An Introduction to the History of Glaucoma

Christopher T. Leffler, MD, MPH I got interested in the history of glaucoma because it was an intellectual puzzle. Most historians agreed that in antiquity glaucoma had something to do with the color of the eye, but they couldn’t agree on whether the color was blue, green, or gray. Nor could they agree on what disease was producing this color. It was simply not clear how this ancient definition evolved into today’s glaucoma concept, which has nothing to do with color. Some writers on glaucoma have described its history as a “mystery.” Others have referred to historical “controversy.” Hopefully, when you get done reading this book, the twists and turns in the history of glaucoma will be clear.

Paradigm Shifts in the Glaucoma Concept

Part of the reason the history has been so confusing is that the glaucoma concept has undergone numerous paradigm shifts.

Hippocratic Era (460-300 bce)
The glaukos eye was the lightest eye, regardless of whether the eye was healthy or diseased. Healthy glaukos eyes were blue, green, or light gray. The idea that a single ancient color term might map on to more than one modern color is not at all controversial within the field of linguistics. In the setting of disease, a bright glaukos eye involved poor vision with a gray or green media opacity. Still, medical treatments could be attempted, and the diseased glaukos eye might improve (just as a keratitis might get better). The diseased glaukos eye probably represented a variety of etiologies producing a very light or bright eye: extensive keratitis, corneal scarring or edema, angle-closure glaucoma, vitamin A deficiency, pannus, etc.

Early Common Era (to 700 ce)
Couching for cataracts was more frequently described along the Mediterranean. A couchable cataract seen through an undilated pupil made the brown eye typical along the Mediterranean look a little bit brighter, but not enough to be in the brightest glaukos category. The diagnoses that produced the brightest glaukos eye (e.g., extensive keratitis) did not improve with couching. It was important not to couch the glaukos eye, and so glaucoma was described as surgically “incurable.”

Medieval Arabic Period (800–1050 ce)
The glaukos hue was translated into Arabic as zarqaa, which also described the light-colored eye in both health and disease. Clinical descriptions become somewhat more complete, and clusters of several glaucomatous signs or symptoms (e.g., a bright eye, a pressure sensation, pain, mydriasis, incurability) might be described.

Medieval Latin Period (1050–1500 ce)
Whereas glaukos and zarqaa were nonspecific light colors (blue, green, or gray), some influential Latin works specified the unfavorable pupillary hue as viridis (green).

The Enlightenment (1700–1850)
As we approach this period, Richard Banister of England described the incurable, palpably hard eye with a green crystalline lens in 1622.

East Asian doctors performed both acupuncture and anterior chamber paracentesis for certain ophthalmic conditions. Beginning in the late 1600s, acupuncture was imported from Asia to Europe. The European oculists viewed themselves as performing acupuncture when they performed anterior chamber paracentesis for a new condition called hydrophthalmia, which came to represent a variety of conditions, some of which were consistent with angle-closure glaucoma.

These developments were a “dress rehearsal” for what came next. Multiple authors at the beginning of the 1700s clearly described angle-closure glaucoma: pain, conjunctival injection, a palpably hard eye, mydriasis, an anteriorly prominent lens, difficulty in surgical cure (only palliation possible), an anteriorly bowed iris, a narrow anterior chamber, and visual field defects. Some ophthalmologists were using a magnifying glass to examine the eye, and this tool might have facilitated these detailed observations. John Thomas Woolhouse called this condition “glaucome” in 1707, following the tradition of certain ancient writers who attributed glaucoma to disorders of the crystalline lens. Some authors noted a green pupil in this disorder. Indeed, patients with the mydriasis of angle-closure glaucoma do sometimes have a green or gray pupil, as documented in photographs, and as you will see in clinic—but only if you look for it.

