Result of Glaucoma Simplex.- In these cases the eyeball will usually appear healthy and may be free from pain, but there is extreme hardness of the ball, excavation of the disc, choroidal atrophy around the disc, arteries contracted, anterior chamber shallow, pupil dilated (may be contracted) and vision entirely lost. An eye remain in this condition for years or pass into degenerative changes at any time.
In the last stages of an absolute glaucoma from any form, the eyeball may enlarge, cornea flatten and sclera bulge. This process is accompanied by severe pain until finally the eyeball ruptures and passes over into atrophy. Another change is where the eyeball shrinks, the secretion all the time growing less, the tension becomes minus and atrophy ensues. This last change may or may not be accompanied with pain, and inflammatory attacks may occur.
Glaucoma Consecutiva.- The preceding forms of glaucoma have resulted from a loss of balance between secretion and excretion in previously healthy eyes, that is, due to either an increased secretion or an obstructed excretion in eyes in which there was no other apparent disease. In this there is a similar disturbance in eyes showing other diseased conditions. All affections of the eye become glaucomatous when, with other symptoms, there is an increase in the tension. The symptoms, then, of secondary glaucoma are increased tension, which may be the only symptom. The accommodation and refraction may be impaired, but, as a rule, the other diseases of the eye will hide this. The vision is impaired, may have iridescent vision, the field is contracted, more or less severe pain, anterior chamber shallow, pupil dilated if not bound down by posterior synechiae from other disease. There is is marked dilation of the episcleral vessels and cupping of the disc. Often there are changes in the from of the globe and the condition terminates in atrophy, as in glaucoma absolutum. The most frequent causes of secondary glaucoma are total adhesions of the iris. Isolated adhesions may also lead to it. Injuries and luxations of the lens. Atheroma of the retinal vessels and tumors of the interior of the eye may cause.
TREATMENT.- This should vary according to the stage of the disease; taken in the premonitory stage where the patient suffers from only occasional attacks of temporary, blindness, pain, etc., while in the interval the vision is good, we may look for benefit from the use of remedies. The best local remedy to be considered is either the sulphate or salicylate of eserine, which may be employed in the strength of from one-half to two grains to the ounce of water and may be instilled into the eye as often as every hour, and should in itself speedidly cut short an attack. Pilocarpine in twice the strength of eserine is preferred by some. Even in some cases of acute glaucoma, if used early and often, the necessity of an operation may be postponed, if not permanently avoided. In all cases the use of eserine should be early, very early, hence we believe it best in cases once having had a premonitory attack, that the patient should be supplied with the eserine with directions as to its use that no time should be lost. The action of the eserine is to cause contraction of the iris and in this way it is drawn away from the iritic angle and the filtration passage opened; it also, by constriction of the vascular system of the eye, diminishes secretion. Mydriatics, especially atropine, must be avoided, as they are liable to cause an acute attack of glaucoma.
Iridectomy.- The introduction of this operation for the relief of glaucoma was empirically made by von Graefe, in 1857, and is still the operation for this disease. Iridectomy has been the means of saving useful vision in thousand of patients who would other wise have been hopelessly blind. While iridectomy is the most valuable remedial agency extant for this disease, still it is not infallible, as in some cases or forms of glaucoma even this operation will not check the disease. The operation is preferable made early, before the vision has been too long affected. In acute glaucoma we can expect to retain the vision where it is at the time of the operation, and if too long standing we usually get more or less improvement in the sight. Iridectomy may also be made to relieve the pain even after the vision is totally and permanently destroyed. It sometimes happens where the first iridectomy has not relieved, that the second or even the third iridectomy or repeated sclerotomies will do so. In acute inflammatory glaucoma an iridectomy is, as a rule, extremely favorable. In operating, the previous use of eserine is advisable, as it renders less liable accidents from sudden relief of the tension, and it has also been advised by Arlt and others that it be used in the sound eye as well, for the mental anxiety caused from the dread of an operation has been considered not infrequently to have been the cause of an attack in the good eye. Ether should, as a rule, be used in this operation, as thorough anaesthesia cannot be obtained from cocaine in a glaucomatous eye. The incision should be made entirely in the sclera, the iridectomy large and care taken not to injure the capsule of the lens, which is liable to occur owing to the shallow anterior chamber, and that the escape of the aqueous be very gradual. The beneficial results of an iridectomy in glaucoma simplex are quite problematical, the statistics of many prominent operators showing that only one-half of these cases are cured by an iridectomy.
Sclerotomy has been strongly advocated by De Wecker, but it has not seemed to have met with the hearty support of the other authorities. In certain cases, especially the haemorrhagic form of glaucoma, sclerotomy may with advantage take the place of Iridectomy. The writer has had the best of results form this operation in a few instances. Sclerotomy is often only resorted to after an iridectomy has failed to give relief. Sclerotomy has usually been made with a Graefe cataract knife, the incision being made wholly in the sclerotic, a bridge of tissue being left above. I have, however, used for the last three years Parenteau’s sclerotomy knife (Fig. 90) as much safer and easier to use while giving equally good results. This knife is used exactly the same as a keratome n iridectomy.
In the premonitory stage, as has already been said, our endeavor should be to cure by the aid of internal medication, which may be done in many cases if we take into consideration the constitutional disturbances which are associated with or cause the intra-ocular trouble. The habits of our patient should receive careful attention. The excessive use of stimulants (either should or tobacco), or any exhaustive mental or physical labor must be strictly forbidden. Only moderate use of the eyes should be allowed, and, during the attacks, or when they follow each other in rapid succession, complete rest is necessary. Bright light, either natural or artificial, should be avoided, or the eyes protected colored glasses. The diet should be good and nutritious, particularly in elderly person, and all indigestible substances for-bidden.
Massage, according to Fick, is of service in the after treatment and in cases of simple glaucoma where futile operations have been performed, to retard as long as possible the decline in visual acuity.
” The result of massage is instantaneous, the hard eyeball grown soft under the physician’s finger, so to say, but its effect is not lasting. The patient should, therefore, learn to massage himself, and practice it daily.”
The results from the use of internal remedies alone in glaucoma seem to me somewhat problematical, In the majority of cases recorded, where no operation was made, the local use of eserine was employed as well as the remedy, and in consequence it is unscientific to give the credit to the remedy alone.
Gelsemium.- Is one of the principal remedies in this disease and is, perhaps, more frequently used than any other. There seems to be no especially characteristic symptoms upon which it is given, hence we come to the conclusion that its use has depended upon the fact that clinically it has proven its valve.
Bryonia.- From its value in serous inflammations in general, this remedy has been given with benefit in glaucoma. It is more often indicated in the prodromal stage. The eyes feel full, as if pressed out, often associated with sharp, shooting pains through the eye and head. The eyes feel sore to touch and on moving them in an direction. There may be a halo around the light, with heavy pain over the eye, worse at night. The usual concomitant symptoms will decide us in its selection.
Aconite may be of service at the commencement of an acute attack when we have much heat, redness and burning pain in the eye, together with fever and other symptoms of the drug generally.
Osmium.- This remedy has proven of value in the hands of some, and from its symptoms should be given a more thorough trial. It has sudden, sharp, severe pains in and around the eye. Dimness of vision, objects seen in a fog. Halo of various colors around a light.
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.