Glaucoma | Operating Microscopes

Glaucoma
By J. A. LIPPINCOTT, A.B., M.D.,
OF PITTSBURG, PA.

General Considerations. The term “glaucoma " is applied to a group of phenomena, the most prominent of which, apart from a greater or less degree of impairment of vision, are an increase in the hardness of the eyeball and an excavation in the head of the optic nerve. Brisseau in the last century and Weller and Mackenzie early in the present directed attention to the first of these two characteristics, the great English observer especially dwelling on its importance and systematically employing a rational method of relieving it viz. puncture of the sclera and of the cornea.

To determine the pressure and degree of abnormal tension palpation is employed in the manner described on page 170. A number of tonometers, or mechanical substitutes for the fingers, have been devised, but, owing to defects which are possibly irremediable, they are not in general use.

In recording the results of palpation of' the globe the method usually employed is that suggested by Bowman, according to which T. stands for normal tension; T. + ? tension probably increased; T. + 1 and T. + 2 still higher degrees; while T. + 3 indicates stony hardness. Care is required not to mistake the rigidity of a thickened eyelid or that of an abnormal sclera for an actual increase in intraocular tension. In doubtful cases the finger tips may be placed on the naked eyeball. In investigating ocular tension the tactus eruditus is an essential qualification, and no o portunity of acquiring it should be neglected.

The excavation of the optic nerve in glaucoma involves the whole or nearly the whole surface of the disk, and attains a considerable depth. Its sides are steep or even undercut, so that the cavity is ampul a. bulging in its deeper portions.

Viewed with the ophthalmoscope, the blood vessels are crowded toward the nasal side, and, as they dip into the pit, make a sharp bend, and frequently disappear behind the overhanging margins. When they reappear on the floor of the excavation they are less distinct and lighter in color, and their continuity is apparently broken, owing to parallactic displacement. From the same cause they appear to move more slowly in response to lateral movements of the object lens used in the indirect examination than they do at the level of the retina. On making use of the direct method a stronger concave or weaker convex lens is required than the one used for the neighboring retinal surface. This difference in refraction constitutes a means of accurately measuring the depth of the excavation, an interval of three diopters corresponding to about I mm.

Arterial pulsation is either spontaneous or is easily induced by light pressure with the finger. This phenomenon is a result of the increased intraocular pressure, which is sufficient to retard the arterial current, except when the latter feels the onward thrust of the cardiac systole. The blood thus enters per saltum, instead of continuously as under normal conditions. Spontaneous venous pulsation is common.

The disk shows a bluish or greenish pallor, and is surrounded by a more or less complete ring, which sometimes appears yellow, probably by contrast with the color of the disk. This ring is due to atrophy of the choroid and is known as the glaucomatous halo (Fig. 239). A low grade neuritis is commonly to be detected in the nerve head containing the pathologic excavation.

common with most of the symptoms in glaucoma, the cupping of the optic disk is a consequence of the increased intraocular tension, the latter taking most effect at the least resisting portion of the ocular envelope viz. the lamina cribrosa. It is probable that the process is favored in many cases by inflammation with softening and, later, cicatricial contraction of the tissues in this region; and this factor would appear to be sometimes sufficient in itself to produce an excavation indistinguishable ophthalmoscopically from one known to result from abnormally high pressure (Fig. 240).

Varieties of Glaucoma. Glaucomatous manifestations range themselves in three principal groups:

(1.) Primary glaucoma, the pathology of which is not positively determined.

11.) Secondary glaucoma, which obviously depends upon some preexisting morbid condition.

(111.) Congenital glaucoma, usually described as buphthalmos.

1. Primary Glaucoma. This variety, which may or may not exhibit signs of inflammation or congestion and is subdivided accordingly, will be first described.

