|
is shown by increased hardness of the eyeball. To discover this you direct the patient to look down and you place the tips of both index fingers over the upper eyelid making geutle pressure with them alternately. When doincr this you notice the globe pits or dimples and that a distinct sense of resistance as from fluid, is given to the fiugers. It is the amount of this resistance which enables you to judge of the intra ocular tension. The glaucomatous eyeball is always harder, tenser, and more resistant than the normal globe. The power of judging between slight differences in tension is only to be arrived at by considerable practice ; and you should never fail to compare one eye with its fellow when estimating intra ocular pressure. As a means of recording our impression with regard to intra ocular pressure, Sir William Bowman introduced the following formula:?T = normal tensiou, T-f-1= slightly increased tension, T + 2 still higher, while T + 3 means strong hardness. In the same way lessened tension is T?1, T?2, and T?3. This formula is generally used. 2.?Rapid increase in any existing presbyopia
slightly^
(Siltjjiiral dlontiuttuiqatioua. V
j
CLINICAL LECTURE ON GLAUCOMA. By SurGEost A. W. D.
LEAHY,
f.r.c.s.,
Offcjr. Residency Surgeon, Hyderabad,
Beccan.
Delivered to the Students of H. H. the Nizam's Medical School, Afzul Ganj Hospital, Hyderabad, 2Gth May 1890.
for selecting the subject of glaulecture on to-day, are the fact that the disease is one of extremely common occurrence in India, though I believe it is frequently not recognised, and is still more frequently allowed to run its course without being subjected to leading au elderly person to continually change proper treatment at the hands of the various Hakeems under whose care the cases come, and his convex spectacles for lenses of a higher that several cases have lately come before you value. 3.?Shallowness of the anterior chamber due in the clinic which you have had the opporto the lens and iris advancing towards the own of aud forming your tunity of watching I cornea. value of the the operation opinions regarding 4.?Alteration in the look of the corner, of iridectomy as the method of treating this | which assumes an appearance of glass, after it disease. has the been breathed upon. This steumij appearance in have of seen, Many you present may is due to oedema of the corneal tissue and districts or large towns in which your homes J cells. have are situated, numerous cases where epithelial persons of sought advice at the dispensaries for gradual i 5.?Lessening of the power in accommodathe corneae. failure of vision in one eye accompanied by tion and loss of sensitiveness attacks of pain iu the globe itself, extending J This latter is sometimes so marked that you down the side of the nose, with some redness of the may pass the tip of the finger over the corneae conjunctiva, increased intra ocular tension, and without giving rise to pain. The diminution in advance ot the iris towards the cornete; and accommodating power, and the anesthesia of the you have doubtless seen, as I have, such cases corneao, are both due to the increased pressure treated, as instances of cold in the eye, neuralgia, on the ciliary nerves as they pass forwards or conjunctivitis, for the relief of which the between the sclerotic and choroid. instillation of a strong solution of atropine has This is a most varying symptom. 6.?Pain. been one of the remedies prescribed. In nine cases It is usually circumorbital ; extending down out of ten these have been cases of glaucoma. the side of the nose, and up over the side of the Classification. Glaucoma is usually divided head, frequently absent in chronic cases; aud into two classes. Primary and secondary. more pronounced should the case become acuter. first we mean cases in which increase It the By may lead to glaucoma being treated as in the intra ocular pressure is the first symp- neuralgia, " tic," or migrane. The pain is due toms we find, while by the term secondary we to irritation of the ciliary nerves. understand those cases in which rise in intra 7.?Dilatation with fixity of the pupil probabocular pressure is a consequence of some mani- ly due to paralysis of the muscular elements of fest preceding change. Primary glaucoma may the iris from pressure on the ciliary nerves, but be acute, subacute, or chronic, and it is to-day by some said to be due to anaemia of the muscular especially to the chronic variety that our atten- curtain from pressure on its blood vessels. The tion will be given. shape of the pupil is frequently elongated horiand most constant prominent zontally, but the direction of the oval may be Symptoms.?The vertical, as was the case with the patient in bed symptom of this disease is:? 1.?Hise in the intra ocular tension, which No. 8, upon whom I operated a few days ago. My
reasons
coma to
=
25
THE INDIAN MEDICAL GAZETTE.
