Glaucoma – theories of Bjerrum 1889-92,
Still very important.
Mogens Norn
Jannik Bjerrum (1851-1920) is well known for his discovery of the arcuate scotoma in glaucoma. On the other hand, his glaucoma - theories are generally not known.
Bjerrum was born in Skærbæk in Schleswig, but this part of Denmark was lost in 1864 in the war against Germany. Bjerrum moved to Ribe in Denmark and from Ribe to study medicine at the University of Copenhagen. Later, he became professor of ophthalmology at this university (1896-1910).
Bjerrum published many scientific papers, especially case stories, only in Danish. For obvious reasons he did not want to publish in German language, as most scientists did at that time (or French, but very seldom English!). Therefore, his papers are not internationally well known.
Between the many detailled case stories are some important conclusions hidden. I have selected and translated the most important of these (my own comments in brackets) :
”Initially, I (Bjerrum) have not searched for it ( the arcuate scotoma), because I have no idea of its existence” (1, p.155).
Field of vision is ”a reversed picture of the radiation of the nerve fibres from the optic nerve.” (1, p.163).
”The decrease in visual power in glaucoma is mostly caused by something in the rim or wall excavation of the disk” (1,p. 165).
”Retinal bleeding by and on the upper border of the optic nerve with inferior scotoma: Should the excavation first have developed afterwards?”
(Bleeding at the optic nerve border is today an important sign of obs. glaucoma. Cf. also Grieshaber et al (2) in 2006: Optic disc haemorrhage due to a disturbed blood-retina barrier before manifest glaucoma. Cold induced flow stop in nail fold capillaries before development of manifest glaucoma, one case report with cold hands and feet. Endothelin 1 was increased).
”To define glaucoma as an increase in intraocular pressure is not appropiate after my (Bjerrum’s) opinion. Glaucoma is a clinical picture”.(3, p.137).
(IOP was at that time measured only by palpation, but Bjerrum has in this sentence predicted the very important normal and low tension glaucoma. Bjerrum’ s point of view should be remembered in cases with increased IOP, where prophylactic antiglaucomatous therapy is suggested).
”The uncomplicated excavation should be understood as a glaucomatous symptom” (3, p. 138). (Ophthalmoscopy and visual field are the most important examinations for glaucoma, not IOP).
”Amaurosis with excavation should be perceived as simple glaucoma” (cf. normal tension open angle glaucoma).
In conclusion, Bjerrum’s glaucoma theories includes damage of the nerve fibres, radiating from the optic papilla and bleeding or disease of the arteries in this region. Bjerrum did not consider the intraocular pressure as important. The arcuate Bjerrum – scotoma is almost pathognomonic for glaucoma.
References.
1. Bjerrum J.: Om en tilføjelse til den sædvanlige synsfelt – undersögelse samt om synsfeltet ved glaukom. Nordisk ophthalmol. Tidsskrift II: 1889, Kjøbenhavn.
2. Grieshaber M, Terhorst T & Flammer J: The pathogenesis of optic disc splinter haemorrhages: a new hypotesis. Acta Ophthal. 2006; 67: 62-68.
3. Bjerrum J.: Om glaukomets kliniske afgrænsning. Nordisk ophthalmol. Tidsskrift V: 1892, Kjøbenhavn.
Jannik Peterson Bjerrum
1851-1920
still very influential