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Online Supplement.
What Was Glaucoma Called Before the 20th Century?
Christopher T. Leffler, MD, MPH
Stephen G. Schwartz, MD, MBA
Francesca M. Giliberti, MD
Matthew T. Young, MD
Dennis Bermudez.
Includes specific pages relevant for cited books.
Additional and more complete quotations and translations are provided in this
supplement.
Constantine the African (c. 1020-1087), translator of Hunain Ibn Is-Haq
(Johannitus, 809-877 AD).
The 9th century translator Hunain, later called Johannitus, wrote an important treatise on
the eye. This work was translated by Constantine the African (c. 1020-1087), who
spent time at the school of Salerno. Latin manuscripts of Hunain’s work attributed to
Constantine and to Demetrius (Galen 1542, pp. 689-90) were identified by the
ophthalmic historian Julius Hirschberg. Hirschberg believed that these represented
separate translations from the Arabic. However, Lindberg had a student who evaluated
the works and determined that they came from a single translation (Lindberg 1976, p.
232). Our analysis of the terms used to describe the cataract colors supports the idea
that these works derive from a single translation (Online Table A).
Constantine singled out venetus (Venice-blue) as an unfavorable pupillary color. It has
been debated whether Venice-blue refers to the color of the waters around Venice or of
the garments worn by Venetian fishermen (David Butterfield, PhD, personal
communication, 2014).
Benevenutus Grassus (12th or 13th century).
Benevenutus Grassus authored De Oculis an ophthalmic work influential well into
the seventeenth century (Leffler, Open Ophthalmology Journal, 2014). Grassus was an
oculist and a teacher at Salerno and later Montpellier in the twelfth or thirteenth
centuries. Grassus cited, and was influenced by, Johannitus (Hunain). Grassus
presented a simplified system based on his own observations. With respect to
unfavorable cataract colors, Grassus made an important change. Constantine’s
translation of Johannitus identified venetus (Venice-blue) as the unfavorable pupillary
color. In contrast, the only true color singled out by Grassus as incurable was green,
viriditas (Grassus p. 8). With the green cataract, the eye is bleared, the onset is
sudden, there may be tearing, and it may be a sequelae of pain (Grassus & Wood 1929
p. 39-40). Grassus noted a separate type of incurable cataract associated with a dilated
iris (Grassus & Wood 1929 p. 40).
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Gerard of Cremona (1114-1187), translator of Ibn Sina (Avicenna, 980-1037).
Latin translations of Ibn Sina (Avicenna) also noted the poor prognosis of the
green pupil. In this case, the color was specifically attributed to an abnormality of the
crystalline humor (viriditate oculi) (Ibn Sina, Bk 3, Fen 3, Tract 2, Chap 34, Ibn Sina
1608 p. 551-2). Avicenna’s work was first translated into Latin in the twelfth century by
Gerard of Cremona (1114-1187), who settled in Toledo (McVaugh, Ostler p.
211). Avicenna’s Canon was taught at the medical school of Montpellier by the early
thirteenth century (McVaugh) through 1650 (Koh).
Avicenna’s discussion of viriditate oculi can be translated as follows:
On the greenness of the eye
Moreover, greenness occurs either because of a cause in the tunicae or a cause
in the humours. The cause in the humours is that, if it was glacial in the eye to a
great quantity, and clear and white, and its position is nearer to the outer parts,
both of an equal quantity, and less; the eye will be a varied green, and properly if
it is not prohibited by the tunica. And if disturbance occurs in the humours, and
the crystalline is low, and the white very large, darkening will occur, just like the
darkening in deep water. And if the crystalline is deep, the eye will be black. Yet
the cause in the tunicae will be the uvea. For if the uvea itself is black, the eye
will be black because of it. And if it is green, the eye will become green. And
indeed the uvea becomes green either from the deprivation of digestion, like a
plant, for in the beginning, when it is born, it is not of an apparent tincture. Rather
it verges towards whiteness, and then with digestion it becomes green, and
because of this cause the eyes of infants are green, and varied; and the variety
of this occurs according to the final humidity, or according to a decrease of the
humidity, which the tincture follows, since, when it has been well digested, like a
plant, when its humidity is decreased, it starts to become white. And indeed this
greenness is because of the dominant dryness. And the eyes of the infirm and of
old men are varied because of this reason; since the extraneous humidity is
increased in old men, and the innate humidity is decreased. Or the colour
emerges there in its creation, not because of the fact that it reaches the uvea,
since it is not present beforehand. And sometimes it comes about on account of
the clarity of the humidity from which it has been created. And sometimes it
comes about for one of two things, when it occurs at the beginning of creation,
and it is known through the goodness and badness of sight. And one greenness
is natural, another accidental. Yet the variety comes forth from the aggregation of
the causes of blackness and the causes of greenness, and it is composed from
them between blackness and greenness, which is a variety. And if this variety
were primitive, as Empedocles thought, the eye would be green, having been
harmed because of its defect from wateriness, which is an instrument of sight.
Some black ones are diminished by greens in sight, since greenness does not
occur because of the harm in them. And its cause is in the fact that blackness,
which is the cause of the whiteness, prevents the penetration of shapes of
colours with its becoming clear, because of the fact that it is opposed to
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translucency and just like that which occurs because of the disturbance of
humidity, and likewise, if the cause is the great quantity of humidity. For if there is
a great quantity, it will not even respond to the motion of palpation and egress to
the front such that therefore it can be cured. And if the eye is green because of
the scarcity of white humour, it will see more in the night and in shadows than in
the day because of what occurs from the motion of light in a little amount of
matter, and it prevents it from becoming clear: for its motion lacks clarity of
things, just as it lacks the clarity of what is in shadows after the light. The black
eye has less sight at night because of its humidity, for the reason that it lacks
palpation and the motion of material to the exterior parts. And a great deal of
material is heavier than a little. Moreover, the black eye increases the vision
powerfully because of the tunica. (Book 3, Fen 3, Tract 2, Ch 34, Ibn Sina 1608,
p. 551-2. Translation courtesy of David Butterfield, PhD, personal
communication, 2014).