Etiology. The predisposing causes of glaucoma have reference to age, sex, race, systemic condition, and the conformation and refraction of the eye.

is rare in the young,' and most frequent in the fifth and sixth decades of life. More women than men suffer from inflammatory glaucoma, whereas more men than women are affected with the non inflammatory form of the disease. In the analysis made by William Zentmayer and William Campbell Posey of 167 cases of glaucoma simplex, men were found slightly more liable than women. The extremes of age noted were thirteen and ninety six Years. These facts are represented graphically by these authors in the following diagram. A disproportionate number of cases are seen in the Jewish race (Knapp), and Egyptians are said to be peculiarly liable. There appears to be a tendency to hereditary transmission. When this is the case the period of life at which the outbreak occurs is earlier in each succeeding generation (De Wecker). The gouty and rheumatic diatheses favor the development of the malady, and those who suffer from arterial sclerosis, chronic bronchitis, or heart disease are liable to the disease. A causal relationship between influenza and non inflammatory glaucoma has been recorded. The author has observed catarrhal disease of the nasal passages in a large proportion of cases of inflammatory glaucoma. Small, hyperopic eyes are more likely to be affected than emmetropic or myopic eyes. This is explained by the limited circumlental space due to the hypertrophy of the ciliarv muscle in hyperopia, and also to the excessive and practically continuous contraction of this muscle in accommodation. The progressive increase in the diameter of the lens throughout life noted by Priestley Smith is claimed by this author as an important etiological factor. There is a relation between smallness of the cornea and glaucoma (normal average horizontal diameter, 11.6; glaucoma, 11.1).

Among the exciting causes may be mentioned various emotions joy, grief, anxiety, etc. producing ciliary congestion, and the incautious use of mydriatics, which, by thickening the peripheral portion of the iris, directly diminish the filtrating area in the anterior chamber. An onset of the disease has been precipitated by exposure to cold, by loss of sleep, worry, neuralgia, and by the ingestion of a hearty meal. Nettleship relates a case which was always worse in warm weather, and lady tinder the author's care can always bring on an attack by abruptly entering a dark or dimly lighted room. Over use of ametropic or improperly corrected eyes may excite glaucoma in an eye predisposed to the disease.

and Pathological Anatomy. The pathogenesis of glaucoma is not definitely settled. Because of the overshadowing importance of the increase in intraocular tension the aim has mainly been to account for this phenomenon; but half a century of active investigation, clinical, experimental, and anatomical, has not resulted in a completely satisfactory solution of the problem.

The hypothesis that glaucoma arises from hypersecretion, produced, according to v. Graefe, by choroidal inflammation, and according to Donders by nervous irritation, has been discarded, and various "retention theories,'; which explain the increased hardness of the eyeball by an obstruction to the escape of the intraocular fluids, have taken its place. The obstruction, in accordance with the views enunciated by Knies, and soon afterward by Weber, is generally considered to be situated at the angle of the anterior chamber, and to consist in a blocking up of this angle by apposition or adhesion of the peripheral portion of the iris to the adjacent sclero cornea, the iris having been crowded forward by the hyperemic and swollen ciliary processes. Knies believed the condition to be one of adhesive inflammation of the iris periphery, while Weber regarded this adhesion as secondary to pressure. In his most recent communication on the subject Knies makes a sharp distinction between glaucoma simplex, which be conceives to be an optic nerve atrophy with excavation, and true forms of glaucoma, which should be considered as an irido cyclitis anterior an inflammation which may occur in varying degrees of intensity. It has been demonstrated by Leber and others that the ciliary region constitutes the principal outlet for the lymph current, which, starting at the ciliarv processes, proceeds forward through the zonula and pupil into the anterior chamber, and thence through the pectinate ligament into the canal of Schlemm, from which it finds its way into the venous system. In the cases in which the iris occupies its normal position it is possible that filtration may be hindered by serosity of the liquids (Priestley Smith) or by a choking of the meshes of the pectinate ligament with pig from the ciliary processes and the posterior surface of the iris (Niesnamoff).

Smith, as already intimated, thinks that an important element is a narrowing of the eircumlental space, due to a senile increase in the size of the lens or to a small ciliarv circle as seen in hyperopic eyes hence a forward displacement of the lens and blocking up of the excreting angle.

