blood differential count in chronic glaucoma
TRANSCRIPT
BLOOD DIFFERENTIAL COUNT IN CHRONIC GLAUCOMA
EUGENE M. BLAKE, M.D. AN New Haven,
Probably all observers agree today that glaucoma is not a disease involving the eye alone but is an ocular expression of some subtile, and to date unrecognized, factor or factors. It is neither possible nor profitable to present all of the ideas that have been put forward in the effort to understand the symptom complex which we call glaucoma. The evidence of disturbances in the vascular system, the sympathetic and parasympathetic nervous systems, endocrine imbalance, psycho-genie factors, and others are all well known.
Much work has been done in the chemistry of glaucomatous patients, the blood content of calcium, potassium, chloride, iodine, and so forth, having been presented by various writers. In the October, 1937, issue of the British Journal of Ophthalmology there appeared. an interesting article by Farid Massoud, of Cairo, Egypt, entitled "Extra-ocular influence in glaucoma (constitutional factors)." The author states that "in the cellular elements of the blood a change occurs in both the red and white corpuscles. An increase in the number of red cells has been noted (Passow), while a change in the differential leucocyte count also occurs. This change in the white cells consists in a relative increase in the large mono-nuclears I have been able to demonstrate since 1929. In acute cases of glaucoma the large mononuclear leucocytes may attain the remarkable extent of 15 to 20 and even 30 percent. One noticeable feature in this connection is their apparent independence from any operative relief
* From the Department of Surgery, Section of Ophthalmology, and the Department of Medicine, respectively, New Haven Hospital.
D JOHN C. LEONARD, M.D.* Connecticut
of intra-ocular tension, their presence seeming to depend not so much on the local condition of the eye as on a general pathological process underlying it, as will be presently explained. Sufficient to refer here to the opinion of Wright, who mentions the probable presence in glaucoma of certain toxins interfering with the function of the reticulo-endothelial system."
Massoud then presents a table of the differential leucocyte count in the cases of 10 patients from the Giza Ophthalmic Hospital. The percentage of large mono-nucleated cells varied from a low of 4 to a high of 30. In some of the cases several counts were made, showing marked variation in the percentage of large mono-nuclears, from a low of 8 to a high of 30 in one case. There appeared no consistent variation in the cases in which several counts were made, some being higher at the beginning of the treatment of the glaucoma, some lower, and some the same at the beginning and at the end of the blood studies.
The article referred to concludes with statement, "The increase in the large mononuclear cells of the blood might be made use of as one of the early signs which, in conjunction with others, helps in the diagnosis of suspected glaucoma." In view of this expression it seemed worth while to make a leucocyte count on a fairly large number of cases in order to determine whether such a high mononuclear percentage can be found in glaucoma patients in a northern climate. Blood smears from 100 successive cases of chronic glaucoma from private practice were therefore taken. The table shows the age, the known duration of the
908 EUGENE M. BLAKE AND JOHN C. LEONARD TABLE 1
DATA FROM 100 CASES OF CHRONIC GLAUCOMA
Case No.
1.
2.
3. 4. S. 6. 7. 8. 9.
10.
11. 12. 13.
14. 15.
16. 17. 18. 19. 20. 21. 22. 23. 24. 25.
26. 27. 28. 29. 30.
31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44.
45.
46. 47.
Age
68
54
34 72 54 42 78 64 59
61
33 53 71
76 68
30 53 75 75 70 77 66 85 58 56
43 63 62 67 75
54 67 56 60 78 62 66 70 57 75 72 47 47 58
71
54 63
Sex
M
M
F M M F M M F
F
M F F
F F
F F F F F F F F F F
M M M F F
M M M F F F M F F F M M M M
M
M F
Known Duration
of Glaucoma
5 yrs.
5 mos.
1 yr. 5 yrs. 8 yrs. 3 yrs. 3 yrs. 2 yrs. 2 yrs.
26 yrs.
2 yrs. 24 yrs.
8 yrs.
3 yrs. 4 yrs.
2 yrs. 2 yrs. I s yrs. 1\ yrs.
19 yrs. 2 | yrs. 8 yrs. 9 mos. 1 yr. 3 yrs.
2\ yrs. I f yrs. 5 yrs. 2 | yrs. 2 yrs.
12 yrs. 3 yrs. If yrs.
11 yrs. 9 yrs. 9 yrs. 8§ yrs. l i yrs. 2J yrs. l i yrs. 6 yrs. 2 yrs. H yrs. 8 yrs.
13 \ yrs.