The colors of unfavorable cataracts in Avicenna (gypsum, green [viride], black, and
yellow [citrinum]) (1608, p. 564-5) figure prominently as unfavorable indicators in
subsequent writings. Avicenna’s Canon was taught at the medical school of Montpellier
by the early thirteenth century (McVaugh 1990) through 1650 (Koh 2009).
Muḥammad ibn Ibrāhīm Ibn al-Akfānī Muhammad ibn Ibrahim Ibn al-Akfani (c.
1286-1348 AD).
Muḥammad ibn Ibrāhīm Ibn al-Akfānī Muhammad ibn Ibrahim Ibn al-Akfani (c. 12861348 AD), who died in Cairo, was a physician referred to by the historian Hirschberg as
Shams Al-Din Mohammad Ibn Ibrahim Ibn Said Al-Singari Al-Misri Ibn Al-Akfani, or
simply Shams Al-Din. Shams Al-Din wrote “The Discovery of Impurities in Ocular
Diseases” (Kashf Al-Rayn Fi Ahwal Al-Ayn) (Hirschberg 1985, vol 2, p. 90-91, section
273.31). Shams Al-Din described “migraine of the eye” (shaqiqat al-ayn) or “headache
of the pupil” (suda’ al-hadaqah), which involved deep eye pain, described as a burning
or pressure sensation, opacification of the ocular fluids, and sometimes a cataract or
dilated pupil (Hirschberg 1985, vol. 2, p. 188). The former term was in use by the 10th
century (Hirschberg 1985, vol. 2, p. 118; Leffler, Clinical Ophthalmology, 2015).
Jacques Guillemeau (1550-1613).
One of the students at Montpellier in the 1500’s was Jacques Guillemeau, who
later became the French royal surgeon, and published an encyclopedic system of
ophthalmology which became the standard for a century (Leffler, Open Ophthalmology
Journal, 2014). Guillemeau specifically cited Avicenna in his definition of glaucoma,
and noted its synonym viriditas oculi (Guillemeau 1585, p. 85). Guillemeau wrote:
“…glaucoma is properly used when the crystalline humor is dry and thick, and the color
of it is green…Glaucoma is uncurable”.
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Lazare Rivière (1589-1655).
Lazare Rivière (1589-1655) continued the medieval Arabic teaching regarding checking
the maturity of cataracts by palpation of the eye:
“If this Operation be, when some part of the Suffusion floweth down (if the eye be
compressed) and appeareth more large, and after returneth to its former station
and figure, it is not successful; because the Cataract is not yet ripe, but thin and
crude: But if by a compressing with the finger there is no change of the shape
and figure of it; it is then ripe, and may be couched with a Needle.”(Riviere 1655,
pp. 70-71)
Jean Riolan the elder (1538-1605).
The hardening of the crystalline lens in glaucoma was noted very rarely by
European writers. For instance, Jean Riolan, the elder (1538-1605), who cited Aetius
and Galen, wrote of glaucoma (1610, p 443-4):
“…or if the crystalline humour is changed into a grey colour (albeit with the
admixture of white and green), which blight is called glaucosis or glaucoma, the
surface of the crystalline humour is hardened [induratur] and overcome by
dryness, and that which should be bright, clear and even becomes uneven.
Under glaucoma everything is seen by us obscurely, and as if through shade:
light is not seen, which occurrence distinguishes it from a cataract [suffusio]. Why
does glaucosis come from old age? Because it is wrinkled by dryness, a
condition that is incurable, just like other diseases contracted from excessive
dryness.”
Jean Riolan, the younger (1580-1657).
Jean Riolan, the younger (1580-1657), also wrote that the crystalline lens could be hard
in glaucoma (1657, p. 142):
“The thickness and hardness of the Chrystallin Humor is properly termed
Glaucosis or Glaucoma, because the color thereof resembles that of an Owles
Eyes: it proceeds from a cold and dry distemper, and is therefore familiar to aged
Persons.”
It seems most likely that the characterization of the crystalline as hard was offered as a
theoretical property, no more amenable to clinical assessment than whether the humor
was dried. Nothing in the statements by either Riolan suggests palpation of the
eye. Perhaps by analogy with hypochyma (suffusio), it was inevitable that palpation of
the eye would be recommended in glaucoma.
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Felix Platter (1536-1614).
Ancient and medieval descriptions of glaucoma, or the glaucous hue, hinted at
phacomorphic or angle-closure glaucoma, but in the modern period we begin to see
very clear descriptions of these conditions.
Such advances were undoubtedly aided by the gradual abandonment of
the view that the crystalline lens was in the center of the eye, with replacement
by the recognition that the lens was positioned anteriorly enough to contact the
iris. The Swiss physician Felix Platter (1536-1614), who trained at Montpellier,
drew the lens anteriorly in 1583 (Lindberg 1976, pp. 175-7). He noted that an
error in refraction occurred when “the Crystalline Humor doth not reside more
towards the fore parts at the Apple, as it is naturally wont to do, but hath its
Scituation exactly in the middle of the Eye.” (Platter 1664, p. 63) Thus, the
anterior position of the crystalline was the normal position, and central
positioning of the lens was an aberration. In fact, Platter noted that the anterior
lens might contact the iris:
“The faults of the grapy Membrane hurt the sight, when its hole, which
they call the Apple...and letting in that light into the Eye, is either stopt up
with some humor, or filth, or is Contracted, or Dilated;...Somtimes this
hole is stopt by a Humor and the Passage for the sight is intercepted; and
this come to pass somtimes from the proper humors of the Eye the
Crystalline and glassy falling into it; as from the change of the Scituation
of the Humors as hath been said, and from the too great largness of the
Apple as shall be said, it may come to pass, and the sight may be so
hindred....” (1664, p. 65)
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Richard Banister (1570-1626).