's view, that glaucoma may be produced by tissue clianges which tend to hinder the exit of fluids by way of the optic nerve entrance, may have a limited field of application, as may also that of Rheindorf, who claims that the obstacle to the nutritive current consists in a sclerosis of the lenticulo zonular diaphragm. Laqueur and others think that glaucoma depends upon obstruction of the intraocular lymphatics, which find their way out with the vena vorticosa.

The anatomical conditions which have been observed in glaucomatous eyes are, among others, the following: (1) Edema, and at a later stage ulcerative processes in the cornea. (2) Scleral changes, including rigidity, fatty degeneration, and equatorial staphylomata. (3) Obliteration (with or without adhesive inflammation) of the angle of filtration, of the spaces of Fontana, and of the canal of Schlemm (Fig. 242, A). (4) Atrophy of the iris, chiefly of the external layers, with destruction of the vessels. (5) Sometimes swelling and sometimes atrophy of the ciliarv processes. In the latter case these bodies shrink backward, and frequently leave the iris in contact with the cornea (Fig. 242, B). (6) Glaucomatous cataract i. e. cataract which is a direct result of tile disease. (7) Fluidity of, and opacities in, the vitreous. (8) Marks of choroidal inflammation, such as atrophy and loss of elasticity of the choroid, and periphlebitis with reduced lumen of the veins, especially the vasa vorticosa. (9) Destruction, partial or complete, of one or more of the retinal layers and detachment of the retina. (10) Lastly, the excavation of the optic nerve, which may or may not show traces of a low grade neuritis. The precise relation of the changes just enumerated to the glaucomatous process cannot in the present state of our knowledge be dogmatically stated. Some of them are probably etiological factors, while others are doubtless results of the continued pressure.

glaucoma may be inflammatory, or simple i. e. non inflammatory.

Inflammatory or congestive glaucoma (glaucoma irritatif ) is classified as (a) acute, (b) subacute, or (c) chronic, according to the severity of the symptoms.

1) Acute Glaucoma (Acute Inflammatory or Congestive Gtaueoma). Period of Incubation, or Prodromal Stage. The prodromal or intermittent stage is characterized by mild attacks, in which the cornea is slightly steamy and anesthetic, the pupil moderately dilated and sluggish, and the anterior chamber somewhat diminished in depth. There is noticeable, but not pronounced, pericorneal injection, and palpation shows some increase in tension. The vision is smoky from the corneal haziness, and rainbows are seen around lights from the same cause. The ophthalmoscope may reveal pulsation of the retinal arteries, but as yet there is no cupping of the disk. When the attack is ended the eye returns to its normal condition, except that the accommodative power is apt to be lessened, the patient requiring stronger reading glasses than before.

The stage of prodromata may last months or years, the intervals between the attacks growing gradually shorter, and may terminate in an acute attack.

b) Period of Attack. The glaucomatous attack, whether preceded or not by an intermittent stage, is suddenly ushered in by violent and excruciating pain in the eye and the corresponding side of the head, with vomiting, fever, and even loss of consciousness. The lids become edematous and the ocular conjunctiva reddened and swollen. The cornea is decidedly hazy, owing to edema of its superficial layers. The haziness is generally most pronounced in the center, and is sometimes accentuated in spots, giving a dotted appearance to the surface. Corneal sensibility is more or less completely abolished, as shown by touching it with a bit of twisted cotton. The pupil is dilated and immobile and shows a greenish or grayish green reflex 1 from the lens. The dilatation is not uniform, so that the pupil is rarely perfectly circular. The iris is discolored and its markings are blurred. There may be, according to most authors, some turbidity of the aqueous and vitreous humors, although this turbidity is considered by others as far from proven. The sight, owing partly to the corneal edema and partly to the compression of the retinal arteries, rapidly fails until fingers can scarcely be counted. In the rare cases in which a view of the fundus is obtainable hyperemia of the disk with pulsation of the arteries is observed, but no change in the disk level is to be expected. Lastly, careful palpation will disclose, even through the edematous lids, a decided hardness of the eyeball a condition which accounts for most if not all of the other phenomena.

