Complete Text (Part 2)

from thence it passes upwards aud downwards; the outer side (tempo- ral) becomes last affected. The contraction is generally diagonal, but may occasionally be concentric; sometimes the field of v a small slit-s ion is nearly completely obliterated, only 1aped portion remaining. Chronic glau- coma furnishes the best instances of the mutilation of the visual ficld. It does not constitute one of the earliest symptoms of glaucoma. In cases of cerebral amaurosis complicated with glaucoma, the field of vision appears to become contracted first at the outer side, and not at the inner, as is usual in glaucoma. 1. Acute Inflammatory Glatcoma. Synon. Ophthalmia arthritica. Premonitory Stage—In the great majority of cases (75 per cent.) there is a premonitory stage, which is charac- terized by the presence of several or all the following symptoms, which are, however, of periodie occurrence, there being in the interval a perfect intermission. When this ceases to be the case, when there are no longer perfect intermissions, but only remissions of the symp- toms, we can no longer designate it the premonitory stage, but must regard it as a confirmed glaucoma. 20 GLAUCOMA, The following symptoms are met with in the premo- nitory stag 1. Increased tension of the eyeball. 2. Marked increase of any existing presbyopia. oo . Venous hyperemia. 4. Haziness of the aqueous and vitreous humors. 5. Dilatation and sluggishness of the pupil. 6. Periodic dimness of sight. 7. The appearance ofa halo or rainbow round a candle. 8. Intermitting pains in and around the eye; these are not always present. 9. Slight contraction of the field of vision. The intensity of these symptoms varies with the se- verity of the attack. They may be so slight as to eseape all observation, or they may be very marked if the attack is severe, and then there are often added to the symp- toms above enuinerated, diminution in the size of the anterior chamber, arterial pulsation, and indistinctness of cecentrie vision, particularly if the illumination be but slight. Let us now consider these premonitory synptonis more in detail. 1. The Increased To * considerable; it sion of the Eycball.—TPhis is gene- ie; s in degree, how- ever, but it mever reaches that stony hardness in which ssible to dimple the eyeball, In families in which glaucoma is hereditary, a marked inerease in the ‘ly life, although the dis- se does uot break ont, perhaps, till a much later period, or even not at all. Tn such tension is met with even in ea G 2s there ean be no objection to look upon this abnormal tension as a ACUTE INFLAMMATORY GLAUCOMA. 21 predisposing clenent of glancoma, more particularly if it be accompanied by hypermetropia, and a dispropor- tional diminution of the range of accommodation. It has been supposed by some that the inereased degree of tension always precedes, for a longer or shorter pe- riod, the other s ( however, met with several marked exceptions to this rule. In some cases in which he operated for glaucoma in the one eye, the other was found to be of a perfectly norinal tension at the time of operation, but was soon ymptoms of glaucoma; Von Graefe has, after attacked by glaucoma, in one case, even by glau- coma filminans. Bunt an increase in the tension of the eyeball should alw should at once lead us to examine as to the presence of ite our suspicion, and other symptoms of glaucoma; if we find none, we should still wateh the eye with care, and warn the pa- tient carefully to observe whether any other symptoms begin to show themselves, ¢. g., rainbows round a ean- dle, rapidly inereasing presbyopia, periodie dimness of vision, &e. We must be upon our guard against the too frequent error, that a sense of fulness or tension within the eye experienced by the patient, is any proof of the increased hardness of the eyeball. For this feel- t without the ing of fulness may slightest increase of tension. Another frequent error is to suppose that all acute inflammations of the eye are aceompanicd by an increase in the intraocular pressure. A carefnl ex- amination of ordin: the conjunctiva, cornea, iv fallaey of this opinion, for the tension will be found 3 sof acute inflammation of is, &e., will at once prove the yea 22 GLAUCOMA, normal. If the degree of tension is increased, we must regard it as a dangerous complication, which is to be carefully watched, lest it be the precursor of other glau- comatous symptoms. 2. Rapid Increase of any Pre-existing Presbyopia—As the persons attacked by glaucoma are mostly beyond forty-five or fifty years of age, some degree of presby- opia is generally already present, but it is found that this often increases in a yery rapid and marked man- ner during the premonitory stage of glaucoma; so that the patient may be obliged, in the course of a few months, frequently to change his reading-glasses for stronger and stronger ones. This rapid increase in the presbyopia appears to be not so much due to a flatten- ing of the cornea through an increase in the intraocular pressure, as to the action of this pressure upon the nerves supplying the ciliary muscle, thus causing the paralysis of the latter. MIlaffiman has called particular attention to the fact that hypermetropia very frequently oceurs together with glaucoma. It does not appear that hypermetropie eyes are more prone to glaucoma than others, but rather that hypermetropia is developed in the course of the disease. The cause of this is, how- ever, still quite uncertain; it is probably to be sought for in some changes in the erystalline lens (rapidly pro- gres: ve senile involution), by which the refractive power of the latter is considerably diminished. 8. Venous Hyperamia.— The congestion of the ciliary veins is generally slight during the premonitory stage, and they never present that peculiar tortuous, dilated ACUTE INFLAMMATORY GLAUCOMA. 