Cases of Primary Acute Glaucoma, of 
Primary Haemorrhagic Glaucoma, 
and of Secondary Glaucoma. Cases of Primary Acute Glaucoma, of 
Primary Haemorrhagic Glaucoma, 
and of Secondary Glaucoma, 
with Remarks and Photo- 
Micrographs. 
WILLIAM F. NORRIS, M.D., 
PHILADELPHIA, PA. 
Reprinted from Transactions of American Ophthalmological Society, 1887. CASES OF PRIMARY ACUTE GLAUCOMA, OF 
PRIMARY HAEMORRHAGIC GLAUCOMA, 
AND OF SECONDARY GLAUCOMA, 
WITH REMARKS AND PHOTO- 
MICROGRAPHS. 
Primary Acute Glaucoma. 
February 2, 1883, M. H., a married woman aged fifty-two 
years, suffering from an attack of acute glaucoma in the left 
eye, presented herself at the Wills' Eye Hospital. She 
stated that the attack had lasted twelve days, coming on 
during a period of mental worry and while at sea, two days 
after having embarked for this country. She noticed that 
the eye first became " cloudy, as if something were in front of 
it which ought to be wiped away," followed the next day by an 
intense pain, which continued during the whole subsequent ten 
days passage, preventing her from eating and sleeping properly. 
The lids were slightly swollen and their veins full, whilst the 
lining conjunctiva was of a dull red tint. The cornea was hazy 
and " needle-stuck," with marked ciliary congestion around its 
entire periphery. The anterior chamber was very shallow, 
and the pupil was irregularly dilated, with a slight synechia 
above and to the inside. Intra-ocular tension was much in- 
creased (T 4~ 2), and the eyeball felt quite hard to the touch. 
The patient complained of intense intra-ocular, temporal and 
frontal pain. The vision in this eye was so impaired that she 
could only count fingers at two and a half feet. 
The patient further stated that on the 5th of August, 1875, 
soon after a moderate dinner, at which she had partaken of 
plain food only, without stimulants of any kind, a severe attack 
of pain and inflammation occurred in the right eye, and that 
the sight rapidly failed while the ball became stony hard. She 
had noticed no previous fogging of the sight, and had been 4 
reading for some hours in the same morning. An iridectomy 
had been performed after the above attack, and the eye had 
remained quiet ever since. Examination showed that there 
was a narrow iridectomy upward, the centre of the cicatrix of 
the incision being in the limbus and each side encroaching 
upon the clear cornea; while just a little to the outside of the 
centre, there was a slight cystoid clavus or impalement of the 
iris in the wound. The eye was quiet and tension normal, 
the ophthalmoscope showing a small optic disk, slightly 
grayish in tint and not excavated-eyeground fairly healthy 
with a hypermetropia of three dioptrics. 
Owing to the patient's extreme feebleness and exhaustion, 
no operation was at the time attempted on the inflamed eye, 
but she was admitted to the hospital, put at rest in bed and 
given good nourishing diet, while a Heurteloup leech was 
applied to the temple and eserine repeatedly instilled into the 
eye. Under this treatment, in two days the cornea became 
less "steamy" and the eye less congested. On the fourth 
day the pain had so far subsided that the patient could sleep 
at night without an anodyne. The pupil, in spite of the 
eserine, was still irregularly ovoid, with its axis at eighty 
degrees, but vision had so far improved that with a plus one- 
eighth spherical lens, the patient could see Sixteen days 
after admission to the hospital (twenty-eight days after the 
commencement of the attack), the eye still remaining as 
above described, an iridectomy upwards and slightly inwards 
was made with a lance-shaped knife, and a large piece of iris 
removed with a single upward snip of the scissors. Twenty- 
four days after the operation, it is noted that the wound was 
firmly healed, but the cornea was still so cloudy that only a 
misty view could be had of the fundus; the vertical vessels 
being best seen with -J- s. 3. D. Two days later the patient 
was discharged, and told to use a weak solution of eserine. 
Two days after leaving the hospital, she returned with a sharp 
attack of catarrhal conjunctivitis in each eye ; this yielded 
to weak astringents, and the eye became clear and quiet. 
On the 1 Sth of April (sixty-eight days after the operation), 
the patient again presented herself at the hospital, and could Plate. I. 
