Glaucoma. 
BY 
JS* 
Flavel B. Tiffany, M. D., 
of Kansas City, Mo. 
A paper read before the Missouri state 
Medical Society, at Jefferson City, -May, 
bi, 1883 
SAINT LOUIS. 
Reprinted from the 
Saint Louis Medical and Surgical Journal 
September, 1883. G L A U C O M A. 
BY 
FLAVEL B. TIFFANY, M . D. 
[Reprinted from the St. Louis Medical and Surgical Journal, Sept, 1883f\ 
ST. LOUIS: 
MEDICAL JOURNAL PUBLISHING COMPANY. 
2622 Washington Avenue, 
1883.. Glaucoma.* By Flavel B. Tiffany, M. D., Kansas City, Mo. 
Gentlemen : In considering the subject of glaucoma, that 
we may better understand the pathology and etiology of the 
disease, I would first call your attention to the anatomy and 
physiology of the organ in which this dire disease is located; 
more especially to the ciliary region, and the parts in close 
proximity. Cursorily glancing at the globe, we find that it con- 
sists of a certain number of tunics and refracting media, with 
numerous vessels and nerves. The structures to which I partic- 
ularly wish to call your attention are Schlemm's canal, and those 
Fig. 5, Section of normal eye through the ciliary region -Williams. 
in near proximity. Schlemm's canal is the circular canal sit- 
*A paper read before the Missouri State Medical Society, at Jefferson 
City, May 16, 1883. 4 
uated at the junction of the cornea with the sclera, in front of 
the ciliary attachment of the iris. (Fig. 5, v. v'.) Internally 
and posteriorly it is bounded by the ligamentum pectinatum 
iridis and the ciliary muscle ; anteriorly and externally, by fibres 
of the cornea and the sclerotic. The iris or diaphragm of the eye 
(J), consists of two sets of fibres, radiating and circular, with 
blood vessels; nerves, etc. Anteriorly the iris is attached to 
the cornea by the ligamentum pectinatum iridis; in fact, this 
ligament is a continuation of the endothelium of the cornea 
(Desemet's membrane, d). The radiating fibres of the iris 
become continuous with those of the ciliary muscle, and ciliary 
processes (Fig. 7),'which muscle and processes are principally 
formed by folds or plaitings of the middle and internal layers 
of the choroid. 
The canal of Fontona is the triangular space enclosed by the 
ligamentum pectinatum, cornea, ciliary muscle, and iris. (Fig. 
5, f. m.) It is crossed by bands of fibres, and is a loose cellu- 
lar net-work which connects with Schlemm's canal. The ciliary 
muscle consists of two sets of fibres : meridianal and circular. 
(Fig. 7, a. & b.) The meridianal take their origin from the 
posterior wall of Schlemm's canal, extending back upon the 
choroid; while the circular are more intimately connected with 
the posterior wall of Fontona's spaces, extending back, and con- 
necting with the fibres of the ciliary processes and suspensory 
ligament. (Fig. 7, a.) In highly myopic eyes the meridional 
fibres are strongly developed, while the circular fibres are 
scarcely to be seen. (Fig. 6.) 
Fig. 6, Section of a myopic eye.-Ivonof. 
In the hypermetropic eye the opposite conditions prevail.. 5 
The meridional fibres are short, while the circular are highly 
developed. (Figs. 7 & 14.) Immediately posterior to the iris 
we have the crystalline lens in its capsule, supported by the sus- 
pensory ligament, the vitrious body, and ciliary processes. 
Fig. 7, Hypermetropic eye.-Ivonof. 
