The term glaucoma goes back to hippocratic times. Its meaning
is disputed; generally accepted to signify greenish -- like the colour
of sea water -- Hirschberg has shown that it is much more likely to mean
bluish. It would appear that in Hippocratic writings hypochyma and
glaucosis
were synonyms, and both vaguely referred to cataract. It is only with later
Greek writers that a distinction was made between the two, glaucoma becoming
the incurable condition as opposed to hypochyma which was curable, though
not always so. Glaucoma which came also to stand for an affection of the
lens itself, as opposed to cataract, which was a perverted humour in front
of the lens. It is not at all unlikely that the term was applied indiscriminately
to all blindness not considered as cataract and in which the pupil changed
its colour. Absolute glaucoma with its "green cataract", as well as pupillary
exudates, were probably included. Whatever else it may have stood for,
it certainly did not stand for chronic glaucoma of today, for in this,
as well as in the bulk of acute glaucoma, the discoloration of the pupil
is not a striking feature. In any case it would only be the terminal stage
of chronic glaucoma that would be recognized and this no doubt passed as
amblyopia, amaurosis or, in later day as suffusio nigra or gutta serena.
Glaucoma, in antiquity, therefore hardly stood for any definite entity.
But the term created a problem in pathology when Brisseau showed that cataract
was a disorder of the lens itself. Some, like Maître-Jan were content
to let both diseases reside in the lens; others, like Brisseau, monopolized
the lens for cataract and satisfied themselves that glaucoma was an affection
of the vitreous, a view that led to much anatomical work to show what exactly
the changes in the vitreous were. Vitreous fluidity, vitreous floaters
and all sorts of vitreous abnormalities were brought forward as evidence
for that view, and the discussions on the subject still persisted towards
the middle of the last century. In these discussions other tissues were
incriminated. Mackenzie, amongst others, blamed varicosity of the choroid.
All these discussions were of necessity futile, for they centred round
a word rather than round a pathological entity. The essential feature of
glaucoma - hypertension - was not not generally recognized till about 1840,
and even so, recognition only extended to acute glaucoma and absolute glaucoma.
It was in fact a new entity that was being built up -- a disease in which
the cardinal sign was increased tension, and in which the name glaucoma
had come to be a meaningless label. The problem was no longer why the pupil
was discoloured but why the tension was increased.
The first clear recognition of absolute glaucoma came with Rikchard
Banister in 1622. Discussing the differential diagnosis between curable
cataract and incurable gutta serena in which "the humour settled
in the hollow nerves, be growne to any solid or hard substance, it is not
possible to cured" he gives foure wayes," one which is "if one feele the
Eye by rubbing upon the Eie-lids, that the Eye be growne more solid and
hard than naturally it should be." The three other tests were no different
from those in common use at that time for determining the curability of
cataract. Banister's tetrad -- long duration, no perception of light, increased
hardness and no dilatation of the pupil on bandaging the sound eye - is
a passable account of absolute glaucoma. His teaching, however failed to
attract any attention. Hardness of the eye is next found in the literature
a hundred and twenty years later, in J.Z.Platner, with nothing like Banister's
completeness. At the beginning of the 19th century it was rediscovered;
it appears in a number of books at about 1820, and in Mackenzie's classical
text-book of 1830 it is given definitely in the differential diagnosis
between glaucomatous amaurosis and cataract
Acute glaucoma, though not under that name, has a more considerable
antiquity. The Arabian Sams-ad-din recognized it as a distinct entity in
the amorphous mass of ophthalmias. He described under "Migraine of the
eye, also known as Headache of the pupil" a condition in which there is
a deep-seated pain in the eye associated with hemicrania and dullness of
the humours; the condition is sometimes followed by cataract and dilatation
of the pupil; if it becomes chronic, tenseness of the eye and poor vision
supervene. This conception of a distinct disease does not, however, seem
to have prospered. Though tentative attempts at the recognition of acute
glaucoma were made by several writers in the 18th century, it is not till
1813 that really convincing description occurs -- an account by Beer. A
form of iritis is differentiated from the other varieties by its distinctive
symptoms and in that it ends in blindness, a greenish hue (glaucoma), a
dilated pupil and cataract -- a tolerable description of the terminal stage
of neglected acute glaucoma, even though the cardinal sign of hypertension
is mission. In his ambitious attempt to describe eye conditions on a basis
of causation, Beer named this acute condition as iritis of gouty origin.
Rainbow colours and hardness of the eye in a condition termed glaucoma
appear five years later in a description by Demours. Subsequent publication
speak of arthritic iris (and ophthalmitis), as well as glaucoma, in describing
conditions which appear to have been the same, apart from the presence
of the greenish pupil reflex in the latter. The first to recognized that
these two conditions were identical was Sir William Lawrence; he considered
glaucoma " to be merely a chronic form of the same inflammation as the
arthritic inflammation affecting the posterior coats of the eye". It was
also he who introduced the term of acute glaucoma (1829).
Lawrence did not link up acute glaucoma with what we now call chronic
glaucoma, but with what now passes as absolute glaucoma -- their link being
not hypertension but the greenish discoloration. It was only when
the ophthalmoscope had revealed cupping of the disc that hypertension as
the essential feature of glaucoma was finally realized. Even so, von Graefe
in 1857 missed chronic glaucoma; he speaks of the acute, chronic (ie, absolute),
and secondary glaucoma and of amaurosis with excavation of the disc. Not
till Donders recognized this last group as glaucoma simplex was the unifying
conception achieved, a teaching that gained greatly from Bowman's simple
numerical notation in recording the findings of digital measurement of
tension.
When the older writers spoke of the incurablitiy of glaucoma, they were
right not only by their standards but by our own, for the condition they
discussed was absolute glaucoma. Acute glaucoma, in contra-distinction
to chronic glaucoma, only emerged after 1830, and that too must have been
incurable, for only very severe attacks would be recognized as glaucoma
and the treatment would not improve matters, for it consisted of the same
as for other forms of iritis. Till 1857, when von Graefe introduced iridectomy
for acute glaucoma, the diagnosis was indeed tantamount to a sentence of
blindness, for even relief from miotic was unknown till about 1875. Not
infrequently matters must have been made worse by treatment for belladonna
was used.
Iridectomy for acute glaucoma received the same mixed reception as every
great innovation, and not altogether without reason. The rationale of the
operation was then rather vague. Von Graefe was led to the operation in
the belief that staphylomata of the cornea regressed after iridectomy,
presumably because of lowering of tension. To not a few surgeons operative
interference meant adding trauma to an already markedly diseased eye. Feeling
ran high and the discussions in the subject were by no means free from
acrimonious tendencies. When the collective experience of the profession
clearly established the value of the operation, discussion ranged as to
its mode of action. To some the favourable results were caused by a filtering
scar induced by the iridectomy, and this led to the various sclerectomies
having filtration as their object.
The cause of the increased intra-ocular pressure was seen by von Graefe
in a serious choroiditis increasing the watery contents of the eye. To
Donders it was due to an increased secretion of the choroid. Stellwag regarded
it as the result of increased pressure in the ocular circulation, whilst
Priestley Smith stressed faulty excretion rather than secretion, the immediate
cause being abnormalities in the angle of the anterior chamber.
Tonometers through the ages
Donders' tonometer (1868) |
von Graefe's tonometer (1862) |
Snellen's tonometer (1900) |
Seeuwen's tonometer (1901) |