The intensity of the symptoms described above begins to subside after a few days or weeks. The pain, corneal haze, palpebral and ocular edema, etc. diminish greatly or disappear; but the pupil remains dilated and sluggish, the pericorneal region somewhat injected, the anterior chamber abnormally shallow, and the vision is usually considerably reduced. Tension continues elevated. This condition is known as the Glaucomatous state (habitus glaucomatosus).

a longer or shorter period of comparative quiet another outbreak may occur, and then another, until the sight is wholly destroyed a condition described as absolute glaucoma. The eye assumes a dull, expressionless look. The cornea is surrounded by a zone of livid or slaty hue. The pupil displays a border of black pigment (ectropium uvee). The lens and the narrow atrophic rim of the iris are crowded against the cornea. The tension of the globe is usually excessive. The ophthalmoscope now generally reveals the characteristic glancomatous excavation. With the advent of blindness the patient in some cases obtains surcease of suffering; in others the attacks continue until relief is afforded by surgical means.

Deqeneration. After the glaucoma becomes absolute striking tissue changes sooner or later begin to manifest themselves. The atrophied sclera succumbs to the intraocular pressure, and bluish black swellings appear between the cornea and the equator. The lens may become opaque (glaucomatous cataract). The eyeball may go on to atrophy, with detachment of the retina, and may show deep furrows in the line of the recti muscles, or the morbid process may end with sloughing of the cornea and panophthalmitis.

some cases of acute glaucoma vision is suddenly and irretrievably lost at the first attack, constituting what is known as glaucoma fulminans.

2) Subacute Glaucoma. This variety presents the phenomena of the acute form of the disease in a much less intense degree, and might not improperly include the prodromal stage of that form. But, whether intermittent or continuous at the outset, it passes by insensible gradations into the third and most common variety viz. :
(3) Chronic Inflammatory or Congestive Glaucoma. The appearance of the eye in this affection is very characteristic. The dull livid or dusky red color of the sclera with its swollen and tortuous veins, the smoky look of the cornea, the irregular dilatation and eccentric position of the pupil, the obvious atrophy of the visible portion of the iris, the marked shallowness of the anterior chamber, and the greenish reflex from the lens, combine to form a picture which, once seen, can always be recognized. The pain, though sometimes severe, is not so intense nor is the corneal insensibility so complete as in acute glaucoma.

Central vision slowly fades, and the visual field gradually contracts, especially on the nasal side. In the later stages cupping of the disk is revealed by the ophthalmoscope. The disease ' if unchecked, proceeds, as does acute glaucoma, to the establishment of absolute glaucoma, and later to one or more of the phases of glaucomatons degeneration.

11. Simple Glaucoma (Glaucoma Simplex, Chronic Simple or Noninflammatory Glaucoma). This is one of the most insidious of maladies. If untreated it usually terminates in blindness ; nevertheless, at least in its early stages, it presents no external signs of the grave changes going on within the eye. After the lapse of months or years there may be slight dilatation and inactivity of the pupil and moderate distention of the anterior ciliary veins.

tension, while seldom pronounced, can in most cases be detected on careful and repeated examination; but it may be entirely absent. In doubtful cases the eye should be tested at different times of the day and tinder various circumstances, especially after a full meal or in the condition of depression following a restless night. It should be remembered also that there is no fixed and universally applicable standard of physiological tension. A careful comparison of the two eyes, especially if one is still unaffected, will tend to eliminate doubt.

objective phenomena just described may occur in attacks resembling those of the prodromal stage of inflammatory glaucoma. At such times the cornea may be hazy and its sensibility may be impaired and rainbow vision may be observed. These attacks in certain cases appear to mark a transition from the simple to the congestive form of the disease.

