patients or other physicians, and these were usually in the early stages of disease.

I have a copy of this study, gentlemen, and I will be glad to leave it if the committee wishes.

The CHAIRMAN. It would be helpful if you would, sir.

Dr. JAECKLE. Thank you, sir.

Mr. ALGER. Is this too lengthy to be included in the record?
The CHAIRMAN. Let us inquire.

Dr. JAECKLE. It is not too long to include in the record but it would be rather lengthy to present here.

The CHAIRMAN. Without objection, it may be included in the rec

ord.

Dr. JAECKLE. Thank you, sir.

(The study referred to follows:)

[Reprinted from the Ohio State Medical Journal, Columbus, Ohio, October 1961]

EARLY DIAGNOSIS OF GLAUCOMA-A DISCUSSION BASED UPON ANALYSIS OF DATA FROM 100 PATIENTS1

The author

(By Charles E. Jaeckle, M.D.)

Dr. Jaeckle, Defiance, is attending ophthalmologist and director,
Department of Ophthalmology, Defiance Hospital.

The early diagnosis of glaucoma is subject to five limitations: (1) the knowledge of medical science, (2) the knowledge of the physician, (3) the knowledge of the patient that he needs the physician, (4) the response of the patient, and (5) the course of action of the physician. In the 1950's medical science made important strides in the diagnosis of glaucoma, as well as in its management. This has directed increased attention to the problem of applying our knowledge. The prominent symptoms and rapid course of acute glaucoma bring patient and physician together quickly. But relatively few patients with glaucoma have the acute form of the disease; the vast majority have chronic glaucoma.

NO DRAMATIC ONSET

No dramatic incident marks the onset of chronic primary glaucoma. The chief characteristic of early chronic glaucoma is its insidious nature. In the absence of an easily recognizable characteristic symptom to warn the patient, how are physician and patient to be brought together early in the disease? Too often they meet too late, but meet they will, for if glaucoma is insidious, it is also relentless. When blindness impends, glaucoma is all to evident. How shall we find the disease stages?

Glaucoma "detection" programs have been conducted. These have been helpful in altering the profession and in educating the public. However useful such programs may be, they are not diagnostic. All persons in whom glaucoma is diagnosed pass through the office or the clinic of the physician. What factors contribute to the early diagnosis? What delays the diagnosis of glaucoma?

The records of 100 glaucoma patients in an average ophthalmological practice were studied. Of 82 consecutive cases on file in 1960, two records (patients long under prior treatment for glaucoma elsewhere) were excluded because adequate early history was unobtainable. To the 80 remaining cases were added the next 20 consecutive cases of newly diagnosed chronic primary glaucoma. Those in the first group had been observed for periods of 1 to 13 years.

1 From the Department of Ophthalmology, Defiance Hospital. Defiance, Ohio. Presented before the section on Ophthalmology at the annual meeting of the Ohio State Medical Association, Apr. 9-13, 1961, Cincinnati, Ohio.

Of these 80, 8 patients had been previously diagnosed and treated by another ophthalmologist. In the remaining 72 cases, the diagonsis was made either on the fist examination or on reexamination, after some years of observation by this examiner.

DIAGNOSTIC CLASSIFICATION

For the purposes of this study the glaucoma was classified by the following criteria:

A. Early

1. Visual field-no changes for 1/1000, or any change for 1/1000 (consistent with the diagnosis), but no change for 2/1000; and

2. Optic cup within physiological limits.

B. Advanced

1. Visual field—any change for 2/1000, or

2. Any cupping of disc characteristic of glaucoma.

C. Late

Advanced cupping and advanced field changes (includes cases of one blind

eye).