Richard Banister, the English oculist, is well-known to have described hardness
of the eye in gutta serena, which he also called black cataract. This syndrome of a hard
eye and longstanding optic neuropathy referred to glaucoma with clear media, such as
many cases of primary open angle glaucoma. Perhaps less attention has been given to
his description in another passage of green, yellow, and white “cataracts.” Banister was
familiar with the writings of Grassus (through the English adaptation by Philip Barrough)
and Guillemeau. These green or yellow cataracts were “uncurable” have “the Nerves
stopped” (optic neuropathy), a glaucous hue of the crystalline lens (not an anterior
membrane), and hardness of the eye. Banister therefore describes many of the criteria
we associate with angle closure glaucoma:
“Amongst imperfect Cataracts, I may speake a word or two, of Black, Green,
Yellow, & White: though they be rehearsed of other Authors, as in the Method of
Physicke, by Philip Barrow:
For the black Cataract, there is no such disease: for a Cataract is a water
congealed, before the Cristaline humour: in this there is no water congealed,
therefore no Cataract: ...For the other three imperfect, and uncurable Cataracts,
as the humour predominateth, that is the cause of them, so is the colour: yet all
have the Nerves stopped, alteration of the colour of the Cristaline humour with a
durosity or hardnesse of the whole Eye, and privation of sight.”(1622, p. 60-1)
Antoine Maitre Jan (1650-1730).
A more detailed description of this condition was offered by French surgeon
Antoine Maitre Jan (1650-1730) in 1707. He described a condition called “protuberance
of the crystalline,” which he said was often confused with glaucoma. Maitre Jan stated
that this condition was often confused with glaucoma, a term which Maitre Jan reserved
for a small, dry crystalline lens which was blue (bleu), green (verd), yellow, or white
(1707, p. 213). With respect to protuberance of the crystalline, Maitre Jan noted: “This
malady is a very particular alteration of the crystalline, in which it is augmented in
volume, loses its transparency and natural figure, and becomes more solid than it
should be naturally.” (1707, p. 210) Patients experienced loss of vision in one or both
eyes, and saw shadows. The pupil was slightly dilated and fixed and sometimes
irregular due to pressure from the swollen crystalline lens. The color of the crystalline
was like a white horn. (1707, p. 211) Maitre Jan assumed that pain in the eye or head
was due to other causes. The condition was incurable. The membrane covering the
cyrstalline was thicker and harder (1707, p. 213) It is unclear if this statement was
made on clinical grounds, based on his interpretation of ancient teachings, or based on
the dissection he performed of a dog who had this condition (1707, p. 216).
Maitre Jan’s treatise also contained his observations supporting the new theory
of cataract, i.e. that the structure displaced by couching was the lens, rather than a
hardened substance anterior to the lens (Hirschberg 1984, vol. 3, pp. 18-19, 226).
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John Thomas Woolhouse (1664-1733/4).
Woolhouse was an English oculist who practiced in Paris. Woolhouse
vociferously objected to the theory of Brisseau and Maitre Jan that the cataract was an
opacified lens, on the basis that the ancients had always termed disorders of the
crystalline lens glaucoma. Woolhouse was indeed familiar with the classical writings, as
well as those of Grassus, Riolan, Guillemeau, and Banister (Leffler, Open
Ophthalmology Journal, 2014). But Woolhouse added an extra finding which had not
been stated explicitly by the ancients: palpable hardness of the eye. As early as April
1707, Woolhouse wrote that the finger could determine whether the crystalline humor
was hard in glaucoma (Woolhouse 1717, p. 36):
“But I have found an infinity of glaucomas of the crystalline humor, where the
vitreous and aqueous humor were healthy. In these one feels a hard crystalline,
resisting the finger, which distinguishes them from true cataracts, and no author,
that I know, has remarked on the following symptoms and diagnostics that my
late father, celebrated English oculist, taught me, and which I never fail to see: a
true glaucoma comes ordinarily little by little to the two eyes over time, after
severe headaches, after blows to the eyes, after long illnesses, or with advanced
age.”
The mention of the finger demonstrates that this is not a theoretical concept, but a
physical property which could be clinically assessed through palpation of the eye.
Woolhouse added:
“In looking obliquely or to the side within the pupil (always almost dilated and
immobile) one will clearly see that it is only just the crystalline changed…the hard
crystalline being thrown forward and strongly pressed forward against the sluice
of the iris while dilating the opening makes us believe that the natural position
remains there. The most often the little arteries of the adnexa we see totally
swollen.” (Woolhouse 1717, p. 36-38)
Woolhouse read both Maitre Jan and Kennedy (James 1934). In his lectures of
1721, Woolhouse stated:
“But cataracts are in this different from glaucomas. Ye cataracts adhere to ye
inside of ye fringe of ye iris and are as it were glued to it. And looking on one
side, one may see its threads above or below or only right or left side.
But ye glaucoma adheres not to ye Iris unless it be quite unsheathed and fallen
out of its calix of ye glassy humor, which all very ripe and hard glaucomas will do
in process of time and thereby imitate so perfectly a true cataract if there will be
no distinguishing ye one from ye other by a sudden inspection. And then ye
feeling is ye only way to have a true knowledge thereof, for such a hard and dry
glaucoma reclining upon ye inside of ye iris dilates ye apple of ye eye and makes
it immoveable, and without spring if it chance to be pushed upon ye hole in ye iris
as a stone in a sling.”(Woolhouse 1721, p. 51.)
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The same descriptions (with more polished wording) are in the version of the
Woolhouse lectures from the early 1720s published by an anonymous student in 1745
(1745, p. 35-36, 99). Woolhouse noted that a glaucoma grown “older and harder” can
press against and hinder the motion of the iris (1745, p. 36):
“As the Glaucoma [the diseased lens] grows older and harder, it advances more
and more towards the pupil, thrusting forwards in the watry humour
[aqueous]…When the chrystalline humour is altogether dryed, and become
thoroughly opaque, it falls naturally out of its proper sinus…and even touches the
inward part of the iris, hindering its muscular motion.”(1745, pp. 35-36)
The published version of the lecture notes explicitly noted that palpation could move the
lens backwards and thereby leave the eye softer:
“Upon this accident the forepart of the eye will feel harder than usual to the
finger; and upon reclining the head backwards, and rubbing the eye, the
chrystalline humour will fall back…and leave the fore-part again softer.”(1745, p.
99)
Modern ophthalmologists speak of an “attack” of angle-closure glaucoma. Woolhouse
used the expression “attaquez” (p. 36) or “attaquée” (p. 164) to describe the onset of
glaucoma. He also noted of glaucoma, ”This distemper appears to the patient
sometimes like little spangles.” (1745, p. 96). Woolhouse stated that the glaucoma was
amenable to the “palliative cure” of depression (couching) (1717, pp. 21, 298; 1745 p.
