GLAUCOMA MALIGNUM, 
WITH AN 
ILLUSTRATIVE CASE. 
BT 
GEORGE RETIRING, M. D., 
SURGEON IN CHARGE OF THE MARYLAND EYE AND EAR INSTITUTE, BALTIMORE. 
[.REPRINTED FROM THE NEW YORK MEDICAL JOURNAL, MAY, 1878.] 
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1878. APPLETON S’ 
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549 & 551 Broadway, New York. GLAUCOMA MALIGNUM, 
WITH AN 
ILLUSTRATIVE CASE. 
MV 
GEORGE REULING, M. D., 
SURGEON IN CHARGE OP THE MARYLAND EYE AND EAR INSTITUTE, BALTIMORE. 
[REPRINTED FROM THE NEW TORE MEDIOAL JOURNAL. MAY. 1878.] 
NEW YORK: 
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1878. GLAUCOMA MALIGNUM, WITH AN ILLUS- 
TRATIVE CASE. 
Glaucoma is a typical form of eye disease, which owes its 
origin to an increase in the intra-ocular fluids, and which, in 
the majority of cases, is accompanied by inflammation. It is 
not my intention to expatiate upon the causes of the increased 
tension, nor to explain the relationship existing between the 
inflammation and the intra-ocular pressure. Inasmuch, in- 
deed, as there may be great tension and no inflammatory 
symptoms {glaucoma simplex), this connection is, as is known, 
the subject of several theories, each of which may be, in a 
measure, correct, since there is no doubt that very different 
causes may lead to increased tension and glaucoma. 
The disease may be divided into two great groups, to par- 
ticularize which division it will be necessary to make a few 
explanatory remarks. It can be proved by direct injection, as 
Leber has shown, that there exists no immediate connection 
between the anterior chamber and the vitreous humor; hence 
the idea of interchange of liquids by endosmosis and exosinosis 
has become an exploded theory. This being the case, Stilling 
was led to conjecture the existence of a defluent canal, the 
office of which must be to carry off' the superabundant, and to 
refurnish the deficient, fluid circulating in the vitreous body. 
This canal, whose office, therefore, is to establish a normal 
equilibrium, he very naturally asserted to be the central tubu- 4 
lar canal of the vitreous body. In order to prove the truth of 
his theory, he made a number of interesting experiments. He, 
for instance, applied a tight ligature around the optic nerve of 
a rabbit, carefully protecting the surrounding parts from in- 
jury, in order to avoid neuro-paralysis. Fite to ten days after 
the application of the pressure, very marked increase of tension 
was produced. The cornea became entirely bereft of sensa- 
tion, the eye became stony hard, and the vitreous body, espe- 
cially its posterior portion, became fluid. The reason for these 
appearances was manifest. If the optic nerve is firmly com- 
pressed, the interchange of fluid from the Pialslieath of the 
optic nerve on the one hand, and the central tubular canal on 
the other, is interfered with. This canal, therefore (that is, 
the central tubular and the Pialslieath), may be called the pos- 
terior drainage or defluent canal; and if closed, by whatever 
means (as shown by Stilling’s experiment), the intra-ocular 
pressure is increased, and excavation of the optic nerve results. 
There is, however, another drainage canal, the anterior, or, 
in other words, the Fontanaic space. If this is closed, as when 
there is total pupillary occlusion, or when the iris is adherent 
to the posterior surface of the cornea, a form of glaucoma is 
produced, the origin of which may be explained by the fact 
that, as pressure in the anterior chamber increases, not as 
much fluid can be carried off by the posterior defluent canal 
in a given time as takes place normally, and that therefore 
glaucoma (excavation of the optic nerve) results. 
There are, therefore, two main divisions of the disease: 
1. When the posterior drainage or defluent canal is inter- 
fered with or closed by some pathological condition: this form 
may be designated, at the recommendation of Stilling, as 
glaucoma jposticuin. 
2. Where the anterior defluent canal, the Fontanaic space, 
is closed (as in glaucoma consecutivum, after, for instance, 
iritis serosa, ulcera corneae, and so on), whereby, as above 
stated, not sufficient fluid can pass from the vitreous into the 
Pialslieath in a given time, in order to maintain a healthy 
balance: this may be called glaucoma anticum. 