Each case was further classified as self-referred, referred by family physician or referred by optometrist, with reference to the examination at which glaucoma was first diagnosed. The results of these classifications are shown in table 1. Three patients in whom glaucoma had been diagnosed by another ophthalmologist prior to examination by the author merit special comment. One of these patients had advanced glaucoma. (See footnote of table 3.) Two had late glaucoma when seen by the first ophthalmologist. Of these two, one was classified as self-referred. This patient had been seen previously by an optometrist who reported that visual acuity with glasses was reduced to 20/100 in one eye. The optometrist prescribed glasses and advised ophthalmological examination. The patient did not consult an ophthalmologist until 5 years later when the disease was advanced. The other of these two late cases of previously diagnosed glaucoma had consulted the ophthalmologist when so advised by an optometrist; the disease was then in the late stages.

Before the onset of glaucoma, as indicated by history, only two patients had never had any ocular complaints. All other patients in this study at some prior period in life had had ocular complaints which had led to their seeking some attention for their eyes, and glasses had been prescribed for all at some time by an ophthalmologist or an optometrist.

The cases were classified as to treatment after the onset of the glaucoma as indicated by history. These data are shown in table 2. Of the two patients who had not previously required glasses, for one glasses were indicated. The other patient consulted an optometrist, no need for glasses was found, and he was advised to consult an opthalmologist.

TABLE 2.-Treatment after onset of symptoms and prior to diagnosis

1 Includes 5 patients seen by an optometrist and advised to consult ophthalmologist. Duration of symptoms before the diagnosis of glaucoma was made is shown in tables 3, 4, and 5. Table 6 indicates the character of the symptoms. Table 7 shows the frequency of certain nonspecific symptoms. The commonest chief complaints were watering, aching, or pain not dependent on use of eyes, and blurred near vision.

TABLE 3.-Duration of symptoms: Patients who sought medical examination and diagnosis initially

1 Glaucoma was diagnosed by a previous ophthalmologist. Complete history of the early period of the disease was not obtainable. The patient had used miotics for over 3 years but had not returned to the ophthalmologist during that time.

TABLE 4.-Duration of symptoms: Patients referred by optometrists

21 case: reported impaired central vision 1 year before medical eye examination. 1 case: reported 1 eye blind when (2 years earlier) first seen by optometrist, history from patient of night blindness 8 months. reported impaired central vision recorded at time of referral, reported last previous change of glasses 1 year prior to referral.

History indicating field defects for 6 months.

42 cases: reported impaired central vision at time of last previous change of glasses 2 years prior to referral: in 1 case, 1 eye blind at time of referral.

2 patients had 1 blind eye when first seen by the referring optometrist. Both denied any awareness of visual disturbance prior to 2 weeks before visiting optometrist, at which time they were referred. 1 had had a change of glasses following nonmedical refraction elsewhere 1 year previously. The other had not been previously examined by an eye physician at any time, had not previously visited the referring optome trist, and had not had a change of glasses for 9 years. The 3d patient had been seen and glasses changed by the referring optometrist 1 year prior to referral; diagnosis of glaucoma with cupping of disk and late field changes made at that time by previous examining ophthalmologist.

5 years before first ophthalmological examination, patient obtained glasses from optometrist, who also advised examination by ophthalmologist.

TABLE 5.-Duration of symptoms: Patients who obtained nonmedical refraction, then sought medical eye examination later

1 1 In each of these cases the patient was blind in 1 eye from glaucoma before examination by the physician, with 1 exception-a patient who was blind in 1 eye from ambylopia and had lost a large area of field of vision and some central vision in the other eye from glaucoma. In the course of obtaining contact lenses from the optometrist, this patient had observed and reported rainbow halos around lights, which were ascribed by the optometrist as due to the contact lenses.

2 Glasses had not been prescribed in 1 case.

3 Patient reported temporary relief of symptoms by changes in glasses.

PROCUREMENT OF GLASSES MAY DELAY DIAGNOSIS

A history of frequent changes in glasses is always suggestive of glaucoma. A number of patients had gone for years without changes in glasses. Others had had frequent changes, sometimes twice within a year.

Of 100 cases of chronic glaucoma studied, only three patients came for opthalmological examination with no symptoms. The symptoms of which the patient complained are not dramatic and were frequently construed by the patient as an indication of a need for glasses, or for change in glasses. The symptoms of which the patients complained had sometimes been temporarily or partially relieved by change of glasses. The chief complaint could frequently be relieved immediately by lenses at the time of examination.