18, 33, 36, 61).
Peter Kennedy (b. 1685, flourished 1713).
Meanwhile, the English surgeon Peter Kennedy (b. 1685) cited Maitre Jan in 1713, but
made one semantic change: like Woolhouse, Kennedy included protuberance of the
crystalline lens as a type of glaucoma (1713, (pp. 94-5):
“Of the Glaucoma, or Disease of the Christaline Humour. It’s certain, the
Christaline is subject to Diseases...especially Decay and preternatural Bigness,
both which commonly pass under the Name of Glaucoma...; the first sort is
commonly of a light Sky blue, or bright Sea Green...the Pupil keeps its former
bigness, whereas in the other sort it enlarges, or the Uvea shrinks, by reason of
the Bigness of the Christaline, and its advancing or forcing forward upon the said
Tunica; in this case it is generally of a whiter Colour...either sort being confirmed,
causes a total Deprivation of Sight, nor is there any Remedy for one or t’other.”
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Charles de Saint Yves (1667-1731).
Subsequent definitions of glaucoma contain many of the elements contained in
angle closure glaucoma. The 1722 description of French oculist Charles de Saint Yves
seems to imply visual field defects:
“That Disease is called Glaucoma, in which the Cristalline is of the Colour
of Sea-water…afterwards it becomes whitish, or greyish…a Sort of Alteration in
the Cristalline, which supervened to a Palsy of the Visual Nerves…This Palsy is,
at first, known by a Dilatation of the Pupil…They still can see Objects, but
imperfectly, and only at the Corner of their Eye, because some Fibres remain not
totally obstructed...the Patients feel an acute Pain in the Fund of the Eye, and in
the Temples; a Gutta Serena follows this Fluxion, and a Glaucoma ensues.” (pp.
231-232)
“The Prognostick of this Disease is very fatal; for, when it is once formed, Remedies are
of no Service; and, when one Eye is afflicted with it, the other is in great Danger.”
(Saint-Yves 1741, p. 234)
Later in this work (p. 291) St. Yves gives an excellent description of an afferent
pupillary defect in Gutta Serena, but notes that in Glaucoma, the pupil is fixed and
dilated.
Benedict Duddell (fluorished 1718-1759).
Benedict Duddell (fluorished 1718-1759), who studied with Woolhouse, wrote in
1729 that glaucoma merely implied a gray opacity, of the crystalline, lens capsule, or
vitreous (p. 166), and in general had no special prognostic significance. However, there
was a particular type of gray opacity of the crystalline lens: “Those Opacities of the
Crystalline, which happen from Strokes or Defluxions, some are of a grayish Yellow,
others of a white bluish Gray…the Crystalline presses against the Edge of the Pupil,
and the Pupil is without Movement…there is very rarely Success by the Needling of
them.” pp. 108-9.
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Michel Brisseau (1676-1743).
In 1705, French physician Michel Brisseau (1676-1743) stated (correctly) that the
structure displaced by couching was the crystalline humor, rather than an anterior
membrane (Hirschberg 1984, vol. 3, pp. 14-18).
Brisseau was not an eye surgeon, though he made important postmortem observations
about the nature of cataract. Brisseau proposed that the green pupil noted by others in
glaucoma might relate to a vitreous disorder. Here is our translation of Brisseau (1709,
p. 42):
“My opinion on these two maladies, is that a Cataract, which is ordinarily white, or
closely approaching this color, is only an obscuration and induration of the crystalline,
and Glaucoma, which is incurable, is an obscuration of the vitreous humor changed to
green, of which the color appears across the crystalline, as if it is this last part which
was itself green.”
Brisseau wrote that he knew of vitreous opacities in two cases of glaucoma (1709, p.
210).
A physician named Barbaroux sent Brisseau the eye from a soldier killed at Dunkerque
(Dunkirk). Brisseau found both the lens and the vitreous to be opaque, and therefore,
concluded that the soldier had both a cataract and glaucoma. No clinical information
about the soldier’s eye condition (if any existed) before death was provided (Brisseau
1709, p. 111).
Brisseau also told the story of one Mr. Bourdelot, who was treated by Mareschal,
surgeon to the king (premier Chirurgien du Roy) (1709, p. 210). All who saw Bourdelot
in life thought that he had a true cataract in both eyes. Postmortem dissection of
Bourdelot’s eyes showed a slight yellow discoloration of the portion of the vitreous close
to the lens. Brisseau concluded that Bourdelot must have had glaucoma (1709, pp.
154-156).
Based on these two cases, it seems that Brisseau never observed a vitreous opacity in
a patient who was observed to have a green pupil or diagnosed with glaucoma in life.
These limitations notwithstanding, Brisseau believed the green color of glaucoma
appeared to emanate from deep within the eye because of its origin in the vitreous
(Brisseau 1709, p. 117).
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Lorenz Heister (1683-1758).
Heister was an early adopter of Brisseau’s theory that a vitreous disorder could produce
a green pupil. Heister described what he called glaucoma in a 40-year-old man with a
dilated and sea-green or gray pupil, sudden pain, vision loss, inflammation in the eye,
no hyphema, and a green color deep within the pupil (Heister 1755, pp. 656-7). Here is
Heister’s case report:
““Mr. Brunschwitz, a surgeon of Breslau, sent me, June 25, 1721, the account of the
case of count Hatzfeld…A gentleman, about forty years of age, had formerly been
troubled with the piles, and with gouty complaints, which went off, but were succeeded
by a violent hemicrania, and an inflammation of his right-eye, the pupil of which was so
much dilated, that scarcely any of the iris could be seen, and he became blind with that
eye, the pupil appearing now like a grey cloud: the other eye had also suffered a good
deal, and was become weaker, so that he could not bear the light…”(p. 656)
“Upon examining his eye, I perceived, upon viewing the pupil, that it had no black
appearance, as in a gutta serena, but was of a grey colour, as the surgeon had related,
or rather of a sea-green, the cloudiness lying deep in the eye, and not just behind the
pupil; so that it was, in my opinion, rather a glaucoma, or opacity of the vitreous
humour…”(p. 657)
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John Taylor (1703-1772).
