +Prof. Ophth. Univ. Colo.; Emer. Prof. Ophth. Phila. Polyclinic; Ex-Ch. +Sec. Ophth. A.M.A.; Ex-Pres. Am. Acad. Med. and Am. Acad. Ophth. and +Oto-Laryng.; Mem. Am. Ophth. Soc. and Honorary Mem. Chicago Ophth. +Society. + +JOHN ELMER WEEKS, M.D., D.Sc. +Prof. Ophth. Univ. and Bellevue Hosp. Med. Coll., N.Y.; Ophth. Surg. +N.Y. Eye and Ear Inf.; Mem. Am. Ophth. Soc.; Hon. Mem. Chicago Ophth. +Soc. and Royal Hungarian Med. Soc. Budapest. + +GEORGE EDMUND DE SCHWEINITZ, A.M., LL.D., M.D. +Prof. Ophth. Univ. Penn.; Ophth. Surg. Univ. Hosp., Phila. Hosp., +Orthop. Hosp. and Inf. for Nerv. Dis.; Consult. Ophth. Surg, Phila. +Polyclinic; Honorary Member Chicago Ophth. Soc. + +ROBERT HENRY ELLIOT, M.D., B.S. LOND., Sc.D. EDIN., F.R.C.S. ENG., ETC., +LIEUT.-COLONEL, I.M.S. +Supt. Gov. Ophth. Hosp., Madras. India; Prof. Ophth. Med. Coll., Madras; +Fellow Univ. of Madras; Honorary Member Chicago Ophthalmological +Society, U.S.A. + +CASEY A. WOOD, M.D., C.M., D.C.L. +Prof. Ophth. Univ. Ill.; Late Prof. Ophth. N. W. Univ.; Ex-Pres. Am. +Acad. of Med.; Am. Acad. Ophth. and of the Chicago Ophth. Soc.; +Ophthalmic Surg. St. Luke's Hosp.; Consulting Ophth. Surg. St. Luke's +and Cook County Hosp.; Ex-Ch. Ophth. Sec. A.M.A.; Editor System Ophth. +Therapeutics. Sys. Ophth. Operations and American Encylopedia +Ophthalmology. + +FRANCIS LANE, A.B., M.D. +Pathologist and Asst. Ophthalmic Surgeon Ill. Char. Eye and Ear Inf.; +Instructor in Ophth. Rush Med. Coll.; Asst, Ophth. Surg. Presbyterian +Hospital. + +E. V. L. BROWN, M.D. +Asst. Prof. Pathology of the Eye, Univ. Chicago; Asst. Prof. Ophth. Rush +Med. College; Ophth. Surg. Ill. Eye and Ear Inf. and Cook County Hosp.; +Mem. Am. Ophth. Soc. + +NELSON M. BLACK, PH.G., M.D. +Author of The Development of the Fusion Center in the Treatment of +Strabismus; Examination of the Eyes of Transportation Employes; +Artificial illumination a Factor in Ocular Discomfort, etc. + +FRANK C. TODD, M.D. +Prof. Ophth. and Oto-Laryng., Univ. Minn.; Chairman Sec. Ophth. A.M.A. +and second Vice-Pres. A.M.A.; Ophth. Surg. Univ. and Hill Crest +Hospital. + +ALBERT EUGENE BULSON, JR., B.S., M.D. +Prof. Ophth. Ind. School Med.; Ex-Ch. Sec. Ophth. A.M.A.; Ophth. Surg. +St. Joseph's Hospital; Editor Jour. Ind, Slate Med. Assn. + + + + +DEDICATED TO +DR. EDWARD JACKSON +DR. JOHN E. WEEKS +DR. GEORGE EDMUND DE SCHWEINITZ +LIEUTENANT COLONEL ROBERT HENRY ELLIOT +HONORARY MEMBERS +BY THE CHICAGO OPHTHALMOLOGICAL SOCIETY +IN RECOGNITION OF THEIR SPLENDID ACHIEVEMENTS +IN THE DOMAIN OF OPHTHALMOLOGY + + + + +ABSTRACTS. + + +I. Etiology and Classification of Glaucoma. + +Abstract:-- + +Etiologic factors include: obstruction of lymph spaces, especially the +angle of the anterior chamber; blood pressure, arterial, capillary and +venous; affinity of tissues for fluids; alterations of the intra-ocular +fluids; inflammations in the eye ball; and failure of a nerve apparatus +to control fluid in the globe. Classification: various types of glaucoma +constituting clinical entities must be recognised, as: simple glaucoma, +recurring exacerbations, congestive, mechanical, and increased tension +arising during uveal inflammations. + +DR. EDWARD JACKSON, Denver. + +Discussion by DR. FRANCIS LANE, Chicago. + + +II. Pathology of Glaucoma. + +Abstract:-- + +(a) Changes taking place in corneal tissue. + +(b) Iris angle with particular reference to the ligamentum pectinatum. + +(c) Variations in the condition of the ciliary body. + +(d) Consideration of the anatomical changes that take place in glaucoma +secondary to retinal and chorioidal hemorrhage. + +DR. JOHN E. WEEKS, New York City. + +Discussion by DR. E. V. L. BROWN, Chicago. + + +III. Concerning Non-surgical Measures for the Reduction of Increased +Intra-ocular Tension. + +Abstract:-- + +(a) The use of myotics; their preparation, method of administration, and +explanation of their action. + +(b) Reduction of increased intra-ocular tension by means of various +mechanical measures, notably massage, vibration massage, suction +massage, electricity and diathermy. + +(c) Indirect reduction of increased intra-ocular tension, brought about +by lowering the general vascular pressure. + +(d) The relation of osmosis, lymphagogue activity, the absorption of +edema, the stimulation of capillary contractility, and the lowering of +the affinity of ocular colloids for water in their relation to the +reduction of increased intra-ocular tension. + +DR. GEORGE EDMUND DE SCHWEINITZ, Philadelphia. + +Discussion by DR. NELSON M. BLACK, Milwaukee. + + +IV. Trephining for Glaucoma. + +Abstract:-- + +(a) The aim of the operation is the formation of a foreign-body-free +fistula. + +(b) It is most important to leave uveal tissue untouched. + +(c) Method of doing this explained. + +(d) The area available for trephining. + +(e) Method of increasing that area. + +(f) Cornea splitting. + +(g) Placing of trephine. + +(h) Technique of using trephine. + +(i) The operation is not difficult. + +(j) The operation valuable as a prophylactic measure. + +DR. ROBERT H. ELLIOT, F.R.C.S., Lieut.-Col. I.M.S., Madras, India. + +Discussion by DR. FRANK C. TODD, Minneapolis. + + +V. Operations Other than Scleral Trephining for the Relief of Glaucoma. + +Abstract:-- + +Most of the ordinary surgical procedures employed for lowering +intra-ocular tension furnish a permanent cure of certain fairly well +defined varieties of glaucoma. They also relieve the symptoms and retard +the progress of other varieties of the disease, even if they do not +perform a cure. In a third class of cases, they either have no effect +whatever in arresting the disease or they hasten its march towards +blindness. + +What operative procedure gives, on the whole, the best results? In other +words, what operation is the easiest of performance, is the least likely +to be attended by serious complications and is available for the largest +number of cases? Reasons for believing that of the better known +procedures simple iridectomy is the least effective, while those +interventions producing a large, thin, scleral filtration-cicatrix are +the most valuable. + +DR. CASEY A. WOOD, Chicago. + +Discussion by DR. A. E. BULSON, JR., Fort Wayne + + + + +Etiology and Classification of Glaucoma + +BY + +EDWARD JACKSON, M.D., + +Denver. + + +It is convenient to start with the conception that glaucoma is increased +tension of the eyeball, plus the causes and effects of such increase; +although a broad survey of the facts may reveal a clinical entity to be +called glaucoma, without increased tension constantly or necessarily +present, and cases of increased intra-ocular tension not to be classed +as glaucoma. + +The physiologic tension of the eyeball is essential to ocular +refraction, and closely related to ocular nutrition. Fully to understand +the mechanism for its regulation would carry us far toward an +understanding of the causes of glaucoma. Normal tension is maintained +with a continuous flow of fluid into the eye and a corresponding +outflow. Complete interruption of the nutritional stream would be speedy +death; partial interruption may be held responsible for most of the +visual impairment and pain of glaucoma. + +The balance of intra-ocular pressure is not maintained by the slight +distensibility of the sclero-corneal coat. Increased pressure does not +open new channels for the escape of intra-ocular fluid; if, indeed, it +does not tend to close the normal channels. + +The affinity of the tissues for water, or, as Fischer explains it, the +affinity of the tissue colloids for water, seems too little related to +the requirements of ocular function to furnish the needed regulation of +tension. The lymph spaces and blood-channels of the eye are large, as +compared with the mass of its tissue colloids. In these spaces and +channels must be sought a means for rapid response to the need for +regulation of intra-ocular tension. Fischer has shown, that when the +enucleated eyeball is placed in a weak solution of hydrochloric acid, +the swelling of the tissue colloids is sufficient in a few hours, to +burst the sclero-corneal coat. But this is an eye in which all +nutritional changes have ceased. He brings together many facts to +support the view that in the living tissues impaired circulation, and +especially diminished oxidation, are the chief causes of increased +affinity of the colloids for water. Such affinity increased by the +impairment of the intra-ocular circulation, may well constitute a factor +making for malignancy in glaucoma. But it can hardly explain the +original departure from a normal pressure balance. + +We must assume that intra-ocular pressure is kept down to the normal +limit, by the prompt response of a regulative mechanism, which +diminishes the flow of fluid into the eye, or permits its more rapid +escape, whenever fluid tends to accumulate in the eye and increase its +tension. + +Little has been done to show that increase of fluid entering into the +eye is the cause of glaucoma. A normal, or even a low arterial blood +pressure is sufficiently above the normal intra-ocular pressure to +furnish a source of increased fluid in the eye. Increased arterial +pressure has been found in a large proportion of cases of glaucoma; and +may be necessary to the production of the highest intra-ocular tension. +A sudden relaxation of the arterial walls, that would permit the +arterial blood pressure to make itself felt in the eye, might cause an +important rise of intra-ocular tension and may be a factor in the +etiology of acute attacks. It affords a possible mechanism through which +may be produced the recognized glaucomatous effects of certain nerve +disturbances. But such attacks are not commonly associated with +noticeable flushing of the head and face generally; and paralysis of the +cervical sympathetic is known to lower the intra-ocular tension. + +Capillary blood pressure must lie between the arterial blood pressure +and the venous blood pressure. It must be closely associated with the +nutritional processes like secretion or inflammation; beyond this we +know little about it. The association of increased blood pressure with +glaucoma seems to be generally an indirect one through vascular lesions +and disturbances of nutrition. + + +_Obstructed Outflow_ + +A reservoir with a free outlet can only fill during a flood; and then +quickly empties itself again. The outflow channels in the normal eye +provide for carrying away of the waste products of such an active +nutrition, that it is hard to think they will become inadequate in +glaucoma until there has been a marked decrease from their normal +capacity. Priestley Smith has pointed out that the glaucomatous eye +softens more slowly than the normal eye after enucleation, in spite of +the fact that a greater force is operating to drive fluid out of the +eye. In his recent tonometric studies Schoenberg noted that under +manipulation the glaucomatous eye softened more slowly than the normal +eye; and suggests this diminished drainage as an important evidence of +glaucoma. + +Obstructed outflow might begin in an abnormal tendency of the tissues to +retain fluid, a tendency that Fischer might locate in the colloids. The +increase of intra-ocular pressure noted in cases of uveal inflammation, +to be presently referred to, may be due to some such tendency. But it is +rational to ascribe to obstruction of the filtration angle of the +anterior chamber, the important part it has been supposed to play in the +pathology of glaucoma. However this obstruction may be brought about, +whether by thickening of the iris root during dilatation of the pupil, +pushing forward of the iris root by the larger ciliary processes of age, +or the enlarged crystalline lens pressing on the ciliary processes; or +by inflammatory adhesion of the iris to the filtration area; ballooning +of the iris, or its displacement by traumatic cataract; or adhesion to +the cornea after perforating ulcer in the secondary glaucomas; or +whether the obstruction is due to the accumulation of experimental +precipitates, as shown by Schreiber and Wengler, or possibly of pigment +granules into Fontana's space; or a process of sclerosis closing the +spaces by contraction of new-formed connective tissue, or the covering +over with proliferating implanted epithelium following injury opening +the anterior chamber; glaucoma follows impairment of this drainage +space, and lessened outflow through it. This blocking of the angle of +the anterior chamber must be regarded as an established fact in the +etiology of glaucoma. But because it is so definitely established, and +because so much work has been done with reference to it, we may attach +to it an undue importance. + +The escape of the outflow of fluid from the eye is ultimately through +the veins. The general venous blood pressure is so low (often negative +in the great veins of the neck during inspiration) that no obstacle can +come from it to the ocular outflow. The venous blood pressure permits +the eyeball to become perfectly soft. We have all seen tension of 5 mm., +or even less; and general venous pressure does not rise to the normal +intra-ocular tension. Increased intra-ocular pressure requires that +there must be some obstacle that keeps the intra-ocular fluid from +reaching the general venous system. This may be in the lymph drainage +system of the eye; but it may also be in the ocular veins themselves. + +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. +Obstruction to outflow of blood through the vorticose veins, by the +increased intra-ocular pressure, has long been a recognized explanation +of the malignant tendency of glaucoma--a part of the vicious circle +established in this disease. There is reason that we should give careful +attention to the views of Heerfordt and Zirm, that obstruction to the +venous outflow may be the effective cause of the disease. Zirm believes +the venous plexus of the choroid is an essential part of the mechanism +for the regulation of intra-ocular tension, the necessary vaso-motor +control depending on nerve centers situated in the iris. + + +_Nerve Control_ + +The accurate control of normal intra-ocular pressure, by mutual +adjustment of inflow and outflow of fluid, is scarcely conceivable +without some highly specialized, extremely sensitive nerve mechanism to +preside over it. This is suggested by analogy with the regulation of +secretion in the lacrimal, salivary, or peptic glands, or the +maintenance of blood pressure in the heart and arteries. Clinical +observations point the same way. Many patients connect their attacks +(especially their earlier ones of ocular discomfort, impaired vision, +haloes around the light, and dilated pupil) with social excitement, +anxiety, worry, anger or fatigue. A patient of mine gave up her card +parties, because an exciting game generally ended in blurred vision, a +rainbow around the light, and a dilated pupil, and sometimes an aching +eye. Another woman watching beside her dying husband and exposed to +extreme cold, had her first attack of glaucoma, so severe as to destroy +the sight of one eye. The other eye, also affected at the time, +recovered good vision, and has remained several years without a second +attack and without treatment. + +Laqueur's first attack occurred at the end of a long exhausting morning +in the operating room, with luncheon delayed two hours. The connection +of his later attacks with anger, worry, embarrassment, even the +excitement of watching a play at the theatre, was noted again and +again. In Javal's case, the attack fatal to one eye came at the +culmination of an exciting electoral campaign. The other eye was +stricken at the termination of the Dreyfus case, in which Javal was +intensely interested. There seems to be a special liability to glaucoma +among those residing at high altitudes, best explained by nerve +influence. The frequency of glaucoma among Jews may be due to a small +cornea, as suggested by Priestley Smith; but it is quite as reasonable +to connect it with a racial excitability or nervous instability. More +definite knowledge of the nervous mechanism concerned in the regulation +of intra-ocular pressure and the production of glaucoma is much needed. + + +_Alterations of Fluids and Tissues_ + +The influence of increased affinity of the tissues for fluid has already +been referred to. That a similar obstacle to the escape of fluid from +the eyeball might be due to a change of character in the fluid, is a +conception that has been entertained as a working hypothesis, and much +experimental and analytical work has been done to test its