Book Review

The Glaucomas

N Engl J Med 1996; 334:1550-1551June 6, 1996

Article

The Glaucomas
Second edition. Edited by Robert Ritch, M. Bruce Shields, and Theodore Krupin. 1807 pp. in three volumes, illustrated. St. Louis, Mosby, 1996. $299. ISBN: 0-8016-7702-5

This handsome set of books on glaucoma provides a comprehensive description of the state of the art. This second edition builds on the strengths of the first edition. I looked particularly at volume 3, Glaucoma Therapy. The book begins with a section on pharmacology, and the first chapter, on compliance, is important. The author takes an objective view of the evidence suggesting that noncompliance is frequent, but he tempers his interpretation of the literature with a compassionate clinician's approach to understanding this behavior and to working with the patient to try to maximize compliance. The brief section on the instillation of ophthalmic drops should be read by all ophthalmologists in training and practice and incorporated into their office routines.

Erickson's description of basic parasympathetic pharmacology is scholarly, drawing heavily on her experience with nonhuman primates. It sets the stage for the subsequent clinical chapters. The long and important chapter on adrenergic drugs deals with systemic effects of the beta-adrenergic antagonists, in addition to the ocular effects. These effects are of particular concern in older patients, who not infrequently have symptoms from these drugs. This chapter is particularly well annotated. The terse chapter on new agents suggests that such agents may soon be available, including cannabinoids. Even in topical form, this latter class of drugs attracts considerable interest and may yet prove useful in treating glaucoma.

The brief section entitled “Therapeutic Overview” consists of two chapters devoted to open-angle and angle-closure glaucoma. Much of the material has been previously covered in this series. In the following section, on laser surgery, uses of the laser in treating glaucoma are adequately addressed in six chapters. The obligatory section on physics is short and written for clinicians, whose understanding of the principles need not be sophisticated. Indeed, a comprehensive description of the physics of each laser-ablative tool on the market greatly lengthens this section. The discussion of medical applications of the laser begins with its use in iridotomy. Laser iridotomy is a real advance over invasive surgery in the treatment of acute angle-closure glaucoma. It makes the treatment of this vision-threatening and potentially blinding disorder relatively easy and controllable. When iridotomy is performed soon after the development of angle closure, it may prevent substantial loss of vision. However, since laser iridotomy is easy to do (and often generates considerable fees), it has been performed far more frequently than surgical iridectomy ever was, with the rationale that the newer procedure prevents attacks of glaucoma. This may be so, but iridotomy is not without its risks and costs, and objective evidence of its benefit is lacking. The authors should perhaps have cautioned against the casual use of the treatment. A clinical trial could be designed to determine whether preventive use actually does decrease the frequency of angle closure in eyes at high risk.

The chapter devoted to trabeculoplasty is adequate. The limited usefulness of this procedure should have been stressed. Laser sclerostomy is a procedure whose time has not yet come. If it is worthy of a chapter, the chapter could have been shorter. Cyclodestructive procedures will probably always be needed for a small group of patients whose intraocular pressure cannot be controlled otherwise. The rationale for these procedures and the current methods of performing them are well described.

The last section of the book deals with a host of surgical procedures that have been used to lower pressure consistently and predictably in eyes that are losing vision from glaucoma. The very length of this section attests to the relative lack of predictable results. A long section nicely describes wound healing, which is altered in glaucoma surgery by foreign implants, antimetabolites and other drugs, and anatomical alterations that lead to fistula formation.

This volume has four parts, each with several chapters written by several authors, most of whom are well known in their fields. Each author maintains some individuality of style and organization, and therefore some chapters are more readable than others. In general, the illustrations are appropriate in number and relevant to the text. The black-and-white photographs are less satisfactory in most cases, and in some cases it is difficult or impossible to identify the disease or anatomical feature of interest.

Barbara E.K. Klein, M.D., M.P.H.
University of Wisconsin Medical School, Madison, WI 53792