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Gonioscopy in Glaucoma
EDITORIALS
Institute is evidently taking steps to pro mote such local study of the problem. But it is to be hoped that the enthusiasm of these clinical centers will not lead them to discredit their field of labor by indis criminate publication of claims which many excellent ophthalmologists may con sider exaggerated, and which may create misleading expectations among the laity. A circular from one of these new cen ters presents an elaborate table of "symp toms indicative of aniseikonia," under the headings of "functional," "local," "neu rologic," and "gastro-intestinal." The list reads remarkably like a classical recital of symptoms attributable to eyestrain. The functional symptoms listed are: asthenopia, photophobia, car or train sickness, excessive fatigue in reading or working at near range, discomfort in at tending movies, lectures, etc., and im paired fusion and stereopsis. The local symptoms : eyes burn or ache, blurring, diplopia, lacrimation, pulling sensation, and blepharospasm. The neurologic symptoms: headaches, vertigo, psychoneurosis, general fatigue, tension or irritability, general nervous fatigue, feeling of pressure in the head, and pain or tenseness in the cervical re gion. The gastro-intestinal symptoms: nau sea, indigestion, and gastric disturbances. Since the difference in size of images is presumed to reside in the brain, and can hardly therefore make important de mands upon the nerve or blood supply of the eye or its external adnexa, one wonders how such symptoms as photo phobia, burning or itching of the eyes, blurring of vision, lacrimation, and blepharospasm can arise from this cause. The "aniseikonia bulletin" from which this list is quoted, issued by the Aniseikonic Clinic of a well-known west ern "sanatorium and hospital," carries in its heading the name of an ophthalmolo
1323
gist M.D., and that of an "O.D." (pre sumably Doctor of Optometry*). In an announcement card accompanying the bulletin it is stated that the work will be done with the instruments and methods indorsed by the Dartmouth Eye Institute and that it will be in charge of Dr. (the ophthalmologist), and of "Dr."* (the optometrist) as technician. W. H. Crisp. GONIOSCOPY IN GLAUCOMA The classification of glaucoma has long been a confused one and should be clari fied. It has been described as being divid ed into two principal types, the primary and secondary. Primary glaucoma has been subdivided into such categories as acute congestive, chronic congestive, and chronic noncongestive or simple glauco ma. Another classification divides the types of glaucoma into compensated and incompensated. It is rather generally con ceded that reclassification is necessary but, as Gradle asks, "do we know enough yet to make it?" Raeder in 1923 introduced a classification based on chamber depth. The opinions were the result of clinical observation. Recently, gonioscopy has made great advances, and it would appear that fur ther study of the angle of the anterior chamber may give us a better understand ing of the etiology of the disease and through this a more rational classifica tion. With a better understanding of the disease the therapy can be handled more intelligently. In 1933 M. Uribe Troncoso and A. B. Reese presented a paper before the Ox ford Ophthalmological Congress on go* At both these points the Aniseikonic Clinic seems to be at variance with the law of the state, which apparently denies to optometrists the professional use of the title "Dr."