23 appearance, so characteristie of chronic glaucoma. Generally, only a few seattered, dilated veins are seen rmnning over the sclerotic. On examination with the ophthalmoscope, the retinal yeins are also found to be dilated and tortuous; there may be likewise spontancous yenons pulsation, or this may be produced by slight ee A. Clouliness of the Aqueous and Vitreous Humors.— we upon the eyeball. The aqueous humor is often found slightly but uniformly haz; dis vitreous humor also becomes a little clonded, but uni- y, rendering the structure of the iris somewhat in- inet, and causing a slight change in its color. The formly so, for on ophthalmoseopie examination, we do not tind dark masses floating about in the vitreous humor, but only a diffused cloudiness, which renders the details of the fundus more or less indistinet. This able in its degree and aly per- laziness of the humors is very vi duration; sometimes it is so slight as to be ceptible, at others it is so considerable as to prevent any ophthalmoscopic examination. I the majority of eases, however, it is but moderate in the premonitor, It ma. few minutes at a time, or it may be less frequent, or of stage. > come on several times a day, lasting but for a longer duration. 5. Dilatation and Sluggishness of the Pupil. —On compar- ing the pupil of the eye affected with premonitory symp- toms of glaucoma with that of the other (supposing this to be healthy), the former will be found somewhat di- lated and sluggish, reacting but slightly on the stimulus of light. The dilatation is never so considerable as in 24 GLAUCOMA, the advaneed stages of glaucoma, when we often find the pupil widely dilated and quite immovable. Its slug- gishn is, however, generally well marked. It is al- way’ neecssary to examine the state of the pupil of each eye separately, for occasionally we find that the pupil of the affected eye may be of the same size as the other, when both eyes are open and exposed to the light, but that it dilates at once when the healthy eye is covered, and then reacts but slightly on the stimulus of light, and even under a strong light does not diminish to the same size as when the other eye is open, Sometimes the dilatation is irregular, which is owing to some of the nerves being more compressed than others. 6. Periodic Dinness of by oceasional intermittent dimness of sight. At such ‘ight.—The patient is troubled times, surrounding objects appear veiled and indistinct, as if they were shrouded in a gray fog or smoke. The degree of dimness varies considerably, as does also the duration of these attacks ; sometimes they may last for at also exist a slight contraction of several hours, at others only for a few minut such a time, there 1 the field of vision; generally, however, there is only indistinetness of eccentric impressions in certain diree- tions. These obseurations may be due to transitory cloudiness of the aqueous and vitreous humors, but they are eaused, for the most part, by disturbances in the eir- culation of the eye. The character of these obseurations may be imitated by pressure upon the healthy eye, and Donders has found that the dimness of vision shows itself as soon as arterial pulsation is produced by this ACUTE INFLAMMATORY GLAUCOMA. 25 pressure upon the eyeball. T have experimented a good deal upon this point, and have arrived at the same re- sults. T have also found, that by regulating the amount of pressure, [ have been able to produce any kind of ol jects ly curation, from the slightest, in which only the ob- ng quite at the periphery of the field of vision appeared somewhat clouded, to that excessive dimness in which the light of a bright lamp was rendered quite unapparent. The increased intraocular pressure, acting directly upon the retina, does not, therefore, appear to be so much the cause of these obscurations; but we must seck for it rather in the impairment of the cirenlation, the stagnation and fulness of the veins, and perhaps, the emptying of the arteries. The increased pressure pro- duces the changes in the circulation, and the, latter causes the obscurations. The truth of this assertion is atta generally brought on by anything that causes conges- also proved by the fact that thes of dimness ave tion of the bloodvessels of the eye; for instance, a full meal, great excitement, long-continued stooping, vio- lent exercise, &e. 7. The Appearance of a Halo or Rainbow round « Can- dle.—This is monitory stage. On looking at a candle, the patient symptom of the pre- Iso a very constant sees a colored halo, or rainbow round the light. The out y side of the ring is red, the inner bluish-green. This has been supposed by some to be a mere physical phenomenon, due to a diffraction (interference) of the rays of light, owing to some change in the refractive media, especially the peripheral portion of the leus. 3 26 GLAUCOMA, It is seen when the pupil is dilated, but disappears when the patient is directed to look through a small opening. It may, however, be also due to congestion of the vessels, for I have seen it sometimes brought on by stooping for some time. 8. Ciliary Neurosis, i. e., pains, more or less acute, in the forehead and temples, and passing down the side of period, some- the nose, occur occasionally at an ea times only at a later part of the premonitory stage, at the same time with the intermittent obscurations, Sometimes, however, they are quite absent. 