Blood vessels of the eye (Fig. 8.) according to Lieber, repre- 
sents the distribution of blood vessels to the eye. The principal 
arterial blood supply to the anterior portion of the eye, is 
through the long posterior (c) and the anterior ciliary arteries 
(f). The posterior penetrate the sclera in a very oblique course 
about midway between the equatorial and posterior parts of the 
eyeball; passing forward in the outer layer of the choroid to the 
ciliary muscle, they divide into several branches, penetrating 
the muscle from opposite sides. These branches uniting, forma 
circle near the periphery of the iris (g & h). the circulus ar- 
teriosus iridis major. The anterior ciliary arteries, eight or ten 
in number, arising from muscular branches of the opthalmic, en- 
ter the eye in the region of the ciliary muscle, unite with the 
circle just described, assisting in the distribution of blood to the 
ciliary bodies, ciliary ligament, and iris. From the circulus ar- 
teriosus iridis major, a series of very important branches is given 
off to different parts of the eye ball, viz.: to the choroid (n) cil- 
iary processes (1) and iris (i). The recurrent branches passing 
back into the ciliary muscle (m) are very numerous, forming a 
perfect meshwork throughout the muscle. The arterial twigs 
to the ciliary processes are short tubes, which enter these bodies 
from the circulus arterious iridis major. After they have trav- 6 
ersed the ciliary muscle, each, of the seventy or eighty processes 
receives two or three twigs; in each process itself, the arterial 
vessels split up rapidly, and subdivide into a considerable num- 
ber of finer tubes, which form a perfect net-work of blood ves- 
sels in this region. From the latter arterioles spring the venous- 
Fig. 8, Section representing the bloodvessels of the eye.-Frey. 7 
radicals of the parts (13), which finally empty into the vente 
vorticosse (x), which veins pierce the sclerotic near the equator- 
ial part of the eyeball. The vessels supplying the iris are all 
derived from the circulus arteriosus iridis major. They form a 
wide vascular net-work through the stroma of the iris, converg- 
ing toward the pupil near its margin they form a new vascular 
circle,(the circulus arteriosus iridis minor) (i). From this, branches 
are still further, given off which supply the sphincter of the 
pupil (k), and finally merge into venous radicals. The veins 
of this part of the eye are nearly as numerous as the arteries; 
crowded close together, they unite at very acute angles to form 
larger branches; some of which finally empty into the venae 
vorticosae (x); others take their exit through Schlemm's canal 
(10). Some twenty-five or more quite large branches, mostly 
from the ciliary muscle (12), leave the eye at this point, where 
they pierce the sclera quite obliquely, and upon its surface empty 
into the ciliary veins (17). Hence we see, gentlemen, that this 
portion of the eye is highly vascular, that the blood vessels are 
closely packed, requiring but a slight disturbance in the anatom- 
ical parts to produce a disturbance in the circulation. Accom- 
panying the blood vessels we find an equally complex structure 
of nerves ramifying and traversing these structures of the eye. 
The ciliary nerves, which supply the cornea, pass through the 
ciliary bodies, ciliary muscle, and iris, via Schlemm's canal to 
the cornea, about sixty in number, terminating as filaments void 
of their medullary sheath, they finally end, according to Cohn- 
heim, in the nucleoli of the epithelial cells of the cornea. 
PHYSIOLOGY. 
The office of the crystalline lens, together with the other refract- 
ing media,is to cause luminous rays to be focused upon the rodsand 
cones of the retina. Now, in the emmetropic or typical eye, the 
Fig. 9. 
refracting media is such that parallel rays, aa or rays coming from 8 
■distant objects, are brought exactly to a focus upon the rods and 
cones of the retina (Fig. 9, f g). For all other rays, viz.: those 
coming from near objects, which are divergent rays (Fig. 9 c), 
there must be some change in the refracting media. In hyper- 
in etropia, on the other hand, this change must take place for 
all rays-rays coming from distant as well as those from 
near objects. The refracting power of the hypermetropic eye 
bo ng too low to focus parallel rays upon the retina, much less 
Fig. 10. 
can it focus divergent rays. (Fig. 10.) This altering power, 
then, plays constantly in the hypermetropic eye. In the myope 
the eye is adjusted for divergent rays; these, only, it focuses 
upon the retina, and hence; for distant objects, it must make use 
Fig. 11. 
of some external power, as concave glasses. (Fig. 11.) This 
power in the eye is called the power of accommodation. And this 
power is located in the ciliary muscle; but just what its modus 
■operandi is, science has not yet determined; it is evident, how- 
ever, that the circular fibres of the ciliary muscle play a very 
important part in the power of accommodation ; for, in the hy- 
permetropic eye, where more than in either of the others, this 
power of accommodation is needed, we find these circular fibres 
predominating, almost to the exclusion of the meridianal (Fig. 7), 
while, in the myope, who has little use, if any, for this power, 
the meridional fibres predominate over the circular. (Fig. 6.) 