It must be here stated, however, that mere closure of the 
Fontanaic space itself does not always produce glaucoma, al- 5 
though, in the great majority of cases, a firm adhesion of the 
periphery of the iris to the cornea (owing either, primarily, to 
the increased pressure or to an inflamed state of the surround- 
ings of the canal of Schlemm, and consequent exudation from 
the iris and the vicinity of this canal) is to he met with in the 
glaucomatous process, and, as above shown, may be either the 
cause (as in glaucoma anticum) or the result (in consequence 
of the pressure in the posterior part of the eye) of the disease. 
As there may be complete closure of the Fontanaic space, 
with no existing nor necessary consequent glaucoma, so there 
may be entire patency of this space in even the most manifest 
glaucoma. In the great majority of cases, however, when 
obliteration of this space exists, it is due to increased tension 
or inflammatory exudation, depending indeed upon, or at all 
events leading to, the disease under consideration (Knies). 
Witli the various subdivisions, Glaucoma injlammatorium 
acutum, G. injlammatorium chronicum, G. simplex, G. con- 
secutivum, I will not engage the time of the reader, but would 
direct his attention to that very peculiar and, happily, very 
rare form of the disease known as glaucoma malignum. 
The disease—of which I will present one case in illustra- 
tion—occurs chiefly in women in the beginning of or during 
the climacteric years (Schweigger), or in those suffering with 
uterine troubles (Manz). (Hoffman’s “ Bijdrage tot de Kennis 
van het glaucoma.” Utrecht, 1861.) 
The patients generally present themselves with all the 
symptoms of a typical glaucoma simplex consummation in the 
one eye, while the other, also affected with glaucoma simplex, 
is still, comparatively speaking, only slightly impaired as re- 
gards vision (Samelsohn, H. Pagenstecher, Schweigger: Oph- 
thalmological Congress at Heidelberg, 1877). However, the 
one eye may offer to view, instead of glaucoma simplex consum- 
mation, a glaucoma injlammatorium chronicum absolutum 
(Arlt), whereas the less affected eye may reveal the picture of 
a glaucoma simplex, i. e., increased tension and excavation of 
the optic nerve, but scarcely a trace of inflammation. 
After the iridectomy, however—although this be performed 
in the most skillful and correct manner—pain sets in, the eye 
reddens, the lens is squeezed into the pupillary area, the eye is 6 
even harder than prior to the operation, or, in other words, an 
acute inflammatory glaucoma develops, which, after the lapse 
of a few days, leads to total blindness (Schweigger, Ophthal- 
mological Congress at Heidelberg, 1877). 
The question naturally presents itself: How is this much- 
to-be-dreaded event—which cannot be prevented or remedied 
—produced ? In spite of the iridectomy, however well timed 
and well performed, the posterior defluent canal (the Pial- 
sheath of the nerve, or the tubular central canal of the vitre- 
ous) may continue obstructed, or the anterior defluent canal 
(the Fontanaic space) may in part remain closed; or the 
sclerotic may be so rigid that, even in spite of the incision, 
the pressure on the nerve continues: whatever the cause, it is 
certain that the intra-ocular tension, instead of being dimin- 
ished and reduced to the normal condition, is increased by an 
acute glaucoma manifesting itself very suddenly; this in- 
creased pressure, however, forces the lens forward (Schweig- 
ger, op. oit., 1. i.), and, it may be, as in two cases described by 
Pagenstecher, and as in the one immediately to be detailed, 
even between the gaping margins of the wound. The lens 
will thus act as an irritant, producing an inflammatory condi- 
tion of the iris and the ciliary body, and also shutting up the 
new defluent canal created by the iridectomy. That a cata- 
ractous condition of the lens may be produced by this protru- 
sion is evident, although this fact alone would not present 
matter for serious reflection if, upon removing the lens, vision 
might be restored, even in part. This is, unhappily, not the 
case; relief from pain may indeed be given by extracting this 
local irritant (Ilirschberg), although such extraction should 
not be undertaken immediately, for fear of resulting intra- 
ocular haemorrhage (Arlt). 
At the last meeting of the Ophthalmological Congress at 
Heidelberg (1877), my friend, H. Pagenstecher, of Wiesbaden, 
described three cases of glaucoma malignum, in two of which 
the lens had been pushed forward and protruded from the 
lips of the wound. In two cases also both eyes were operated 
on in one sitting. 
Schweigger described six cases, all occurring in women at 
the climacteric period. Hirschberg mentioned a case which 7 
happened in a diabetic patient, and Samelsolm narrated a per- 
fectly similar case to those above treated of, i. e., where, after 
iridectomy had been performed for glaucoma simplex, malig- 
nant glaucoma supervened, ending, of course, in total loss of 
sight. 