The Ophthalmoscope Is Invented (1850–1870)
With Helmholtz’s ophthalmoscope of 1850, observers noted an excavated optic neuropathy in the classic (angle-closure) glaucoma with a green pupil. The palpable hardness of the eye in the classic glaucoma had been known since the early 1700s, but the excavation of the nerve suggested that pressure was a defining and central characteristic of the disorder. In 1857, Albrecht von Graefe described iridectomy for glaucoma. The excavated optic neuropathy was also seen in quiet eyes with a normal external appearance, which had always been called amaurosis. In 1861, Donders noted elevated intraocular pressure in amaurosis with optic nerve excavation. He suggested that these cases be included as a type of glaucoma, and specifically called them glaucoma simplex. Thus, glaucoma no longer represented a lighter-colored eye. Rather, all pressure-induced excavated optic neuropathies were considered glaucoma.

Angle-Closure Mechanism Elucidated (1870–1939)
Theodor Leber worked out the pathway for aqueous circulation, with its outflow through the anterior chamber “filtration angle” in the 1870s. The anteriorly bowed iris, which had already been seen in glaucoma for two centuries, was now understood to be blocking aqueous outflow. Glaucoma came to be seen as elevated intraocular pressure resulting not from excess secretion, but rather from inadequate aqueous outflow. Miotic therapy was introduced, to pull the iris away from the angle. A broad peripheral iridectomy was understood to be removing iris tissue that had been obstructing aqueous outflow at the angle. Anterior sclerotomies were termed filtration surgeries, as the surgeons sought to simulate the natural outflow pathways.

This advance in the understanding of the mechanism of angle-closure glaucoma was a setback for the glaucoma simplex concept. Angle closure, at least intermittently or at some stage, was presumed to be the cause of all glaucoma by many authors. Without gonioscopy, it was hard to disprove this notion. Most cases of glaucoma in this period would have some degree of positive symptoms, such as pain, haloes, or injection, to bring the patient to the doctor.

Open Angle Glaucoma Elucidated (1940s Onward)
Gonioscopy with a contact glass was described early in the 20th century. However, the impact of this technique on the glaucoma concept was not fully felt until the 1940s, when gonioscopy became more widespread and was used to classify glaucoma as open or narrow angle. Of course, the open angle disease had always been around, but such cases would traditionally have presented at an end stage. In eras when life expectancy was shorter, many such cases would not have presented at all. The discovery of open angle glaucoma led to identification of glaucoma cases and suspects through community screening programs, beginning in the 1940s. By the 1980s, the complexity of diagnosis led to calls for all adults to visit an eye specialist to be evaluated for glaucoma.

What Is New in This Book

It is a great time to study history. We can start with the amazing contributions of masters like Julius Hirschberg and Max Meyerhof. We can digitally search and retrieve millions of books, journal articles, newspapers, diaries, and letters. We can obtain documents and correspond with subject matter experts from all over the world. Increasing numbers of ancient and medieval texts have been translated into Western languages—some just in the last few years. So, it is no surprise that this book contains a great deal of new information. Some technologies, such as anti- vascular endothelial growth factor agents, advanced techniques for optic nerve imaging, and minimally invasive glaucoma surgeries, were developed too recently to be in prior treatises on the history of glaucoma. But even with respect to prior eras, new scholarship can upend deeply rooted beliefs. For instance:

• Have you ever seen it written that the ancient Greco-Romans thought that the crystalline lens is positioned in the exact center of the eye? In fact, the ancients knew the lens is positioned anteriorly. —It is sometimes written that the term cataract was first used in an ophthalmic sense with the 11th century translation from Arabic to Latin of Constantine the African. This idea is incorrect.
• It has been written that the eye was first examined with the magnifying glass (loupe) by Georg Joseph Beer, or perhaps one of his students, in the early 1800s. But, in fact, the loupe was used to examine the eye in the early 1700s and may have assisted oculists in better describing angle-closure glaucoma.
• Have you ever wondered why glaucoma is sometimes compared to a thief? It’s probably not what you think.

