A Case of Chronic Simple Glaucoma 
TREATED WITH ESERINE. 
S. O. Richey, m. d., Washington, D. C. 
[Read before the Medical Society of the District of Columbia.] 
This is not written with a hope of adding anything new to 
the subject, nor with an intention to fully discuss the varying 
views of its pathology, but only to report a case, in my judg- 
ment, worthy of record, because it is one of “ the type of the 
whole group of glaucomatous diseases.” 
On January 21, 1885, I examined Mrs. F., aged 37 years, 
whose left eye was blind from absolute glaucoma; the vision 
of her right eye was A°<x, and much blurred. She knows the 
left eye to have been blind for seven years; the right has been 
affected for that length of time, but she does not know whether 
it has been diseased for a longer time than seven years or not. 
When she was about eighteen years old she noticed the halo, 
and had flashes of light, but these do not now continue. The 
right eye has been sensitive to light for seven years, but she 
has never had any pain in either of her eyes. 
Just before Christmas she sewed quite a good deal, using 
her mother’s glasses, before which time she had not used her 
eyes for a year at close work. “ The room seems full of 2 
Richey— Glaucoma. 
smoke,” as she looks about it now. She was frightened 
into consulting a physician by finding that, although she could 
see the form, she could not distinguish the face of her pastor 
in the pulpit a few days since. 
A lens serves only to interrupt the vision of the right eye. 
The discs are well cupped with sharp outlines. The excava- 
tion is deeper in the left eye, and the nerve is atrophied. Ten- 
sion -f- 3 ; both feel like small marbles; the media are clear, the 
pupils half-dilated and regular; the anterior chambers are shal- 
low, and the corneae anaesthetic. The field of vision is limited 
to the nasal half. 
Her general health is bad; her digestion is poor, associated 
with great mental depression. The idea of an operation 
creates dread, and the treatment adopted is sulphate of eserine 
(gr. y to f ?i), applied twice a day, with dry cups to the tem- 
ples. 
January 25th. Vision of right eye, f§; tension + 2. There 
is no very marked change in the size of the pupils, nor in the 
depth of the anterior chambers. Liquor potassae arsenitis 
in gtt. ii doses was given ter in die, to correct fermentation, 
and kal. iod. after meals, to hasten tissue change, are added. 
January 29th, the pupils are normal in size, but still sluggish, 
due now probably to the eserine. Vision, f£. The improve- 
ment constant and gradual until* March 28th, when vision, f§; 
the tension normal. The field is not altered. 
November nth, 1885, eleven months after the first inter- 
view, the field is not changed; the tension is normal; vision, 
in the right eye, is slightly less than normal, and her general 
condition is much improved. She has been advised to persist, 
for a time, in the occasional use of the myotic, because the con- 
dition is a very chronic one ; that she must avoid mental ex- 
citement, and preserve her general bodily health in the hope Rich ey— Glaucoma. 
3 
that this interruption to the progress of the disease may be 
permanent. , Iodide of potash was exhibited with a view to 
breaking up any adhesions of the iris that might exist, upon 
the basis of its action in the treatment of posterior synechia. 
This also has been continued at intervals. 
The special features of the case are : the age of the patient 
when first affected (eighteen years); the great amount of ten- 
sion tolerated for so long a time, and the degree of vision re- 
covered without operation. There was no hypermetropia, and 
the necessity for convex lenses at her age may be explained 
by the probability of the suspensory ligament being put so much 
on a stretch by pressure that accommodation was interfered 
with, or that the retina, being obtunded by pressure, required 
larger images than usual. 
Mr. Henry Powers * says : “ Eserine is a valuable remedy, 
and he is inclined to doubt whether some of the results at- 
tributed to sclerotomy might not really have been due to the 
use of eserine. If the pupil responded to eserine, he would 
certainly continue its use and not operate at that time.” 
This affection, presenting itself in so many ways, is least 
hopeful in the chronic simple form, which rarely announces its 
presence before the age of fifty years, and makes slowr, insidi- 
ous progress, generally without any inflammation, as in this 
case, and commonly proves fatal to vision, whatever the treat- 
ment. Though many expedients are helpful, it is very intracta- 
ble. 
The methods of relief are surgical, except the use of myot- 
ics ; iridectomy, sclerotomy, and stretching the supra-trochlear 
nerve,—the last suggested by Badal, of Bordeaux, in 1882,— 
each founded upon a rational theory of the pathogeny of the 
affection. 
* O. Review, 1882, p, 262. 4 
Rich ey— Glaucoma. 
Increase of tension is pathognomonic of the disease, and 
whether this is due to hypersecretion or an impeded out- 
flow of the intra-ocular fluids, opinions differ. Priestly Smith* 
says : “ It is certain that glaucoma is essentially due to pres- 
sure ; that it is cured by reduction of tension, and that this 
reduction is due to restored filtration.” 
It was upon this theory of the nature of glaucoma that 
Graefe performed iridectomy, to relieve swelling of the ciliary 
folds, and the adhesions of the iris at the iritic angle, which 
obstruct the entrance of the intra-ocular fluids to the canal of 
Schlemm, though Wolfef claims the benefit from iridectomy to 
be due to the removal of a section of the diseased nerves, 
upon the theory of nutritive changes in the nerve-centers. 