The case I will now describe presented to view all the 
characteristics of the disease treated of in the above. It is 
very interesting, inasmuch as it serves to enrich ophthalmo- 
logical literature with a rare instance of true glaucoma malig- 
num, and a detailed account will therefore be given. 
The status pr mens of the case, when she presented herself 
at the Institute, July 6, 1875, was as follows: 
Mrs. R., of slender build and in feeble health ; about forty- 
live years of age. 
Left eye: Yisual power equal zero. The media, including 
the crystalline lens, cloudy; so much so that the fundus can- 
not be seen. Tension extreme (T. 3, of Bowman’s classifica- 
tion : the ball cannot be dimpled, even by firm pressure). 
Sclerotic white and glistening—owing to atrophy of the sub- 
conjunctival tissue. Extremely shallow anterior chamber; 
iris atrophic; cornea flattened and bereft of sensation. She 
has had repeated exacerbations of frontal pain, which have in- 
creased in intensity of late, and are now—at the time of her 
admission into the Institute—very severe. 
Right eye: Tension somewhat increased (T. 1, Bowman); 
pupil slightly dilated and slow to react. Field of vision con- 
tracted toward nasal side. Media clear; vision not greatly 
reduced (about one-third); there is, however, well-defined ex- 
cavation of the optic disk, extending to the inner margin. No 
spontaneous, but easily producible, arterial pulsation. Pres- 
byopia rapidly increasing. No ciliary neuralgia. 
The diagnosis was glaucoma infammatorium chronicum 
consummatum in the left, and glaucoma simplex in the right 
eye. 
The prognosis as to vision in the left eye was, of course, 
nil. An iridectomy was, however, proposed for this eye, in 
order, simply, to alleviate the pain and to arrest the inflamma- 
tory exacerbations. The prognosis regarding the right eye 
was, of course, decidedly more favorable, the great probability 8 
being that the process would be checked, and sufficiently use- 
ful vision retained in this eye after the operation. A broad 
upward iridectomy was accordingly performed in both eyes. 
The immediate result of the operation was most satisfactory. 
A clear and large pupil was obtained, unattended with any 
bleeding into the anterior chamber, and the tension in the 
right eye had diminished immediately subsequent to the iri- 
dectomy, so that the finger could easily impress it. 
The patient was visited by me and my assistant several 
times during the day, as well as in the evening. Her condi- 
tion was found to be very good. That night, however (it is 
worthy of remark that these cases of malignant glaucoma— 
that is, acute inflammatory ensuing upon chronic inflamma- 
tory or simple glaucoma—always show themselves during the 
first night after the operation. V. Schweigger, op. cit., p. 22), 
she had had an attack of angina pectoris, to which she was 
subject, and, the nurse informed me, had sat up in bed in her 
attempt to get breath. She had suffered intense pain in and 
around the eyes during the night. 
On carefully removing the bandage, I discovered that both 
eyes were extremely congested, the lips of the incisions gaping 
and the upper margin of each lens protruding, having been 
squeezed between the wounds. 
Owing, perhaps, to the effort of sitting up in bed, or, 
simply and alone, to that unaccountable tendency to increased 
pressure and inflammatory appearances which, luckily, mani- 
fests itself in but comparatively few eyes, an acute glaucoma 
had taken the place of the simple glaucoma in the right, and 
a renewed inflammatory exacerbation had followed upon the 
consummated disease in the left eye; the crystalline lenses 
were pushed forward into the lips of the wounds by the in- 
creased pressure, joined to the exertion of the patient, and 
that unfortunate condition known as glaucoma malignum was 
produced. 
Oblique illumination revealed to me, when the bandage 
was first removed, a small opacity in the right lens, spreading 
from the point of pressure (the lips of the wound) toward its 
centre. The left lens, as has been said, had been murky be- 9 
fore the operation, having participated in the general degen- 
eration of the different tissues of this eye. 
I did not deem it advisable to extract the lenses, dreading 
hemorrhage, and preferring to replace them by means of the 
recumbent position and the pressure-bandage. 
After the lapse of about fourteen days both wounds were 
firmly closed, and I proposed the operation of extraction of 
the right lens to the patient and her relatives, to be performed 
in a few weeks. This I was not permitted to do, the husband 
objecting, nor did I insist, as I was aware that no useful vision 
would have resulted after so manifest a case of malignant 
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