Complete Text (Part 1)

LASS. PYSeP TOMS, DFAGNOSIS, § TREATMENT. PRTER DIRCK KEYSER, M.D. PHIEADELP WIA: © BUR leer ON. TS64. GLAUCOMA: SYMPTOMS, DIAGNOSIS, AND TREATMENT. PETER DIRCK KEYSER, M.D. norte PHILADELPHIA: LINDSAY & BLAKISTON. 1864. Entered, according to Act of Congress, in the year 1864, By P. Dirck Keyser, In the Clerk’s Office of the District Court of the United States for the Eastern District of Pennsylvania. ‘ CAXTON PRESS OF SHERMAN & Co. To HENRY TIEDEMANN, M.D., This Brochiire 18, IN TESTIMONY OF THE WONT EATER AND YRLENDSUIY, THE AUTHOR. PREFACE. Snoutp any apology be deemed necessary for obtruding on the medical public a new pamphlet ou ophthalmic science, it may. perhaps, be furnished by the interest which that department of medicine and surgery has acquired in the last few years, and the attention it now commands from the pro- fession. I have endeavored in these pages to lay before the reader, in an easy and practical form, the latest theories relating to Glaucoma, so as to en- able him at once’ to grasp the most salient and important points in the symptoms, diagnosis, and treatment of this disease. 1 have chiefly followed the views of Professor A. Von Graefe, of Berlin, in the diagnosis and treatment of this disease; indeed, we are mainly indebted to his admirable and important researches vill PREFACE. for the elucidation and treatment of this and many other diseases of the eye. The substance of this work is from my notes taken while attending the clinical lectures of Pro- fessor Von Graefe, during the winter of 1863 and 1864, in Berlin, and I have compiled and pub- lished them, thinking that they would not only be of interest, but of advantage to the medical pro- fession in this country. 500 Noxtu Povrrn Srreet, September, 1864 GLAUCOMA. Tue term glaucoma was applied by Tlippocrates to all opacities situated behind the pupil. After a time, it was confined to those which presented a green appear- ance, the nature of which was not, however, understood, although the fact was recognized that such green opa- the seat of the affection was supposed to be in the vitreous cities were not curable by operations. By som lianmor, by others, in the retina and optie nerve. At a later period, it was thought that glaucoma was due to a peculiar inflammation of the choroid, which ocewred sons, Henee it was termed most frequently in gouty pei arthritic ophthalnia, a name still retained by some wri- ters, Lawrence considered that the symptoms of glau- an affection of the retina and coma were caused by choroid, Weller gave a most excellent and graphic description of the symptoms of glaucoma, including in it many of the principal and most important points, ¢. g., the intenmitting course of the disease, the sluggishness and dilatation of the pupil, the cireumorbital pain, the rainbows round a candle, ke. He also made mention ie first of the tenseness of the eyeball, but Macken 10 GLAUCOMA. pointed out (in 1830), the importance of the latter symptom. In 1851, Helmholtz discovered the ophthalmoscope, which has proved of such incaleulable value in diseases of the eye, and has so completely revolutionized ophthal- mie surgery. The first results of the ophthalmoseopic examination of eases of glaucoma were negative ; soon, however, it was ascertained that there alway existed a peculiar alteration in the optic dise in all cases of well- marked glaucoma. In 1854, Edward Jiiger gave an ex- ecllent illustration of the ophthalmoscopie appearances of the optic nerve-entrance in a case of glaucoma, show- ing the peculiar displacement of the vessels at the edge of the dise, the slight rim surrounding the latter, &e. It was, however, reserved for the great genius of Von Graefe to unite these various and disjointed links of the chain of symptoms presented by glaucoma, and welding them into one connected whole, not only to found the modern doctrine of glancoma, but at the same time, to bless humanity witli a cure for this hitherto irremediable disease. Soon after Jtiger’s delineation of the ophthal- moscopie appearances ofthe optic disc, Von Gracfe de- scribed these peculiar appearances still more accurately, and at the same time, pointed out a most important fact, viz., that an arterial pulsation exists in the optie nerve in glaucoma, being either spontaneous, or produ- cible by a very slight pressure upon the eyeball, a pres- sure far less than is necessary for its production in the normal eye. Within a short time after rds, he also discovered that the peculiar appearance of the optic GLAUCOMA, iG dise, which had been supposed by him and other obsery- ers to be due to an arching forward of the optic nerve- entrance, was in reality due to its being exeavated or cupped. Tle at once reeognized the connection of these two symptoms (the ex eayation and the spontancous or easily producible arterial pulsation), with the increased hardness of the globe, and his clinical observations soon. showed him that all the other symptoms were also sion. The closely connected with this augmented te next problem was, to solye how this tension might be permanently diminished. All the usual remedies, such as mercurials, antiphlogisties, diuretics, diaphoretics, had proved as insufficient in his hands, as in those of other practitioners. Mydriatics, which had been found to diminish intraocular pressure, were next had recourse to, but they also proved of no avail. He then tried tap- ping the anterior chamber, but this was only followed by atemporary benefit, which soon pass dist stayed b nd away again, The ed, nor could the relapses be ase gradually progress y a methodical repetition of the paracentesis, for he found that its therapeutical effect beeame each time less, and finally null, as far as the sight was con- cerned. In only two eases out of a