In tae emmetrope the two sets are more nearly equal. This rea- 
soning concerning the use of the accomodation power, depends 9 
upon the fact that, as a rule, people are more engaged with near 
objects tlr;n with distant. 
ETIOLOGY. 
This brings us to tho etiology of glaucoma, for I wish to 
take the position, gentlemen, that hypermetropia, and its first 
cousin, presbyopia, if not the original causes of glaucoma, 
are at least largely, almost infinitely concerned in its develop- 
ment. Let me emphasize, gentlemen, byrepeating the structure 
of the hypermetropic eye. In hypermetropia, as we said, the 
refractive power of the eye is too low or the antero-posterior 
axis of the eyeball is too short, so that when the eye is in a 
state of rest, parallel rays are not united upon the retina, 
but behind it. (Fig. 10.) To remedy this condition, in order 
that the hypermetrope may be able to get a clear image of the 
object, the eye undergoes a change in its power of refraction 
sufficient to unite the rays upon the retina. 
" The less the power of refraction of the hypermetropic eye, 
the greater must be this effort of accommodation and it must 
increase, of course, proportionately, as the object is brought 
nearer to the eye." Hence, we see that the hypermetrope is using 
his power of accommodation all the time, whether he is looking 
at near objects or at those at a distance; there is, then, a con- 
stant strain of accommodation. The ciliary muscTe and pro- 
cesses are constantly at work, so long as the individua' is re- 
garding any object, be it near or distant. Hence the reason of 
the circular fibres and ciliary processes of the hypermetropic eye 
beingso much more developed than those of either the emmetro- 
pic or myopic eye. Let us notice what takes place in the act of 
accommodation. The pupilary margin of the iris moves forward, 
while tl • ciliary margin is drawn outwards towards Schlemm's 
canal, the anterior surface of the lens becomes more convex 
and advances toward the cornea, the anterior chamber becomes 
more shallow, and its contents (aqueous humor) either become 
more dense, or escape more freely through some channel, prob- 
ably Schlemm's canal, the office of which canal, doubtless, is 
to transmit the fluids of the chambers of the eye; thereby al- 
lowing a constant change in these fluids of which, reasoning 
from analogy, there is a necessity in order that the eye may re- 
main in a healthy condition. We are led to this belief by the 
fact that, under special conditions, there is a very copious secre- 10 
tion of the aqeuous humor as, for instance, after the operation of 
paracentesis of the cornea and of iridectomy in which the 
chambers are evacuated, and the cornea collapses; in a few 
seconds the humor is re-established, and the cornea resumes its 
normal curvature. This copious flow presupposes a secreting 
membrane (Descemet's membrane) which, to be in a healthy con- 
dition, must be active, and the supply constant. Consequently, 
the drain must also be constant. This drain must be either by 
the process of exosmosis, or through some canal or duct. The 
sclera and cornea are both dense structures, and the exosmosis 
through them would be slight. Just at their junction, as we 
have seen, is Schlemm's canal, opportunely situated for this 
very work of draining, hence we are presumably logical in con- 
cluding that this is its function. Presbyopia is not an anomaly of 
refraction, but, of accommodation. It is a condition which ap- 
pears in every emmetropic and hypermetropic eye after a cer- 
tain period of life. In the emmeotropic eye it appears at the age 
of forty-five years; in the hypermetropic it may appear much 
earlier. 
What is presbyopia? It is simply an arrest of the power 
of accommodation; an insufficiency upon the part of the 
ciliary muscle to perform its function. For a certain number of 
years we are able to see near objects as well as those at a dis- 
tance. Whenever we want to look at a near object, the little 
ciliary muscle, springs into action, renders the lens more con- 
vex, adjusting it so as rightly to focus divergent rays upon the 
retina, and we get a clear image of the object; but. after a cer- 
tain years this muscle, which is almost constantly 
called into use in the emmetrope, because as a rule we are largely 
employed with near objects, and in the hypermetrope is used 
wtYAoui cessation, becomes tired (in common parlance), and re- 
fuses to perform its function, and the individual experiences a 
corresponding dimness of vision. You may readily see, gentle- 
men, that if this condition is allowed to go on without being 
corrected by the proper glasses adjusted, some lesion is almost 
sure to arise. As a further evidence that this condition is due 
to weariness of the ciliary muscle, I would call attention to an 
occasional phenomenon termed by the laity " second sight." By 
the use of glasses the muscle is relieved of its work, and after 
resting lor a period of time, (several years) its power is re-estab- 
lished, and the person is able to read even the finest print with 
the naked eye. An instance of which I had a few days ago in 
the testimony of a patient nearly eighty years of age. He had 
used glasses for nearly twenty years, when he was able to lay 
them aside, and read fine print with the naked eye. 