1324
EDITORIALS
nioscopic findings following the Elliot operation. They stated that the examina tion of the angle of the living eye by means of the gonioscope and contact glass has passed from the "era of experiment to the stage of clinical application." In their opinion this examination also gave important information in a variety of conditions related to the angle of the chamber of the living eye. They advo cated that with this method every oph thalmologist, after some training and with a little patience, should be able to "see the angle as easily as the anterior seg ment with the slitlamp." This presupposed that the ophthalmologist was properly trained in the use of the gonioscope and in the anatomy and physiology of the region. To the average ophthalmologist, however, the procedure seemed too com plicated to warrant its adoption in prac tice. Stimulated particularly by the work of Troncoso, Otto Barkan in 1936 developed his method of gonioscopy, using the mi croscope head of the slitlamp suspended from an easily adjustable arm. This method has greatly simplified the proce dure, so that an examination can be made in the office in a very few moments. Since Troncoso's work was published, various papers have appeared from time to time on the findings in the angle in glaucoma as seen by the gonioscope. That this method of examination may become of importance in the intelligent care of glaucoma is suggested by the recent ap pearance in the American Journal of Ophthalmology of two rather practical papers on this subject. In Otto Barkan's paper, read before the Pacific Coast Oto-Ophthalmological Society in 1939, he suggests that the choice of operation in glaucoma be based on its classification according to the fol lowing types: "trabecular glaucoma with a wide or open angle or a narrow angle,
or iris-block glaucoma with a shallow chamber and narrow angle." This classi fication was based on work done since 1936. This year Sugar read a paper before the Chicago Ophthalmological Society in which he also reports his theory and clas sification based on work done by Gradle and himself during the last few years. Their findings in general corroborate the findings of Barkan. The continued study of the iris angle by means of gonioscopy in the various ophthalmological centers of the country should eventually give us a better under standing of the etiology of one of the most difficult diseases with which the ophthalmologist must cope. The work done so far would suggest that the type of glaucoma can be deter mined by study of the angle, and that the operative procedure indicated may be based on gonioscopic findings rather than on purely clinical judgment. If this should be true it would probably greatly improve the operative prognosis of glaucoma. We have all had the experience of care fully controlling the tension medically and having the patient disappear to return later with complete loss of vision because he hadn't used his drops. Often he states that he went away from home for a time and forgot his drops and found that the eye didn't bother him so he felt the drops were no longer necessary. This occurs with sufficient frequency to cause some ophthalmologists to feel that every case of glaucoma should be classed as surgical. With a better understanding of the dis ease and a guide with which to decide upon the operative procedure, we may be able to improve markedly the surgical results. If this can be accomplished, per haps the therapy of glaucoma may in the future be regarded as purely surgical. Ophthalmologists should read all pa pers on the study of glaucoma with the
EDITORIALS gonioscope with an open mind, and more detailed studies should be made of the disease with this newer method. As a re sult of this we may completely revise our conception of the etiology and care of glaucoma. Frederick C. Cordes.
VITAMIN T H E R A P Y IN OPHTHALMOLOGY Elsewhere in this issue are to be found two articles, by careful investigators, on eye diseases due to vitamin deficiency and their treatment with vitamins of various sorts. It is unnecessary here to recall the history of the discovery of the vitamins and the disorders produced by the lack of them in both the animal and man. The subject forms a glorious and fasci nating current chapter in medicine, and every physician is now awake to this in formation, if not from scientific sources, at least from the literature of the drug houses and from the daily press and lay magazines. One can say that there is no deficiency of vitamin awareness, at any rate. It is but natural that in the enthusiastic reception of this knowledge, abuses should have crept in. If the history of any drug or healing agent be investigated, this same abuse at the onset of its appli cation will be found. A search of the medical literature of the past will disclose serious articles in first-rate journals by outstanding men, devoted to astonishing reports of successful therapeutic results in all sorts of conditions from the use of such drugs as quinine, thyroid extract, cocaine, and a host of others including tobacco. The first flush of excitement following the announcement of a thera peutic discovery led naturally to its ap plication to a legion of misunderstood conditions, sometimes with an amazingly good effect; witness, for example, the
1325