.194
8.?Congestion of the small and large episcleral vessels in the ciliary region, just beyond the periphery of the cornese. With the ophthalmoscope we find :? 9.?Pulsation of the veins and arteries on the optic papilla, and where they come round This pulsation is readily the margin of the disc. seen when we use the direct method of examination, and though pulsation of the retinal veins is sometimes met with in cases of disease of the mitral valve, or even very occasionally as a physiological phenomenon, pulsation in the arteries is pathognomonic of considerable increase in intra ocular pressure. 10.?Cupping of the disc. Rise in ocular tension means increase in the amount of pressure which is exerted on the inner surfaces of the tunics forming the globe of the eye. This pressure is exerted evenly and equally; with the result, that the weakest spot in the The weakest wall of the globe yields to it. spot here is undoubtedly the lamina cribrosa, where it is perforated by the optic nerve, and the optic papilla is as a result in glaucoma backwards giving rise to the " cupped pushed This pathological cupping disc " of the disease. of the disc is altogether different from the physiological depression so commonly noticed in healthy persons. Thus in glaucoma the depression is a sudden and sharp one involving the whole breadth of the papilla and limited by in old cases of the a sharp circular margin which disease is quite white from the atrophy of the increased pressure. choroid that results from On examining the cupped disc in a glaucomatous eye by the direct method, we find we can readily trace the vessels curling over the edge of the cup, but that, in order to follow them down into the bottom of the depression, we require (assuming the surgeon to be an emmetrope) the addition of a minus or bi-concave The depth of the lens in front of the eye. cup, the severity of the extent therefore, some to and increase iu intra ocular pressure, ma}' be gauged by the strength of the bi-concave lens thus required. The scale is one dioptric=? 0f a So that should a?3D lens be millimetre. necessary to enable you to see the bottom of the disc, the depth of the cup will be equal to
the^
1 millimetre.
11.?The
patient frequently complains
seeing colored
halos
and
rings
of
around the flame of a candle or lamp, and sudden flashes of light are also mentioned as one of the symptoms. 12.-? Contraction of the field of vision. This contraction is first noticed on the nasal side, and is due to the increased intra ocular pressure, causing the least sensitive portion of the retina to become anaesthetic. At the same time some diminution takes place in central vision, and later on the temporal portion of the field also
becomes
[July
contracted,
so
that
gradually
1890.
absolute
blindness results. You must not expect to meet with all these twelve symptoms in every case of glaucoma. Many cases will run their course, and present only three or four of the above symptoms, while the
degree
of
to any particular pain, and fogginess of vision, will depend greatly upon the acuteness of the disease. Take for example a typical case
prominence given
symptom, such
as
the
of
glaucoma such as that of the man now before you on whom I performed double iridectomy. He is over 50 years of age, and complained eight years ago of recurring attacks of fogginess of vision lasting for from several hours to three days. "When this fogginess passed away, his vision at first was as clear as ever. These attacks occurred principally at night, and he used to see a halo round the flame of a candle. Later on he began to suffer from attacks of pain in each eye extending round the orbit and over the side of the head. After several attacks of fogginess, his vision by degrees became permanently damaged, and he visited the hospital for treatment. On examining him we found both pupils persistently dilated, and oval in shape. The tension of the globe of both eyes was 2. The irides were pushed forward against the cornese, and the anterior chambers were all but obliterated. Vision in his left ej7e was equal to counting fingers at 10 feet, while that of his right eye was only equal to counting them at five feet. The left eye was attacked after the right one, and was at the time of examination the seat of acute pain. Both cornea) were slightly steamy, and the media were so hazy that with the ophthalmoscope nothing could be made out regarding the condition of the optic papilla and retina. You have been able to judge of the improvement in this case after the performance of a double iridectomy.