13 yrs. 4 yrs.
Highest Recorded Tension (Schiotz)
40
34
30.5 56 85 67 40 28 30
40
26 40 40
'29 50
34 30 34 29 26 23 34 75 29 22
70 65 40 28 70
75 40 75 45 37 37 60 34 40 25 50 25 29 48
85
75 75
Complicating Conditions
Previous bilateral trephining
Chronic alcoholism. Closure central artery O.S.
Asthma Parkinsonian tremor
Iritis, O.S. 1? yrs. ago
Bilateral iritis 20 yrs. ago. Cardiac disease
Rheumatic with exoph. goiter
B.P. 210 mm. Hg Hypertension Chr. sinusitis. Hy
pertension, B.P. 2004-mm. Hg.
Hypertension Pernicious anemia 4
yrs.
'' Nervous breakdown''
Hypertension
Arthritis Diabetes O.S. Previously oper
ated on for glaucoma. Sec. iritis
Hay Fever
C.N.S. lues
Sinusitis, iritis, asthma
Cardiac disease Sinusitis
Hay Fever
Silicosis. Ret. pigmentosis Cholesterin crystals
in lens. Obesity. Hypertension.
Acute bilateral glaucoma
Differential Blood Count (%)
Monos.
7
2
7 8 6
10 6 5 6
3
6 5 3
5 6
8 5 4 9 8 5
10 2 4 7
3 13 7 5 5
2 2 3 5 9 6 7 8 6 6 8 4 4
10
10
8 4
Non. Seg.
2
3
2 4 0 4 6 8 6
4
5 5 5
1 3
8 5 2 6 3 6 2 3 0 5
3 7 6 4 5
7 5 4 4 6 3 3 7 4 9 2 6 5 0
1
4 1
Seg.
71
49
55 48 47 61 57 69 65
57
48 46 60
62 47
55 58 58 59 58 54 49 66 63 61
53 57 60 73 53
57 51 66 52 58 46 63 60 46 62 55 65 68 71
83
53 54
Lymph.
19
38
33 38 42 24 30 15 22
35
38 42 31
28 41
26 24 35 24 30 33 34 29 31 23
41 19 24 17 35
30 39 26 33 25 44 25 20 42 21 26 24 20 16
5
27 36
Eos.
1
8
3 1 5 1 1 3 0
1
3 2 1
4 3
3 8 0 2 1 2 5 0 2 4
0 2 2 1 2
2 2 1 5 2 1 2 5 1 0 8 1 2 3
1
7 5
Bas.
0
0
0 1 0 0 0 0 1
0
0 0 0
0 0
0 0 1 0 0 0 0 0 0 0
0 2 1 0 0
2 1 0 1 0 0 0 0 1 2 1 0 1 0
0
1 0
BLOOD COUNT IN CHRONIC GLAUCOMA 909
TABLE 1—Continued
Case No.
48. 49. 50. 51. 52.
53. 54. 55. 56. 57.
58. 59. 60. 61. 62.
63. 64.
65. 66. 67. 68. 69. 70. 71. 72. 73. 74.
75. 76. 77.
78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88.
89. 90. 91 . 92. 93. 94. 95. 96. 97. 98. 99.
100.
Age
58 41 58 67 74
56 64 63 73 90
67 28 37 46 70
67 65
73 77 62 76 78 57 59 76 67 72
61 59 54
70 59 69 48 71 63 76 49 67 66 71
38 69 75 59 76 61 86 76 82 64 61 55
Sex
F M M M F
M M M F M
M F M F F
F F
M F F M F F F F F F
F F F
F M F F F F F F F F F
F F F F F F F F F M F F
Known Duration
of Glaucoma
3* yrs. \\ yrs. 1* yrs. 5 yrs. 3 * yrs.
If yrs. 6 yrs. 21 yrs. 2* yrs.
15 yrs.
16 yrs. 9 mos.
10 yrs. 3 yrs.
20 yrs.
4 yrs. 1 yr.
13 yrs. 7 mos. 3 yrs. 6 yrs. 2 | yrs. 2* yrs. 24 yrs. U yrs. 4 yrs. 3 yrs.
4 yrs. 1 \ yrs. 9 yrs.
2 * yrs. 16 yrs. 10 mos.
1 i yrs. 1 yr. 7 mos. 8 mos. 6 yrs. 7 yrs.
10 yrs. 13 yrs.
1 yr. 2 yrs. 5 mos. 3* yrs. 3 yrs. 1 yr. 6 yrs. 14 yrs. 7 mos. 4* yrs. 4 yrs. 1* yrs.
