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Prior to the happy advent of technically correctly placed filtering cicatrices, a large number of surgeons depended almost exclusively on the use of myotics in so-called simple, chronic or non-inflammatory glaucoma. This is not the place to introduce a discussion of the comparative value of iridectomy and myotic treatment in simple glaucoma as based upon statistical records.
There is a good deal of clinical evidence to indicate that in this type of glaucoma, as well as in the so-called sub-acute varieties, myotic activity is increased by a mixture of pilocarpin and eserin in the same solution, exactly as a mixture of arecalin and eserin is more potent than either of the drugs in separate solution.
We do not usually compare the statistics of early aseptic days with those of the pre-antiseptic period, and I do not think we ought to compare the statistics of myotic treatment with ordinary iridectomy any longer, but that we should wait until we can make a comparison between the results of prolonged myosis and those of an improved modern technic which establishes a permanent filtration.
The great trouble with myotic treatment is not its lack of efficiency, but the difficulty of carrying it out successfully on ambulant patients, even in the better walks of life.
The substance isophysostigmin, found with eserin in Calabar bean, according to Ogiu, exceeds in its myotic activity the sulphate of eserin, i. e., 1/80 of a grain of the drug is equal to 1/60 of a grain of the sulphate of eserin, but it is certainly not less irritating than physostigmin, and according to Stephenson's researches, is more so, and in this sense has no superiority over the usual alkaloid.
We must wait now for a sufficient period of time and then compare the value of myotic treatment with that of operations by means of which satisfactory filtration is produced. We are somewhat in the position that general surgeons occupied when aseptic methods first became prevalent.
In the meantime the patients who will not or cannot submit to operation must be reckoned with. Doubtless many patients with chronic glaucoma can be satisfactorily managed with myotic treatment, although personally I have always advocated operation when this could be performed, but it cannot always be performed.
Many authors, for example, Darier, Grandclement and others, are strong in their recommendation of adrenalin, particularly if this drug is added to the various myotic mixtures, and yet adrenalin is certainly not without danger in the treatment of glaucoma. McCallan has seen a number of instances of striking increase of intra-ocular tension following this instillation in the conjunctival sac.
It has always been easy to attribute the myotic action of these drugs, or at least, of eserin, to their stimulant action on the peripheral ends of the oculo-motor, thus causing sphincter contraction, and to a depressing action on the sympathetic fibers, thus causing removal of the action of the dilatator of the iris.
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