9. The field of vision is occasionally somewhat con- tracted ; generally, however, there is only some inc tinctness of eccentric impressions in certain directions, more particularly if the illumination is but slight. At the commencement, these symptoms only show themselves at long intervals, of perhaps several months. At fi : objects appear somewhat hazy and indistinet, that there is a rainbow round a candle, accompanied perhaps by a ight pain round the eye, and down the side of the nose. On st the patient only notices that the surrounding nnining the eye during one of these attacks, we find the tension im sed, the veins on the sclerotic somewhat dilated, with perhaps a delicate rosy zone ronnd the cornea, the aqueons humor slightly clouded, sh on the stimu lus of light. With the ophthalmoscope, the vitreous the"pupil somewhat dilated, and sluge humor is perhaps found somewhat hazy, the retinal veins dilated and tortuons, showing cither a spontaneous ye- nous pulsation, or this may be readily produced by slight ACUTE INFLAMMATORY GLAUCOMA. 2a pressure upon the globe. If the attack be severe, these (litte muy, in such a case, be superadded spontaneous t symptoms may be strongly marked, and there arterial pulsation, dinimess in certain portions of the field of vision, and diminutions in the size of the anterior cham- her. Tn other eases all the premonitory mptoms are so slight that they are unuoticed by the patient. He may have only rema ked that he is getting rapidly sighted, and that he has had frequently to change his reading-glas: If, therefore, a person complains to us of this rapid inerease of presbyopia, we should at once ascertain whether any other premonitory symptoms of glaucoma are present. Gradually the intervals between these periodic at- tacks become less and les: At first, perhaps months elapse between exch attack, then weeks, then days, and when they occur at intervals of a tew days only, the second stage, the glaucoma evolutum, may be expected, although this may even occur when the intervals are still distant. If the periodic attacks no longer leave behind them a normal pupil and a normal acuteness of vision, still more, if the optic nerve is already cupped, we must no longer designate it as the premonitory stage, but a case of glaucoma evolutum, with periodie increase of the symptoms (Von Graet The premonitory stage may last for an indefinite pe- riod; years may even elapse before it leads to confirmed s, it does not pa glaucoma even after the second or third attack, there glaucoma; but in the majority of « tend beyond a few months, or it ma over into * such prominence that the patient i 28 GLAUCOMA, being only remissions, and not clear and well-defined intervals, between the attacks. Sometimes, a5 has been mentioned above, the premonitory symptoms are so slight as quite to escape the notice of the patient, par- till perfectly healthy. It is s already been lost ticula rly if the other eye i different, however, where one eye hi by glaucoma, for then the patient's attention and anx- iety are at once aronsed by any of the premonitory symptoms, and he early consults his medical attendant, the sight of the second fearfnl lest he should also los ey ea : In the great majority (about 75 per cent.) of cases, acute inflammatory glaucoma is preceded by a more or Jess marked premonitory stage, of varying duration. The intervals between the premonitory attac less and less frequent, until the attacks reeur perhaps The patient become every two or three days, or even every day. is then suddenly seized, frequently at night-time, and after having passed perhaps several sleepless nights, by a severe, often excruciating pain in and around the eye, which extends to the forehead, temple, and down the eor- responding side of the nose, as far asthe extremity of the hone. Sometimes this pain extends also to the corre- sponding half of the head, and even to the oceiput, whieh causes it often to be mistaken for an attack of rheuma- tism. At the same time there may be considerable eon- stitutional disturbance, febrile excitement, and severe ymptoms may be of supposed to be suf- , and the affection of nausea and vomiting, and these s fering from a severe Dilions attac ACUTE INFLAMMATORY GLAUCOMA. 29 the eye is either overlooked, or is thought to be depen- dent upon this. But the eye shows marked symptoms of acute internal inflammation. The eyelids may be much swollen, red, and putty, The conjunetival and sub- conjunctival vessels are injected, the veins, in particular, being dilated and gorged. There may also be very con- siderable serous chemosi , Which completely hides the deeper subconjunetival vascularity, and the rosy zone ronnd the cornea. There is also much photophobia and lachrymation, but accompanied by very little mucous discharge, and this chiefly of a thin, frothy character, ‘The cornea is clouded on its posterior surface, being per- haps studded with minute opacities, deposited from the aqueous humor. The sensibility of the cornea may be never at- also somewhat diminished, but this anesthesi tains the same degree ax in chronic glaucoma, where it is often so great that the cornea may: be tonehed, or even rubbed with a roll of paper or the brush of a qnill-pen, without its being felt. Oc sionally the anaesthesia is only partial, being confined to a certain portion of the eor- nea, This loss, or diminution, in the sensibility, is due to the compression of the nerves supplying the cornea by the iner ‘ed intraoenlar pressure. proved in cases of acute glaucoma, where the sensibility at once returns alter diminution of the tension by iridectomy or para- centesis, The sensibility of the cornea is best tested by touching it delicately with a finely-volled spill of silk lids well i art, paper, care being taken to keep the ey x0 that the conjunctiva is not touched. In healthy eyes, 30 GLAUCOMA, the cornea is so exquisitely sensitive, that the slightest touch of a foreign body will be felt and resented. The anterior chamber is found to be somewhat more shallow, the iris being pressed forward, and even, per- haps, in eontaet with the cornea, the aqueous humor clouded, the iris somewhat discolored and of a dirty hue; in some eases, there may even be