Pathology.?The rise iu intra ocular tension glaucoma is due to interference with the exhalation or escape of fluids from within the interior of the globe. The exhalation probably takes place through many channels, the chief in
of
which, however,
is
a
formed by the coats of the behind the margin of the
small ring of tissue eyeball immediately
cornea) and iu front To this space of the ciliary margin of the iris. the name of the "filtration area" is given. For filtration through this area to be complete the fluid in the anterior chamber must be able to reach it. If from any cause the ciliary processes and the periphery of the iris are pushed forward, " the space of the " filtration area is encroached from the anterior upon, and the exit of fluid chamber is impeded. Obstruction to the exit of fluids from within, leads to its.accumulation, and a consequent rise in the pressure exerted on the llius is the glauinner surface of the globe, comatous process started. Much has beeu written
July
18a0.]
LEAHY ON GLAUCOMA.
m
the iris is so much displaced forwards that the the pathology of glaucoma, but nearly all anterior chamber is practically non-existent, the that within excess of fluid are writers agreed operation is very difficult, if not impossible, to the globe is the true explanation of the glauperform. (2) The ciliary processes may be wounded comatous process, but as to the reason for this and haemorrhage from them take place into the Two principal views have excess they differ. eye. (3) The iris frequently becomes prolapsed found strong supporters. Firstly, that the exof fluid is due to hypersecretion takiug cess through the incision, and has to be cut off, thus converting the operation into an iridectomy. place within the globe. Secondly, that it is due of outflow of a to obstructed normal amount Many years ago the late Mr. Henry Hancock introduced an operation for the relief of glausecretion. Among ophthalmologists supporting coma to which the name of Cilicotomy was the theory of hypersecretion are Yon Grade, The eyelids being secured iu an open while and given. Douders, Von Hippel, Griiuhagen ; condition by the introduction of the stop spring the list of those who have accepted the second speculum, the eye is steadied by pinching up a view as explaining the reason of the excess of fold of conjunctiva and fluid within the globe in glaucoma, contains the sub-coujuuctival tissue close to the corneas near the nasal names of Max Kines, Adolf Weber, Leber, and angle of the globe, a Beer's Cataract knife with its back that the Brailey. Priestly
is shown by increased hardness of the eyeball. To discover this you direct the patient to look down and you place the tips of both index fingers over the upper eyelid making geutle pressure with them alternately. When doincr this you notice the globe pits or dimples and that a distinct sense of resistance as from fluid, is given to the fiugers. It is the amount of this resistance which enables you to judge of the intra ocular tension. The glaucomatous eyeball is always harder, tenser, and more resistant than the normal globe. The power of judging between slight differences in tension is only to be arrived at by considerable practice ; and you should never fail to compare one eye with its fellow when estimating intra ocular pressure. As a means of recording our impression with regard to intra ocular pressure, Sir William Bowman introduced the following formula:?T = normal tensiou, T-f-1= slightly increased tension, T + 2 still higher, while T + 3 means strong hardness. In the same way lessened tension is T?1, T?2, and T?3. This formula is generally used. 2.?Rapid increase in any existing presbyopia
slightly^
(Siltjjiiral dlontiuttuiqatioua. V
j
CLINICAL LECTURE ON GLAUCOMA. By SurGEost A. W. D.
LEAHY,
f.r.c.s.,
Offcjr. Residency Surgeon, Hyderabad,
Beccan.
Delivered to the Students of H. H. the Nizam's Medical School, Afzul Ganj Hospital, Hyderabad, 2Gth May 1890.
