PROGNOSIS-In all forms of glaucoma the prognosis is always bad, if the disease is allowed to follow its own course, as blindness inevitably results sooner or later. When, however, the proper treatment is undertaken in acute glaucoma the prognosis may be said to be favorable, doubtful in glaucoma simplex and unfavorable in the absolute or haemorrhagic glaucoma. that is, in acute glaucomas, the further progress of the disease can often be stooped and vision, as a rule, preserved where it is without further loss; where the disease has been of but a short duration, there may be complete restoration of sight after an iridectomy.
Varieties of Glaucoma-This disease may be divided into two general classes; primary glaucoma, which arises without previous disease of the eye, and secondary glaucoma, or that form in which we can see some previous disease of the eye, to account for the glaucoma.
Glaucoma Acuta-Usually the patient has had warning of impending danger in the way of certain premonitory symptoms-due to an increased tension and not to inflammation. There is premature recession of the near point. This impairment of the accommodation, where the patient is unable to use his ordinary glasses, but keeps changing every little while for stronger and stronger ones, is always suggestive of glaucoma. He complains also of having noticed a periodic dimness of vision, as though clouds of smoke were coming before the eyes from time to time. There is seen a rainbow of colors encircling a light, and, upon examination of the eye at this time, there will be detached a slight increase of the tension; the cornea is a little dull and diffusely clouded, the pupil is dilated and sluggish, the field of vision may be contracted and there may be hyperaemia of the retina. Such an attack lasts a few hours, when the eye returns to normal, and may remain so for weeks or months, when another seemlier attack occurs. These infrequent attacks may occur for years, the eye gradually undergoing changes so that it is not normal between attacks, and in this way gradually pass into a chronic glaucoma. As a rule, however, the attacks become more and more frequent, when suddenly there comes on an attack of acute glaucoma. The onset is apt to occur during the night and sets in with severe pain in the eye and head, which increases in severity and is accompanied by rapid loss of vision and often by vomiting, fever and general prostration. These attacks are usually brought on by some sudden excitement or grief, or some venous congestion as from a feeble heart. Upon examination of the of the eyes we may find any or all of the following symptoms. The lids are swollen and may be oedematous; conjunctiva inflamed, possibly chemosed; scleral vessels injected, eyeball protruded, lachrymation, photophobia, cornea hazy and may have lost its sensitiveness to touch, iris discolored, pupils, aqueous cloudy and anterior chamber shallow. there is intense pain in the eye and head, the eyeball is hard, the vision impaired and the field contracted. Ophthalmoscopic examination is often unsatisfactory on account of the haziness and general inflammation of the eye; but, if possible, there may be seen an excavation of the optic disc, the retinal arteries are small and pulsate, the retinal veins enlarged and there may be slight extravasations of blood.
An attack of acute glaucoma may last from a few hours to several days or weeks, when the symptoms will gradually subside, the vision improves and the eye becomes normal again. these attacks usually follow one another, the intervals growing less and less, until it finally passes into what is called chronic or absolute glaucoma. In some cases the first attack will be of unusual severity, in which the vision does not return, the tension does not decreases and the dullness of the cornea persists. These cases are called glaucoma fulminans. The cupping of the optic nerve is frequently not present in an attack of acute glaucoma. The impairment of the vision may mean that it is reduced to the faintest glimmer of light, which De Wecker says is due to ischaemia, of the retina. the pain in acute glaucoma is often so intense that the patient may ignore a complete loss of vision and demand relief for his neuralgia, and in this way often mislead the physician.
Glaucoma Chronica-This form may develop from an acute attack, or directly from the premonitory stages. In fact, it generally does not amount to an actual attack, but develops gradually the symptoms of the acute, irritation being absent.
Among its symptoms we find the anterior ciliary veins enlarged and tortuous, the sclerotic has a dull, leaden hue, the cornea is hazy and loses its sensitiveness to touch, the pupil is large and inactive, the iris is discolored and becomes atrophied, the anterior chamber is shallow, the tension is increased, may be Plus 3. An ophthalmoscopic examination shows an excavation of the optic disc, the retinal veins large and the arteries small and pulsate. There is a progressive failure of sight, the field becomes more and more contracted and the halo around the light is seen. The pain in chronic glaucoma varies, though, as a rule, is not so violent. If the disease has come on gradually it may be entirely absent, though rarely is, and in other cases it may be severe. there may be a remission of the symptoms in some cases, or they may continue all the time, but become increased from nervous excitement. Chronic glaucoma gradually leads on to absolute.
Glaucoma Simplex-This is considered by those who claim glaucoma to be a non-inflammatory disease to be the most characteristic form, as in this variety of glaucoma there are no inflammatory symptoms. We sill simply find an increased tension which may vary at different times, but usually not elevated to the degree we have in other forms, and in some cases we may never find the tension distinctly increased. The pupil is dilated and sluggish, though, as a rule, not so much so as in acute or chronic. The vision is impaired and the field contracted, there is no pain or haziness of the cornea and with the exception of some distension of the anterior ciliary veins the eye looks quite normal. With the ophthalmoscope there is seen an excavation of the optic disc, some choroidal atrophy around the disc and displacement of the retinal vessels. the characteristic signs of glaucoma simplex are the increased tension, excavation of the disc and the regularity with which the pressure acts upon the circulation of the retina, first limiting and then abolishing the field of vision. the central vision, as a rule, gradually diminishes but sometimes remains good until the field of vision. has become almost lost. The absence of pain and inflammation together with the very gradual loss of vision renders the patient often unconscious of any trouble until late. In the excavation of the disc in glaucoma the edge of the discoverhangs so that the vessels wholly or partially disappear from view as they pass over the margin of the disc: some claim they are always displaced toward the inner side and believe that in any excavation where the vessels are not so displaced the cupping is not the result of glaucoma. The choroid around the excavated disc in glaucoma may be detached by the pressure, often presenting the appearance of posterior staphyloma. Glaucoma simplex is usually chronic in form and may terminate in acute inflammatory glaucoma or in absolute. Fuchs says: “Glaucoma simplex always attacks both eyes,” but this statement is not borne out in my own experience.
Glaucoma Haemorrhagica-This may be considered a primary glaucoma when associated with haemorrhage, or secondary when it is caused by haemorrhage. The symptoms are the same as those already detailed under acute or chronic forms, plus the greater tendency to haemorrhage on account of the degeneration of the vessels. The haemorrhage occurs especially from the retinal vessels. Varicose and aneurismal dilatations, together with changes in the walls of the retinal vessels, have been frequently found. Sudden relaxation of the tension by an iridectomy has often resulted in a serious intra-ocular haemorrhage, causing destruction of the eye. The pain in this form of glaucoma, when there may be but even a slight increase of the tension is often unbearable and frequently necessitates enucleation. In many cases the haemorrhage is the cause of the outbreak of acute symptoms when there were no glaucomatous signs before. Haemorrhagic glaucoma generally affects but one eye and is usually found in old people with arterio-sclerosis.
Glaucoma Absolutum.- By this we mean a glaucoma that has run its course, or all cases that have resulted in a total loss of sight. The results very somewhat, whether due to acute, chronic, or simple glaucoma.
Result of Acute of Chronic Glaucoma.- In this the anterior ciliary veins are large and dark, especially at the recti muscles; the conjunctiva is thinned, the sclera pale, the cornea rough, hazy and not sensitive to touch; the pupil is dilated to a mere rim, which is in contact with the cornea; the lens is cataractous and pushed forward near to the cornea, the pain often continues severe and the patient has the subjective symptoms of photopsies and chromopsies.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.