correctness. +This work has been so slightly related to practical ophthalmology, and +so contradictory in its results that alterations in the fluids can only +be regarded as a possible etiologic factor. Glaucoma secondary to +intra-ocular hemorrhage, operations on the lens or its capsule, or +severe nutritional disturbance may be capable of such explanation. + + +_Different Kinds of Glaucoma_ + +A better grasp of the etiology of glaucoma may be attained by +considering separately various types of cases; although perfectly +typical cases may be rare; and cases of mixed type and etiology much +more frequent. + +Simple glaucoma has been recognized as closely related to atrophy of the +optic nerve with deep excavation. No line of demarcation can be drawn +between them, except by reserving the term of glaucoma for cases that +depart from the pure type, terminating in glaucoma of some other kind, +which is no more significant than the passage of a conjunctivitis into a +keratitis, or an iritis into a glaucoma. Cases of simple glaucoma do run +their course of many years to complete blindness, or to death, without +exacerbations, inflammation, or characteristic pain. In such cases the +intra-ocular tension does not rise suddenly; and it may be little or not +at all elevated above the usual normal limit. + +For nine years I have watched the progress of such a glaucoma in a man +now aged 87, with slow development of glaucomatous cupping of the optic +disc, now more than 3 D. deep. The tension has never been noted at more +than Plus T (?), and when taken with the tonometer varied from 9 to 32 +mm. for the worse eye, and 13 to 24 mm. for the other. Similar cases in +which the tension lay within the commonly accepted normal limits have +been reported recently by Bietti and Stock. + +In the eye there is probably a normal equilibrium between blood +pressure, tissue activity, and intra-ocular tension. This may be +destroyed either by increasing the intra-ocular tension, or lowering the +tissue activity, or the blood pressure. Lowered blood pressure has been +suggested by Paton as an explanation of symptoms usually ascribed to +vascular obstruction. Rising blood pressure may be required in old age +to compensate for diminished tissue activity; and it is conceivable, +under normal intra-ocular tension, that diminished nutritional activity +may result in the same symptoms as are produced in other eyes by +increased tension. Glaucoma is probably not so much an increase of +tension as a loss of balance between intra-ocular tension and +nutritional activity. + +In contrast with the above are the cases marked by sudden elevations of +ocular tension recurring repeatedly over long periods without permanent +visual impairment. Laqueur's case continued of this character for six +years, under the use of miotics, and then was cured by iridectomy, the +cure remaining permanent with normal vision until his death after 30 +years. Millikin has reported the case of a patient who in five years had +"many hundreds" of attacks, in which vision was impaired, haloes +appeared about the light, the pupil dilated, the cornea became steamy, +and tension rose to plus T. 1 or plus T. 2. After iridectomy the attacks +ceased, leaving no pathological cupping of the disc, full vision, and a +good field. I have seen cases of this type in women under middle age, +and of marked nervous instability. + +A third type which will come to be more generally recognized, as the +tonometer comes to be more widely used, includes cases in which there is +little beside the increase of intra-ocular tension to justify their +mention in a discussion on glaucoma. A patient, then aged 21, suffered +three years ago from a scotoma almost central; and was first seen six +months after that with a macular choroidal atrophy and abnormal +pigmentation. She suffered, we afterwards concluded, from choroidal +tuberculosis. A recurrence involving adjoining choroid occurred fourteen +months ago. There was at the start pain, slight dilatation of the pupil, +and slight general hyperemia of the globe. The tension of the eyeball +rose to 60 mm., that of the fellow eye being 20 mm. Under miotics the +tension fell at first but slightly. It was 55 mm. at the end of a week; +but after two weeks came down to normal, 20 mm. A month later the +tension rose to 28 mm., but for a year has continued normal; the eye did +well under tuberculin treatment, and without any local treatment. In +September of this year I had two cases of iritis in which the +intra-ocular tension rose to 45 and 52 mm., respectively, and gradually +returned to normal, with the cure of the iritis under atropine. In one +of these cases, a lady of 70, I used atropine also in the other eye, +but the tension of that eye remained normal, 22 to 24 mm., throughout. +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. But it may become suddenly worse, or go on to complete blindness +with pain, demanding enucleation, after some temporary perturbation, as +the performance of a glaucoma operation. It is pre-eminently the kind of +a case you would prefer would go to some one else. + +Each of these types illustrate a distinct cause or group of causes. The +first type brings us near to what may be the essential nature of +glaucoma, impairment of ocular nutrition by the intra-ocular tension, +which is generally elevated, but may not be above the usual normal. A +special weakness in the nutrition of nerve tissue may be assumed. It +would help to explain the cavernous atrophy of the optic nerve +associated with simple glaucoma. The second type shows impairment of the +regulative mechanism permitting rapid rise of the intra-ocular pressure. +In persons of good nerve nutrition and strong recuperative power, it may +exist for years without doing permanent damage. But joined to causes of +the first type, lowered nutritive activity, it causes rapid and +permanent loss of sight. The third group are cases associated with +glaucoma only as causes. In eyes with low nutritive power, or subject to +exacerbations of increased intra-ocular pressure, uveal inflammations +may prove disastrous. The fourth type shows the results of the +combination of the causes of the other types; with the elements of acute +or slow malignancy added--the impaired circulation and lowered oxidation +producing some degree of edema of the tissues that insures a fatal +result. + +This is no complete presentation of my subject, but a selection of facts +bearing on the etiology, to serve as a foundation for the discussion of +those practical aspects of glaucoma which are to claim your attention +through the papers and remarks of subsequent speakers. + + + + +Dr. Edward Jackson's Paper on Etiology and Classification of Glaucoma + +Discussion, + +FRANCIS LANE, M.D. + +Chicago. + + +Not one of the theories thus far propounded to explain the essential +cause of increased intra-ocular tension is satisfactory. Our present day +knowledge apparently ceases with a more or less incomplete understanding +of the mere circumstance under which increase of tension in general +depends. + +The question of the source of the normal intra-ocular pressure must +first be solved before any discussion of a pathological increase can be +engaged in. This question primarily hinges on whether the corneo-sclera +is to be regarded as an unelastic capsule with a fixed volume, or as a +yielding envelope with an ever changing capacity. + +This brings us at once to the consideration of that theory which +probably has held our attention for the longest period of time, _i. e._, +the volumetric theory. According to it, the normal intra-ocular tension +depends on the volume of fluids within the eyeball. Any variation in the +quantity of the contents gives rise to a change in the pressure, +therefore, the globe has been regarded as "an elastic capsule, whose +capacity, form, and internal pressure depend on the balance struck +between a constant inflow, or formation of aqueous, and a proportionate +outflow or resorption." (Henderson.) + +Hill has satisfactorily demonstrated that, under physiological +conditions, the hydrostatic pressure within the eye and the skull is +identical; it rises and falls simultaneously; it is the same as the +cerebral venous pressure; it is constantly varying, depending directly +on the general circulation. Upon these findings Henderson based his +opinion that the physiological properties of the tunica fibrosa and the +skull are identical, realizing at the same time, that the rigidity of +the corneo-sclera, because of its fibrous nature, is not as firm as the +cranium. In accepting this belief the inference was that the cubic +capacity of both coverings is fixed. Applying these conclusions to the +eye, it can be said that the pressure of the fixed intra-ocular volume +varies with the venous tension within the bulb, which in turn is +influenced by the general circulation. Such a conception, while not +strictly in accord with recognized physiological teachings, proves that +the normal intra-ocular pressure is not a question of volume content, +but that it is purely a question of pressure of a fixed volume within an +unyielding capsule. Dr. Jackson virtually puts aside the volumetric +theory with his statement, that "the balance of intra-ocular pressure is +not maintained by the slight distensibility of the sclero-corneal coat." +Further discussion on the inadequacy of the volumetric theory need not +detain us. + +It is well to recall a few anatomical features because of their bearing +on the theories herein considered. + +1. The angle of the anterior chamber is a true angle and not an annular +sinus. + +2. The meshwork of the iris angle (ligamentum pectinatum), a cellular +structure at birth, undergoes a progressive and physiological fibrosis +with early subsequent sclerosis, until finally it becomes a fibrous +structure. The individual strands of this meshwork are more than two +times as large at advanced age as at birth, consequently the alveoli of +the meshwork becomes markedly reduced in size. + +3. The spongy nature of this meshwork affords free access of aqueous to +the venous sinus of Schlemm, thence by tributaries into the +supra-choroidal space and anterior uveal venous system. + +4. Fuchs's iris cripts afford direct access of aqueous to the veins of +the iris. + +Furthermore, two simple principles are taught by physics: Fluids are +incompressible and they seek the lowest hydrostatic level. The +application of these perfectly obvious principles to the eyeball makes +the intra-ocular pressure the same as that within the elastic venous +walls, which is the lowest circulating pressure within the bulb. + +To summarize: The aqueous has direct access to the anterior uveal venous +system; the physiological thickening of the strands of the meshwork of +the iris angle supplies a mechanical obstruction between the anterior +chamber and the venous sinus of Schlemm; intra-ocular pressure stands at +the same level as the intra-venous, consequently, the hydrostatic +pressure is the same on both sides of the iris angle meshwork, because +the canal of Schlemm is a secondary venous system; lastly, the outflow +of aqueous into the venous sinus is by diffusion, not by filtration, +because the pressure is the same on both sides of the meshwork. + +These facts and deductions have given rise to the present day +circulatory theory of intra-ocular pressure, so we now can approach the +predisposing and exciting factors which determine glaucoma. + +The central fact to be borne in mind is, if the physiological pressure +is vascular in origin and nature, the pathological pressure must +likewise be derived from the same source. + +Sclerosis of the meshwork of the iris angle is the predisposing factor +because it hinders free access of aqueous into the venous sinus of +Schlemm. Sclerosis alone, however, will not cause glaucoma so long as +access to the iris veins can keep the intra-ocular pressure at the +intra-venous level, and, too, as long as the exciting cause is absent. + +The exciting cause is vascular, maintained and influenced by the general +circulatory pressure. 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. When +these two factors coexist in their varying combinations, pathological +increase of pressure results--in short, glaucoma. + +Syphilis, rheumatism, gout, auto-intoxication and many other +constitutional disorders are well recognized agencies which induce +sclerosis in body tissues, so there can be little doubt that these +conditions produce pathological sclerosis of the meshwork of the iris +angle. Psychic disturbances, congested portal or renal system, hard +mental or muscular work, etc., etc., induce increased pressure of the +general circulation, and so simultaneously the intra-ocular pressure. + +According to the edema theory advanced by Fischer, glaucoma is +"essentially an edema of the eyeball, and for its production we must +hold responsible the same circumstances which are responsible for a +state of edema in any other part of the body." The magnificent +experimental work of this investigator has shown that edema is nothing +more or less than an increased capacity of the protein colloid tissues +for water; that the most important factor leading to this increased +hydration capacity is an abnormal production or accumulation of acid +content, effected by those agencies which are instrumental in causing +sclerosis and an increase of blood pressure. + +It seems that both of these theories afford an explanation for many of +the secondary pathological manifestations which characterize the +intra-ocular tissues during a glaucomatous onset. + +Fischer criticizes the Henderson theory on the ground that increased +blood pressure alone does not lead to edema--edema is thwarted by high +blood pressure. On the other hand, if Fischer believes that sclerosis of +the meshwork of the iris angle is a result and not a cause of glaucoma, +then it would seem that Henderson has the better of the argument. The +physiological changes in this structure, which take place with advancing +age, can rightfully be looked upon as a predisposing factor in glaucoma. + +Dr. Jackson has presented all other phases of this part of the +symposium in such a comprehensive manner that nothing further remains to +be said. + + + + +Pathology of Glaucoma + +BY + +JOHN E. WEEKS, M.D., + +New York City. + + +In reviewing the pathology of glaucoma it seems proper to consider the +various structures and tissues of the eye in logical order. + +_Lids and Conjunctiva._ "The only change observed in these tissues is a +reflex edema, excited apparently by pressure on the ciliary nerves and, +probably, irritation of the vaso-motor fibers of the sympathetic." + +_Lachrymal Gland._ Hyper secretion due to reflex irritation. + +_Cornea._ As has been shown by Priestley Smith, the cornea in +glaucomatous eyes is, as a rule, smaller than in non-glaucomatous eyes, +the mean of a series of measurements being 11.1 mm. horizontally and +10.3 mm. vertically in glaucomatous and 11.6 mm. horizontally and 11 +mm. vertically in non-glaucomatous eyes. In cases of considerable +increase of tension, particularly if the onset is sudden, the +circulation of lymph in the cornea is interfered with, the anterior +layers of the cornea become edematous, the spaces between the lamellae +filled with albuminous fluid. Some of this fluid finds its way through +Bowman's membrane, apparently by way of the minute channels which permit +the passage of small nerve twigs, and enters the epithelial cell layer. +The fluid finds its way between the epithelial cells in the deeper +layers, apparently being taken into some of the superficial cells by +imbibition. Some of the swollen surface cells open spontaneously and +discharge their contents, others drop off. The process causes a +roughening of the surface of the cornea and produces a faint haziness. +There is another form of haziness that develops on sudden rise in +tension and completely disappears on subsidence of the tension. This is +due, as has been shown by V. Fleischl (Sitzungsberichle d. Weiner Akad. +d. Wissensch, 1880) and others, to increased tension on the fibrillae of +the cornea, a double refraction being induced. In cases of long +continued increase of tension minute permanent vesicles form in the +epithelial layers, particularly in the superficial portion. Anaesthesia +of the cornea develops, due to pressure on the nerve fibers that are +distributed to the epithelium, the compression probably occurring along +the course of the long ciliary nerves, from which the corneal nerves are +derived, as they pass between the choroid and the unyielding sclera +(Collins & Mayou). + +In advanced cases of glaucoma after the congestive period has subsided +the cornea becomes somewhat condensed, the lymph spaces contracted; a +condition of sclerosis obtains. Alteration in the shape of the cornea +occurs only rarely in adult life. When it does occur it takes place in +corneae that have suffered from keratitis. The alteration is usually in +the form of ectasiae. In infancy and early youth (buphthalmia) the cornea +may become uniformly enlarged and globular. Often, however, the +enlargement of the cornea is irregular. Increase in tension may produce +fissures in Descemet's membrane. These occur more frequently in the +cornea that have suffered a change in shape, as in buphthalmos. 