for selecting the subject of glaulecture on to-day, are the fact that the disease is one of extremely common occurrence in India, though I believe it is frequently not recognised, and is still more frequently allowed to run its course without being subjected to leading au elderly person to continually change proper treatment at the hands of the various Hakeems under whose care the cases come, and his convex spectacles for lenses of a higher that several cases have lately come before you value. 3.?Shallowness of the anterior chamber due in the clinic which you have had the opporto the lens and iris advancing towards the own of aud forming your tunity of watching I cornea. value of the the operation opinions regarding 4.?Alteration in the look of the corner, of iridectomy as the method of treating this | which assumes an appearance of glass, after it disease. has the been breathed upon. This steumij appearance in have of seen, Many you present may is due to oedema of the corneal tissue and districts or large towns in which your homes J cells. have are situated, numerous cases where epithelial persons of sought advice at the dispensaries for gradual i 5.?Lessening of the power in accommodathe corneae. failure of vision in one eye accompanied by tion and loss of sensitiveness attacks of pain iu the globe itself, extending J This latter is sometimes so marked that you down the side of the nose, with some redness of the may pass the tip of the finger over the corneae conjunctiva, increased intra ocular tension, and without giving rise to pain. The diminution in advance ot the iris towards the cornete; and accommodating power, and the anesthesia of the you have doubtless seen, as I have, such cases corneao, are both due to the increased pressure treated, as instances of cold in the eye, neuralgia, on the ciliary nerves as they pass forwards or conjunctivitis, for the relief of which the between the sclerotic and choroid. instillation of a strong solution of atropine has This is a most varying symptom. 6.?Pain. been one of the remedies prescribed. In nine cases It is usually circumorbital ; extending down out of ten these have been cases of glaucoma. the side of the nose, and up over the side of the Classification. Glaucoma is usually divided head, frequently absent in chronic cases; aud into two classes. Primary and secondary. more pronounced should the case become acuter. first we mean cases in which increase It the By may lead to glaucoma being treated as in the intra ocular pressure is the first symp- neuralgia, " tic," or migrane. The pain is due toms we find, while by the term secondary we to irritation of the ciliary nerves. understand those cases in which rise in intra 7.?Dilatation with fixity of the pupil probabocular pressure is a consequence of some mani- ly due to paralysis of the muscular elements of fest preceding change. Primary glaucoma may the iris from pressure on the ciliary nerves, but be acute, subacute, or chronic, and it is to-day by some said to be due to anaemia of the muscular especially to the chronic variety that our atten- curtain from pressure on its blood vessels. The tion will be given. shape of the pupil is frequently elongated horiand most constant prominent zontally, but the direction of the oval may be Symptoms.?The vertical, as was the case with the patient in bed symptom of this disease is:? 1.?Hise in the intra ocular tension, which No. 8, upon whom I operated a few days ago. My
reasons
coma to
=
25
THE INDIAN MEDICAL GAZETTE.
.194
8.?Congestion of the small and large episcleral vessels in the ciliary region, just beyond the periphery of the cornese. With the ophthalmoscope we find :? 9.?Pulsation of the veins and arteries on the optic papilla, and where they come round This pulsation is readily the margin of the disc. seen when we use the direct method of examination, and though pulsation of the retinal veins is sometimes met with in cases of disease of the mitral valve, or even very occasionally as a physiological phenomenon, pulsation in the arteries is pathognomonic of considerable increase in intra ocular pressure. 10.?Cupping of the disc. Rise in ocular tension means increase in the amount of pressure which is exerted on the inner surfaces of the tunics forming the globe of the eye. This pressure is exerted evenly and equally; with the result, that the weakest spot in the The weakest wall of the globe yields to it. spot here is undoubtedly the lamina cribrosa, where it is perforated by the optic nerve, and the optic papilla is as a result in glaucoma backwards giving rise to the " cupped pushed This pathological cupping disc " of the disease. of the disc is altogether different from the physiological depression so commonly noticed in healthy persons. Thus in glaucoma the depression is a sudden and sharp one involving the whole breadth of the papilla and limited by in old cases of the a sharp circular margin which disease is quite white from the atrophy of the increased pressure. choroid that results from On examining the cupped disc in a glaucomatous eye by the direct method, we find we can readily trace the vessels curling over the edge of the cup, but that, in order to follow them down into the bottom of the depression, we require (assuming the surgeon to be an emmetrope) the addition of a minus or bi-concave The depth of the lens in front of the eye. cup, the severity of the extent therefore, some to and increase iu intra ocular pressure, ma}' be gauged by the strength of the bi-concave lens thus required. The scale is one dioptric=? 0f a So that should a?3D lens be millimetre. necessary to enable you to see the bottom of the disc, the depth of the cup will be equal to
the^
1 millimetre.