The cupping of the optic disc is held by Mooren| to be due 
to changes external to the eye, and he is convinced that “ The 
presence or absence, and breadth and depth of the excavation 
are not dependent in any way on the degree of increase of in- 
tra-ocular pressure ; . . . . that even the most brilliant thera- 
peutic results will not alter the fact that in glaucomatous excava- 
tion of the optic nerve, or in the excavation of glaucoma sim- 
plex, with or without inflammatory symptoms, we have to deal 
with some anomaly of nutrition of the optic nerve.” 
All observers agree that there is no fixed relation between 
intra-ocular tension and the disc-cupping, though when there 
has been great tension with little or no cupping, the fact has 
been attributed to the greater power of resistance of the optic 
papilla. 
Gowers§ records the fact that “ Glaucoma is sometimes ob- 
* Ophthalmic Review, 1882, p. 261. 
■(•Wolfe, On Diseases and Injuries to the Eye, 
JArchiv. Ophth., March, 1884. 
§ Medical Ophthalmoscopy, p, 172. Richey—Glaucoma. 
5 
served in cases in which there was long standing liability to 
unilateral neuralgia, . . . that optic atrophy has resulted from 
the same cause, and that irritation of the fifth nerve may in- 
crease intra-ocular tension.” Douders* refers to the fifth nerve 
as controlling intra-ocular secretions, and Griinhagen and 
Hippelf found that irritation of the trigeminus produced in- 
creased intra-ocular pressure. 
From the foregoing it may be seen that there are at least 
two methods of accounting for glaucoma : the pressure theory 
and that of a neurosis. These are not necessarily antagonistic, 
for each may explain one stage of the same attack. Each at- 
tack must have an initial stage, as, in secondary glaucoma, a 
dislocated lens, or an intra-ocular hemorrhage; so, in primary 
♦ 
simple glaucoma, some disturbance of the sympathetic system 
may interfere with the balance existing between the secretion 
and filtration of intra-ocular fluids, and by increasing tension, 
inaugurate a “ vicious circle.” 
Iridectomy is the most reliable of all the measures adopted 
in glaucoma, though it sometimes fails, and in some cases the 
probability of hemorrhage forbids it. Its influence may be 
explained in accordance with either theory, for it acts in both 
ways, relieving tension, and by removing a section of the 
nerve, but Mooren thinks it “ useless in all cases of glaucoma- 
tous disease which do not originate in the eye but in the cen- 
tre of nutrition of the optic nerve.” Badal’s operation of 
stretching the supra-trochlear nerve is based upon the theory 
of a neurosis, and has been efficient in some cases—even in 
some which have defied other efforts at relief. It is, however, 
not reliable, and should be only a last resort. 
Sclerotomy reduces tension by opening a way between the 
*Klin. Monatsblatt fur Augenheilkunde, 1884, p. 434. 
| Arch, fur Ophthal. B. xiv. 3, p. 219. 6 
Richey—Glaucoma. 
aqueous chamber and the sub-conjunctival space, producing 
an anterior staphyloma and establishing permanent drainage. 
It is likely to be followed by distortion of images in conse- 
quence of the staphyloma. The necessity of using a myotic 
diminishes the importance of the procedure, and the objection 
has been made that it excites sympathetic inflammation. As 
the incision must be made within the sclerotic, it is probable 
the ciliary region has been wounded in such instances. 
Priestly Smith claims the essential part of this operation 
and iridectomy to be the same, only the incision is more favor- 
ably made in sclerotomy ; that when the incision is made as 
peripheral in iridectomy, it is the more reliable operation, and 
the effect is more perjnanent, although it is not so safe in cases 
where there is immediate danger of hemorrhage. Argyle 
Robertson’s operation of trephining the cornea has been suc- 
cessful in a few cases, but has not at any time met with gen- 
eral adoption. Paracentesis is a measure to gain time, or to 
discover the amount of vision that may be recovered by an 
iridectomy in acute glaucoma. 
Eserine, it is said, gives its best results in acute primary 
glaucoma, and may entirely relieve the eye, but while it some- 
times improves the condition in simple chronic glaucoma, this 
improvement will probably not be permanent. 
Williams,* of Boston, has not an impression favorable to the 
use of eserine in glaucoma, and doubts its efficiency in this 
affection in the hands of others. This view is one for which 
it is difficult to account, as the drug has unquestionable powers 
to reduce tension. 
Snellf believes that eserine not only improves vision but 
arrests the progress of chronic simple glaucoma. 
* Williams, Diagnosis and Treatment of Diseases of the Eye, 1881. 
fOn Eserine and Pilocarpine in Glaucoma, and Eserine in Ocular Neuralgia, Rich ey— Glaticoma. 
7 
I have not found it produce follicular conjunctivitis, to 
which Wecker refers, because, I think, I have not been accus- 
tomed to use it in so strong solution. The milder solutions 
have in my hands been as useful as the strong ones and with- 
out any misadventure, though they must be used more fre- 
quently. The frequency of application of a mild preparation 
lessens the tendency to spasmodic myosis, The action is 
more gentle and less likely to produce congestion of either the 
conjunctiva or the iris. Eserine is preferable to pilocarpine, 
because this disposition to spasm may be controlled, and it 
maintains myosis for a longer period.