value of sulfanilamide in trachoma, often with no effect and occasionally with dis astrous and unanticipated results, as, for example, the cataract formed consequent to the dinitrophenol treatment of obesity. Our knowledge and application of vita min therapy is at present in the state of ferment and flux through which the eval uation of all of the drugs in the phar macopeia have passed. An enthusiastic hunter sees an Indian behind every tree. Any patient with an ocular condition that has so far defied an exact knowledge of its treatment is now being dosed with vitamins that are given locally and gen erally in shotgun mixtures. They have been fanatically prescribed in conditions as far apart as cataract and retinitis pigmentosa, myopia and interstitial keratitis, primary optic atrophy and Mooren's ulcer. For example, unsupported claims are made daily, at least verbally, that cataract can be prevented, a fact most difficult to prove, and not only that, but cured as well by the ingestion of vitamins, either in capsule form under all sorts of confusing trade names, or by the daily consumption of one raw carrot. It is natural that the vitamin craze is wide open to exploitation by the unscrupulous. The only difficulty seems to be that the public is now so well educated that the physician finds that the majority of his patients are already taking vitamins of their own initiative and have been doing so for some time. The only way in which our prejudices can be debunked is by the publication of articles by competent and trustworthy observers who have access to a large amount of clinical and experimental fa cilities. The question, "Is this honest work ?" must be constantly posed. Subtle influences such as the desire to satisfy enthusiastic ambition, or to promote the interests of pharmaceutical benefactors must be searched for and weighed in the
Institute is evidently taking steps to pro mote such local study of the problem. But it is to be hoped that the enthusiasm of these clinical centers will not lead them to discredit their field of labor by indis criminate publication of claims which many excellent ophthalmologists may con sider exaggerated, and which may create misleading expectations among the laity. A circular from one of these new cen ters presents an elaborate table of "symp toms indicative of aniseikonia," under the headings of "functional," "local," "neu rologic," and "gastro-intestinal." The list reads remarkably like a classical recital of symptoms attributable to eyestrain. The functional symptoms listed are: asthenopia, photophobia, car or train sickness, excessive fatigue in reading or working at near range, discomfort in at tending movies, lectures, etc., and im paired fusion and stereopsis. The local symptoms : eyes burn or ache, blurring, diplopia, lacrimation, pulling sensation, and blepharospasm. The neurologic symptoms: headaches, vertigo, psychoneurosis, general fatigue, tension or irritability, general nervous fatigue, feeling of pressure in the head, and pain or tenseness in the cervical re gion. The gastro-intestinal symptoms: nau sea, indigestion, and gastric disturbances. Since the difference in size of images is presumed to reside in the brain, and can hardly therefore make important de mands upon the nerve or blood supply of the eye or its external adnexa, one wonders how such symptoms as photo phobia, burning or itching of the eyes, blurring of vision, lacrimation, and blepharospasm can arise from this cause. The "aniseikonia bulletin" from which this list is quoted, issued by the Aniseikonic Clinic of a well-known west ern "sanatorium and hospital," carries in its heading the name of an ophthalmolo
1323
gist M.D., and that of an "O.D." (pre sumably Doctor of Optometry*). In an announcement card accompanying the bulletin it is stated that the work will be done with the instruments and methods indorsed by the Dartmouth Eye Institute and that it will be in charge of Dr. (the ophthalmologist), and of "Dr."* (the optometrist) as technician. W. H. Crisp. GONIOSCOPY IN GLAUCOMA The classification of glaucoma has long been a confused one and should be clari fied. It has been described as being divid ed into two principal types, the primary and secondary. Primary glaucoma has been subdivided into such categories as acute congestive, chronic congestive, and chronic noncongestive or simple glauco ma. Another classification divides the types of glaucoma into compensated and incompensated. It is rather generally con ceded that reclassification is necessary but, as Gradle asks, "do we know enough yet to make it?" Raeder in 1923 introduced a classification based on chamber depth. The opinions were the result of clinical observation. Recently, gonioscopy has made great advances, and it would appear that fur ther study of the angle of the anterior chamber may give us a better understand ing of the etiology of the disease and through this a more rational classifica tion. With a better understanding of the disease the therapy can be handled more intelligently. In 1933 M. Uribe Troncoso and A. B. Reese presented a paper before the Ox ford Ophthalmological Congress on go* At both these points the Aniseikonic Clinic seems to be at variance with the law of the state, which apparently denies to optometrists the professional use of the title "Dr."
1324
EDITORIALS
nioscopic findings following the Elliot operation. They stated that the examina tion of the angle of the living eye by means of the gonioscope and contact glass has passed from the "era of experiment to the stage of clinical application." In their opinion this examination also gave important information in a variety of conditions related to the angle of the chamber of the living eye. They advo cated that with this method every oph thalmologist, after some training and with a little patience, should be able to "see the angle as easily as the anterior seg ment with the slitlamp." This presupposed that the ophthalmologist was properly trained in the use of the gonioscope and in the anatomy and physiology of the region. To the average ophthalmologist, however, the procedure seemed too com plicated to warrant its adoption in prac tice. Stimulated particularly by the work of Troncoso, Otto Barkan in 1936 developed his method of gonioscopy, using the mi croscope head of the slitlamp suspended from an easily adjustable arm. This method has greatly simplified the proce dure, so that an examination can be made in the office in a very few moments. Since Troncoso's work was published, various papers have appeared from time to time on the findings in the angle in glaucoma as seen by the gonioscope. That this method of examination may become of importance in the intelligent care of glaucoma is suggested by the recent ap pearance in the American Journal of Ophthalmology of two rather practical papers on this subject. In Otto Barkan's paper, read before the Pacific Coast Oto-Ophthalmological Society in 1939, he suggests that the choice of operation in glaucoma be based on its classification according to the fol lowing types: "trabecular glaucoma with a wide or open angle or a narrow angle,