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. The oblique openings--passages for the venae vorticosae--are +said to be narrowed. The openings for the passage of the anterior +ciliary vessels are enlarged in many, particularly in advanced cases. +Minute herniae at these openings are sometimes present. Dilatation and +tortuosity of the anterior ciliary veins are due apparently to excessive +flow of blood through them on account of the abnormally small amount +carried off by the venae vorticosae. In the stage of degeneration, +ectasae of the sclera occur most frequently near the equator of the +globe. Spontaneous rupture may take place. + +_Anterior Chamber._ The anterior chamber is shallow, as a rule. This is +almost without exception in primary glaucoma in adults. In secondary +glaucoma in which occlusion of Fontana's spaces occurs as a result of +the deposition of fibrin or other inflammatory products the anterior +chamber may be of normal depth, or deeper than normal. Very deep +anterior chamber may occur in glaucoma, due to retraction of lens and +iris following fibrinous or plastic exudation into the vitreous, or +when it occurs in congenital glaucoma, due to enlargement of the globe. + +_Aqueous Humor._ The aqueous humor, as has been pointed out by +Uribe-Troncoso (Pathoginie du Glaucome 1903) contains a greatly +increased quantity of albuminoids and inorganic salts in glaucoma. In +acute glaucoma the increase of albuminoids (blood proteids) is greater +than in chronic glaucoma. The aqueous humor becomes slightly turbid in +acute attacks, coagulating more readily than the normal. The plastic +principle contained in the aqueous is rarely sufficient to cause +adhesion between the margin of the iris and the lens capsule, but the +colloid nature of the aqueous, according to Troncoso, lessens its +diffusibility and prevents its free passage into the lymph channels. The +increase in albuminoids is a consequence of congestion and venous stasis +and does not precede the attack. + +_Filtration Angle._ The changes that occur in the filtration angle +before it is encroached upon by iris tissue are sclerosis of the +ligamentum pectinatum in adults to which Henderson (Trans. Ophth. Soc. +U.K. Vol. xxviii) has called our attention; the accompanying sclerosis +of the other tissues to the inner side of Schlemm's canal; and, in some +cases, the deposition of pigmented cells derived from the iris and +ciliary processes (Levinsohn) which serve to obstruct the lymph spaces. +In many of the cases of acute glaucoma and almost all of the cases of +chronic glaucoma of long standing the filtration angle becomes blocked +by the advance of the root of the iris. + +_Iris._ In acute glaucoma the iris is congested and thickened. It is +pushed forward and may lie against the cornea at its periphery. When the +attack subsides, the iris falls away from the cornea. Aside from the +congestion, the primary changes that take place in the iris are +indicative of paresis of the fibers of the motor oculi that supply the +sphincter pupillae, and stimulation of the fibers from the sympathetic +producing vasomotor spasm. The long diameter of the pupil apparently +lies in the direction of the terminal vessels of the two principal +branches of each long ciliary artery which form the circulus iridis +major, where the vasomotor spasm would have the greatest effect in +lessening the blood supply. The haziness of the cornea and slight +turbidity of the aqueous contribute greatly to the apparent change in +the color of the iris. In cases of simple chronic glaucoma there is but +little evidence of edema of the iris. If the iris lies in contact with +the sclera and cornea for some time, it becomes adherent (peripheral +anterior synechia). As the disease progresses, the stroma of the iris +atrophies and contracts. There is very little evidence of small-cell +infiltration or the formation of cicatrical tissue. Numerous slits may +develop in the iris through which the fundus of the eye may be seen +(polycoria). The pigment layer does not atrophy in proportion to the +stroma of the iris; by the contraction of the stroma of the pigment +layer is doubled upon itself at the pupillary margin, forming a black +ring of greater or less width (ectropian uveae). The iris becomes +attached to the pectinate ligament and to the endothelium of Descemet's +membrane. In a very few cases the closure of the angle is not complete +at the apex, a small space remaining comparatively free for a long time. +The adhesion of the iris to the pectinaform ligament and cornea is not +uniform at all parts of the periphery; it varies in width. Portions of +the iris angle may remain open while other parts are closed. 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 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. They press against the root of the +iris and the equator of the lens, forcing them forward. There is edema +of the ureal tract, apparently from transudation of serum. Many small, +and sometimes rather large hemorrhages may occur. There is but little +small cell infiltration, indicating almost total absence of what is +ordinarily recognized as true inflammation. It is probable that the +secretion from the glandular zone of the ciliary body is increased. + +On subsidence of the congestion, as after miotics or iridectomy, the +tissues may return to very nearly a normal condition. The iris recedes +from contact with the ligamentum pectinatum and cornea and the +filtration angle is again open. In some cases the iris becomes adherent +to the head of the ciliary processes and, when atrophy of the ciliary +body occurs, is drawn backward at the base of the iris by the receding +tissues. If the hypertension persists or is repeated at varying periods, +a slow atrophy of the uveal tract sets in. Eventually the ciliary body +becomes very much reduced in thickness, is flattened out, the ciliary +processes reduced in size and the blood vessels disappear or are reduced +much in caliber. Those that persist possess walls that are much +thickened. This is particularly true of hemorrhagic glaucoma. + +In advanced absolute glaucoma the chorioid may become reduced to a very +thin membrane consisting of connective tissue and pigmented cells, +scarcely distinguishable even by moderate powers of the microscope. +Atrophy is marked in the vicinity of the venae vorticosae. Czermak and +Birnbacher describe proliferation of the endothelium of the large veins +with contraction and obliteration of their lumen. + +_Optic Nerve and Retina._ In the acute form the retina and optic nerve +present the same condition that is present in the vascular tunic; +namely, that of venous stasis with the consequent edema. Frequently +minute hemorrhages occur in the retina, particularly in violent acute +attacks. Cupping of the discs slowly develops, causing more or less +stretching of the nerve fibers over the edge of the cup. The gradual +diminution of the field of vision is due in greater part to death of +peripheral nervous elements of the retina, those parts of the field +farthest removed from the large arterial trunks suffering first. 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 congestive (inflammatory) glaucoma, the typical +field of vision shows most marked contraction on the nasal side. The +disturbance of the nutrition of the retina accounts in greater part for +the various forms of visual field met with. + +Death of all of the perceptive elements of the retina eventually occurs. +The loss of nutrition is apparently not the whole cause of blindness. +Atrophy of the nerve fibers follows death of retinal neurons, but +atrophy of some of the nerve fibers may be, and probably is, due to the +pressure and traction exerted upon them at the margin of the disc. It is +probable that too much importance has been given to this mode of +interference with the nerve fibers. However, the change in the position +of the lamina cribrosa must exert a deleterious effect, particularly on +those fibers which pass through the peripheral meshes, the shape of +which must necessarily be much distorted. In glaucoma simplex, which is +largely devoid of marked congestive periods (acute attacks), a +surprisingly high degree of acuity of vision may exist with a deep +excavation and pale nerve. Careful studies of the retinal vessels in +glaucoma (Verhoeff Arch. of Ophth. XLII. p. 145; Opin. Soc. Francaise +d'Ophth. 1908) disclose the fact that an increase in the elastic tissue +and connective tissue elements occurs in _some cases_, also +proliferation of the endothelial cells, which serve to irregularly +narrow and, in some instances, obliterate the lumen of the vessel. +Arteries and veins are both affected. Hyaline degeneration of the media +also occurs. The process is not uniform. + +_Glaucomatous Cup._ The excavation of the disc progresses slowly and is +due in part to stretching the fibers of the lamina cribrosa pressing +this structure outward, and partly to atrophy and disappearance of the +nerve tissue and much of the vascular tissues in the nerve head. The +displacement backward of the lamina cribrosa may cause that structure +to lie behind the outer surface of the sclera. Atrophy and cystic +degeneration of the nerve trunk follows destruction of retinal neurons +and cupping of the disc. Neuroglia remains in part. Connective tissue +elements increase in the optic nerve as the nerve fibers disappear. + +_Glaucomatous Ring._ The development of the pale circle which surrounds +the disc, particularly in glaucomatous eyes, is due to a very slight +recession of the pigment layer of the retina and of the margin of the +chorioid at this point with some atrophy, apparently consequent on the +beginning retraction of the lamina cribrosa and slightly increased +pressure of the nerve fiber layer on the underlying tissues at the +margin of the disc. This permits the sclera to show through a very +little at this part. In some eyes in which there is a beginning +sclero-chorioiditis posterior, the condition is very similar to that +presented by the glaucomatous ring. + +_Field of Vision._ The two pathological processes that operate to +destroy the function of the retina suffice to produce scotomata in the +field of vision of varying shapes. The typical glaucomatous field in the +acute cases shows a defect most pronounced to the nasal side. As has +been shown by Bjeraum, the blind spot corresponding with the optic disc +is enlarged in glaucoma, a relative scotoma often connecting it with the +blind nasal portion of the field either above or below the horizontal +meridian (Straub). The field in a simple glaucoma is apt to approach +concentric limitation; namely, more like the field in simple atrophy. +This is consistent with the fact that simple glaucoma in many cases +possesses the characteristics of glaucoma plus atrophy of the optic +nerve. + +_Vitreous._ During the acute attack, the vitreous may become slightly +turbid by transudation of serum from the vessel of the ciliary body and +the chorioid and may become filled with fibrin. In some chronic cases +in which absolute glaucoma is reached the development of small blood +vessels in convoluted loops springing from the vessels of the discs has +been observed. 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. In all of the cases in which the eye has been +examined microscopically obliteration of Schlemm's canal has been +reported. This is thought to be a defect in development. Magitot (Ann. +d'Oculis CXLVII) suggests that injury to mesoderm which pushes itself +between the ectoderm and anterior surface of the lens would account for +the failure in development of Schlemm's canal. The changes that occur in +the tissues of the eye appear to be largely due to the stretching +consequent on the more or less uniform distentions of the globe as a +result of hypertension. + +_Cornea._ This portion of the fibrous membrane is enlarged, globous or +flattened, irregularly thinned, particularly at the periphery, where it +may be as thin as tissue paper, nebulous because of the stretching of +its fibers principally, but in some degree (differing in different +cases) to edema of the epithelial layer. Fissures occur in Descemet's +membrane. + +_Anterior Chamber._ This is very deep in the greater number of cases. +However, this rule has many exceptions. + +The vascular tunic may be congested in young infants, but atrophy soon +develops and may reach an extreme degree. The sclera ordinarily becomes +quite thin throughout, but may retain almost a normal thickness at the +equator of the globe and posteriorly. Posterior sclera ectasae may +develop. The iris, as a rule, hangs free from the cornea, often +tremulous because of retraction of the lens beyond the iris plane. In +some cases the iris is partly or totally adherent to the posterior +surface of the cornea. + +The vascular membrane (iris, ciliary body and chorioid) and the retina +become atrophic, the atrophy varying in degree in various parts. +Detachment of the retina may occur, often preceded by or accompanied by +subretinal hemorrhage. The optic disc becomes deeply cupped and the +tissues of the optic disc and optic nerve extremely atrophied. The +crystalline lens may become cataractous and shrunken. Spontaneous +rupture of the suspensory ligament with consequent subluxation of the +lens may follow. + +_Secondary Glaucoma._ The pathological conditions that precede +secondary glaucoma are many and differ widely. They may be briefly +classified as: + +1. Those that cause a partial or complete closure of the lymph spaces +and Schlemm's canal by cicatrical contraction, as in sclero-keratitis. + +2. Those that cause obstruction to the lymph spaces at the filtration +angle by the deposition of fibrin or cellular elements, as in iritis, +hemorrhage into the anterior chamber, etc. + +3. Those that cause obstruction of the filtration angle by advancement +of the iris and lens, as occurs when the volume of the contents of the +vitreous chamber is increased, as from retinal or chorioidal hemorrhage +or neoplasm. + +The various changes are so numerous that they need not be described +further here. The ultimate changes due to high tension resemble those +already described. + + + + +Dr. John E. Weeks' Paper on Pathology of Glaucoma + +Discussion, + +E. V. L. BROWN, M.D., + +Chicago. + + +I would like to emphasize one of the newer features of the pathologic +anatomy of glaucoma, one which has received too little attention in this +country: the _lacunar_ or _cavernous atrophy_ of the _optic nerve_. + +The name accurately describes the condition. Tiny clear spaces form in +the lamina cribrosa and in front and behind it in the nerve tissue. +Their exact nature is unknown. Usually they are entirely empty, often +they are traversed by fine glial fibers. They seem to be in no relation +to the blood vessels. Adjoining lacunae are supposed to fuse to form +larger cavernae and these finally merge and constitute the final +glaucoma cup. The lamina may then bridge across the space like a cord, +or lie back against the end of the nerve trunk. + +Schnabel considered all glaucoma cups to be formed in this way, +independent of tension. His views were strongly supported by Elschnig, +but as vigorously opposed by others. Axenfeld cites the fact that the +glaucoma cup may disappear after operation. (I myself have seen a cup of +7 D. reduced to 1 D. in the course of a year after the tension had been +lowered from 62 to 12.) Stock found the same lacunae in eight cases of +myopia. The last extended study of the subject was made by E. v. Hippel, +who found lacunae in 20 of 33 cases (60 per cent); enough certainly to +make one look for them carefully in every case. He publishes a large +number of excellent photo-micrographs, but none more typical than one I +have in my