Highest Recorded Tension (Schiotz)
27 25 29 40 70
29 60 60 31* 65
60 29 70 55 34
37 40
38 16 27 55 48 31* 46 34 23* 75
38 40 55
31* 48 65 75 31 75 40 25 30
100 55
34 25 29 48
34 80 75
34 30 60
Complicating Conditions
Hypertension
Essential atrophy iris, O.D.
Diabetes and retinitis
Hypertension Hemorrhagic glau
coma O.D.
Bilateral iritis ' ' Psycho-neurosis.''
Ret. hemorrhage
Arteriosclerosis. Rheumatism
Albuminuria
Encephalitis- Parkin-sonism. Thrombosis central vein retina
Hyperthyroid Encephalitis Parkinsonism Arthritis
Macular hemorrhage, O.D.
Infected teeth
Diabetes
Diabetes
Diabetes
Different
VIonos.
6 8
11 5 9
7 6 6 4 3
11 2
15 7
10
1 13
5 3
12 3 5 5 8 6 9 3
3 6 8
9 8 7 6 8 6 6 4 5 5 5
8 1 8 2 4 3 8 5 2 4 5 7
Non. Seg.
4 5 2 S 3
4 10 2 2 2
3 5 5 7 8
5 6
5 4 9 4 7 0 4 8 8 5
2 2 4
8 5 3 6 6 7 0 3 3 3 5
1 5 7 4 2 0 3 5 0 5 8 8
ial Blood Cou
Seg.
63 59 62 57 68
57 58 52 64 83
57 49 77 43 71
62 48
72 73 54 67 69 59 60 66 62 62
58 52 63
52 63 43 50 55 52 61 44 68 42 64
58 76 73 60 64 58 59 64 85 57 68 57
Lymph.
26 27 23 32 16
29 24 36 30 12
25 31 16 41 11
32 30
16 19 21 23 16 35 26 20 19 30
33 37 24
29 24 45 36 30 25 31 49 22 46 26
31 18 10 33 30 33 28 25 13 32 17 27
nt (%)
Eos.
0 1 2 1 3
3 2 4 0 0
4 0 0 2 0
0 3
2 1 2 1 3 0 2 0 2 0
4 3 1
2 0 2 2 1
10 2 0 0 4 0
2 0 2 1 0 6 1 1 0 2 2 0
Bas.
1 0 0 0 1
0 0 0 0 0
0 0 0 0 0
0 0
0 0 2 2 0 1 0 0 0 0
0 0 0
0 0 0 0 0 0 0 0 2 0 0
0 0 0 0 0 0 1 0 0 0 0 1
910 EUGENE M. BLAKE AND JOHN C. LEONARD glaucomatous process, the highest tension recorded by the Schiotz tonometer, the percentage of monocytes, and any known outspoken complications, such as diabetes, syphilis, and other conditions.
DISCUSSION
As one can observe by inspection of the table, the ratio of female patients (67) to male patients (33) is 2:1. The age distribution is the usual one for glaucoma patients, 86 percent being 50 years old or older.
Inspection of the differential blood counts done on capillary blood taken from these 100 patients reveals the interesting fact that 94 percent of the patients had monocyte counts which fell within the normal range of 2 to 10 percent. The range of monocyte percentage was 2 to 15 percent, the six counts above 10 percent being distributed as follows: 11, 11, 12, 13, 13, 15 percent.
The differential counts were all done by one individual (J. C. L.), thereby eliminating the variable personal factor that is usually present when differential counts are made by several individuals. The blood films were all stained in the usual
manner with Wright's stain. One might ask why there is such a dis
crepancy between our findings and those of Massoud in Cairo, Egypt. It has long been known that the monocyte count may be elevated in protozoan infections. These types of infection are, of course, much more prevalent in Egypt than they are in our section of the world. This fact, we feel, casts considerable doubt upon the value of the monocyte count in the diagnosis of glaucoma in the East, and we now feel, as a result of our present study, that the monocyte count has absolutely no value in the diagnosis of glaucoma in our country,
SUMMARY AND CONCLUSIONS
1. A differential count was made on the blood of 100 consecutive unselected glaucomatous patients. 2. These blood films were stained with Wright's stain and a differential count was made by one individual. 3. The monocyte percentage ranged from 2 to 15 percent, 94 percent of the patients having monocyte counts within the normal range of 2 to 10 percent. 4. The monocyte count is of no value in the diagnosis of glaucoma.