great number thus treated, did it prove of lasting benefit. Paracentesis having been of no avail in permanently reducing the intraocular pressure, he next had recourse to iridectomy, having found that it proved of great benefit in uleerations and infiltrations of the cornea, by diminishing pressure; and that in cases of partial sta- phyloma of the cornea, and in staphyloma of the sclero- 12 GLAUCOMA. tic, the protruding part often receded completely after this operation. Te first tried iridectomy in glaucoma, in 1856, and soon found that it not only permanently diminished the intraocular pressure, but that it might indeed be re- garded a true curative treatment of the glaucomatous proe aving, however, like every other therapeutic agent, its natural limits, Since that time iridectomy has been recognized by most of the eminent oculists in Europe, as the only eure known at present for glau- coma; but although it has achieved most brilliant re- sults in the Lands of many of the most distinguished ophthalmic surgeons, there are yet some English ocu- lists of repute who condemn the operation completely. My own experience of the beneficial etlects of in- dectomy in glaucoma, enables me, not only to recom- mend the operation most strongly, but even to trust to uo other remedies, as they have all proved insutlicient, and most valuable time would thus be permitted to pass y, when an irideetomy might still save the eye. We shall sce hereafter that an accurate prog- <pected from iridectomy nosis of the benefits to be y be made in the majority of cases, and it will be shown why the operation may have proved unsuccessful But too frequently were expected of it; it was tried for the aps, in chronic cases of glau- coma, which were beyond help: it proved, as might ma in the hands of some practitione: impossibilities first and only time, pe hatve been foretold, unsuccessful, and was then at once d scarded as useless. GLAUCOMA, 13 The commencement of the disease, the development of the different symptoms, and the course which glan- coma may run, present numerous variations, and for this reason a precise classification is somewhat difficult. But on closer observation, it will be found that the se- yeral varieties also show a great tendency to pass over into each other. The family resemblance of these different forms is very marked, for they are distin- guished from the commencement, by certain character- ie symptoms, and although they will vary somewhat in their course, they all, but too surely, lead, sooner or later, to that last hopeless condition, in which the eye- ball is stony hard, the pupil widely dilated and fixed, the refractive media clouded, the optic dise enpped, and the sight either entirely or nearly entirely lost; that condition, in short, to which our forefathers confined the term glaucoma. The modern school of ophthal- mology, however, no longer limits the name glaucoma to this last hopeless condition, but embraces in it all the varieties of the disease trom their commencement, which lead to this last stage. Tn regarding the differ- ent varieties of glaucoma from a clinical point of view, we are particularly struck by the fact, that one class of cases is distinguished from the commeneement by more or less marked inflammatory symptoms, whilst another appears, in the commencement at least, to be free from inflammation, although in its course, inflammatory symptoms, even of an acute kind, generally make their appearance. We may, therefore, divide cases of glau- vom into two principal classes : oe 4 GLAUCOMA, T. Cases attended with inflammatory symptoms, TL. Cases in which there are apparently no inflamma- tory symptoms present. Glaucoma may exist as a primary disease, or may ting affection. We find that the different varieties of glaucoma show complicate a previously © certain common characteristics, and we may generally recognize the four following stages: 1. A premonitory stage (glaucoma imminens, inci- piens of Von Graefe) ; 2, A stage in which the glaucoma is fully developed (glaucoma cyolutum, confirmatum, Von Graefe); 3. A stage in which quantitative perception of light has been completely lost for some time (glaucoma abso- lutum, consmmnatum, Von Graefe) ; 4. A stage in which the eye undergoes glaucomatous degeneration (Von Graete). [. Iyvnammatory GLaveoMa. We distinguish qvo principal forms of inflammatory glanconia,—the acute and the chronic. As it is of consequence, in the examination of eases of glancoma, that the observer should know how to estimate the degree of intraocular pressure, and the extent of the field of v sion, I shall, before entering upon wv description of the symptoms of glaucoma, ex- plain in w manner the tension of the eyeball is to be estimated, and the extent of the field of vi tained. OU ASeeT= INFLAMMATORY GLAUCOMA, 15 A just appreciation of the degree of tension of the eyeball is of great importance in glaucoma, for in the inajority of cases it is considerably increased. AL though there is some difference in the degree of tension inet with in perfectly normal eyes, a cording to the age of the patient, the temperament, and individual peculi- it is but seldom very marked, and generally yaries but inconsiderably from the normal standard. But the amount of tension may undergo occasional variations, at times becoming more inereased; this aug- mented tension lasting for a certain time, and then again diminishing. Tt is necessary, therefore, to exa- mine the tension of the eye at different times, if other symptoms of glaucoma be present, without a marked increase in the tenseness of the eyeball. The degree of tension is to be ascertained in the fol- lowing manner: The patient being direeted to look slightly downwards, and gently to close the eyelids, the surgeon applies both his foretingers