possession. + +I have been especially interested in this subject because I have met +with a complete and total glaucoma cup, with the typical (ampulliform) +undermining of the scleral ring, in a pair of eyes without increased +tension. The (Schiotz) tonometer was used daily for 70 consecutive days +and never registered more than 12-14 mm. Hg. The man had been blinded by +wood alcohol. At the time I could find no other report in the +literature, but overlooked a publication by Lewin and Guillery. +Friedenberg has since reported cases of the same nature. + +If other conditions than increased tension can produce a typical +(ampulliform) glaucomatous excavation of the disc, why may not the +cavernous atrophy and cup in glaucoma be due in part at least to similar +processes, possibly in the nature of a toxic oedema of the nerve, either +in association with tension or independent of it, as contended for by +Schnabel? + + + + +Concerning Non-Surgical Measures for the Reduction of Increased +Intra-ocular Tension + +BY + +GEORGE EDMUND DE SCHWEINITZ, M.D., + +Philadelphia. + + +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 +opinions and experiences from all over the world as to these surgical +measures. But true as this is, we are not yet in a position to discard +non-surgical procedures (1) because operation is not always possible, +(2) because operation is not always permitted, and (3) because in +certain circumstances operation is not advisable. Hence a glance at the +non-surgical methods of reducing increased intra-ocular tension is not +out of place, and for convenience they may be catalogued as follows: + +1. Myosis produced by means of solutions of various drugs, a myosis +followed by reduction of intra-ocular tension. + +2. Reduction of tension by means of various mechanical measures, notably +massage, vibration massage and suction massage, and by means of +electricity and diathermy. + +3. Indirect reduction of intra-ocular tension, accomplished by lowering +general vascular pressure. + +4. Reduction of ocular tension by stimulation of osmosis, of lymphagog +activity, of absorption of edema, and of capillary contractility, and by +decreasing affinity of ocular colloids for water. + +1. _The Myotics._ Of these, eserin (physostigmin) and pilocarpin, with +their respective salts, the sulphate and the salicylate in the first +instance, and the hydrochlorid and the nitrate in the second, are well +established in favor and efficiency. Personally, it has always seemed to +me that the salicylate of eserin is preferable to the sulphate, but I +have not persuaded myself that the nitrate of pilocarpin possesses +material advantages over the hydrochlorid, although some authors prefer +it. With arecalin, the alkaloid of the Betel nut, I have no experience, +nor have I used its mixture with eserin, recommended by Merck as more +potent than either of the drugs in separate solution. + +The substance isophysostigmin, found with eserin in Calabar bean, +according to Ogiu, exceeds in its myotic activity the sulphate of +eserin, _i. e._, 1/80 of a grain of the drug is equal to 1/60 of a grain +of the sulphate of eserin, but it is certainly not less irritating than +physostigmin, and according to Stephenson's researches, is more so, and +in this sense has no superiority over the usual alkaloid. In general +terms, it may be said that the time has not arrived to make a preachment +"on the passing of eserin and pilocarpin." + +_Physiologic Action._ Concerning the ocular, physiologic action of the +two chief alkaloids respectively of Calabar Bean and of Jaborandi, there +still exists difference of opinion. It has always been easy to attribute +the myotic action of these drugs, or at least, of eserin, to their +stimulant action on the peripheral ends of the oculo-motor, thus causing +sphincter contraction, and to a depressing action on the sympathetic +fibers, thus causing removal of the action of the dilatator of the iris. +But complete experimental proof of such action is wanting, and it is +probable that myosis follows a direct stimulation of the sphincter +muscle fibers, aided, perhaps, by contraction of the iris vessels, +although the last named effect is denied by so competent an authority as +Hobart Hare. + +Exactly how the myotics reduce intra-ocular tension is not definitely +proven. Usually it is taught that because of the myosis the base of the +iris wedged in the angle of the anterior chamber is loosened and +withdrawn, precisely as a fold in a coat is straightened by a tug on the +fabric beneath it. Experiments, however, for example, by E. E. +Henderson, have shown that the rate of filtration in an eye with +artificially raised pressure is considerably larger when it is under the +influence of eserin than it is when under the influence of atropin; that +is by the contraction of the pupil the iris-surface filtration is +increased and consequently the pressure is reduced. We all know that +Thomas Henderson maintains that the results of iridectomy are beneficial +because the raw edges of the coloboma, which do not cicatrize, permit +access of the aqueous to the iris veins, and that myotics, inasmuch as +they contract the pupil, open the iris crypts and therefore act, less +efficiently, perhaps, but act none the less like an iridectomy. The +normal intra-ocular pressure is uninfluenced by myotics because this +pressure represents the lowest circulatory pressure in the eye, and +further contact between aqueous and veins cannot reduce it below this +level, another point which is made by Thomas Henderson in support of his +contention. + +The clinical fact remains that either by mechanical means, as it were, +in the liberation of a plugged filtering angle, or by the increasing of +iris-surface filtration, the myotics markedly reduce the abnormal +intra-ocular pressure. + +_Methods of Administration and Indications._ With the methods of +administration of the myotics we are all so familiar that time need not +be wasted in their reiteration, except to refer to a few practical +points. In acute glaucoma, and every one knows that in this disease +their action is often prompt and sometimes curative, eserin in a +strength of one to four grains to the ounce may be instilled with +sufficient frequency to establish myosis, and its action in this respect +is enhanced if the congestion of the eye is lowered by measures to which +I shall refer later. There is a good deal of clinical evidence to +indicate that in this type of glaucoma, as well as in the so-called +sub-acute varieties, myotic activity is increased by a mixture of +pilocarpin and eserin in the same solution, exactly as a mixture of +arecalin and eserin is more potent than either of the drugs in separate +solution. + +Prior to the happy advent of technically correctly placed filtering +cicatrices, a large number of surgeons depended almost exclusively on +the use of myotics in so-called simple, chronic or non-inflammatory +glaucoma. This is not the place to introduce a discussion of the +comparative value of iridectomy and myotic treatment in simple glaucoma +as based upon statistical records. We must wait now for a sufficient +period of time and then compare the value of myotic treatment with that +of operations by means of which satisfactory filtration is produced. We +are somewhat in the position that general surgeons occupied when aseptic +methods first became prevalent. We do not usually compare the statistics +of early aseptic days with those of the pre-antiseptic period, and I do +not think we ought to compare the statistics of myotic treatment with +ordinary iridectomy any longer, but that we should wait until we can +make a comparison between the results of prolonged myosis and those of +an improved modern technic which establishes a permanent filtration. In +the meantime the patients who will not or cannot submit to operation +must be reckoned with. Doubtless many patients with chronic glaucoma can +be satisfactorily managed with myotic treatment, although personally I +have always advocated operation when this could be performed, but it +cannot always be performed. This rule should guide us, namely, to begin +with a comparatively weak solution of the selected drug, for example, as +Posey has advocated a tenth of a grain of salicylate of eserin to the +ounce, and the strength gradually increased so that at the end of some +months the patient is using a solution 1 grain to the ounce; or if the +pilocarpin is preferred, solutions in double these strengths. It is my +own belief, and that of many who have studied this subject, that if, +without eserin irritation, a myosis can be maintained, and if the +treatment can be begun early enough, the chances of preserving vision +and the field of vision are good. I believe that the two most important +instillations during the twenty-four hours of the number necessary to +maintain this myosis are on retiring and if possible in the very early +morning, some time between two and four o'clock. Most patients can be +taught to wake themselves at the proper period of time, and are little +inconvenienced by this disturbance of their sleep. I believe that eserin +irritation is most successfully avoided, not by preparations of the +myotics in combination with the antiseptics, for example, tricresol, +which has been so much advocated, but by ordering very small quantities +of the solution, insisting that it shall be frequently renewed and +sterilized at each preparation, and that a half an hour after its +instillation, during the day time at least, the eye shall be thoroughly +flushed with some mild antiseptic solution, for example, boric acid and +sodium chlorid. Whether the action of the eserin on the choroidal +circulation, which is maintained by Wahlfours, aids in this favorable +action of the myotics remains to be proved. It has been maintained by +this author and by others who have followed him. + +The great trouble with myotic treatment is not its lack of efficiency, +but the difficulty of carrying it out successfully on ambulant +patients, even in the better walks of life. It is hard successfully to +maintain in a patient with chronic glaucoma what I may call an eserin +life, just as it is hard to maintain in a person with an enlarged +prostate a catheter life and escape infection, resulting, if it occurs, +in the one instance in a difficult and stubborn conjunctivitis, and in +the other in a cystitis. Still, we are obliged to use myotics, and the +way to employ them to the patients' best advantage, I have ventured to +repeat in spite of the universal familiarity with the methods. Perhaps +we may reach that happy day when, especially with improved tonometric +methods, increased skill in measuring the rate of filtration and better +instruments for determining the light sense, we can anticipate the +advent of glaucoma and get ahead of the ocular and visual deterioration +which increased tension produces, by performing preventive operations +which shall aid nature's filtration channels in the establishment of an +artificial one. But increased tension is not the whole story of +glaucoma, and a filtering cicatrix is not the last word in surgical +therapeutics, and there is much to learn. + +2. _Reduction of tension by means of various mechanical measures, +notably massage, and by means of electricity and diathermy._ Massage is +of ancient lineage. In general terms, in so far as ocular massage is +concerned, it may be applied to the eye with the finger tips (ordinary +massage), by means of various instruments (vibration massage), and with +the help of certain suction cups (suction massage, which is indeed a +form of vibratory massage). Many authors are satisfied with their +results without the employment of any instrument, and prefer simple +massage with the tip of the finger to any form of the instrumental +variety, to quote the words of Casey Wood. At one time in my career I +experimented very extensively with massage, not alone for the purpose +of reducing intra-ocular tension, but in various diseases of the lid and +cornea, and taught a trained nurse, who herself had a nebulous cornea, +to make what I may call a specialty of this particular therapeutic +procedure. She became exceedingly skillful and was quite faithful. We +believed that the best results were obtained in a seance of two or three +minutes, the finger tip being used over the lid, and the surface of the +cornea lubricated with a drop of pure olive oil, although in glaucoma +the addition of the oil is not necessary. Four movements were utilized, +the first a stroking movement in lines radiating from the central +pressure, very much as the spokes of a wheel radiate from the hub, +second a circular movement, third a pressure movement, a little dipping +motion, so that the cornea was slightly depressed, and finally, a gentle +tapping movement, precisely the same, except that it was a diminutive +one, as the tapping movement that the Swedish masseur makes. Usually +each movement occupied from a half to one minute, according to the +results desired. I agree with Casey Wood that such a technic furnishes +just as good results as any one with the aid of an instrument. + +Referring particularly to the reduction of intra-ocular tension, many +surgeons have been impressed with the value of various instruments. +Thus, Ohm, who has worked particularly in the reduction of the increased +tension of secondary glaucoma, for example, after discussion of lamellar +cataract, advocates the Piesbergen instrument, which makes 3,000 +vibrations a minute, and is applied over the closed lids. I think the +instrument best known is the one introduced by Malakow. For this purpose +the point of an Edison electric pen is armed with a small ivory ball, +and the vibration rate varies from 200 to several thousand a minute, the +rapidly revolving ball being passed over the closed lids, in some +instances directly upon the cornea itself. I am frankly afraid of these +vibrating machines, and again make a plea for the finger tip, just as I +am afraid of a Von Hippel trephine, and prefer one which is rotated with +the fingers. + +A special investigation of pressure massage according to the method of +Domec has been made by Paul Knapp of Basel. This, as you know, consists +in applying the thumb to the cornea through the closed lids, and making +repeated pressures upon it at the rate or 60 to 100 a minute. He checked +his results with the tonometer after 200, 500 and 1,000 pressures, and +found that even in normal eyeballs such massage was followed by a fall +of intra-ocular tension, the average being nearly 9 mm. after a thousand +pressures. Within three-quarters of an hour the tension returns to the +normal. In acute glaucoma such massage is not available, but it is of +assistance in encouraging a reduction of the intra-ocular tension and +keeping it at a normal grade after operative work, particularly after a +filtering cicatrix has been made, as was well shown by Weeks in his +study of glaucomatous eyes operated upon by the Lagrange method. It is +interesting to remember that Paul Knapp, in the course of this +investigation, observed reduction of the tension after the use of +holocain. + +Another method of reducing the intra-ocular tension is by the suction +method, which consists in the use of certain cups from which the air is +exhausted by means of a suction apparatus. Domec uses an elliptical eye +cup, the concave margins of which fit closely about the globe. The air +is exhausted with each respiration of the patient and from 50 to 200 +tractions are made at each sitting. Domec is of the opinion that this +method succeeds in two ways, namely, in producing analgesia by traction +on the ciliary nerves, and in reducing intra-ocular tension. + +Unfortunately, it is difficult for regular physicians to make reference +to massage of the eyeball lest their words should be misquoted by +irregular practitioners who employ this method, selling various +instruments to trusting patients, and attributing to this simple and +often beneficial procedure all sorts of marvelous influences. Doubtless +all of us have seen eyes utterly ruined because the patient has trusted +to the advertisements of these people, and has continued to use some +foolish little suction pump, when what his eye needed was operative +procedure or skilled therapeutics. + +If I should sum up my opinion of massage in the reduction of +intra-ocular tension, I would say that it is useful in enhancing the +action of myotics, and particularly useful, as Domec, Knapp, Ohm, Weeks +and many others have shown, after the filtering