The English oculist John Taylor (1703-1772), who called himself the “Chevalier”,
should have known of Duddell’s works, which rebutted Taylor by name. Although often
derided as a charlatan, Taylor wrote in 1736 one of the most complete descriptions of
glaucoma, which contains many elements consistent with angle closure (pp. 27-29):
“And this preternatural Plenitude of the Contents of these Vessels by degrees so
increases the Volume of the whole Chrystalline, as to place its anterior Surface
immediately behind the inner Circumference of the Pupil…the Volume of the
Chrystalline is so greatly augmented, as to raise the Circumference of the Pupil
towards the Cornea, and violently press on the Uvea. And by this great Increase
of the Volume of the Chrystalline, the Plenitude of the Globe is greatly
augmented, as to occasion Degrees of a preternatural Pressure on the
immediate Organ of Sight. And this preternatural Pressure on the Uvea and
immediate Organ of Sight, is attended with Degrees of a violent Pain immediately
in the Fund of the Globe…” (p. 27)
“Of the diagnostic and prognostick Signs, and Cure of the several Species
of the Glaucoma. When the Patient begins to complain of a Diminution of Sight,
on inspecting the Pupil, we perceive Degrees of a small Opacity continu’d thro’
the whole Seat of the Chrystalline…the Volume of the Chrystalline is so
increas’d, as to appear immediately plac’d behind the inner Circumference of the
Pupil.
In the second State of this Disease, the Patient complains of Degrees of
the most violent Pain in the fund of the Globe, and of such a Diminution of Sight,
as to be unable, from any Direction of the Axis of the Eye, to see more than the
Shades and Colours of certain Objects. On examining the Pupil, we perceive the
Volume of the Chrystalline to be so greatly augmented, as to have raised the
Circumference of the Pupil towards the Cornea, to near ¼ of the healthful
Thickness of the anterior Chamber of the aqueous, that the alter’d Chrystalline
continues to maintain its healthful Figure, and appears of a dark bluish Colour.
In the last State of this Disease, the Patient complains no longer of Pain,
but of such an entire Loss of Sight, as to be insensible of Light…that the alter’d
Chrystalline…appears of a pale Green Colour.”(p. 28-30)
Taylor’s evaluation of the vision with “any Direction of the Axis of the Eye” implies a
least a crude evaluation of the visual field. Taylor performed couching, which he
believed worked only in the earliest stages of the disease.
12
Johannes Zacharias Platner (1694-1747).
German surgeon, and former Woolhouse student, Johannes Zacharias Platner
has traditionally been credited with first calling the palpably hard eye glaucoma (Terson
1907; Hirschberg 1986, vol. 6, p. 158) in his 1000-page long Institutiones Chirurgiae,
published the first of many times in 1745. In this work, Platner cited Taylor’s treatise on
disorders of the crystalline. According to Platner, in glaucoma (Hirschberg 1986, vol. 6,
p. 158):
“The main pathology lies in the crystalline lens which swells up. This can be
recognized with the index fingers. The hard eye will resist finger pressure. In
severe cases there will be pain. The color in the eye will change to sea blue
[marinae aquae, Platner p. 769]. In older cases the pupil will dilate and this is
called mydriasis. With that all faculty of vision disappears and amaurosis begins.”
George Chandler (d. 1823).
The English surgeon George Chandler (d. 1823) cited Platner in 1775, and wrote: p. 1213.
“Another vitiated state of the chrystalline besides those mentioned, is, if
that with its covering is much, and in such manner tumefied, as that the other
parts of the eye are compressed by it; this is known by the following marks, a
hard eye resisting to the finger, swelled and more prominent than is naturally
usual to it; there is a certain sensation of weight and pain in it; that which is
opposed to view within the eye hath the colour of the sea: At length, if the
disease hath been of long standing, the pupil is dilated, and a mydriasis comes
on; but because both the vitreous humour and the retina are pressed by the lens,
which is much swelled, the faculty of seeing entirely perishes, and a gutta serena
takes place; they call this disease a glaucoma.” (p. 12-13)
Antonio Scarpa (1752-1832).
The Italian anatomist Antonio Scarpa (1752-1832) wrote in 1816:
“In general, those cases of amaurosis may be regarded as incurable…those in
which the pupil is immoveable…where it has lost its circular figure, or is so much
dilated as to appear as if the iris were wanting, having also an unequal or fringelike margin; in which the bottom of the eye, independently of the opacity of the
crystalline lens, has an unusual paleness, similar to horn, sometimes inclining to
green [verde, Scarpa p. 221], reflected from the retina, as if from a mirror; which
are accompanied with pain of the whole head, and with a constant or an
intermitting sense of painful tension in the eyeball…” (Scarpa/Briggs, p. 454-455)
Scarpa seems to have recognized the relevant signs, but, like Celsus, did not
necessarily group them together into a single pathologic entity.
13
James Wardrop (1782-1869).
James Wardrop of Scotland, in the 1818 volume of his Morbid Anatomy, defined
glaucoma as bluish-gray cataract with a dilated, immovable pupil (plate XII, Fig 2) p.
263. He also noted that vitreous has dull greenish color with insensibility of retina in
glaucoma (p. 127).
Antoine-Pierre Demours (1762-1836).
French oculist Antoine-Pierre Demours, MD stated in 1821 that after cancer,
glaucoma was the most serious disease to attack the eye (1821, p. 553). The light of a
candle might be covered by a cloud with the colors of the rainbow at the borders (1821,
p. 554). Pain, a dilated and irregular pupil appearing the color of the sea, vision loss,
and an augmented crystalline ensue (1821, p. 554-5). Conjunctival vessels are injected
and the globe becomes hard to the touch (“le globe devient dur au toucher.”) (1821, p.
555) The attack may impair the appetite (1821, p. 555)
14
George C. Monteath (1788-1828), translator of Carl Heinrich Weller (flourished
1817-1831).
Georg Josef Beer (1763-1821) of Vienna, Austria, described a condition he
termed cataracta viridis or cataracta glaucomatosa, which influenced numerous of his
students. One such student, German ophthalmologist Carl Heinrich Weller recorded
European ophthalmic teaching, including that of Beer in 1819 (Leffler 2012). Weller's
description of glaucoma was translated by Scottish ophthalmologist George C.