The cardinal symptom of simple glaucoma is a slow but steadily progressive failure of vision, especially peripheral vision. In some cases a good degree of central visual acuity is preserved for a long time, while the field of vision is so encroached upon that the patient, although able to distinguish fine print, may not see well enough to walk about. In such cases blindness comes on suddenly, as by the abrupt drawing of a curtain.

field of vision is almost always restricted. The nasal side generally suffers most, but the limitation is very often concentric (according to Zentmayer and Posey this is the most frequent phenomenon), or the field may assume any one of a great Dumber of bizarre forms. Frequently sector like defects are seen. Scotomata partial or total are often found. According to Bjerrum, areas of special visual acuity, taking the form of rings or segments of rings with a width of 10' to 20', and touching the blind spot at their inner margin, are sometimes observed.

the following visual fields the boundaries for white are represented by a continuous line, those for blue by an interrupted line, those for red by a line of dashes and dots, and those for green by a dotted line:

As a rule, the color fields show no disproportionate loss. The field for blue may even be coextensive with that for form. It is also true, however, that the color fields may be contracted, while the form field is intact a fact which tends to diminish the value of the evidence derived from examinations of the visual field in diagnosticating between glaucoma and opticnerve atrophy.

As in the early stages of inflammatory glaucoma, premature presbyopia is commonly seen. Excavation of the optic nerve is the most striking objective, as visual impairment is the leading subjective, feature of the disease. The cupping is rarely absent when the patient presents himself for examination, which is usually after the malady has made decided progress. Furthermore, the depression is now generally found to be characteristic, as described at the be( inning of this chapter, although it is sometimes shallow (Fig. 239).

Diagnosis. Rapidly increasing presbyopia, occasional mistiness of sight, and “rainbow vision," so frequently the harbingers of glaucomatous trouble, should arouse suspicion.

glaucoma has been mistaken for iritis. The dilated pupil and the hardness of the eyeball in the former affection ought generally to make such a mistake impossible. The pupil may, however, be bound down by adhesions due to a previous inflammation of the iris, and the author has seen one case of intermittent glaucoma in which the pupil, though free, was of normal size. We must in such cases be guided by the history and by the other symptoms, especially the abnormal hardness of the globe. That increase of tension, rainbow vision, and shallowness of the anterior chamber are, as pointed out by Schweigger, sometimes observed in iritis, should be borne in mind, but other symptoms of iritis will then Dot be lacking.

Simple glaucoma when typical is easily recognized. When the tension is not perceptibly elevated, and other external symptoms, such as sluggishness of the pupil and fulness of the ciliary veins ' are absent, reliance must be placed on the character of the excavation of the optic nerve, which in glaucoma, as already pointed out, covers the whole surface of the disk, has steep sides, and is deeper than the normal level of the lamina cribrosa. Physiological excavation involves only a portion of the disk, while the remainder of the surface presents a healthy appearance. The excavation due to atrophy of the nerve affects the entire disk surface, but it is shallow and slopes gradually to its deepest point. Moreover, the nerve head is much more anemic, proportionately to the depth of the cup, than in glaucoma (consult Fig. 131). The greatest difficulty arises when an atrophic process attacks a nerve which is the seat of an extensive physiological pit. Flatness of the disk in the sound eye is evidence of glaucoma, since physiological cupping is bilateral (Schweigger).' The absence of the knee reflex as indicative of central disease would point to atrophy.

The shape of the visual fields, especially the color fields, and their relation to the acuity of vision are of decided, though Dot unqualified, diagnostic importance. In atrophy of the optic nerve good central vision and color appreciation are not so apt to be retained with a contracted field for form as in glaucoma. (Compare with page 448.) In doubtful cases the totality of the phenomena must be considered, and sometimes a positive diagnosis should be reserved and the course of the affection carefully watched.

The unfortunate mistake of regarding the grav or green reflex from the lens as indicating incipient cataract, and the (Consequent advice to wait for ripening which never comes, are happily much rarer now than they were before improved methods in medical teaching, including instruction in the use of the ophthalmoscope, were inaugurated.

. Had v. Graefe done nothing else for ophthalmology, his discovery in 1856 of the curative power of iridectomy in glaucoma would alone have secured for him an imperishable fame. Other remedial measures operative and medicinal have been since devised, but they are almost universally considered to be of secondary importance.