angle has been opened by +a proper operative procedure. It seems to me that it is distinctly our +duty to inform patients that it is no panacea, and that they must never +trust themselves in the hands of irregular practitioners who pretend to +cure all ocular ills with massage. + +_Electricity._ The credit of first using high frequency currents in the +treatment of glaucoma belongs to Truc, Imbert and Marques, and Roure's +experiments indicate that this current suitably applied appears to have +an influence not only in reducing the arterial tension, but also the +ocular tension. Thus, in an interesting series of experiments he has +been able to reduce an arterial pressure of 200 mm. to 140 mm., and an +ocular tension of plus 2 to the normal after eighteen applications of +the high frequency current. The current is applied for ten to fifteen +minutes at a time twice a week. Some surgeons, for example, Wuerdemann, +have suggested the use of electricity combined with massage, and have +apparently achieved satisfactory results. + +The constant current has also been much employed for the purpose of +reducing intra-ocular tension. Coleman quotes Le Prince's observations, +who applies the negative pole to the eye and the positive pole to the +neck, gradually passing a current of 30 to 40 ma. during a quarter of an +hour, and who reports notable diminution of tension. Coleman points out +that in his own experience he has not found any patient who would +willingly tolerate more than 19 ma. of current with an ordinary sized +electrode, although he grants that it is possible that Le Prince used a +very large electrode. Unfortunately he does not mention its size. +Ziegler of my own city, who has studied most scientifically and +intelligently the use of electricity in diseases of the eye, announces +this rule: The positive pole should be used in all inflammatory +processes of the eye, glaucoma excepted, and with this rule Coleman +agrees. Now, although the negative pole is a stimulant and therefore not +generally indicated in inflammation, as Coleman points out, the object +in view is to diminish the density of the ocular capsule and its +tension, hence the negative rather than the positive pole should be +used, inasmuch as the former, according to him, while it is a sedative, +hardens tissue and would tend to increase intra-ocular tension by +diminishing excretion. Moreover, in chronic glaucoma the ordinary +inflammatory processes are not present, indeed, primary acute glaucoma +itself is not an inflammation. + +I have no personal experience in the use of the constant current with +negative pole application to the eye in the reduction of increased +intra-ocular tension, but quote for our general benefit the opinions of +those who have employed it. I have always been very frankly pessimistic +in regard to the therapeutic value of electricity in ocular disorders. +Perhaps I am wrong; I am willing to be enlightened. There seems little +doubt that Truc and Imbert's observations that high frequency currents +can temporarily reduce intra-ocular tension is correct, that they are +able to relieve the pain of primary and of secondary glaucoma would +seem to be proved by many observations, some of which I have myself +made, and other very accurate and excellent ones have been made by +Risley in Philadelphia. + +A word might be said in regard to _diathermy_. According to Zahn, the +method of applying diathermy to the human eye is to take a layer of +cotton wool 1 cm. thick soaked in a 2 per cent solution of sodium +chlorid, which is applied close to the outside of the lids. On this is +put an electrode 15 cm. in size with a large indifferent electrode +applied to the back of the neck. It is not germane to the subject to +name the various ocular diseases which were treated in this manner, but +Clausnizer has made an investigation of the influence of diathermy on +intra-ocular tension. In a number of diseases, for example, +iridocyclitis, the method produced distinct rise of pressure. In one, a +patient with secondary glaucoma, prior to the diathermic application +the tension was 371/2 mm., after the passage of the current it had +fallen to 28 mm., but the next morning the tension rose to 45 mm. In a +patient with chronic glaucoma no definite alteration of tension could be +found. This observation is mentioned, not because it puts us in +possession of a valuable therapeutic measure, but largely because it is +a good example of how in this disease it is wise to investigate any +method which furnishes a hope of relief. + +In a few instances endeavor has been made to reduce the intra-ocular +tension, or at least to relieve glaucomatous symptoms, by galvanism of +the cervical sympathetic, for example, by placing one electrode along +the whole length of this nerve in the neck and one on the back of the +neck on the opposite side, 15 to 20 ma. of current being used. Good +results have been reported by an observer named Allard. I confess that I +am entirely faithless in regard to any results that may be reached in +this manner. It is possible that as the positive pole is a sedative, if +there were any influence, the influence of sedation would be present, +but certainly it has over and over again been experimentally proved that +irritation of the cervical sympathetic quite rapidly produces elevation +of intra-ocular tension of 2 to 4 mm. In some experimental work the +primary elevation of intra-ocular tension was followed by a secondary +drop. + +3. _Indirect reduction of increased intra-ocular tension brought about +by lowering general vascular pressure._ Much has been written in regard +to the association between increased vascular pressure and increased +intra-ocular pressure. It is not my province to analyze observations +often contradictory and not infrequently inaccurate. This much seems to +be established: First, that at corresponding ages there is usually a +higher average blood pressure in glaucomatous subjects than there is in +non-glaucomatous subjects; second, that arteriosclerosis and therefore +usually increased blood pressure, with all its concomitant conditions, +is correctly classified as an exciting cause of glaucoma; and third, +that the regulation of this increased blood pressure is part of the +advantageous management of increased intra-ocular pressure, although it +may be too much to say, as Gilbert has, that blood pressure and +intra-ocular pressure rise and fall together. It may be true, as Thomas +Henderson says, that the intra-ocular pressure is influenced by changes +in the general arterial or general venous pressures, whereby a rise in +general arterial pressure induces a proportionate rise in the +intra-ocular pressure, but it would seem that future investigations must +confirm this statement before it can be entirely accepted, as well as +his further statement that the effect of an increased general venous +pressure is a direct one, producing millimeter for millimeter a +corresponding increase in the intra-ocular pressure. + +Now, it goes without saying, if these data are correct, or even only +partly correct, that part of the treatment of the increased intra-ocular +pressure state must be constitutional in that the vascular pressures +should be lowered in order that the beneficial effect of their +relationship to the intra-ocular pressure shall be established. It is +further a great mistake to drive down a high arterial pressure simply +because that exists. In other words, it is often necessary from the +general standpoint that a certain amount of plus pressure shall remain +if the patient's general well-being is to be maintained. There must +always be a differential diagnosis between plus pressure and what may be +called over plus pressure. That is to say, a man may be perfectly +comfortable and properly need, for example, a pressure of 160 or 165 +mm., which is above the physiologic limit, but which is a plus pressure, +while some disturbance in his general life may add to that 10, 15 or 20 +mm. more of pressure, which is then the over plus amount. This over +plus amount may be in association with a rise of intra-ocular pressure, +and must be eliminated if the latter is to be controlled by a +non-operative procedure, or, indeed, by an operative one. + +It is no easy matter to determine the presence of increased venous +pressure, although there are tolerably accurate instrumental technics, +and yet, as Henderson points out, it is just this increased general +venous pressure which is often detrimental. Therefore the perfunctory +use of such drugs as nitrite of amyl and the other nitrites may not be +in the least indicated when, for example, the venous pressure depends +upon inability of the right heart to perform its functions, and the drug +needed may, for example, be digitalis. Far better than pressure-reducing +drugs like nitrite of amyl, urgently indicated in some instances and for +some purposes, is the regulation of life and the restoration to their +normality of the metabolic processes, the elimination of the worry +which is usually the exciting agent that brings about the over plus +pressure, which may have as one of its expressions an acute rise of +intra-ocular tension. 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. This does not for a moment mean that prior, +for example, to operative work it is not necessary to get rid by means +of drugs of an over plus tension, for surely the elimination of such an +over plus tension may be the means of preventing, for example, an +intra-ocular hemorrhage, and in this emergency we must not lose sight +of Gilbert's recent investigation, who has found that blood withdrawn to +the extent of 8 grams to each kilogram of the body weight always +produces lowering of the intra-ocular tension, appearing in six to eight +hours and lasting to the next day in simple glaucoma, and in +inflammatory glaucoma commencing the day after the venesection and +lasting two to three days. It is not necessary for me to point out the +value of free purgation and diaphoresis in this respect. + +In most instances the successful maintenance of a glaucomatous life, +exclusive of operative interference, in addition to sustained myosis, +demands the investigation of the patient's metabolism, which must be +kept at the normal standard, the removal of the evil effects of +auto-infection, as we are wont to call it, and especially the +elimination of the cause which is responsible for the over plus tension +of the arteries and of the veins. This is best secured by just such +regulation of life as has been referred to, aided when necessary by the +ordinary drugs which the patient's condition indicate, and the success +of all treatments, be they operative or non-operative, is enhanced if +such a happy state of affairs can be brought about. + +I am firmly convinced that every glaucomatous patient, and I now refer +to those who are the subjects of chronic progressive glaucoma, should be +carefully studied from the general standpoint by the oculist with the +aid of an expert internist, just as I am convinced that the modern +expert internist should not study his cases of cardio-vascular disease +without the help of the oculist. Perhaps I am going a little far afield, +but in justification of my statement I want to quote the opinion of Dr. +Hobart Hare, one of America's most expert clinicians, on blood pressure, +because it seems to me much harm has been done by the more or less +brutal knocking down of blood pressure simply because blood pressure +above the normal existed. "Concerning the matter of high blood +pressure," writes Hare, "independent of cerebral lesions, the longer I +study the matter the more convinced I am that this blood pressure is +devised by nature to compensate for fibroid changes in peripheral +vessels, in order that tissues which would otherwise be cut off from +adequate blood supply may receive plenty of blood, and I consider it one +of the most vital points to ascertain whether a pressure is what may be +called the patient's pathological norm, that is, the pressure which is +required in the face of vascular changes, or whether this pressure is in +excess of his pathological norm. If it is in excess, measures directed +to bring it to the pathological norm should be instituted, but if the +pressure found proves to be the pathological norm it is a bitter mistake +to lower it, be the pressure what it may. If it is lowered below the +pathological norm, all manner of disturbed cardiac action, etc., may +result. There is no more reason for reducing a blood pressure below his +pathological norm than there is for reducing it below his physiological +norm. The adjustment of a man's blood pressure to his pathological norm +often has to be as correctly done as the adjustment of a watch which is +losing or gaining time." + +I shall not quote Hare's elaborate methods for determining these various +points because they do not belong to a paper of this character, but I +quote his admirable advice because it emphasizes what I believe to be an +essential in the treatment of chronic glaucoma, exclusive of operative +work, that is, the intelligent co-operation of the oculist and the +internist. + +Some such thought was in the mind of Ibershoff, who quotes Sterling and +Henderson's views that the rate of secretion depends upon and varies +with the difference in the blood pressure and the tension of the +eyeball, and that the specific gravity of the secretion increases +directly with the blood pressure and inversely with the ocular tension. +Should the blood pressure be very high, paracentesis, for example, would +apparently not be the proper procedure, and the resulting difference +produced between the blood pressure and the eye tension would cause a +rapid reformation of fluid with higher specific gravity and higher +osmotic coefficient. The proper procedure in these circumstances is +first properly to reduce the blood pressure, or what I have, quoting +Hare, ventured to call the over plus pressure. + +4. _The relation of osmosis, lymphagogue activity, absorption of edema, +capillary contractility and decreased affinity of ocular colloids for +water to the reduction of increased intra-ocular tension._ We are all +familiar with the attention which was directed some years ago to the +statements coming from French clinics that the treatment of glaucoma +should include the administration of osmotic substances as adjuvants in +the reduction of increased intra-ocular tension. Particularly was this +treatment advocated by Cantonnet in the administration of daily doses of +3 grams of chlorid of sodium, preceded, of course, by a careful urinary +examination and the estimation of the amount of urine and its contained +chlorids. Carefully this dose was increased in proper circumstances to +15 grams per diem, and in Cantonnet's original paper good results were +achieved in 12 of the 17 patients so treated. I have myself experimented +somewhat, not with the administration of sodium chlorid by the mouth, +but with the introduction by the bowel of fairly large quantities of +physiologic salt solution in patients with glaucoma whose quantity of +urinary secretion was markedly below the normal, and in one or two +startling instances, which have been reported, achieved success in the +rapid reduction of the intra-ocular tension when by this technic the +urine secretion rose to the normal amount. To be sure, myotics were +also used, but these myotics were insufficient, totally so in the two +instances noted prior to the enteroclysis. + +Very interesting are the observations on the subconjunctival injections +of various substances, notably the citrate of sodium, because of its +power of decreasing the affinity of ocular colloids for water. This +method of treating increased intra-ocular tension, introduced, as you +know, by Thomas and Fischer, has met with confirmation from a number of +sources in spite of the fact that Happe's experimental study failed to +confirm Fischer's observations; indeed, he even reports in several +instances a rise of tension. + +As you will remember, the strength of ordinary crystallized sodium +citrate in water should be from 4.05 to 5.41 per cent. Of this five to +fifteen minims are injected, the eye having been previously cocainized +and adrenalinized. With frequent injections the weaker of the two +solutions is mixed with 2 to 4 parts of physiologic salt solution. These +authors in no sense claim to cure glaucoma, but to ameloriate it and +reduce the tension. Weekers has used the salts of calcium, 3 grams a +day, with success in so far as lowering of