Complete Text (Part 4)

of the subeonjunctival tissue, and to a diminution in the calibre of the subconjunctival arteries. The cornea gradually loses its sensibility more and more, frequently, however, only in certain portions. It also becomes flatter. The anterior chamber becomes shallow, the aqueous humor clouded, and this turbidity may change with great rapidity, occurring perhaps seve- ral times a day. Tt may be produced by any exeite- ment or fatigue, often coming on after a full meal, excessive exercise, &e. The iris is pushed forward, so as to be perhaps almost in contact with the cornea. It is dull and discolored, its fibrille being more or less ob- literated, and not showing a clear and distinct outline. The pupil is widely dilated, and either immovable or extremely sluggish on the stimulus of light. The field of vision becomes greatly contracted, assuming, per- haps, a slit shape. As has been before pointed out, the contraction of the ficld in glaucoma begins, as a rule, at the immer side, extending from thence upwards and downwards, so that the outer portion is the last to be- come affected. Vision progressively deteriorates, the fixation often becomes eccentric, and finally the sight ed, so that not even a rem- may be completely des nant of quantitative perception of light is left, even al- 42 GLAUCOMA. though the light be intensified by means of a powerful biconvex lens. On ophthalmoscopic examinatiou, we find that the fandus always appears more or less clouded, often to such an extent as to prevent our distinguishing the details of the background of the eye. This haziness is due to opacity of the aqueous and vitreous humors, and in some cases also of the cornea and lens. But if the media remain sufficiently clear to permit an exami- nation, we find the retinal veins widely dilated and tor- tuous, the arteries diminished in calibre, and presenting either a spontaneous or easily producible pulsation; the optic nerve more or less deeply cupped, and the vessels rlaced at its periphery. The chief and character- istic difference between the acute and the chronic in- flammatory glaucoma is, that the latter may lead to even complete destruction of sight, without any symp- toms of severe inflammation or severe pain. There may only be insidious attacks of chronic, frequently re- curring inflammation, leading gradually to loss of sight. At first, these inflammatory attacks may be intermit- tent, occurring at considerable intervals, but later they may only show remissions. In other cases again, after the eye has been suffering for some time from these in- sidious chronic inflammations, it may be suddenly at- tacked by a severe acute exacerbation, causing very great pain and suffering. These acute exacerbations may recur again and again. The pain may be so severe that recourse must be had to an irideetomy for its re- lief, ever although there is no chance of restoring any | sight. In such cases, the patient and his friends must CHRONIC INFLAMMATORY GLAUCOMA. 43 be warned beforehand that the operation is not per- formed for the sake of giving any sight, but only in order, if possible, to relieve the pain. In many cases, particularly if the iridectomy be made sufliciently large, the relief may be permanent; in others" it is only tem- porary. When speaking of acute glaucoma, it was inentioned that after the first acute attack the disease might gradually pass over into chronic inflammatory glaucoma, no fresh acute attack occurring, but only chronic, latent inflammatory exacerbations. Sometimes the course of chronic glaucoma is so insidious that the sight of the eye may be completely lost without the pa- tient being aware that anything was the matter with this eye, the other being well. Perchance he closes the good eye, and then discovers the blindness of the other, and thus often supposes the vision to have been sud- denly lost. On being questioned, he may remember that he occasionally experienced slight pain in and around the eye, which he supposed to be rheumatic; that it occasionally became somewhat reddened, and watered a little, which was attributed to a cold; but otherwise he noticed nothing peculiar. This may not only occur amongst the humbler classes, following pur- suits which require but little employment of sight in reading, &c., as among laborers; but it may even hap- pen amongst men of literary habits and avocatious, em- ployed for many hours daily in reading and writing. When the disease has run its course, and all sight is lost, Von Graefe terms it glaucoma absolutum. Then all chance of benetiting the sight hy an operation is past. 44 GLAUCOMA, The lens frequently becomes opaque, assuming the pe- culiar greenish