Fig. 1. Section of Globe, M. H. x3. 
Fig. 2. Iridectomy, M. H. x!6. 
Fig. 3. Sclerotomy, M. IT. x!8. 5 
read Sn. at thirteen inches with sph. O + cyl. ax. 
165°. The eye, however, never became quiet, the patient 
returning at intervals with attacks of blepharitis and conjunc- 
tivitis until August 6th, 1884 (nearly a year and a half after 
the operation of iridectomy), when she had a sharp attack of 
pain which was not relieved by eserine. Two days subse- 
quently a sclerotomy downwards was performed: this was 
done without the use of an anaesthetic. Nervous shock with 
chills down the back followed the operation, though there was 
no pain in the eye. 
In November the eye was still unquiet and a cystoid cicatrix 
w'hich had formed was becoming more prominent and bulging. 
At this time a stye formed at the outer angle of the lower lid, 
which suppurated by the use of hot stupes. 
In April, 1885, there was a fresh attack of inflammation 
of the eye with hypopyon; this disappeared in a few days, 
leaving the eye still irritable and the anterior chamber ob- 
literated except just.opposite the iridectomy. 
On the 16th of April, 1885, the eyeball was enucleated 
under ether, without accident, and the wound healed rapidly. 
Except that the patient has occasional attacks of eczema on 
the back of the wrists, there is no evidence of nerve-disease or 
constitutional dyscrasia, and the right eye (July, 1887) still 
remains quiet and serviceable, giving a vision of IB 'with cor- 
recting glass and having a good field of vision, which is here- 
with appended. 
The photomicrograph now projected upon the screen (Vide 
Fig. 1, Plate 1), shows a section of the enucleated eye. It 
exhibits a cystoid cicatrix on the side of the iridectomy, and 
shows the corneal lamellae separated and its tissue loosened 
throughout, especially in the neighboihood of the cicatrices of 
incision. On the side opposite the iridectomy is seen a cut in 
the membrane of Descemet, and the cicatrix of the sclerotomy 
leading outward and downward from it. The remnants of the 
hypopyon are visible as a band of fibrillated and nucleated 
tissue at the bottom of the anterior chamber adjoining the 
sclerotomy scar. The choroid is thickened and its blood- 
vessels dilated; the larger trunks where they approach the 6 
vortex, being filled with blood. At the optic entrance, the 
nerve fibres in the head of the nerve have shrunk, and have 
been pulled away from the concave lamina cribrosa by the drag 
of the cutting knife. We have thus a specimen of glaucoma 
before the formation of an excavation, and while the softening 
atrophic changes in the head of the nerve, which make it so 
readily give way to intra-ocular pressure, are taking place. 
More highly magnified sections1 show these processes in de- 
tail. The ciliary nerves where they pierce the sclerotic have 
an increase of the fibrous tissue envelope around and between 
the fibres, with proliferation of their nuclei; perhaps this is 
preparatory to the atrophy which has often been found in 
the ciliary nerves of complete glaucoma. • 
EXPLANATION. 
This field has been reduced to one-twelfth of its original size. It was 
obtained by the carrying inwards on a large ruled black-board, of a centime- 
tre square of unglazed white or colored paper on a dead-black card; the 
patient being placed at about twenty-five centimetres distance from the 
fixation point, which consisted of a small white cross. The outer ruled 
lines represent the furthermost boundaries of the white field; the dotted 
lines bound the yellow area; the stroked lines designate the outer boun- 
daries of the blue field; whilst the ringed lines give the limits of the red 
field. 
' Figs. 2 and 3, Plate I., and Fig. 1, Plate II. Plate 11. 
Fig. 1. Optic Nerve Entrance, M. H. x21. 
Fig. 2. Iridectomy, B. x!6. 
Fig. 3. Optie Nerve Entrance, B. x!6. 7 
Miss E. B., aged seventy, applied for treatment at the 
hospital of the University of Pennsylvania, February 20, 
1879, with marked haemorrhagic retinitis and incipient cortical 
cataract in each eye. She said that she had had an attack of 
sudden loss of vision about a year previously, and that the 
present dimness of sight had come on suddenly with a flash 
of light, ten days ago, whilst stooping. 