tension is concerned, +although it must be stated, as a reviewer of his work has said, that his +recommendation of this drug in these respects is poorly supported. On +the other hand, Tristiano seems to have proved that calcium chlorid is +capable of lowering ocular tension and clinically may be used as an +adjuvant in the treatment of glaucoma for this purpose, largely because +he believes that he has proven that it facilitates the absorption of +edema. Darier has reported that a single subconjunctival injection of a +milligram of iodate of sodium has cleared the cornea and lessened the +intra-ocular pain in glaucoma. + +What shall be said in regard to certain medicinal agents which stimulate +the lymphagogue activity of the eyeball in their relation to the +reduction of intra-ocular tension, notably of dionin? Toczyski's +experiments with this drug on the normal eye indicate that it produces +first a rise of tension, which shortly falls to the normal and sometimes +below it, the tension being high as long as the primary narrowing of the +pupil is maintained, but more than one author, particularly A. Senn, +holds an opposite view and reports acute glaucoma following its +instillation into a chronic glaucomatous eye. He believes that dionin +not only does not reduce the tension but hinders the filtration through +the anterior lymph channels by the pressure of the edema which is +produced on the veins and by the increased secretion of the ciliary +processes. In spite of this statement, most of us must agree with Karl +Grossman's observations that certainly in acute and particularly in +chronic secondary glaucoma, this is a most valuable agent, especially if +it is combined with holocain, which Paul Knapp in his well-known +research has proved can reduce the tension even of the normal eye. I +cannot think that anybody who has systematically used dionin with +holocain, the former in gradually increasing strength, beginning with 2 +per cent and going up to 8 per cent, in various types of acute glaucoma, +particularly of the secondary variety, can fail to have noted a +favorable influence. + +Many authors, for example, Darier, Grandclement and others, are strong +in their recommendation of adrenalin, particularly if this drug is added +to the various myotic mixtures, and yet adrenalin is certainly not +without danger in the treatment of glaucoma. McCallan has seen a number +of instances of striking increase of intra-ocular tension following this +instillation in the conjunctival sac. Harmon has had a similar +experience, as also has Senn. It is possible that in these circumstances +the solution was too strong. Should the rise of tension occur, and I +have seen it myself, it is doubtless due to the fact that this drug +dilates the pupil, which would be especially dangerous if the dilatation +should occur before contraction of the ciliary vessels; also the +narrowing of the ciliary veins by the adrenalin might by virtue of this +narrowing obstruct the gate of outflow. I have never been able to +persuade myself that, except as an adjuvant to operative work, there was +any real therapeutic value in the instillation of adrenalin. + +A word in regard to the effect of general narcosis on intra-ocular +tension. Thus, Neuschuler has observed that narcosis causes an elevation +of the intra-ocular tension of from 2 to 6 degrees as measured with +Fick's tonometer. These observations were made while he was +experimenting on irritation of the sympathetic as a method of producing +increased intra-ocular tension. This is not in accord with Axenfeld's +recent observations. It is well known, this observer points out, that +after the period of excitation and muscular rigidity disappears, there +is a lowering of blood pressure in chloroform narcosis and coincidently +a sinking of the intra-ocular pressure. Not only this, the intra-ocular +tension of normal eyes during this narcosis drops several millimeters. +Only such eyes as have high hypertony, for example, in absolute +glaucoma, are unaffected during chloroform narcosis. In the light of +this observation it will be interesting to measure the tension both of +normal and glaucomatous eyes during narcosis in a large series of cases, +and if it is confirmed there will be an additional reason why in many +circumstances general narcosis is advantageous in glaucomatous patients. +Formerly I thought it was essential, if iridectomy was to be performed, +lest some sudden movement on the part of the patient might bring the +point of the knife in contact with the lens. I have rarely employed it +in corneo-scleral trephining, and yet if there is this temporary +reduction of intra-ocular pressure, it is not without a certain +therapeutic value, and the matter is mentioned as a suggestion that +additional observations along this line shall be made. + + + + +Dr. George Edmund de Schweinitz' Paper on Concerning Non-Surgical +Measures for the Reduction of Increased Intra-ocular Tension + +Discussion, + +NELSON MILES BLACK, M.D., + +Milwaukee. + + +It seems almost useless to attempt any discussion of Dr. de Schweinitz' +most terse and comprehensive paper. However, Dr. de Schweinitz mentioned +the close relationship which should exist in the non-surgical treatment +of increased intra-ocular tension between the internist and the +ophthalmologist, but neglected to mention a corresponding relation which +should exist between the rhinologist and the ophthalmologist, and +possibly between the dental surgeon and the ophthalmologist. + +I would like to refer to the _now_ recognized close relationship which +exists between disease of the nasal accessory sinuses and diseases of +the eye. The definition of glaucoma found in Dr. 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. 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 produce glaucoma._ Probably the most important +obstruction to the exosmosis is at the angle close to Schlemm's canal." + +The following hypothesis is based upon Fischer's edema theory of +glaucoma and the relation of the circulation of the eye and orbit and +that of the nose and the accessory sinuses, the minute anatomy of which +is not as yet thoroughly understood. However, sufficient work has been +done to make it appear that the lymph channels which drain the eyes and +orbits empty into the same main channel as do those which drain the +sinuses. Admitted for sake of argument that such is the case, then +disease either acute or chronic of one or more of the sinuses with the +accompanying inflammatory reaction, congestion and stasis, will cause an +increased amount of fluid to be taken care of by the lymph channels +draining these sinuses. This will in turn cause flooding of the common +lymph channel, producing a stagnation in the flow of fluid from the +orbits and eyes at the junction with the main channel, with backing up +of the fluid within these channels and retention of the waste products +within the orbits and eyes; thus will be brought about conditions most +favorable (to quote from Fischer's theory of glaucoma) "to an abnormal +production or accumulation of acid in the eye. In consequence of this +abnormal acid content the hydration capacity of the ocular colloids is +raised and glaucoma results, not because water is pushed into the ocular +colloids, but because these suffer changes which make them suck in water +from any available source." + +This hypothesis also might suggest why the subconjunctival injection of +sodium citrate in addition to alkalinizing the ocular contents, may be +effective in reducing tension, _i. e._, the amount of fluid injected +beneath conjunctiva may overcome the stagnation in the lymph passages, +flush out these channels and improve ocular elimination. + +Fischer in a personal letter says: + +"You have two possibilities for the production of glaucoma with sinus +disease: A toxic factor due to poisons being carried into the eye; and +second, interference with a proper blood supply to the eye through +compression of the efferent or afferent blood vessels supplying the eye +from edema of the tissues about the eye consequent upon the sinus +infection. Either is associated with the production of substances which +increase the hydration capacity of the ocular colloids." + +If such is the case why could not the existence of pyorrhea and blind +abscesses about the roots of the teeth be the source of the toxic +factors mentioned by Fischer? Hence the suggested association of the +dental surgeon with the ophthalmologist in these cases of apparently +idiopathic increased intra-ocular tension. + +It would be well to state here a cursory examination of the mouth will +not discover root abscesses any more than such examination will +discover non-suppurative sinus disease. A careful examination of each +tooth together with radiograms of the entire maxilla are absolutely +essential to determine their presence or absence. + + + + +Trephining for Glaucoma + +BY + +ROBERT HENRY ELLIOT, M.D., + +London, England. + + +Mr. President and Members of The Chicago Ophthalmological Society: + +As the hour is late I propose to take up only the principal points in +connection with my subject and to deal with each one shortly. + +First: The operation of trephining is suitable, not merely for chronic +cases, but for sub-acute and acute cases of glaucoma as well. I would +urge on your attention that, of all the operations dealing with +glaucoma, this one involves the minimum of surgical violence, and +should, therefore, in acute cases be the operation of choice. It is, +moreover, much safer than any other operation I know of, and is no less +certain in its results. I do not advise trephining in the secondary +glaucoma following intumescent cataract, for in such cases the +semi-fluid lens bulges into and blocks the trephine hole. Nor for +obvious reasons do I recommend it in cases where there is reason to +believe that a communication exists between the aqueous and vitreous +chambers. + +Second: The object of trephining is to tap and permanently drain the +aqueous fluid from the anterior chamber of the eye into the +sub-conjunctival space; in doing so it is essential to avoid as far as +possible all interference with the uveal tissue. The purpose of an +iridectomy is to avoid the danger of the iris in the neighborhood of the +wound being drawn and impacted in the trephined hole. We have found in a +large number of cases in which an iridectomy has been omitted, that the +results have been in no way inferior to those in which a piece of iris +has been removed, provided always that no subsequent iris prolapse +takes place. In pursuance of our purpose to avoid uveal tissue, we split +the cornea, and place the trephine as far forward as such splitting will +allow, and we bear on the trephine in such a way that it cuts through on +the corneal edge of the wound first. This insures establishing our +fistula in the most anterior position possible, and, therefore, as far +away as possible from the ciliary body and the angle of the chamber. + +Third: The difficulties of the operation. Far too much stress has been +laid on these. Trephining is an operation which can be performed by any +surgeon who is used to ophthalmic manipulations, and who has good sight. +It is essential that he should work in a good light. The necessary +technique can be acquired from a written description. It is not for a +moment necessary that the surgeon who wishes to learn trephining should +see the originator of the operation at work. If, however, he feels +diffident at undertaking the procedure until he has seen it done by +another, there are many centers in this country where the operation is +now being successfully performed. I would mention amongst those which I +have visited New York, Minneapolis, St. Louis, Nashville, Louisville, +Detroit and Chicago. I have seen results of trephining by American +surgeons which could not be bettered anywhere. + +Fourth: I am sure that everybody will recognize the difficulties of +operating during such a tour as I am now making. I have so far in the +last month performed over seventy trephinings in ten cities, and in +twice as many clinics. To adapt one's self to different clinical +methods, different assistants and different nurses is so difficult that, +as you are aware, many distinguished surgeons refuse to work out of +their own clinics. One cannot expect the results of such a tour to be on +a par with those one obtains in one's own quiet daily surroundings. I +am, however, confident that you will make a generous allowance for +these difficulties, and I gladly welcome the suggestion that all the +cases which I have operated on in America be collected together and +reviewed as a whole. + +Fifth: In conclusion I would like to express the pleasure with which I +listened to Dr. de Schweinitz' paper. I believed from the title that +there might be a wide divergence of opinion between us. I find to my +great relief that we are in absolute accord. I know, however, that there +are in America and elsewhere able men who consider that the medical +treatment of glaucoma should be pushed as long as possible. I cannot but +feel that this is a survival of the dread that most surgeons have felt +in recommending one of the older operations for glaucoma. We have now in +our hands a method so safe, so easy and so certain that I feel sure that +this dread will ere long pass away, and that the diagnosis of glaucoma +will then be followed by a very early operation. In India I have gone +farther than this, and where one eye has shown high tension, I have +frequently trephined both. The prophylactic use of the operation is more +than justified in that land of long distances and scattered medical aid, +and where the patient is not likely to return a second time for surgical +help. This prophylactic trephining is a proposition that I put before +you today for your consideration, reminding you at the same time that +glaucoma is practically invariably a bi-lateral condition. I have seen +even in America not a few people blind in both eyes who might have +retained the sight of the second eye had the surgeon advised a double +sclerectomy when he first saw the case, despite the fact that the second +eye was then to all appearances non-glaucomatous. + + + + +Dr. Robert Henry Elliot's Paper on Trephining for Glaucoma + +Discussion, + +FRANK C. TODD, M.D., + +Minneapolis. + + +It is very difficult for one of limited experience to discuss a subject +presented so ably by Lieutenant Colonel Elliot to whom we are indebted +for the sclero-corneal trephine operation. He has already over a period +of a little over four years performed over 900 trephinings, and has made +a most careful subsequent study of the results of those operations on as +many cases as he had the opportunity to observe. + +Anyone who has read Colonel Elliot's book on the sclera-corneal +trephining operation will be struck with the fact that he has not only +had a tremendous experience in ophthalmic surgery, but that he has made +the best of that unusual opportunity, and that to a foundation of a +careful training he has added the experience of twenty-two years of hard +painstaking work. + +I have recently had the privilege of entertaining Colonel Elliot in my +own city, where I had the opportunity of assisting him and hence closely +observing his technique in eighteen trephinings. It has since been my +duty, and responsibility I may add, to care for those eighteen eyes. For +two years I have been doing the Herbert tongue flap, or a similar +operation. The results have been highly satisfactory thus far and +similar to those following the trephining operation, which operation I +have performed in a number of cases during the past ten months. My +conclusions as to these two operations are favorable to the trephining +operation because the Herbert tongue flap operation is much more +difficult, and hence less certain than the Elliot trephining operation. + +The time for discussion does not permit a detailed statement of the +results nor experiences in the handling of these trephining cases. Of +the entire number five totally blind eyes were trephined. Tension was +reduced in all but one. In that one hemorrhage occurred at the time of +the operation. One of these blind eyes had not been totally blind longer +than a few weeks. Hand movement vision developed in this eye. Another +eye totally blind one year has thus far developed perception of light. +Of the cases with varying degrees of vision from hand movements to +six-ninths all but one have either remained the same or shown some +improvement. The one exception