11.?The
patient frequently complains
seeing colored
halos
and
rings
of
around the flame of a candle or lamp, and sudden flashes of light are also mentioned as one of the symptoms. 12.-? Contraction of the field of vision. This contraction is first noticed on the nasal side, and is due to the increased intra ocular pressure, causing the least sensitive portion of the retina to become anaesthetic. At the same time some diminution takes place in central vision, and later on the temporal portion of the field also
becomes
[July
contracted,
so
that
gradually
1890.
absolute
blindness results. You must not expect to meet with all these twelve symptoms in every case of glaucoma. Many cases will run their course, and present only three or four of the above symptoms, while the
degree
of
to any particular pain, and fogginess of vision, will depend greatly upon the acuteness of the disease. Take for example a typical case
prominence given
symptom, such
as
the
of
glaucoma such as that of the man now before you on whom I performed double iridectomy. He is over 50 years of age, and complained eight years ago of recurring attacks of fogginess of vision lasting for from several hours to three days. "When this fogginess passed away, his vision at first was as clear as ever. These attacks occurred principally at night, and he used to see a halo round the flame of a candle. Later on he began to suffer from attacks of pain in each eye extending round the orbit and over the side of the head. After several attacks of fogginess, his vision by degrees became permanently damaged, and he visited the hospital for treatment. On examining him we found both pupils persistently dilated, and oval in shape. The tension of the globe of both eyes was 2. The irides were pushed forward against the cornese, and the anterior chambers were all but obliterated. Vision in his left ej7e was equal to counting fingers at 10 feet, while that of his right eye was only equal to counting them at five feet. The left eye was attacked after the right one, and was at the time of examination the seat of acute pain. Both cornea) were slightly steamy, and the media were so hazy that with the ophthalmoscope nothing could be made out regarding the condition of the optic papilla and retina. You have been able to judge of the improvement in this case after the performance of a double iridectomy.
Pathology.?The rise iu intra ocular tension glaucoma is due to interference with the exhalation or escape of fluids from within the interior of the globe. The exhalation probably takes place through many channels, the chief in
of
which, however,
is
a
formed by the coats of the behind the margin of the
small ring of tissue eyeball immediately
cornea) and iu front To this space of the ciliary margin of the iris. the name of the "filtration area" is given. For filtration through this area to be complete the fluid in the anterior chamber must be able to reach it. If from any cause the ciliary processes and the periphery of the iris are pushed forward, " the space of the " filtration area is encroached from the anterior upon, and the exit of fluid chamber is impeded. Obstruction to the exit of fluids from within, leads to its.accumulation, and a consequent rise in the pressure exerted on the llius is the glauinner surface of the globe, comatous process started. Much has beeu written
July
18a0.]
LEAHY ON GLAUCOMA.
m
the iris is so much displaced forwards that the the pathology of glaucoma, but nearly all anterior chamber is practically non-existent, the that within excess of fluid are writers agreed operation is very difficult, if not impossible, to the globe is the true explanation of the glauperform. (2) The ciliary processes may be wounded comatous process, but as to the reason for this and haemorrhage from them take place into the Two principal views have excess they differ. eye. (3) The iris frequently becomes prolapsed found strong supporters. Firstly, that the exof fluid is due to hypersecretion takiug cess through the incision, and has to be cut off, thus converting the operation into an iridectomy. place within the globe. Secondly, that it is due of outflow of a to obstructed normal amount Many years ago the late Mr. Henry Hancock introduced an operation for the relief of glausecretion. Among ophthalmologists supporting coma to which the name of Cilicotomy was the theory of hypersecretion are Yon Grade, The eyelids being secured iu an open while and given. Douders, Von Hippel, Griiuhagen ; condition by the introduction of the stop spring the list of those who have accepted the second speculum, the eye is steadied by pinching up a view as explaining the reason of the excess of fold of conjunctiva and fluid within the globe in glaucoma, contains the sub-coujuuctival tissue close to the corneas near the nasal names of Max Kines, Adolf Weber, Leber, and angle of the globe, a Beer's Cataract knife with its back that the Brailey. Priestly