or iris-block glaucoma with a shallow chamber and narrow angle." This classi fication was based on work done since 1936. This year Sugar read a paper before the Chicago Ophthalmological Society in which he also reports his theory and clas sification based on work done by Gradle and himself during the last few years. Their findings in general corroborate the findings of Barkan. The continued study of the iris angle by means of gonioscopy in the various ophthalmological centers of the country should eventually give us a better under standing of the etiology of one of the most difficult diseases with which the ophthalmologist must cope. The work done so far would suggest that the type of glaucoma can be deter mined by study of the angle, and that the operative procedure indicated may be based on gonioscopic findings rather than on purely clinical judgment. If this should be true it would probably greatly improve the operative prognosis of glaucoma. We have all had the experience of care fully controlling the tension medically and having the patient disappear to return later with complete loss of vision because he hadn't used his drops. Often he states that he went away from home for a time and forgot his drops and found that the eye didn't bother him so he felt the drops were no longer necessary. This occurs with sufficient frequency to cause some ophthalmologists to feel that every case of glaucoma should be classed as surgical. With a better understanding of the dis ease and a guide with which to decide upon the operative procedure, we may be able to improve markedly the surgical results. If this can be accomplished, per haps the therapy of glaucoma may in the future be regarded as purely surgical. Ophthalmologists should read all pa pers on the study of glaucoma with the
EDITORIALS gonioscope with an open mind, and more detailed studies should be made of the disease with this newer method. As a re sult of this we may completely revise our conception of the etiology and care of glaucoma. Frederick C. Cordes.
VITAMIN T H E R A P Y IN OPHTHALMOLOGY Elsewhere in this issue are to be found two articles, by careful investigators, on eye diseases due to vitamin deficiency and their treatment with vitamins of various sorts. It is unnecessary here to recall the history of the discovery of the vitamins and the disorders produced by the lack of them in both the animal and man. The subject forms a glorious and fasci nating current chapter in medicine, and every physician is now awake to this in formation, if not from scientific sources, at least from the literature of the drug houses and from the daily press and lay magazines. One can say that there is no deficiency of vitamin awareness, at any rate. It is but natural that in the enthusiastic reception of this knowledge, abuses should have crept in. If the history of any drug or healing agent be investigated, this same abuse at the onset of its appli cation will be found. A search of the medical literature of the past will disclose serious articles in first-rate journals by outstanding men, devoted to astonishing reports of successful therapeutic results in all sorts of conditions from the use of such drugs as quinine, thyroid extract, cocaine, and a host of others including tobacco. The first flush of excitement following the announcement of a thera peutic discovery led naturally to its ap plication to a legion of misunderstood conditions, sometimes with an amazingly good effect; witness, for example, the
1325
value of sulfanilamide in trachoma, often with no effect and occasionally with dis astrous and unanticipated results, as, for example, the cataract formed consequent to the dinitrophenol treatment of obesity. Our knowledge and application of vita min therapy is at present in the state of ferment and flux through which the eval uation of all of the drugs in the phar macopeia have passed. An enthusiastic hunter sees an Indian behind every tree. Any patient with an ocular condition that has so far defied an exact knowledge of its treatment is now being dosed with vitamins that are given locally and gen erally in shotgun mixtures. They have been fanatically prescribed in conditions as far apart as cataract and retinitis pigmentosa, myopia and interstitial keratitis, primary optic atrophy and Mooren's ulcer. For example, unsupported claims are made daily, at least verbally, that cataract can be prevented, a fact most difficult to prove, and not only that, but cured as well by the ingestion of vitamins, either in capsule form under all sorts of confusing trade names, or by the daily consumption of one raw carrot. It is natural that the vitamin craze is wide open to exploitation by the unscrupulous. The only difficulty seems to be that the public is now so well educated that the physician finds that the majority of his patients are already taking vitamins of their own initiative and have been doing so for some time. The only way in which our prejudices can be debunked is by the publication of articles by competent and trustworthy observers who have access to a large amount of clinical and experimental fa cilities. The question, "Is this honest work ?" must be constantly posed. Subtle influences such as the desire to satisfy enthusiastic ambition, or to promote the interests of pharmaceutical benefactors must be searched for and weighed in the