was an eye having six-ninths vision. A +small button hole iridectomy was made; prolapse of the iris into the +wound occurred four days later requiring incision. Upon incision of the +prolapse intra-ocular hemorrhage occurred, causing nearly total +blindness for two weeks. Vision is clearing fast and it remains yet to +be seen what the final results may be. One buphthalmic eye trephined by +myself gave good results. + +I have as yet seen no cases of remote infection, but the report of +Axenfeld and some others would indicate that this occurred following the +Lagrange as well as the trephining operation, the then bulging +conjunctiva having become eroded and infection having taken place +through the eroded conjunctiva as shown when stained with flourescin. + +The opinion, not yet conclusive, that I have thus far formed as a +consequence of my experience and the information obtained from others of +greater experience is as follows: + +First: That in those cases of chronic glaucoma in which iridectomy has +been of benefit in preventing or retarding the oncoming of blindness, +the result has apparently been secured by reason of the fact that +filtration has been produced, and not merely because a piece of iris has +been removed. + +Second: That in chronic glaucoma (in acute glaucoma iridectomy has +proven a satisfactory operation) when the progress of the disease +cannot be arrested by non-surgical treatment (an even in some of these, +where, for instance the patient cannot be kept under observation or will +not carry out the treatment) some form of operation intended to produce +filtration should be performed. + +Third: The Elliot sclero-corneal trephining operation carefully +performed in accordance with the author's technique in the light of our +present knowledge seems to be the best and safest operation to produce +that result. + +Fourth: That to glaucoma may be added buphthalmos and staphyloma, as +diseases often capable of relief by trephining and indeed toward the +relief of which trephining is the best form of operation yet presented. + +Fifth: That the results secured when the operation is well done and the +after care is properly followed out are satisfactory, in that the +operation in a large proportion of cases apparently permanently lowers +the tension to normal or below normal, relieves pain, prevents the +oncoming blindness (otherwise inevitable) and in many cases causes an +improvement in the acuity of vision, in the visual field. And in +occasional cases of blindness of not too long duration, it restores some +vision, occasionally to a marked degree. + +Sixth: That it is not a simple nor easy operation and should, therefore, +be performed only by an operator well trained in ophthalmic surgery. The +careful and skillful technique of the originator of the operation +perhaps accounts for his greater success in its results and those who +perform the operation should follow his technique and be capable of +handling complications that may later arise. + +In conclusion, Mr. President, I wish to say that we ophthalmologists the +world over are indebted to Lieutenant Colonel Elliot not alone for his +contributions to our knowledge, but for his persistence against +precedent and criticism in establishing the facts upon which rest the +foundation for the success of his operation, and for so emphasizing the +great importance of this epoch-making achievement. + +It is because we respect his wisdom gained by incessant study and +experience in a country where climatic conditions are such that a man of +ordinary energy would have failed to do even average work that we so +readily welcome the teaching of this enthusiastic evangelist. + +His pilgrimage to our country will be the means of starting many in this +new field, and we shall soon be able to draw more definite and final +conclusions from our own experiences. + + + + +Operations Other than Scleral Trephining for the Relief of Glaucoma + +BY + +CASEY A. WOOD, M.D., + +Chicago. + + +In this paper I shall say a few words about the large number of +operative procedures that, apart from trephining, or, preferably, +_trepanation_, have been urged in the treatment of the various forms of +glaucoma. Their name is legion and among them we find peripheral +iridectomy; anterior sclerotomy; irido-sclerotomy; scleriritomy; de +Wecker's dialysis of the iris; Hancock's division of the ciliary muscle; +the incision of the iridian angle of de Vincentiis; sclero-cyclo-iridic +puncture; the Sterns-Semmereole _sclerotomia antero-posterior_; the +_transfixio iridis_ of Fuchs; Antonelli's peripheral iritomy; Holth's +formation of a cystoid cicatrix; Hern's operation; Terson's +sclero-iridectomy; Abadie's ciliarotomy; Ballantyne's incarceration of +iris method; Masselon's small equatorial sclerotomy; Simi's equatorial +sclerotomy; Galezowski's sclero-choriotomy; excision of the cervical +ganglion; removal of the ciliary ganglion; Querenghi's operation of +sclero-choriotomy; Bettremieux's simple anterior sclerectomy; Heine's +cyclodialysis; Herbert's wedge-isolation operation; Verhoeff's operation +with a special sclerotome; Holth's sclerectomy with a punch-forceps; +Walker's hyposcleral cyclotomy; posterior sclerotomy; T-shaped +sclerotomy; and last but not least the Lagrange form of sclerectomy with +its various modifications by Brooksbank James, myself and others. + +In addition to the foregoing list--which is by no means complete--there +are several combinations of operations, as, for example, the Fergus +trephining operation, which is really a combination of a sclero-corneal +trepanation and a cyclodialysis. + +So far as it is practicable there is a certain amount of wisdom in +comparing the results of an operative procedure with others with which +it is brought in competition, and I believe we are even now in a +position to form at least some idea of the comparative value of the +three methods that comprise the great majority of interventions made use +of by ophthalmic surgeons at the present time. I refer to _iridectomy_, +the _Lagrange operation_, and the _Elliot operation_. So far as regards +the last named procedure, I congratulate this Society that it has had an +opportunity of seeing a demonstration and hearing a discussion by the +famous ophthalmic surgeon who perfected it. + +As regards the others let me recommend to you the complete description +of them given by Posey in _A System of Ophthalmic Operations_. + +Let us consider the first of the three procedures just +mentioned--_iridectomy_--introduced by von Graefe. The mechanism of its +mode of cure is best studied in cases of acute primary glaucoma, when +there is apposition of the periphery of the iris to the cornea. In these +acute cases there is probably only a mere _apposition_, and the blocking +up of the sclero-iridian angle is largely mechanical. Here the root of +the iris is readily removed in its entirety and a really peripheral +iridectomy is easily done. When, however, a true _adhesion_ between +corneal and iridic tissue takes place the filtration angle is not so +easily opened. True peripheral adhesions are not readily broken up or +separated, and the iridectomy is, for that reason at least, not +effective. Moreover, this form of anterior synechia (resulting from a +true union of iris and cornea) is so intimate that the iris root is, by +the iridectomy, torn away only at the sclero-iridian angle at the +anterior border of the adhesion--and does not open up a channel into +Schlemm's canal. It is not, therefore, difficult to understand why +iridectomy alone in any of the forms of chronic glaucoma fails to open +up the true filtration spaces and does not provide a drain that permits +of an escape of fluid from the posterior chamber through the loose +tissue that surrounds it into the canal of Schlemm. Treacher Collins +found, after a careful examination of eyes upon which iridectomy had +been performed for glaucoma, that it is extremely rare for the initial +section to pass through the pectinate ligament, while Schlemm's canal +invariably escapes. Moreover, since the sclero-corneal incision is +uniformly oblique, the position and extent of the external wound does +not always furnish evidence of the character of the internal wound. In +all likelihood many cases of relief or cure following iridectomy are +those due to the formation of cystoid scars or minute fistulae, rather +than as a result of the removal of a portion of the iris periphery. + +The best brief tabulation of the results obtained by iridectomy, in +glaucoma, is to be found in Weeks' textbook on _Diseases of the Eye_, +page 417: "Sulzer reports as follows: Acute glaucoma, 149 cases; +improved, 72.5 per cent; serviceable vision preserved, 11.3 per cent; +vision impaired at once, 4.08 per cent; very little vision, 12.12 per +cent. + +"Zentmeyer and Posey: In simple glaucoma central vision increased in 60 +per cent; remained the same in 20 per cent; diminished in 20 per cent. + +"Wygodski: Inflammatory glaucoma, 37 cases; improvement, 76 per cent; +unimproved, 5 per cent; deterioration, 19 per cent. Sub-acute (chronic +inflammatory), 147 cases; improvement 10 per cent; unimproved (condition +the same as before iridectomy), 40 per cent; deterioration, 30 per cent; +blindness, 20 per cent. Cases operated on at an early stage gave 85 per +cent of good results. Simple glaucoma, 104 cases; improvement, O.96 per +cent; condition as before, 10.5 per cent; deterioration, 52 per cent; +amaurosis, 36.5 per cent. + +"Hahnloser and Sidler: One hundred seventy-two eyes observed not less +than ten years after operation; acute inflammatory, 31 eyes; good +results, 64 per cent; relatively good, 13 per cent; blind 23 per cent; +chronic inflammatory, 37 eyes; good result, 29.9 per cent; relatively +good, 27 per cent; blind, 43 per cent; simple glaucoma, 76 eyes; good +results, 42 per cent; relatively good, 28.9 per cent; blind, 28.9 per +cent." + +As far as the _Lagrange procedure_ is concerned, you will remember that +after eserinization an oblique incision is made through the sclera by +means of a narrow Graefe knife and a large conjunctival flap secured. +This is obtained by making a peripheral section of the sclero-corneal +margin with the knife and, as soon as the edge of the knife reaches the +upper limit of the anterior chamber, it is turned backward and brought +out through the sclera obliquely. The conjunctival flap thus formed is +turned back over the cornea, and the fragment of sclera that is left +attached to the cornea is removed by means of a fine pair of delicate +curved scissors. Following this an iridectomy is performed. The +conjunctival flap is now replaced and a bandage applied. + +This operation opens a large filtration passage for the intra-ocular +fluids and the prompt healing of the wound with its mucous covering +prevents prolapse of the iris. + +Under no circumstances must iris be left between the lips of the wound. + +Although Lagrange advocated iridectomy in all cases in his first +communication, he no longer judges the procedure to be necessary in all +instances, reserving it for cases in which for any reason, such as +hypertension, prolapse is to be feared. + +While Lagrange holds that it is necessary to open the anterior chamber, +Bettremieux thinks that a removal of but a portion of the thickness of +the sclera suffices. His procedure is as follows: After raising a flap +of conjunctiva from the neighborhood of the limbus a medium sized +needle, curved and flattened towards its point and firmly grasped in a +needle holder, is thrust superficially into the sclera tangentially to +the upper edge of the cornea, so as to become fixed in the capsule of +the eyeball. A small shaving of the sclera, about 1/2 mm. thick, 11/2 to 2 +mm. broad and from 2 to 3 mm. long, is then excised by means of a narrow +Graefe knife. The scleral slip is then freed from the conjunctiva at +each end and the mucous membrane brought together over the wound by fine +catgut sutures. + +As you are well aware, numerous operators regard the Lagrange operation +as superior to the iridectomy of von Graefe because they believe there +is filtration through the newly formed tissue between the lips of the +operative wound. Among those of many observers the conclusions of +Ballantyne may be quoted: "The results of sclerectomy vary according to +the degree of hypertension of the eye operated on. Three varieties of +cicatrix are distinguishable according to the amount of sclera excised: +(1) that in which there is mere thinning of the sclera owing to the +excised portion not reaching the posterior surface of the cornea +(conjunctiva smoothly covers the cicatrix); (2) that represented by a +subconjunctival fistulette, due to excision of the whole thickness of +the sclera, in an eye with moderate tension (the conjunctiva lies +smoothly over the cicatrix); (3) the fistulous cicatrix with an +ampulliform elevation of the overlying conjunctiva, resulting from +excision of the whole thickness of the sclera in an eye the seat of high +tension. In cases of high tension, even a simple sclerectomy will allow +ample filtration, owing to the gaping of the wound, while in cases +without elevation of the tension, sclerectomy will be quite ineffectual. +Lagrange therefore proposes the following rules of procedure: (a) If +tensions is normal to +1, do sclerectomy without iridectomy, the amount +of sclera excised being inversely proportionate to the degree of +hypertension. (b) If tension is +1 to +3, do sclerotomy-iridectomy, the +iridectomy being added to avoid entanglement of the iris. Lagrange does +not recommend his operation for acute glaucoma. It is especially adapted +for cases of chronic simple glaucoma." + +During the past ten years or more I have been doing a modification of +the Lagrange operation, the details of which (The Operative Treatment of +Glaucoma with Special Reference to the Lagrange Method, _The Canadian +Medical Association Journal_, November, 1911) I have elsewhere +published. + +As stated in this paper I have modified the procedure to the extent of +removing _all_ the conjunctiva attached to the borders of the operative +wound. I admit that this intervention exposes the root of the iris and +the ciliary body, but I have never yet had the slightest infection of +the wound. I attribute this freedom from sepsis to careful cleansing of +the conjunctival sac and to other pre-operative precautions, but +especially to the use, before and after the operation, of White's +ointment--a preparation of 1-3000 mercuric chloride in sterile vaseline. +One cannot use sublimate in such a strong _watery_ solution, but the +vaseline seems to modify it and to allow of such slow absorption that it +is not only a non-irritant but a most excellent antiseptic application +in operations on the eye. + +In any event the result of the Lagrange operation proper, as well as my +modification of it, is to produce a drainage-oedema about the incisional +wound which persists almost indefinitely. In many cases this swelling +amounts to a bleb which may be increased by massage of or pressure upon +the eyeball. The efficacy of the operation in lowering intra-ocular +tension is to some extent measured by the degree and the constancy of +this epibulbar oedema; indeed, I suspect that the most successful +examples are those in which sclera fistulae, minute or otherwise, form +as a sequel of the operation. + +My object in excising the conjunctiva about the sclero-corneal flap, is +to delay union of the wound edges, to widen the bridge of loose +cicatricial tissue between them, to prevent such a complete growth of +the endothelium as would cover the wound and block the exit of fluids, +and to insure intra-ocular rest. + +In cases of _chronic_ increase of intra-ocular tension associated with a +quiet uveitis or an iridokeratitis, when the patient exhibits traces of +old synechiae, or where there is danger of their re-formation, I do not +hesitate to use atropia as long as the wound of operation has not +healed. + +To the present time I have done 72 operations of the sort and have seen +no reason to alter the opinion of it expressed in the article mentioned. +Whatever objection may in the future arise--and I freely confess that +it _seems_ to be fraught with the dangers that many of my colleagues +have pointed out as probable--I have so far not seen a single case of +infection of the wound of operation. While I believe the +anti-glaucomatous results to be excellent, I may also claim that the +operation is of the simplest character; and it is easy of performance +and the resulting