Symptoms manifestly unrelated to glaucoma or refractive error__ Symptom characteristically associated with glaucoma-recurrent

rainbow

halo____

Nonspecific symptoms manifestly unrelated to refractive error (flashes of light, pain after resting).

Nonspecific symptoms---

TABLE 7.-Nonspecific symptoms-Early cases

Number

Symptoms:
Watering.

Burning-

Aching, soreness, or pain not dependent on close work___.

Other discomfort___

of patients

16

8

17

9

All but one of these patients did in fact require glasses. Some obtained glasses, frequently in the late stages of the disease, without medical examination and diagnosis. Two patients obtained glasses on the prescription of an ophthalmologist. When glasses had been prescribed elsewhere, they were frequently satisfactory. The need to prescribe different glasses after medical eye examination was not found any more frequently in these patients than in patients generally. All had persistence of symptoms despite the prescription of glasses. Indeed, the need for change in glasses was in some cases not a primary condition, but a symptom of glaucoma.

In two cases necessary medications had been prescribed for ocular conditions other than glaucoma. The presence of other conditions masked the presence of glaucoma. The treatment of other conditions and the prescribing of glasses led to delay in diagnosis.

INTERRUPTION OF MEDICAL CARE

Several patients had been considered glaucoma suspects by this or a previous examiner several years before the diagnosis of glaucoma was made. Some of these patients passed from medical observation in the interval. When they again came under medical care the diagnosis was obvious and the glaucoma not in the early stages.

One patient had been seen and treated by an ophthalmologist for very late glaucoma in one eye, with no preservation of useful vision. Glaucoma was not diagnosed in the fellow eye at that time. The patient was insistent that she had not been instructed to return for further medical care. She passed from medical supervision and was seen over a period of several years by a competent, conscientious optometrist, who referred the patient for medical care when he first recognized impaired central vision in the second eye as an indication for medical services. Unfortunately glaucoma was then advanced in the second eye. Blindness in one eye frequently did not alert the patients in this study to the fact that they required the services of the physician. Blindness in one eye was not regarded by conscientious optometrists, who were competent refractionists to be an indication for referral for medical care by the ophthalmologist. In several instances glaucoma could be diagnosed early when a conscientious optometrist referred the patient for medical care because of poor vision with glasses, not suspecting glaucoma, but suspecting other disease.

The availability of information from previous medical eye examinations made possible the diagnosis of early changes in the optic disc, and of rising tension when the higher tension did not exceed the accepted normal range. It also provided the opportunity for medical evaluation of changes in refraction. Review of these cases suggests that in some instances diagnosis might have been made sooner if the physician had had a higher index of suspicion of glaucoma, and required the patient to report back for observation after a shorter interval than sometimes elapsed between examination and reexamination. The use of the tonometer in routine diagnostic examination of all adults proved of increasing value. The changing criteria for the diagnosis of glaucoma and the diagnostic exclusion of glaucoma in the last 15 years were reflected in the case findings and the diagnoses at different times in the period covered by the study.

CONCLUSIONS

Many patients with early glaucoma and even many with advanced glaucoma were unaware that they required medical services other than the prescribing of glasses. Some patients were unaware of the distinction between the medical services of a physician for patients with ocular complaints, and the nonmedical service of refraction and the provision of glasses.

Glaucoma cannot be “recognized" or "detected" by the patient, or by anyone else with less than a medical training. It must be diagnosed by a physician. Glaucoma cannot be diagnosed until patient and ophthalmologist are brought together. It cannot then be diagnosed in the early stages unless the ophthalmologist looks for it by routine medical inquiry always and invokes the resources at his command for special inquiry often. No patient comes to a physician “just for a refraction," even if he so states. Advice as to continuing medical care is often indicated. When glaucoma has been diagnosed in one eye, and the ere does not require treatment because of blindness, the patient should nevertheless be kept under continuing medical supervision.