In performing iridectomy' for glaucoma the coloboma should be made upward, so as to be covered by the upper lid, unless the superior portion of the iris appears to be specially atrophic, and therefore more difficult to remove. The incision should lie in scleral tissue, should be of ample size, and should be completed with deliberation in order to prevent too sudden a reduction in tension, which might be attended with intraocular hemorrhage, rupture of the zonula, or other disastrous consequences. The bit of iris excised should be extensive, and should embrace the whole width of this tissue up to its ciliary margin. The angles of the wound should be left entirely free, an iris repositor being used if necessary.

operation, which should of course be made with precautions against sepsis, requires in inflammatory cases the use of a general anesthetic, as cocain under these circumstances is very imperfectly absorbed. Hemorrhage into the anterior chamber is not infrequent, but the blood usually undergoes absorption in a few days. Retinal hemorrhages are also occasionally seen. These are generally not extensive, and they soon disappear.

cicatrix from imperfect apposition of the lips of the operation wound is sometimes unavoidable. Moreover, though a blemish, it may serve to facilitate filtration.

The most brilliant results of iridectomy are obtained in acute inflammatory glaucoma, especially when the operation is done without delay. The pain, high tension, and corneal cloudiness promptly disappear, and the vision is rapidly and decidedly improved sometimes, indeed, entirely restored.

the chronic forms of the disease the operation, owing to the degeneration and excavation of the optic nerve, does not accomplish so much. In chronic inflammatory glaucoma, however, the morbid process is usually checked unless the iris tissue has become degenerated (Gruening).

simple glaucoma the experience of v. Graefe, Bull, Nettleship, Fuchs, and others shows that by means of iridectomy the existing vision is preserved or slightly improved in about half the cases. In some of the remaining half the influence of the operation is negative; in others it seems to expedite the morbid process; while in a small proportion estimated by some authors at about 2 per cent. the iridectomy is followed by pericorneal injection, steaminess of the cornea, and great increase in tension. The anterior chamber remains empty and vision is almost always destroyed. This condition, which is very rarely observed in the congestive types of the disease, has received the name of malignant glaucoma. The predisposition to it seems to affect both eyes. Hence the propriety of Schweigger's rule to operate on the worse eye first, even if it be blind. If' this heals smoothly, the other may be expected to follow a similar course, but, as Friedenwald has shown, it may occur even where the operation on the first eye has healed without complication.

Absence of increased tension and a greatly restricted visual field diminish, although they by no means annihilate, the chances of benefit from iridectomy in simple glaucoma.

The modus medendi of iridectomy is not understood. The explanations so far attempted are merely of speculative interest.

Of the numerous operative procedures devised to substitute iridectomy in the treatment of primary glaucoma, the majority, including those of Hancock, Knies, Nicati, Pflfiger, Vincentiis, Badal, and Parinaud, and the combined sclerotomy of De Wecker, serve chiefly to illustrate the ingenuity of their inventors. Iridectomy has only one serious rival viz. sclerotomy, and this is by almost universal consent relegated to a subordinate place. Sclerotomy, the technique of which is described on page 569, ought to be performed when the symptoms persist after a well executed iridectomy, and preferably opposite the latter. It may also be resorted to when the iris has undergone degenerative changes which would be likely to preclude a satisfactory excision of this tissue. If done in a case of simple glaucoma with a contractile pupil, eserin should be previously instilled in order to prevent prolapsus iridis. Priestley Smith and Harold Gifford strongly recommend scleral puncture 5 mm. behind the cornea as a preliminary step to iridectomy in eases where the anterior chamber is very shallow.

cases of absolute glaucoma which are attended with great pain unre¬lieved by iridectomy, or in which this operation is impossible of performance, enucleation, or, according to some, optico ciliary neurotomy, becomes necessary.