filtration-scar is large and (perhaps) more permeable +to the changed intra-ocular fluids than the quicker healing wounds of +the usual Lagrange and Elliot procedures. + +It is regarded by most operators as desirable that there should not be +long delayed healing of the operative wound, and the fact that the +conjunctiva covers the incision is often spoken of as an advantage, +partly because it shields the large open area produced by the Lagrange +incision from infection. + +My experience of this modified operation continues to be that it is +necessary to clear the neighborhood of the operation wound entirely of +conjunctiva. If the down-growth of epithelium into the operative wound +is permitted the effects are by no means as pronounced, and the eventual +lowering of tension is not as permanent as they otherwise would be. + +Another matter: I am satisfied that the delayed filling of the wound by +connective tissue is desirable in most cases of _chronic_ glaucoma. A +complete drainage of the intra-ocular fluids that results from long +delayed union of the wound edges, allows the interior of the eye to +regain, as far as possible, the _status quo ante_. On the other hand the +comparatively early closure of the wound (or the termination of _free_ +drainage and minus tension) tends to re-establish the _status +glaucamatosus_. Whether these desirable results are to be realized or +not will, of course, depend upon a future experience larger than I have +yet had. This modification of the Lagrange operation seems to be a +radical one and I do not expect its adoption until the results of an +extended trial are carefully recorded and reported. + +Quite recently several operators, who have been in a position to do so, +have contrasted the results obtained by the Elliot method and those +following the Lagrange procedure. Probably the most important of these +observations is the experience of Meller (Die Sklerektomie nach Lagrange +und die Trepanation nach Elliot) set forth in a paper read by him at the +last meeting of the _Deutsche Naturforscher und Aertze_. In this report +Meller gives an account of 389 sclerectomies following the usual +Lagrange procedure. Twelve per cent of the cases were of acute glaucoma; +61.5 per cent of chronic inflammatory glaucoma, and 9 per cent of simple +glaucoma. The rest of the operations were done in other forms of the +disease. In more than half the cases the usual iridectomy was performed; +in 30 per cent the procedure was peripheral; in 4 per cent there was no +iridectomy. The patients were studied during a period of five years. In +more than half the instances there was a pale, cystic, oedematous +cicatrix; in 11 per cent the scar was ectatic, and in the remainder the +field of operation was quite flat. The form of the scar was described in +most instances, but it was not noticed that there was a definite +relation between the cicatrical formation and the intra-ocular tension. +In 70 per cent of the cases a good result followed the operation, but in +10 per cent the result was decidedly unsatisfactory. Cloudiness of the +lens set in in 4 per cent of the cases, while posterior synechiae +developed in the great majority of them. In 2.3 per cent the eye was +attacked by iridocyclitis and in 3.4 per cent enucleation was found to +be necessary. Six eyes became atrophic but were not, for various +reasons, removed. One and three-tenths per cent of the eyes operated on +were lost from late infection. Vitreous was lost in 6.2 per cent. Two +eyes became blind from expulsive hemorrhage. The large majority of +these complications arose in the eyes operated on for chronic glaucoma. +There were fewer eyes lost following the operation for glaucoma simplex +than in the other forms of the disease. Recurrences were noticed in 11.3 +per cent of all the cases; in simple glaucoma 14.3 per cent as against +the acute and chronic forms with 6 per cent. A return of the glaucoma +was noticed in 7 per cent of the pale, oedematous, post-operative scars, +in 16 per cent of the flat cicatrices, and in 24 per cent of the ectatic +variety. Considerable stress is laid upon the fact of the marked +softness of the eyes after each operation. There were histological +examinations made of the eyeballs in 11 cases, in which the position of +the incision and excision, the development of the scar tissue, and the +appearance of the complications were duly set forth. The operator then +gave a history of over 178 trepanations after the Elliot method and +compares them with the procedure of Lagrange. He concludes that the +Elliot trephining operation is less dangerous, is more likely to be +followed by the development of a cystic scar, and leads to loss of the +eye in only 2.4 per cent of the eyes operated on. In Elliot's cases the +percentage of relapse was more noticeable than in the Lagrange cases +where no iridectomy was done. This observer concludes that the method of +Elliot is to be preferred to that of Lagrange, and that in the former +case iridectomy is an important factor in obtaining a favorable result. +This being the case one cannot truthfully say that trephining alone can +take the place of the old Graefe iridectomy. On the other hand, +trephining may with advantage be employed instead of iridectomy for +cases difficult or dangerous under the latter method. + +Whatever difference of opinion was noticeable at the Vienna meeting, all +of those present, especially Meller, the reader of the paper just +quoted, were decidedly of the opinion that the Elliot operation is in +every respect the one best adapted to buphthalmia, or congenital +glaucoma. + +In conclusion let me say that the acceptance or rejection of Colonel +Elliot's procedure or any other operation is not to be decided by the +percentage of iritis, secondary cataract, relapses, lost eyes, etc., but +by deciding whether or not his procedure in the various forms of +glaucoma gives the best results, including the preservation of +comfortable eyes. In other words, we are seeking not the operation that +will cure _every_ case of glaucoma but the one which is capable, _in the +hands of the average ophthalmic surgeon_, of relieving or curing _most_ +cases of that affection. + + + + +Dr. Casey A. Wood's Paper on Operations Other than Scleral Trephining +for the Relief of Glaucoma + +Discussion, + +ALBERT E. BULSON, JR., M.D., + +Fort Wayne. + + +Increasing belief in Colonel Elliot's view that trephining should be the +operation of choice in any form of glaucoma, makes it difficult to +consider operations other than trephining in anything but a spirit of +disfavor. + +Until recently the decision as to the kind of operative procedure to be +employed for the relief of glaucoma has depended on the form and stage +of the disease, and the amount and character of the vision of the +affected eye. Many operators still hold that an iridectomy is the most +valuable of all operations for acute inflammatory glaucoma, and not a +few hold that the operation has a decided place in the treatment of +simple glaucoma. The operation is not without difficulties, and one is +inclined to agree with Elliot who says that "The man who can make a +'finished iridectomy' quietly and cleanly has graduated as an ophthalmic +operator." The difficulties of an iridectomy are especially pronounced +in those cases in which the anterior chamber is extremely shallow and +the iris is pressed against the cornea. It is in such cases that the +success of the operation is increased by the addition of posterior +sclerotomy and the intelligent use of miotics prior to the performance +of the iridectomy. Even then the permanent results of the iridectomy +will be modified in proportion to the success secured in freeing the +filtration angle and opening Schlemm's canal by thorough removal of the +root of the iris. + +The failure of many apparently well executed iridectomies may be +attributed to the fact that the iris is not removed to the extreme +root, and the remaining stump is sufficient to block the drainage. This +is especially apt to be the case in chronic glaucoma where the iris is +adherent to the cornea, and in efforts to free the filtration angle by +an iridectomy the iris is torn off in front of the adhesion and the +filtration angle is not opened. + +As Elliot has pointed out, iridectomy is most open to attack on the +ground of safety. We have to take into account the large scleral wound +made, and the fact that this lies close to the ciliary body. The sudden +release of all tension and the simultaneous weakening of the supports of +the lens and vitreous body create very unfavorable conditions under +which to make the crucial step of the operation. + +The poor results following an iridectomy in chronic glaucoma have led to +the devising of many substitute operations, of which those tending to +the production of a filtering scar are now preferred, and, experience +shows, hold out the most hope of bringing about long continued relief. +It even is considered probable that the effects of an iridectomy which +brings about more or less permanent reduction in the intra-ocular +pressure is due to the formation of a filtering scar which augments +whatever results may have been secured in the attempt to open up the +drainage into the canal of Schlemm. + +Dr. Wood has referred to several of the many substitutes for iridectomy +that have been proposed, and it is unnecessary to enumerate them again +or to attempt to point out their good or bad features. It is sufficient +to say that for the average operator and the larger per cent of cases, +the operation which is easiest to perform, is attended with the least +risk and offers the best hope of permanent results should be the one of +choice. Sympathectomy has failed to secure a place in ophthalmic +surgery, sclerotomy has not been found adequate, and cyclodialysis is +not sufficiently simple of execution or permanently beneficial in its +results to give it prominence. + +Of the operations proposed for the formation of a filtering cicatrix, +those of Elliot and Lagrange are justifiably the most popular. Those of +us who have had the pleasure of seeing the trephining operation done by +Col. Elliot are impressed with the fact that the operation, even in the +hands of its originator, is not, when properly done, uniformly easy of +performance. It does, however, offer the advantage of carrying with it +the minimum amount of risk, and the apparently permanent results secured +justify the ophthalmologist in acquainting himself with the technique of +the operation, for, as pointed out by Sydney Stephenson and others, "the +technique is responsible for success or failure." Furthermore, there is +no sufficient reason why the field of usefulness of the operation should +be confined to the chronic forms of glaucoma, and Col. Elliot +unhesitatingly recommends trephining as safer and more efficient than +any other operative procedures at present employed for the relief of +acute glaucoma. + +The success of the Lagrange operation, which, like the Elliot operation, +aims to produce a fistulous communication between the anterior chamber +and the sub-conjunctival area, depends upon securing the removal of a +relatively large section of all of the layers of the scleral and corneal +lip of the wound, so that a permanent opening, covered by the replaced +conjunctival flap, is made. Unlike the trephine operation which was +evolved from it, the Lagrange operation requires the same kind of an +opening of the eyeball as required for a well executed iridectomy, and a +properly placed section entirely in scleral tissue, with a good sized +conjunctival flap, are elements which enter into the ultimate success or +failure of the procedure. + +Aside from the dangers incident to a wide incision in the neighborhood +of the ciliary body and the possibility of accident to the lens or +vitreous body, or of intra-ocular hemorrhage, there is for the average +operator the added difficulty and danger in removing a piece of sclera +of the exact size required. The technique of the operation is even more +difficult and exacting than in the performance of the trephine +operation, and it also compares unfavorably in safety. + +The advisability of removing the conjunctival flap, as advocated by Dr. +Wood, as a modification of the Lagrange operation, may be seriously +questioned, for aside from the fact that apparently no advantages in +aiding permanent filtration are added, there is, added to the objections +to the Lagrange operation already mentioned, the very serious +disadvantage of subjecting the area at the root of the iris to infection +for a prolonged period of time. The advantages of the protection +afforded by a conjunctival flap far outweigh the disadvantages of a +remotely possible interference of drainage by the blocking of the open +wound with conjunctival tissue. The fortunate experience of Dr. Wood in +not having infection in a wound which remains open and unprotected for +variable lengths of time is not likely to be the experience of any +considerable number of operators, and probably will not always be the +experience of Dr. Wood. Furthermore, the possibilities of damage by +hemorrhage from the choroidal or retinal vessels, delayed formation of +the anterior chamber and adhesion of the capsule of the lens to the +wound, and the injurious effects of even slight trauma subsequent to the +operation, including loss of vitreous, are increased by omitting the +conjunctival flap. + +The modern operation for the relief of glaucoma, by which a filtering +scar is produced which permits escape of liquid from the anterior +chamber, is the one which apparently holds out the most hope of +permanently relieving the condition. While success will depend always to +a certain extent upon the personal equation, yet it seems now that for +a large majority if not all of the cases we are justified in abandoning +all other operations than trephining, notwithstanding the verdict of +Elschnig and others that fistula forming operations eventually will be +discarded in favor of iridectomy and cyclodialysis. + +Late or secondary infection, not unknown following iridectomy, may +follow the trephine operation, and already some fifteen or sixteen cases +have been reported. But while this possibility is a real danger, which +improved technique may greatly minimize (Col. Elliot has not seen a case +of secondary infection in an experience of over 1200 trephining cases of +his own and a large number of others performed by his assistants and +pupils) the ultimate verdict must rest with results as compared with +other measures. At present, as pointed out by Meller, whose statistics +Dr. Wood has cited, trephining heads the list of remedial measures for +the relief of glaucoma, and it has the advantage of being applicable to +any form of the disease, to be relatively free from danger, either +immediate or remote, and to produce the highest percentage of favorable +results. The addition of an iridectomy in every case of trephining does +not unduly complicate the operation and has much to commend it in +offering the patient every possibility of relief. + + + + +INDEX + + PAGE +ETIOLOGY AND CLASSIFICATION OF GLAUCOMA, + _Edward Jackson, M.D._ 9 + +ETIOLOGY AND CLASSIFICATION OF GLAUCOMA, + Discussion, _Francis Lane, M.D._ 28 + +PATHOLOGY OF GLAUCOMA, + _John Elmer Weeks, M.D._ 37 + +PATHOLOGY OF GLAUCOMA, + Discussion, _E. V. L. Brown, M.D._ 57 + +CONCERNING NON-SURGICAL MEASURES FOR THE +REDUCTION OF INCREASED INTRA-OCULAR TENSION, + _George Edmund de Schweinitz, M.D._ 61 + +CONCERNING NON-SURGICAL MEASURES FOR THE +REDUCTION OF INCREASED INTRA-OCULAR TENSION, + Discussion, _Nelson Miles Black, M.D._ 101 + +TREPHINING FOR GLAUCOMA, + _Robert Henry Elliot, M.D._ 107 + +TREPHINING FOR GLAUCOMA, + Discussion, _Frank C. Todd, M.D._ 113 + +OPERATIONS OTHER THAN SCLERAL TREPHINING +FOR THE RELIEF OF GLAUCOMA, + _Casey A. Wood, M.D._ 121 + +OPERATIONS OTHER THAN SCLERAL TREPHINING +FOR THE RELIEF OF GLAUCOMA, + Discussion, _Albert E. Bulson, Jr., M.D._ 141 + + + + + +End of the Project Gutenberg EBook of Glaucoma, by Various + +*** END OF THIS PROJECT GUTENBERG EBOOK GLAUCOMA *** + +***** This file should be named 23544.txt or 23544.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/2/3/5/4/23544/ + +Produced by Bryan Ness, Martin Pettit and the Online +Distributed Proofreading Team at http://www.pgdp.net (This +book was produced from scanned images of public domain +material from the Google Print project.) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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