Monteath in 1821:
“A greenish, grey opacity of the vitreous humour, by which the sight is entirely
destroyed, or considerably impaired, is called Glaucoma.” This condition
involves “increasing, piercing, and rending pains, bursting as it were the
eyeball,…the pupil dilates, and becomes elongated towards both canthi, and the
sight progressively decreases…After the opacity of the vitreous humour has
proceeded to a greater or less length, the lens not unfrequently becomes
gradually muddy or cataractous, and assumes a greenish, grey aspect,
(Cataracta Viridis, Cataracta Glaucomatosa, which consequently can never be
operated upon with success,) increases in circumference, fills the posterior
chamber, pushes the iris forwards, seats itself in the already much enlarged
pupil, and now even diminishes considerably the anterior chamber.” (Weller
1821, vol. 2, p. 27-28)
Weller reprinted a figure from Beer showing the glaucomatous cataract, which he
described as sea-green in color, with an irregular pupil (Weller 1821, vol. 2, Plate 2, Fig.
8, pp. 286-291).
In summary, the eighteenth and early nineteenth centuries made observations in
glaucoma which were consistent with angle-closure. Ophthalmologists in many cases
incorporated elevated eye pressure and a greenish hue to the pupil in the
diagnosis. On the other hand, even Beer and his followers recognized that the greenish
hue was not perfectly sensitive or specific for the syndrome with lens swelling (Weller
1821, vol. 2, p. 291).
Weller (1821, vol. 1 or 2) makes no mention of examining patients with a candle or
catoptrics. Weller recommended “extract of Hyosciamus or of Belladona” preoperatively
(vol 2, p. 17), and for the treatment of iritis (vol. 2, pp. 50-51), or before examining the
eye (vol. 2, p. 176). The pupil could be examined with a glass (vol. 2, p. 176).
15
George Guthrie (1785-1856).
Weller’s description of glaucoma was cited by George Guthrie, who wrote in
1823:
“The disease termed Glaucoma consists essentially in an alteration of the
component parts of the vitreous humour…The lens is generally at last
implicated…It is never primarily affected…The eye has a general unhealthy
appearance, arising from a turbid state of the cornea, which has lost its brilliancy,
although in no one part has it become opaque. “ On the sclera appear “several
tortuous dark red vessels”. “If the eye is examined by the touch, it will be found
rather firmer or harder than natural…The dilatation of the pupil is always
accompanied by a marked irregularity of its edge, sometimes rendering it
angular, whilst it is always perfectly fixed or immoveable, and occasionally drawn
to one side, sometimes to both, rendering the pupil oval. The patient cannot
distinguish light from darkness. The diagnosis of a disease that cannot be
relieved by operative surgery is now sufficiently established…the pupil, instead of
looking of a brilliant black, seems dull…This concave appearance [of the pupil]
soon becomes of a dull yellowish colour, tending to green…As the disease
advances, and the other symptoms become more marked, the greenish yellow
colour increases in intensity, and the space occupied by the lens now becomes
gradually implicated by it, the lens swells, presses the iris forwards into the
anterior chamber, and a cataracta glaucomatosa is completely formed.” (1823, p.
214-5)
Guthrie continued: “The patient cannot distinguish between light and darkness. This
capability was lost under symptoms of amaurosis, of flashes of light of various colours,
in the eye; and, above, all, the progress of the disease has been, and in all probability
continues to be, marked by pain, of a severe and often excruciating nature, not only as
affecting the eye, but the forehead and the side of the head. The disease may have
come on slowly, it may have developed itself under an attack of acute inflammation, or it
may have appeared suddenly…” (Guthrie 1823, p. 216)
Guthrie did not describe trauma. Guthrie believed that inflammation of the iris or of the
choroid could produce glaucoma (Guthrie 1823, p. 218). The disorder could be
characterized as an “attack”. (Guthrie 1823, p. 219) Surgery can be tried if the patient
can see light, as without surgery certain blindness will result (Guthrie 1823, p. 219).
16
George Frick (1793-1870).
George Frick, an American ophthalmologist who trained under Beer, wrote in 1826 of
one type of iritis in which:
“The iris is more contracted, the pupil is not dilated uniformly, but acquires an
oval or oblong shape. The pupillary margin of the iris projects backwards towards
the lens, so that nothing of the smaller circle of this membrane is
perceptible. The pains now increase and the vitreous humour becomes affected,
presenting a greyish green appearance, or opacity at the bottom of the eye. The
lens is soon affected in like manner, exhibits a sea-green colour, swells, and
appears to project forward into the anterior chamber, giving rise to the cataracta
viridis, or is better denominated by Professor Beer, cataracta
glaucomatosa. During these changes, the attacks of pain are rendered more
violent and continued, and the varicose state of the eye increases. The cornea
having lost its lustre, appears as if completely dead, and the vision is totally
destroyed.” (p. 73)
17
William Mackenzie (1791-1868).
Scottish ophthalmologist, William Mackenzie, the former student of Beer, and then
partner of Monteath, wrote in 1833:
“The eyeball, in glaucomatous amaurosis, always feels firmer than natural” (p.
475)
“Indeed, in the earliest stage, the greenish reflection, which we designate by the
name of glaucoma, appears to come from the very bottom of the eye. As the
disease advances, the apparent opacity always of a greenish colour, and often
sea-green, is seen as if occupying the centre of the vitreous humour, and at last
appears to be immediately behind the lens” (p. 584)
“It not unfrequently happens, after glaucoma has continued for some time,
that the lens becomes opaque…Ultimately the pupil is dilated, and the retina
becomes insensible to light…the pressure of the accumulated fluid within the
eye, is probably the cause of the total blindness which results at last…A green
cataract is always attended with glaucoma. On dilating the pupil by belladonna,
the green appearance presented in simple glaucoma seems to retire to a greater
depth behind the iris…Glaucoma is frequently combined with arthritic
inflammation…the sclerotic and conjunctiva become loaded with varicose
vessels of a livid colour, the pupil dilates irregularly, the lens becomes opaque,
and is pushed forward so as almost to touch the cornea; the junction of the
sclerotic and cornea becomes of a pearly-white colour; racking pain is
complained of in the eye and head, and vision becomes totally extinct. After
some time, the inflammatory symptoms subside, and the contents of the eyeball
begin to be absorbed, so that it shrinks to less than its natural size, and, instead
of the preternatural hardness which it formerly presented, becomes boggy.