non surgical treatment of glaucoma consists principally in the instillation into the conjunctival sac of solutions of eserin or pilocarpin of modcrate strength, gr. I/8 to I/2 to f 3j, although much stronger solutions are frequently required. Myotics are most serviceable in the prodromal stage of inflammatory glaucoma, but they will often hold an acute attack in check, and thus permit of delay if circumstances prevent an immediate operation. They are useful in many cases of simple glaucoma, especially with increased tension, in which an operation is contraindicated or is rejected by the patient. It is known that iridectomy in a case of unilateral glaucoma is sometimes suddenly followed by the appearance of the disease in the normal eve. The use of eserin in the latter at the time of the operation is believed to be an efficient means of averting the danger. As regards the use of myotics, the general consensus of opinion is that they are rarely more than palliative in their action. They should not be employed too long, because, apart from the external irritation often produced by them, they tend to increase ciliarv congestion, and they do not always retard the progress of the excavation in the optic nerve.

efficacy of massage of the eyeball, recommended by Gould and other observers, has not yet been sufficiently tested. It might be useful in deepening a shallow anterior chamber previously to operating.

remedies for glaucoma do not have much vogue, but the reports of Sutphen and Friedenwald indicate that sodium salicylate in large doses has decided therapeutic value.

Glaucomatous tendencies should be combated by the correction of refractive errors, by the avoidance of constipation and of over indulgence in eating and drinking, by regular open air exercise, and, above all, by the cultivation of self control, since a glaucomatous attack so frequently means the explosion of emotional dynamite.

. Secondary glaucoma is the name employed to describe a condition

in which the more striking phenomena of glaucoma increase of tension, sha llowness of the anterior chamber, etc. are developed as consequences of some antecedent disease or injury.

The pathological conditions which most frequently give rise to secondary glaucoma are perforating wounds of the cornea, either accidental or surgical (e. g. bypopyon operations), suddenly closed corneal fistule corneal cicatrices, especially with staphyloma or incarceration of the iris, serous iritis and irido occlusion of the pupil, traumatic cataract with swelling of the lens, dislocation of the lens, either forward against the cornea or backward into the vitreous, intraocular tumors, and contused wounds of the eyeball. The author has observed glaucoma follow a blow causing rupture of the choroid.

1. Hemorrhagic glaucoma is consecutive to retinal hemorrhage due to atheromatous or hyalin disease of the blood vessels. It may appear with albuminuric retinitis. The intensity of the symptoms varies very much in different cases, as does also the time of their appearance after the discovery of the extravasations. It is difficult in many cases to decide whether the glaucoma is produced by the hemorrhage or the hemorrhage by the glaucoma. In severe cases hemorrhage into the vitreous entirely obliterates the fundus reflex.

2. Complicated glaucoma comprises those cases of the disease which arise during the progress of some other affection, but in which the causative influence of the latter is doubtful. The most noteworthy of such complications are cataract, atrophy of the optic nerve, pigmentary retinitis, and myopia of high degree.

. The treatment of the different forms of secondary glaucoma depends upon etiological considerations. A swollen or dislocated lens should be removed, an incarcerated iris set free, and an occluded pupil remedied by a generous iridectomy.

Hemorrhagic glaucoma responds badly to any form of treatment. Iridectomy is dangerous, being liable to be followed by increased retinal hemorrhage. Anterior sclerotomy or eserin may prove of service. In some cases posterior selerotomy has been found beneficial. General treatment should not be neglected ergot, cautious use of cardiac sedatives, the alteratives, and strict regulation of diet and mode of life.

. Buphthalmos. Kerato globus, Congenital Hydrophthalmos (Glaucoma Congenitum). This is a form of glaucoma pertaining to childhood, and characterized not only by elevated tension and cupping of* the optic disk, but also by enlargement of the globe. The cornea, which may be either clear or opaque, is usually very thin and its diameter greatly increased. The anterior chamber is deep, the pupil dilated, and the iris tremulous from stretching or rupture of the zonula. The lens remains small. The pathology is obscure, but the condition is supposed to be due to an inflammation of the uveal tract dating back to intra uterine life and causing an obstruction to excretion. The distention of the eyeball is explained by the fact that the sclera of the child is more yielding than that of the adult.

Treatment. Iridectomy is contraindicated. Stolting reports favorable results from repeated sclerotomies, and Snellen from frequent puncturing of the anterior chamber. Eserin and pilocarpin should be tried. The prognosis is very unfavorable.

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