hue so characteristic of glaucomatous cataract. The glaucoma absolutum may exist for a length of time without the eye undergoing any changes, except that atrophy of the iris, choroid, and optic nerve, become more and more apparent. In other cases, fre- quent, often véry acute and violent, inflammatory symp- toms show themselves, accompanied by intense ciliary neurosis and headache. In the last stages of the dis- ease other changes oceur,—the iris becomes reduced to a narrow streak, the cornea opaque and softened, more particularly in its central portions, and hemorrhagic effusions take place into the anterior chamber, the vi- treous humor, and the inner tissues of the eyeball. Sclerotie staphylomata are formed, and suppurative inflammation may even occur, leading to atrophy of the globe. Von Graefe calls this the stage of glaucoma- tous degeneration. In it, irideetomy no longer proves assure remedy for the inflammatory complication. Ge- nerally sight is completely lost. Sometimes the one eye may be lost from chronic inflammatory glaucoma, or from the apparently non-inflammatory form (glaucoma simplex), and the other be attacked by acute glaucoma. I. Tum arrarentiy NoN-InFLAMMATORY GLAUCOMA. Amaurosis with Glaucomatons Excavation of the Optic Nerve (Von Graefe). Glaucoma Simplex (Donders). This disease was fora long time considered as distine- tive from glaucoma, with which it was supposed to have NON-INFLAMMATORY GLAUCOMA. 45 nothing in common but the excavation of the optic nerve. First deseribed by Von Graefe under the title of “Amaurosis with excavation of the optie nerve.” But he has now also adinitted it into the glaucomatous group of « The course of the disease is often exceedingly insidi- bASCS. ous, so that it may be considerably advanced before the patients pay any particular attention to it, supposing, but too frequently, that the increasing weakness of sight is simply owing to old age. Though this impairment of vision may be noticed also for distance, it makes itself particularly felt in reading, writing, sewing, &c., and convex glasses are found but of slight assistance. There is generally no premonitory stage, for the intermittent obscurations, rainbows found a candle, &e., are mostly due to some slight inflammatory attack, accompanied by ive media. cloudiness of the refrac The external appearance of the eye may be perfeetly healthy. The refractive media may be quite clear, the cornea sensitive, the anterior chamber of the normal size, the iris healthy and not discolored, or but very slightly so, this being only apparent on comparison with the iris of the other, healthy eye; the pupil perhaps slightly dilated and a little sluggish. But the eyeball is and with the generally found to be abnormally tens oplithalmoseope we observe that the optie nerve shows a glaneomatons exeavation, Sometimes this inerease in tension varies greatly, being very marked at one time, and hardly, if at all, apparent at another; it is of great consequence, therefore, to examine such eyes frequently, 5 46 GLAUCOMA, and at different periods of the day. There is still a good deal of discrepancy of opinion as to the invariable pre- sence of increased tension of the eyeball in this form of glaucoma. Some assert that tension is always increased in all cases of glaucoma simplex; others, again, think that although this undoubtedly does occur in the ma- jority of cases, yet that in others it is absent. Von Graefe, in particular, maintains, that the intraocular tension is not in all cases increased in a marked man- ner. He thinks that the occurrence of glaucomatous excavation of the optie nerve, without any marked in- crease in the tension of the eyeball, may be explained thus: That perhaps the resisting power of the optic pa- pilla varies in different individuals, perhaps, also, at dif ferent ages. Just as iritis and*irido-cyclitis serosa may occasionally be observed, particularly in young indi- viduals, to exist for some length of time with an unmis- takable increase of tension, without any excavation; may istance of the optic papilla be absolutely or relatively so diminished, that an exceedingly slight increase of tension may al- not, on the other hand, the power of r ready cause an excavation? But every, even the most considerable increase of tension, requires to act some time before it leads to cupping. The truth of this is shown in cases of acute glaucoma, where there is no cup directly after the first acute attack, although this may have lasted for some weeks, during which the in- traocular pressure was greatly increased. In glaucoma fulminans it is somewhat different: there it appears to supervene early. But a long-continued, though slight