These are just examples. This book contains new translations from Arabic, Latin, German, French, and Spanish. There is new information from unpublished manuscripts and journals. There are photographs from private collections.

Philosophy of the Book

The medical field usually does not advance because some genius with special powers of observation (and a great bedside manner) descends to earth. Rather, talented doctors, with all of their foibles, use the tools handed to them by predecessors and peers to make incremental advances within an environment over which they have little control. Even Helmholtz, who deserves enormous credit in ophthalmology, modestly stated that his revolutionary ophthalmoscope merely used the optical principles established by others. My goal when telling a story is not to lionize doctors, nor to excessively highlight their flaws. Rather, it is simply to relate facts that accurately paint a picture. For instance, if I mention that a surgeon did not wear gloves when operating, it is not to make him look foolish. Rather, I am trying to show how expectations and procedures evolved over time. Ultimately, I hope you come away with a sense of what it was like to be a doctor, or a glaucoma patient, in the past.

From a scholarship standpoint, I have tried to list page numbers in the books cited, so the quotes can be checked. Also, I have encouraged contributing authors to include complete quotations, so that the reader can get a feel for the language of the period and can come to their own conclusions about what the original author meant.

Limitations of the Book

I hope we have gotten the big picture correct—especially about how the concept of glaucoma evolved over time. Also, I hope we have told stories fairly and accurately. But we did not tell every story about glaucoma that deserves to be told. For instance, we did not cover the history of ophthalmology in India, South America, or some other regions. We reviewed the lives of many in the field, but there are other important contributors who could have been profiled. And so on. There are more stories to be told and more books to be written. But I hope you can use this book as a starting point for your historical research. Most of all, I hope the humanity of the doctors and patients comes through, and you really get a sense of what the times were like.

Foreword

Earlier generations of ophthalmologists who oversaw the care of glaucoma patients could only dream of the extraordinary diagnostic tests and technologies that we have available today for managing glaucoma. Most likely, they also could not have conceived that there would be so many amazing medical and surgical therapies for glaucoma that are now used to ameliorate and even cure some of these patients. From where and from whom has all this originated? Study of the medical history, particularly the history of glaucoma, can provide an insight.

Assessment of the structure and function of the optic nerve and lowering of intraocular pressure, for example, are pillars of glaucoma management, but few people know where they came from and who created them. Since the invention of the ophthalmoscope in the mid-19th century, most relevant diagnostic and therapeutic entities in glaucoma have been built upon knowledge that previously existed combined with the curiosity and persistence of more than one individual. It is probable that these ideas did not appear magically to any one of them. Rather, these concepts, like so many others that we take for granted today, were developed as the result of collaborative creativity that built upon existing knowledge of the disease and its treatment. And all those who imagined, conceived, and propagated them were innovators. Learning about the history of glaucoma provides the underpinnings and an opportunity to understand the prevailing ideas at the time of these new ideas and how such innovations were transformed from just being disruptive esoteric concepts into the reality of clinical practice. Learning about the past provides a perspective for current care of glaucoma.

Although many such entities came about first in the imagination of a single person, virtually all of them depended on the collective wisdom of both earlier and contemporary colleagues. And the collaborations that created the changing concepts of glaucoma were not just between generations, but also among peers. In fact, our current understanding of glaucoma largely has arisen after ideas have been handed off from one group of scientific and medical innovators to the next. In some cases, the original ideas about the pathogenesis of glaucoma and its diagnostics and therapeutics were accepted quickly by those who understood their use and embraced change. The acceptance of others was an evolutionary process that required a better understanding of where they would fit and how the best could be employed in their research or clinical management. This sometimes meant reframing one’s understanding of glaucoma pathobiology and pathophysiology, and then implementing the ideas into practice and assessing whether they would lead to more sensitive and specific methods for diagnosis or, perhaps, more effective and safer treatments. Regardless of the result, such paradigms not only enhanced knowledge and care of glaucoma, but led to the reconceptualization of glaucoma to build upon for future progress. And there still is so much to learn from studying the past that can inform our clinical care and research!