to the upper part of the eyeball behind the region of the cornea. The one nst the eye so forefinger is then pressed slightly a gently as to steady it, whilst the other presses the eye, and estimates the amount of tension, ascertain ing whether the globe can be readily dimpled, or whether it is perhaps of a stony hardness, yielding not wre of the in the slightest degree even to the firm press finger. The beginner will do well to make himself thoroughly conversant with the normal degree of ten- sion, by the examination of a number of healthy eyes, and then, if he should be at all in doubt as to the de- 16 GLAUCOMA, , gree of tension in any individual ease, he should test the tension of the patient’s other eye (if healthy), or that of some other healthy eye, so as to be able to draw a comparison between them. If there is much edema of the lids, or conjunctival chemosis, or if the eyes are small and deeply set, it may be difficult accurately to estimate the degree of tension. It is also to be borne in mind that the normal tension has a certain range or variety in persons of different age, build, or tempera- ment; and according to varying temporary states of system as regards emptiness or repletion. The extent of the field of vision may be ascertained in the following manner; The patient being placed straight before us, at a distance of from fifteen to eigh- teen inches, is directed to look, with the eve under exa- mination (closing the other with his left hand) into one of our eyes. In this way any movement of his eye may be at once detected and cheeked. Whilst he still keeps his eye steadily fixed upon ours, we next move one of our hands in different directions throughout the whole extent of the field of vision (upwards, downwards, and laterally), and ascertain how far from the optic axis it is still visible; we then approach the hand nearer to the optic axis, and examine up to how far trom it he is able to count fingers in different directions. The number of the extended fingers is to be constantly changed, and the examination to be repeated several times, so that we may ascertain whether the patient ean count them with certainty, or whether he hesitates in his an- swe We may thus 8, or only guesses at their numbe INFLAMMATORY GLAUCOMA, 7 readily discover whether the field of vision is of normal extent, or whether it is defective or obliterated in cer- tain directions. We inay term that part of the field in which the pa- tient can still distinguish an object (a hand, a piece of chalk, &e.), the quantitative field of vision, in contradistine- tion to that smaller portion in which he is able to count fingers, and which may be designated the qualitative field. The folowing method of examining the field is still more aecurate, and IT should advise its adoption in all eases where it is of inrportance to have an exact map of the extent of the ficld, as in glaucoma, detachment of the retina, &c., so that a record nay be kept of the condition of the field during the progress of the disease, or that we may be able to compare its extent before and after an operation. The patient being placed before a large black board, at a distance of from twelve to sixteen inches, is direeted to close one eye with the hand, and to keep the other steadily fixed upon a chalk dot, marked on the centre of the board and on a level with his cye. A picce of chalk, fixed in a dark handle, is then gradually advanced from the periphery of the board towards the centre, and the spot where the chalk first becomes visible is then marked upon the board. This proceeding is to be repeated throughout the whole extent of the field; the different points at which the becomes visible are then to be united by a object firs line, which indicates the outline of the quantitative field of vision, The extent of the qualitative visual field is next to be examined, and it is to be ascertained how far . 18 GLAUCOMA, from the central spot the patient can count fingers in different directions. The points thus found are also to be marked on the board, and the marks afterwards united with each other by a line, which should be of a different color or character to that indicating the extent of the quantitative field, so that the two may not be confounded. It need hardly be mentioned that care is to be taken that during the examination the patient’s eye remains steadily fixed upon the central spot, that the other eye is kept closed, and that his distance from the board is not altered. The extent of the field in- wards will, naturally, vary according to the prominence of the paticnt’s nose. But the sight of the patient may be so much impaired that he can no longer count fingers even in the optic axis, being only able to distinguish between light and dark, as in cases of mature cataract, severe cases of glaucoma, &¢., and yet it may be of great importance to know whether or not the field of vision is of normal extent. This may be readily ascertained in the follow- ing manner: The patient is directed to look with the one eye (the other being closed) in the direction of his up- lifted hand (held on a level with his eye, and at a dis- tance of from twelve to eighteen inches). A lighted candle is then held in difterent portions of the visual field, and the furthest point at which it is still visible in various directions is noted, the candle being alter- nately shaded and uncovered by our hand, so as to test the readiness and accuracy of the patient's answers. ACUTE INFLAMMATORY GLAUCOMA. 19 Care should be taken to shade the candle when it is removed to another portion of the field. The contraction of the field in glaucoma is generally yery characteristic. In the great majority of cases it commences at the inner (nasal) side (the outer part of the retina being the first to suffer),