Glaucoma


Gelsemium is one of the principal homeopathic remedies in the treatment of Glaucoma and is, perhaps, more frequently used than any other. Find its indications here….


THE name comes down from olden times, and was employed because, in certain advanced classes, the pupil acquires a greenish hue (pinkish, green). Glaucoma should be more broadly defined as an excess of pressure within the eye, plus the causes of and the consequences of that excess. In the preparation of this chapter very liberal use has been made of the most excellent work by Priestley Smith on “The Pathology and Treatment of Glaucoma.”

Anatomy-The important part which the iritic angle plays in the causation of glaucoma makes a knowledge of its anatomical construction important. According to Waldeyer the iritic angle is the point where the tissue of the iris, cellular stroma of the ciliary body, muscle of accommodation, and the posterior and external portions of the cornea and sclerotic intersect (Fig.89). These structures jointly form a peculiar cavernous tissue composed of flattened and rounded elastic trabeculae, which, as a continuation of Descemet’s membrane, forms toward the canal of Schlemm true fenestrated lamellae. Into the continuation of Descemet membrane forms toward the canal of Schlemm true enters the elastic tendons and cellular tissue of the ciliary muscle. The membrane of Descemet splits up in this fenestrated lamellae. Toward the anterior chamber this trabecular tissue is arranged cross-wise, leaving in front of the more closely constituted trabecular tissue large spaces called Fontana’s spaces, which are simply the large meshes of the tubercular tissue that merges into the membrane of Descemet and is then called the ligamentum pectinatum iridis. Fontana’s spaces communicate in this way directly with the anterior chamber. The canal of Schlemm is formed by a series of spaces or fissures of the cavernous tissue toward the external surface of the eye in the sclerotic, hence the spaces of Fontana and the canal of Schlemm are nothing more than a serious of continuous lacunae in the trabecular tissue and all communicating together. They belong to the lymphatic system and never contain blood during health. The canal of Schlemm communicates with the sclerotic veins and thus completes the connection between the anterior chamber and the venous circulation. A system of valves is supposed to exist which prevents the blood from passing into Schlemm’s canal and the anterior chamber.

The zonula of Zinn is a transparent structure extending from the posterior surface of the ciliary process to the lens. It is derived from the hyaline layer on the surface of the ciliary body, and, as it passes to the border of the lens, separates, leaving a small triangular space called the canal of petit. Through this structure transfusion readily takes place from the vitreous to the aqueous humor.

Physiology of Secretion and Excretion- The normal intra- ocular pressure is equal to about 25 mm of mercury, and the pressures in the aqueous and vitreous chambers are equal. An excess of even 5 mm. in the vitreous would cause a displacement of the lens and iris. A tension of plus 3 is equal to an intra- ocular pressure of about 80 mm., but a pressure equal to 200 mm. of mercury has been produced experimentally in animals by compression of the aorta and simultaneous irritation of the fifth nerve.

The maintenance of the normal pressure in the chambers of the eye depends upon the dye secretion and excretion of the fluids which traverse them. The intra-ocular fluid to the vitreous, lens and aqueous, and is well adapted for this purpose by the peculiar arrangement of its secreting surface into ridges and grooves, which are in direct contact wit the vitreous and aqueous. Pathological changes confirm this fact, for eyes excised in the first stages of infiltration of the vitreous show an inflammatory exudation extending into the vitreous from the ciliary body. In a shrinking of the vitreous it becomes detached from the retina, but remains adherent to the ciliary body. Disease of the ciliary body always tends to destruction of the vitreous. Priestly Smith has made an elaborate series of experiments regarding secretion and excretion and concludes that “the fluids which nourish the vitreous body and lens and fill the aqueous chamber are secreted chiefly by the ciliary portion of the uveal tract. The larger part of the secretion passes directly into the aqueous chamber, forward through the pupil and out at the filtration angle. A very much smaller portion passes backward through the vitreous body and escapes at the papilla. The hyaloid membrane and zonula, which separate the two chambers, are readily permeable by the vitreous fluid.”

The escape of the fluids from the anterior chamber by filtration through the ligamentum pectinatum into the canal of Schlemm and sclerotic veins has been proven by the experiments of Leber.

PATHOLOGY-In the advanced stages of glaucoma there may be found, from the long existing intra-ocular pressure, pathological changes in nearly all the structures of the eye. The pathological changes have not been determined from examination of eyes that have been lost from glaucoma, and therefore only show the results of the increased tension without giving any light as to the cause of the disease. The most important changes are those found occurring at the iritic angle and which result in a partial or total occlusion of the vessels composing or entering into the canal of Schlemm. They consist of inflammatory changes at the junction of the cornea, sclera and iris. These changes seem to still further hinder the excretion of the fluids from the eye and in this way augment the trouble. The uvea in recent cases shows evidence of inflammatory oedema, with marked distension of its veins. The ciliary processes are greatly distended and push forward the periphery of the iris against the sclera and cornea, where there is formed a permanent adhesion. Later, from atrophy, there is a retraction of the ciliary processes away from the iris, but peripheral synechia remain. The iris atrophies, its vessels walls become thickened and their calibre become contracted or obliterated. the ligamentum pectinatum becomes condensed into tough, fibrous tissue, and, finally, even Schlemm’s canal disappears. The ciliary muscle as well, as the processes atrophy and the atrophy of the choroid, results in obliteration of it vessels. In the cornea there is found between the anterior lamellae, and especially between the epithelium and Bowman’s membrane minute drops of fluid (Fuchs). The sclera gives evidence of inflammatory action and fatty degeneration. The aqueous is more albuminous than normal. the fibres of the optic nerve become inflamed and atrophy in the later stages. The lamina cribrosa loses its power of resistance and is pressed backward. The retina shows a thickening and cystoid degeneration, with subsequent atrophy. There may be fluidity and detachment of the vitreous and the lens cataractous.

SYMPTOMS-There are certain characteristic signs or symptoms of glaucoma more or less regularly found in all varieties of the disease which may be interestingly studied individually.

Recession of the Near Point or diminution of the range of accommodation is one of the earliest prodromal symptoms. As this disease is especially one of old age, we naturally have more or less presbyopia, but in glaucoma the presbyopia increases rapidly and is greater than it should be at that time of life. It is due to the increased intra-ocular pressure upon the choroid, ciliary body and suspensory ligament of the lens, causing paralysis of the ciliary nerves.

Changes in refraction-Glaucoma may occur in any condition of the refraction, although hypermetropes are more predisposed to it and it is found in from 50 to 75 per cent. of the cases. Glaucoma may also cause hypermetropia from a flattening of the cornea and slight shortening of the antero-posterior diameter or the eye from the pressure.

Iridescent vision-The halo rainbow of colors around a light is perfectly circular, and the size and breadth of each colored ring increases the further the light is from the eyes. The intensity of the colors vary with the light, the red being the brightest by gas or candlelight and the blue by electric light. The arrangement of the colors is also the same. There is, first, a colorless space surrounding the light; the internal ring next to the colorless space is always the blue or bluish-green, while the out ring is red. the generally accepted explanation as to the cause of the halo is, that it is due to a diffraction of the rays entering the eye, as a result of the opacity in the cornea.

The Increased Tension-This symptom is the essential one that characterizes the disease. Nearly all the other symptoms and the pathological results of the disease are either directly or indirectly due to the increased tension this symptom is due to an increase in the contents of the eye, but the cause of the increase in the contents is still not definitely settled. the degree of increased tension may very from T plus? to T plus 3. For the method of determining the tension of the eye see page 22.

A. B. Norton
Norton, A. B. (Arthur Brigham), 1856-1919
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.