The symptoms…are the following: viz. sensations of fiery and prismatic
spectra, muscae volitantes, misty and indistinct vision, and pain across the
forehead…In some instances the glaucomatous eye is still sensible to objects
placed to one or other side of the patient, while in every other direction it
distinguishes nothing.” (p. 587-588)
“In its fully formed stage, glaucoma is absolutely incurable.” (p. 589)
“The removal of the crystalline lens from a glaucomatous eye not only
lessens very much the greenish appearance of the humours, but improves the
vision of the patient.” (p. 590)
Mackenzie opined that lens extraction might prevent glaucoma at an early stage, but
noted that results were variable due to inflammation in some cases. (p. 590)
Mackenzie’s 1833 text contains no references to catoptrics. Mackenzie does note that
one Dr. Brewster examined a conical cornea with a candle, and noted aberrations in the
reflection (Mackenzie 1833, p. 438), but Mackenzie never states that he examined a
patient himself with a candle. Mackenzie mentioned belladonna 93 times (1833), both
for diagnosis (1833, p. 477), therapy of central cataracts (p. 482), and preoperatively (p.
502).
18
It is only in 1841 that Mackenzie becomes interested in catoptrics, which he defined as
“the theory of reflected light” (p. 6), and the Purkinje images from the front and back of
the cornea and lens (pp. 212-214). Mackenzie cites Purkinje’s 1828 paper (Mackenzie
1841, pp. 212-214)
William Lawrence (1783-1867).
English ophthalmologist William Lawrence wrote in 1844:
“The name of glaucoma…is now used to denote an affection of the eye attended
with alteration in the colour of the pupil…The first symptom is pain in the head,
usually situated over the brow…At the same time, the patient begins to complain
of dimness or weakness of sight; and, if we examine the eye, we find that instead
of exhibiting its natural black colour, the pupil is sea green, clear green, muddy
green, or yellowish green. There is a discolouration, which, if we look at it in a
strong light, appears like a yellowish metallic reflection, and sometimes concave;
it looks almost as if there was a portion of metal at the bottom of the eye. The
pupil at the same time is rather dilated, and the iris sluggish…Sometimes vision
is impaired in one eye and not in the other, though the pupil may be equally
discoloured in both.
In the progress of the disease, vision gradually grows worse…The affection does
not always stop at this point, but sometimes attacks the lens, and renders it
opaque, so that it is no uncommon thing for cataract to occur subsequently in an
eye which was originally attacked by glaucoma. (p. 494) The cataract thus
produced is greenish, yellowish, or dirty white, (catararcta viridis or
glaucomatosa).
Sometimes the lens and iris are pushed forwards, so that the latter is convex; it
may even be in contact with the cornea. The external vessels of the globe are
sometimes enlarged and varicous…
It takes place at or after the middle period of life…
The situation of the discolouration has naturally led to the supposition that it
arose from change of structure in the vitreous humour, and it has accordingly
been assumed, without direct evidence, that inflammation of this structure
produces the phenomena of glaucoma….(p. 495)
The phenomena of glaucoma, according to these dissections, must be referred to
disease of the choroid and retina…
The discolouration of the pupil arising from glaucoma, and that from cataract,
may be distinguished by the tint of colour. In glaucoma it is green or yellowish
green, and if we look at the eye laterally, we see no discolouration, whilst in
cataract the pupil is grey, or greyish white, and it has the same appearance in
whatever direction it is viewed…(p. 497)
The prognosis in glaucoma is unfavourable, we have no means of changing that
condition of the internal parts, on which the loss of transparency depends…we
19
cannot restore the vision which has been lost; and all we can expect to do, is to
preserve the little sight which remains.” (p. 498)
Lawrence recommended bleeding and medications, but not surgery (Lawrence, 1844,
pp. 498-9).
Albrecht von Graefe (1828-1870).
The observers best-suited to understand the greenish hue of glaucoma might be
those who were trained to observe it in the pre-ophthlamoscopic era, but could correlate
these observations with ophthalmoscopic findings. Albrecht von Graefe (1828-1870)
noted “The name glaucoma formerly indicated a vague, expressionless symptom — a
sea-green, bottle-green, or dirty-green background of the eye, seen through a fixed,
dilated pupil.” (1859, p. 288)
For the north European authors (e.g. Platner, Chandler), the color of the sea was
sometimes explicitly stated to be green (e.g. Kennedy, Saint Yves, Mackenzie, Graefe)
and indicated glaucoma.
Graefe continued, “We see glaucoma, in its most typical variety, sometimes
occurring in previously healthy eyes in the form of acute inflammatory attacks.” (1859, p.
290) He also noted “…the iris in glaucoma appears more convex anteriorly…” (p. 294)
and a patient may see “rainbows around the flame of a candle” and experiences “pains
in the forehead and temples” (p. 297) with “the pupil irregularly dilated.” (p. 298) Graefe
found iridectomy an effective treatment in glaucoma (p. 313). Graefe also noted some
cases of glaucoma after trauma involving “swelling of the lens” which makes contact
with the iris (p. 371). Not only iridectomy, but also cataract extraction, if it can be
accomplished, is curative in these cases (p. 372). Elsewhere he noted, a “very common
cause of increased pressure is a swollen, cataractous lens…” and he noted a case in
which extraction of the lens was curative after the failure of iridectomy. (p. 378) He
listed “removal of the swollen or displaced lens” as adjunctive treatment, even if
iridectomy was primary (p. 380).
Although some contemporaries called cases with a similar excavation of the optic
nerve “glaucoma”, Graefe was not willing to use this terminology in 1857.(p. 305-8) Of
course, Graefe’s contemporaries ultimately prevailed, and expanded the scope of the
term glaucoma. By 1858, Graefe became willing to include some other causes under
the rubric of glaucoma if they caused the type of damage to the optic nerve due to
elevated intraocular pressure that was seen in typical glaucoma (1859, p. 380).