This lesion, the direct result of the strain of the power of 
accommodation induced by hypermetropia and presbyopia, at 
least sets with a wonderful impetus toward glaucoma. And 
here allow me to suggest, gentlemen, the importance of every 11 
physician being able to recognize these anomalies, and to cor- 
rect, oi' have them corrected before the complications arise. 
What is glaucoma? Glaucoma, as I believe, is a disease in 
which there is an obstruction ofSchlemm's canal with some lesion 
in the ciliary region, which is peculiarly liable to be disturbed 
here on account of the very complicated net-work of blood 
vessel and nerves entering and leaving the eye at this point. 
SYMPTOMS OF GLAUCOMA. 
1. Increased tension of the globe. 
2. Rapid increase of any pre-existing presbyopia. 
3. Venous hypersemia. 
4. Dilatation and sluggishness of the pupil. 
5. Cloudiness of the aqueous and vitreous bodies. 
6. Periodic dimness of sight. 
7. Appearance of a halo of prismatic colors about a light. 
8. Contraction of the field of vision. 
9. Ciliary neuralgia. 
10. Antesthesia of the cornea. 
11. Scotomata. 
12. Arterial pulsation at the fundus of the eye and cupped 
disk. 
Von Graefe has divided glaucoma into four stages : 
I. Premonitory-Glaucoma imminens, where many, or evert 
all of the above symptoms may appear, though with intermis- 
sions, and in a less marked degree than in the second stage. 
II. A fully developed stage-Glaucoma evolutum. 
III. The third stage he terms Glaucoma Consummatum, a. 
stage in which quantitative perception of light has been com- 
pletely lost for some time. 
IV. The fourth stage is where the eye undergoes glaucoma- 
tous degeneration, and instead of the eyeball being over tense,, 
the tension often falls much below the normal. 
Considering the different symptoms as given, we shall en- 
deavor to show clearly the relation between cause and effect.. 
Taking them in the order given : 
First symptom-The patient complains of a fullness of the eye 
ball, as though the globe was too large for the orbit, and upon ex- 
amination we find that the tension is considerably increased ; the 
pressure made upon the globe with the eye closed and directed 
downwards, reveals the eye as hard, varying from a slightly per- 
ceptible increase to thatof stony hardness, according to whether 
the disease has reached the first, second, or third stage. Now to 12 
Fig. 14. Section of a glaucomatous eye in ciliary region.-Tiffany. 
what is this increase of intra-ocular tension due? In the physio- 
logical eye we know that there is a constant escape of the aqueous 
fluid; probably through the canal of Schlemm. In the glaucoma- 
tous eye (Fig. 14) we find the following conditions, viz.: swelling 
of the ciliary processes, hypertrophy of the ciliary muscle, adhe- 
sions of the iris to the cornea, obliteration of Fontona's spaces, 
and consequently obstruction of Schlemm's canal; as a result of 
which we have an accumulation of fluids, or intra-ocular tension; 
and upon this, gentlemen, hang all the other symptoms. 
Second symptom-Rapid increase of any pre-existing pres- 
byopia. The patient fines it necessary to change his glasses 
very frequently for stronger ones What does this mean ? It 
means that the biliary muscle is becoming involved, and is rapidly 
loosing its power of accommodation. 
Third symptom-Venous hypersemia. The anterior ciliary 
veins become engorged and tortuous, which is simply due to the 
intra-ocular tension which impedes the circulation. 
Fourth symptom-Dilatation and sluggishness of the pupil. 
Upon examination we find that the pupil is more or less dilated, 
according to the stage of disease, and does not respond readily 
to the stimulus of light. 