Robert N. Weinreb, MD
University of California San Diego
La Jolla, California
USA

Table of Contents

Foreword
Robert N. Weinreb

An Introduction to the History of Glaucoma
Christopher T. Leffler

1. Glaucoma in the Ancient Greek and Roman Worlds
Christopher T. Leffler, Stephen G. Schwartz

2. Glaucoma in the Medieval Arabic World
Christopher T. Leffler, Wasim A. Samara,Tamer M. Hadi, Ali Salman, Faraaz A. Khan

3. Glaucoma in the European Middle Ages and Renaissance
Christopher Leffler, Eric Peterson

4. Buphthalmos
Harry Mark

5. The Early History of Glaucoma in East Asia
Christopher Leffler, Ka-Wai Fan

6. Hydrophthalmia and Paracentesis
Christopher Leffler, Stephen G. Schwartz

7. Glaucoma during the Enlightenment and Early Modern Periods (1700-1849)
Christopher Leffler, Stephen Schwartz

8. John Thomas Woolhouse (1664-1733/4) and his Family of Oculists (1600-1751)
Christopher T. Leffler, Stephen G. Schwartz

9. “Chevalier” John Taylor and His Descendants
Stephen G. Schwartz, Christopher T. Leffler

10. Georg Joseph Beer and Glaucoma
Harry Mark

11. Helmholtz and the Development of the Ophthalmoscope
Richard Keeler

 12. Glaucoma: A Pressure-Induced Optic Neuropathy (1850-1870)
Christopher Leffler

13. Aqueous humor dynamics
Harry Mark

14. Angle Closure Glaucoma Since 1871
Christopher Leffler, Surbhi Bansal

15. The History of Malignant Glaucoma
Andrzej Grzybowski, Piotr Kanclerz

16. The History of Tonometry
Steven Newman

17. A History of Perimetry and Visual Field Testing
Chris Johnson

18. Open Angle Glaucoma in the Twentieth Century
Christopher Leffler

19. The History of Glaucoma Medications
Tony Realini, Eva DeVience

20. The History of the Surgical Microscope in Ophthalmology
Richard Keeler

21. The History of Glaucoma Surgery and Laser Treatment
Reza Razeghinejad, Joanna Liput, George Spaeth

22. Sympathectomy for glaucoma: its rise and fall (1898-1910)
Robert M. Feibel

23. The Pathogenesis of Glaucomatous Optic Neuropathy
Sohan Singh Hayreh

24. Mechanisms of Glaucoma Without Elevated Intraocular Pressure
Russell Swan, Brandon Baartman, Michael Greenwood, John Berdahl

25. The History of Pediatric Glaucoma
Jana Bregman, Janet Alexander, Sara Fard, Mona A. Kaleem, Natario L. Couser

26. The History of Glaucoma in Mexico
Rolando Neri-Vela

27. The History of Neovascular Glaucoma
Adam Pflugrath

28. The History of Iridocorneal Endothelial Syndrome
Surbhi Bansal

29. The History of Pseudoexfoliation
Andrzej Grzybowski. Piotr Kanclerz

30. The History of Pigment Dispersion Syndrome and Pigmentary Glaucoma
Lynn E. Harman, Curtis E. Margo

31. Uveitic Glaucoma
Christopher Donovan, Lynn E. Harman

32. Immunological Mechanisms in Glaucoma: History of Ideas and Hypotheses
Lynn E. Harman, Curtis E. Margo

33. The Evolution of the Optic Disc Analysis: Past and Present
Fritz Dannheim

34. The History of Optical Coherence Tomography
Rachel L. Anderson, Joel S. Schuman

35. Glaucoma and other Ophthalmic Disorders in Selected Artists
James Ravin