In the right eye V. = by holding the card in the upper 
part of field ; this being slightly improved by a convex 
lens. The ophthalmoscope showed a long black spike in the 
anterior cortical, the centre of the lens and the vitreous humor 
being clear. The disc was slightly prominent, and the retinal 
veins full and tortuous, with a haemorrhage into the sheath of 
the upper nasal vein. Numerous haemorrhages into the retina, 
one fan-shaped and extending inwards and upwards from the 
disc, another, a large one, occupying the upper macular region 
just above the fovea. In the lower part of the retina there 
were several white splotches of absorbing haemorrhage. 
Vision of the left eye, which was slightly improved by a con- 
vex lens, equalled Shoots of opacity were visible in the 
anterior cortical of the lens. The optic disc showed a partial 
glaucomatous excavation, most pronounced to the temporal 
side; scleral ring being broadened all around. Haemorrhages 
of older date, with one touching nasal side of the disc. 
Fields of vision could not be satisfactorily taken, owing to 
the extreme restlessness of the patient and the want of steady 
and continuous fixation; blind spots being encountered at 
times where the chalk (or even a candle-flame) was lost to 
view. 
On April 1st, the right eye being much more cloudy, its 
cornea hazy, and its tension increased, with a slight haemorrhage 
into the anterior chamber, which had failed to yield to eserine 
and temporal blood-letting, it was resolved to perform an 
iridectomy, notwithstanding the unfavorable symptoms : this 
was done with a lance knife incision at the upper part of the 
cornea, the operation being completed without any accident 
Primary Hcemorrhagic Glaucoma. 8 
except that on cutting the iris the anterior chamber filled 
with blood. The wound healed, and the eye did well until the 
fourth day, when, just after instilling some drops of eserine, 
an attack of violent pain came on, accompanied by increased 
clouding of the cornea, followed on the ninth day by a recur- 
rence, without any exciting cause. On the twenty-fourth day, 
the patient had lost all perception of light in the eye, and the 
cornea was still too hazy to permit a view of the details of 
the fundus, although a faint red glare could be seen through 
the pupil. The cicatrix was bulging, with large red vessels 
running to it. Tension equalled 4~ 2. This condition was 
followed every few days by a series of exacerbations with in- 
tense pain and greater cloudiness of the cornea. The left 
eye remained about as at first examination. The patient 
being unwilling to part with the eye, on the 27th of May an 
attempt was made to perform a neurectomy. The internal 
rectus was divided, and a cat-gut suture passed through its 
proximal end, but the muscle was so rotten that the stitch 
pulled out on the slightest tension. The optic nerve was then 
cut, and the posterior end of the globe turned forward to 
make sure that the optic and ciliary nerves were all thoroughly 
divided. At this time there was so free a haemorrhage into 
the capsule of Tenon, that the lids were swelled shut, and the 
fissure closed so tight that it was impossible without constant 
forcible pressure to retain the eyeball in the socket, this per- 
sisting even after cutting the outer canthus. The eyeball 
was, therefore, enucleated, the wound healing slowly, though 
without accident. The patient was discharged a month later. 
The vision of the left eye at this time was -fVk, the pupil 
being round, the iris sluggish, and tension slightly increased. 
A year later she returned to the Dispensary, when vision had 
fallen to 
Dr. Edward Jackson, who saw her subsequently, kindly in- 
formed me that in September, 1880, she still had occasional 
pain in the eye, although it was never severe; that vision was 
dimmer, but there was still sight enough to go about unaided; 
and that this state of affairs continued unchanged until the 
patient died of apoplexy one year later. Plate III. 
Fig. 1. Retina, B. x50. 
Fig. 2. Cystoid Cicatrix, G. xl6. 
Fig. 3. Optic Nerve Entrance, G. x25. 9 
The photomicrographs of sections of the enucleated eye 
(Figs. 2 and 3, Plate II., and Fig. 1, Plate III.), show that there 
is a commencing more or less saucer-shaped excavation of the 
optic disc, which is deepest to the temporal side; the tissue 
once forming the head of the nerve being pressed down 
against the tissue of the lamina cribrosa, to which it is united. 
The lamina cribrosa is also curved backwards. These changes 
must have taken place in a period of three months, because at 
the first presentation of the patient, repeated and careful ex- 
aminations showed that the disc at that time was slightly 
prominent. A further study of these sections shows that 
there were haemorrhages in the sclerotic, and in and around 
the canal of Schlemm. The retina is also full of haemorrhages, 
which are mostly irregular in form, and lie in the inner nuclear 
layer, though occasionally passing outwards and invading the 
outer nuclear layer, even to the external limiting membrane; 
there being but few in the fibre layer. 