To what are these conditions due ? In our anatomical review 
we found that the motor nerves supplying the circular fibres 
of the iris, viz.: branches of the third pass through the ciliary 
regions; hence, with the other structures, they become involved, 
and consequently lose their functional power, leaving those 
which supply the radial fibres, viz.: sympathetic, to gain a 
preponderanceof power and thus produce dilatation and inactivity 
of the pupil. 13 
Fifth symptom-Cloudiness of the aqueous and vitreous hum- 
ors. The aqueous humor is found to contain leucocytes, epithel- 
ial cells with more or less granules of pigment. The patient 
complains of seeing specks or cobwebs floating before his eyes. 
Upon examination, the vitrious is found to contain pigment, cor- 
puscles, and striae floating about, showing that some dissolution 
of the ciliary processes or choroid, or both, has taken place; 
originally due to the lesion in the power of accommodation and 
obstruction of Schlemm's canal. 
Sixth symptom-Periodic dimness of sight. The patient in 
the premonitory stage, often complains of periodic dimness of 
sight. This is probably due to temporary disturbance of the in- 
tra-ocular circulation. This dimness can be easily produced by 
merely pressing upon the globe (thus) showing that a very 
slight disturbance of the intra-ocular circulation will affect the 
visio n. 
Seventh symptom-The halo of prismatic colors around the 
light. This is one of the most constant sy mptoms of glaucoma, 
especially in the earlier stages. The outer part of the ring is red, 
the inner bluish green. " This halo is only seen when the pu- 
pil is dilated, and it is probably due to a diffraction of the rays 
of light owing to a change in the refracting power of the lens," 
especially at the periphery, or that portion nearest the ciliary 
region or seat of the disease. Hence, we refer this symptom to 
the lesion of the ciliary muscle. 
Eighth symptom-Contraction of the field of vision. The 
field of vision is usually greatly limited. The contraction usu- 
ally beginning in the equatorial portion of the globe, going on to 
such an extent that the patient will describe his limitation of 
vision as if he were looking through a tube. The most proba- 
ble reason of this limitation of the field of vision beginning in 
the equatorial region is, that this is the portion of the retina 
nearest to the seat of the disease (ciliary region), and also that 
the venae vorticose leave the eye at this part. 
Ninth symptom-Ciliary neuralgia. This symptom in the 
accute form of glaucoma is always present throughout all the 
different stages. The patient complains of a sense of aching and a 
tightness of the globe, with pain extending toward the right O£- 
over the brow, through the temples and down the nose. 
" The pain is most severe. Sometimes of an almost madning 
character; but the most intense agony is often felt in the back 
of the head this is usually accompanied with severe vomiting, 
assuming the character of a bilious attack, for which by the su- 
perficial observer, it might be taken. This ciliary neuralgia is 
undoubtedly due to the pressure upon the ciliary, and branches 
of the trigeminal nerves as they pass into the eye and through 
the ciliary region. 
Tenth symptom-Anesthesia of the cornea. This is quite a 
frequent symptom of glaucoma, especially in the chronic form.. 14 
The cornea becomes so anaesthetic that it can be touched with 
the finger or brush without occasioning the slightest pain. We 
have seen that the nerves supplying the cornea pass through the 
ciliary region, a sufficient explanation for this phenomenon. 
Eleventh sympton-Scotomata, or blind spots, of which the 
patient occasionally complains, is usually due to hemorrhagic 
patches upon the retina, referable to the intra-ocular tension. 
Twelfth symptom-Arterial pulsation at the fundus of the 
•eye and cupped disk. These symptoms, which the opthalmo- 
Fig. 12. Glaucomatous cup.-Noyes. 
Fig'13. Profile view of Glaucomatous cup.-Noyes. 15 
scope may reveal, provided there is not too much cloudiness of 
the refracting media of the eye, arc quite pathognomonic of 
glaucoma. The glaucomatous cup involves the whole optic disk 
(Fig. 12 & 13), while the physiological cup is simply a. shallow 
depression confined to the center of the optic disk. In the glau- 
comatous cup the margin is abrupt, sharp, and often excavated, 
and as the vessels curl over its edge, they appear interrupted or 
distorted. (Fig. 12.) The optic disk is usually encircled by a 
light colored band, which is due to the sclerotic shining through 
the atrophied choroid. At the margin of the disk, where the 
blood vessels wind up over,a distinct arterial pulsation may be seen 
cither spontaneous or caused by a slight pressure upon thetrlobe, 
which is synchronous with the heart's beat. The cause of these 
symptoms is evidently intra ocular tension, and the reason of 
their location may be explained by the fact that the foramen- 
opticum is located at the fundus of the eye. 