Graefe observed this greenish hue of the pupil in his own patients. He described
a woman:
“in her fortieth year…The left eye had many years before become very weak, and
gradually blind…On the right side there had occurred, also many years ago,
periodical obscurations and, for more than a year, increasing weakness of
20
vision. On examination, I found on both sides the well-marked appearances of
chronic glaucoma: the globes tense…the aqueous humour slightly turbid, the
pupils much dilated…on both sides perfectly fixed, of a greenish appearance; the
anterior chamber flattened, the iris in spots very discoloured and atrophied. The
ophthalmoscope showed…the optic nerve was on both sides very much
excavated…functional examination showed on the left side only a trace of
quantitative perception of light; on the right side fingers could yet be counted as
far off as three to four feet…The field of vision was extremely contracted” (pp.
350-351).
Her condition improved with iridectomy.
Graefe explained this glaucomatous hue:
“The muddiness of the aqueous humour, and the dulness of the posterior surface
of the cornea, with the irregular refraction of light (mydriasis) and the yellow lens
(age of the patient), are the chief causes of the glaucomatous hue of the
pupil…(p. 301-2).”
By 1858, Graefe was willing to consider certain disorders involving excavation of the
optic nerve to be types of glaucoma if he believed they involved elevated intraocular
pressure (1859, p. 380). At this point, he still did not consider amaurosis with
excavation of the optic nerve to be a type of glaucoma. However, by 1864, it was
established that many, even if not all, cases of such quiet eyes, which Donders called
glaucoma simplex, did involve elevated intraocular pressure (Keyser 1864, pp. 4546). Indeed, by 1864, even Graefe was willing to accept such cases as a type of
glaucoma (Keyser 1864, p. 45).
21
Type of Lighting Used to View the Pupil.
One hypothesis offered to explain the green pupil is that early 19 th century physicians
observed the pupil with candle light or daylight, as opposed to the ophthalmoscope
(Snyder 1965). To be fair, the author never claimed there was any evidence for this
theory, and never claimed he or his contemporaries had observed a green pupil in any
eye diseases with any type of lighting. The author merely asked whether the type of
lighting might make a difference. The author characterized candle light and day light as
“yellow light”, and characterized the ophthalmoscope as “white light.” In reality, the
spectrum of light can be quite complicated and irregular for certain types of light, such
as fluorescent lighting. Nonetheless, for many radiant light sources, the emitted
spectrum can be summarized by the temperature of a black body which emits a similar
spectrum. The hotter the color temperature, the flatter the spectrum over the visible
wavelengths (400-700 nm). The sun is quite hot, and has a color temperature of
approximately 5000 K to 7000 K (Davis 1931, p. 5, 18). In contrast with Snyder’s
statement, daylight is considered to be a source of white light (Davis 1931, p. 3-4),
because all wavelengths are represented about equally over visible wavelengths.
Candle light has a color temperature of 1900 K (Davis 1931, p. 19), which might be
considered yellow light. Tungsten incandescent filaments have a color temperature of
2600 to 3100 K (Davis 1931, p. 19). Thus, tungsten light is intermediate between the
candle light and sunlight. In addition to characterizing sunlight as yellow, when it is
really white, the author focused on one particular author (Mackenzie). It is true that
Mackenzie had developed an interest in catoptrics, which he defined as “the theory of
reflected light,” in his later works (by 1841). In practice, catoptrics involved examining
the eye with a candle, and noting the Purkinje images from the cornea and lens. But
this was a later development not only for Mackenzie, but also for the field of
ophthalmology. We must remember that the green pupil had been observed for over
500 years. And if the ancient Greek and Roman and medieval Arabic terms for the
glaucous hue implied green in some pathologic cases, then this hue was seen for nearly
2 millennia. During most of that time, daylight, which is actually a white light, would
have been the most common light source—not candle light. Moreover, we have to
remember that it was not until the early 19th century that authors routinely used
belladonna to dilate the pupil to examine the eye. But the green pupil and/or mydriasis
were observed well before the 19th century. (The ancients knew about dilating agents,
but did not routinely use them to examine the eye.) Photographs show that neither
candle light nor sunlight is required to observe a green hue in angle closure glaucoma.
Nonetheless, Snyder’s hypothesis that the light might make a difference is reasonable,
and worthy of further study. We believe William Lawrence’s observations regarding the
direction of incident light are relevant (see above). When one views the eye through an
operating microscope, one might see a red reflex if the cataract is not too dense. If one
pulls away from the microscope and looks at the eye from an oblique angle, the lens will
look green. We have observed a similar phenomenon in angle closure glaucoma. The
angle of the incident light and the angle of viewing are relevant.
22
Chronic hyphema depositing “blood pigments” in the anterior lens capsule.
An alternate explanation for the green hue is that neovascularization produces
chronic hyphema (Drews 2006). The hyphema results in the deposition of “blood
pigments” in the anterior lens capsule (Drews 2006). Four of the eight figures in this
article (50%, Drews 2006) have either a hyphema, or a ghost cell hypopyon. Some of
the cataracts did look somewhat green. All 8 of the cataracts were exceedingly dense,
so that one did not get the sense was seeing green light scattered from deep within the
pupil. It appeared that one was seeing the color of the capsule and most anterior layers
of cortex. This appearance fits with the proposed mechanism of pigments deposited on
the anterior lens capsule. Some of the historical descriptions did not discuss the depth
within or behind the pupil which seemed to be accounting for the greenish hue. But
when this issue was discussed (e.g. Brisseau, Heister, Wardrop, Frick, Mackenzie,
Lawrence), there was a consensus that the green color was coming from deep within
the eye, behind the pupil. In fact, many authors used that appearance to support their
contention that the posterior structures (vitreous, choroid, or retina) were primarily
affected in glaucoma.
We have shown that for many centuries, if not millennia, observers have been
astute enough to observe mydriasis and an anteriorly prominent lens. The green pupil
has often been noted in association with either or both of these findings. The theory of
a neovascular/hyphema-origin of the green pupil might be supported if one could find
examples in the historical literature of a green pupil associated with hyphema and
incurability, but without mydriasis and without an anteriorly prominent lens. We have
not come across such an example yet. Even if such an example exists, this mechanism
does not seem to be a dominant theme accounting for the green pupil.
23
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