Although we often see extensive retinal haemorrhages with- 
out increase of intra-ocular pressure, yet in this case the 
haemorrhages in the retina seem to have been the exciting 
cause of the increased intra-ocular pressure. I am inclined to 
think that this is not infrequent, where they occur in an eye 
in which there is any obstruction to the return circulation of 
the blood or lymph. The case is interesting, because it 
presents one of the rare complications which may render the 
operation of neurectomy nugatory. 
Secondary Glaucoma supervening after a Peripheric Linear 
Operation foi Cataract. 
M. G., aged sixty-six years, was admitted to the hospital 
of the University of Pennsylvania on the 27th of September, 
1886. The patient stated that ten years previously, whilst 
in Manchester, England, he had had an operation for cataract 
performed upon the right eye, followed by a similar operation 
upon the left eye one year later. Both of these operations 
were successful, the patient seeing "fairly well" with his 
glasses. Eighteen months after the first operation a secondary 10 
operation was done upon the right eye, the pupillary opacities 
being needled. After this the eye appears never to have 
become altogether quiet.1 
Examination of the right eye showed that it was red, its 
cornea hazy, and that there was much increase of tension 
(T2). No light perception. Just above the cornea there 
was a cicatrix from a peripheric linear operation for cataract, 
the cicatrix being cystoid and bulging at both ends. The 
left eye presented a somewhat similar cicatrix, less cystoid 
than that of the fellow-eye, though slightly prominent, with 
impalement of the iris at each end of the scar; the outer end of 
of the cicatrix being most prominent. With this eye the patient 
could see to count fingers at five feet. The eye was watery, 
sensitive to light, and giving out readily when any object was 
fixed. 
On the 27th of October, he was admitted to the hospital. 
On the day following, ether was administered, and the sightless 
eye enucleated, causing a free haemorrhage into the capsule of 
Tenon, with swelling and closure of the lids, which was readily 
controlled by a pressure bandage. With the exception of 
more discharge than usual from the socket for a time, there 
was no drawback to the healing. The sympathetic irritation 
in the fellow-eye was entirely relieved, which at present with 
+ I sph. has a vision of 
The microphotographs (Figs 2 and 3, Plate III.), show sec- 
tions through the extensive cystoid cicatrix, and through the 
complete excavation of the head of the nerve. 
In conclusion: a study of the cicatrices of these three 
operations shows, in each case, a displacement of the relative 
position of the corneal flap and of the corneal stump from 
which it was cut. In each instance the edge of the flap rides 
up a little, while the cut edge of the proximal portion of the 
cornea projects deeper into the anterior chamber. In com- 
paring them with the beautiful and careful drawings of Becker 
1 In a letter dated 30th July, 1887, Mr. David Little of Manchester, England, writes : 
"When I saw him last, it was January, 1886. It was then noted, " right eye inflamed 
since November last, sight lost for six years." At present, conjunctiva with thick puru- 
lent discharge. Iris bulging at each corner of wound. Anterior chamber half filled 
with blood. No perception. T.-J-2." . . . . " Date of first operation was April, 1875." 11 
in his " Atlas of the Pathological Topography of the Eye," 
we find that a large majority of his plates representing flap 
operations, with and without iridectomy, Graefe extractions, 
and iridectomies, show a displacement of the cut edges in a 
corresponding manner-while two of them (Plate VII. Fig. 2, 
in the large Atlas, and Fig. XXI. of the small Atlas1), give 
examples of the end of the flap being deeper in the anterior 
chamber, while the proximal edge of the cornea rises slightly 
above it. In a few instances only are the inner edges of the 
incision nearly on the same level. 
These facts seem to me to present good anatomical reasons 
for the utmost diligence on the part of the practitioner to pre- 
vent any undue motion of either the body or eyes of the patient 
after operations, until the wound is sufficiently closed by ad- 
herence of the cut surfaces to make it probable that it wifi 
not readily give way or be displaced. 
1 " Photographische Albildungen von Durchschnitten gesunder und kranker Augen." 
Wien, 1876.