If it is of the acute form, the course isoften rapid, destroying 
the vision in a few hours. 
•'In the chronic form the course of the disease is slower, and 
may extend over a period of years, but it is steadily onward, 
and if not relieved by timely treatment, sooner or later dooms 
the eye to irremediable blindness." 
Before proceeding to the treatment of glaucoma, I would 
note the fact that primary glaucoma sometimes attacks the myopic 
eye. This I believe to be due to the same cause as in hypermetropic 
and presbyopic, easily explainable in the fact that the myope 
frequently uses his glasses adjusted for distant objects, in read- 
ing, thereby necessitating a demand upon the accommodative 
power, which, as we have seen is, by nature, weak in the my- 
opic eye, and easily overworked. 
THE COURSE OF GLAUCOMA. 
TREATMENT OF GLAUCOMA. 
In glaucoma imminens, or earlier, a prophylactic treatment is 
often effectual.. The anomaly of refraction or accommodation 
is to be corrected by the proper adjustment of glasses. Eserine 
I have found, also, very useful. Its preventative action is as fol- 
lows : 
It contracts the pupil, and thereby draws the iris away from 
Sehlem in's canal, and permits again the free escape of the aque- 
ous humor, and so relieves the intra-ocular tension. 
All use of mydriatics should be avoided, as then- action is dia- 
metrically opposed to the desired results. They dilate the pupil 
and thereby draw the iris back more completely, closing the 
canal. Indeed, the use of mydriatics, from this very action, 
may induce glaucoma. When the disease is once established, as 
in glaucoma evolutum, there is but one treatment which offers 
any assurance of permanent cure or relief; and that is iridecto- 
my or sclerotomy. The results of these operations in acute 16 
glaucoma have been most brilliant. In the chronic form they 
will arrest the progress of the disease. And if made in the 
earlier stage, will often restore a portion, if not the entire amount 
of sight lost* In the acute form the operation should be made 
as soon as possible after the prodromal stage has set in : for every 
hour delayed is most valuable time lost; for, as we have seen, 
this form of the disease often runs its course in a few hours, 
reaching the form of glaucoma absolution, a stage in which quan 
titative perception of light is comletely lost. Paracentesis, ami 
other operations, have been recommended for glaucoma, but their 
effect, is only temporary or transient, as they do not remove the 
cause of the intra-ocular tension. Iridectomy, or sclerotomy, 
is efficient in doing this, as in either operation the incision is 
made through the sclera at or in close proximity to Scblemm's 
canal. The wound, uniting, acts as a filter for the fluids, for a 
time at least, until the canai has fully regained its function. Of 
the two operations, iridectomy and sclerotomy, I prefer sclerot- 
omy, for the following reasons, viz.: It accomplishes the desired 
results with a greater degree of certainty. It is less dangerous 
to the iris and crystalline lens; it doesnot disfigure the pupil, 
causes much less pain, takes less time and instruments, and is 
easier made. The steps for making this operation, are as follows : 
1. A few drops of a solution of one grain of sulphate of eser- 
ine to an ounce of distilled water must be droped in the eye before 
the operation. 
2. The operation, if possible, should be made without nar- 
crosis. 
3. Section, may be made upwards or downwards. 
4. Enter the sclera with Von Graefe's knife at one m. m. 
from the edge of the cornea, as if about to make a scleral flap. 
(Fig. 15.) 
5. When the knife has made the counter puncture, it is to 
be pushed slowly forward, and the operation ended if possible by 
the withdrawal of the knife, which should be done very slowly. 
6. Flap is not to be completed, but the apex is to be left. 
(Fig- 16.) 
Fig. 15. 
7. Eserine must again be dropped into the eye and a band- 
age applied. 
Fig. 16. 
The authorities consulted in writing this article are Frey, Satterth- 
waite, Wells, Lawson, Noyes and Abadie.