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correctinglenses, no longer exists; but is liable to be-excited consensually by efforts at accommodation. As this class includes many high myopes its exception is an important one. In this connection it should be mentioned that the inconvenience and even pain excited by the first attempts to wear strong correcting glasses are not a contraindication to their continued use. These may be tempered to the impatience or skepticism of the patient by partial correction or interrupted use of the glasses; but they are of precisely the same significance as the cramp or soreness produced by any other unfamiliar exertion and co-ordination of muscular effort. They are -always temporary, and usually trifling in comparison to the benefit soon realized from persisting in the effort.
CONSTANT CORRECTION OF HIGH MYOPIA. BY GEORGE C. HARLAN, M.D., PHILADELPHIA, PA.
Perhaps I should hardly have dared to bring so trite a subject as the correction of myopia before this meeting, but when Dr. Jackson assured me recently that he had the temerity to do this thing, it occurred to me that my private records might furnish, as illustrations, the cases of some patients who had worn strong glasses for a good many years. I remember, when a member of the International Congress in New York in 1876 intimated a desire to know the practice of his colleagues as to the constant correction of myopia, hearing a youthful ophthalmologist sitting near me mutter contemptuously, " Why does he take the time of the Congress with that? Why don't he go read his text-books ?" It is probable that that was just what he had been doing, and that it was the unsatisfactory result of his investigation that induced the question. He did not take up much of the time of the Congress, however, as the question was ignored. There seemed to be a general impression that it was finally settled, though if each one had given his opinion as
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HARLAN: Constant Correction of Hig1z Myopia.
to just how it was settled, there would probably have been considerable diversity. At any rate, after sixteen years more of ophthalmological progress, comparison of text-books, papers that appear from time to time in medical journals, discussions in societies, talks with colleagues, and the occasional examination of floating patients who have been under treatment at home and abroad, show that there is far from being a general consensus of opinion on this important practical subject and that it is still one, like Sancho Panza's puzzling legal case, "concerning which many things may be said on both sides." For myself, a rather careful experience of a good many years has convinced me that excessive convergence without accommodation is the most important factor in progressive myopia, and that our most valuable therapeutic measure is the restoration, as nearly as possible, of the normal relation of these two
functions. As I have included only cases which I have chanced to have an opportunity to examine after a full correction of from 4 D. upward had been worn constantly for more than five years, I have been greatly disappointed with the smallness of the number, but have taken some comfort from the reflection that no news is, to a certain extent, good news, as patients are not only likely to return' if their glasses prove unsatisfactory, but are prone to attribute a great variety of ills to the delightfully tangible cause of a pair of spectacles. These may at least serve as a text and an excuse for expressing my opinion. CASE I. P. N., school boy, aet. I4, Dec. 23, '74.' Has never worn glasses. 0. D. and 0. S. with -7.5 D. 2B. With correction can read only 4.5 Sn. and not nearer than 20". Slight partially atrophied crescents to outer side of discs. Otherwise normal. Rx. -4 D. in spectacles for constant use and -4 in eyeglass to be added occasionally for distance. June 6, I875, has a near point of 8" with full correction and V.= -2Q Rx. Franklin glasses. Julyg, 1875,has now P.=3i"
with full correction, Rx. -7.50 D. constant. June, i886, V.=-2Q sharp- and no' increase M. after eleven years. CASE II. D. S., female, age I3, Oct. I875. Has never worn glasses. 0. D.-20 D. and 0. S.-i8 D. -2-8- (without
HARLAN: Co;zstanit Correction of High Myopia.
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mydriatic) atrophic crescents, with -I6 D. reads at 6", Rx. -t6 D. constant. Nov., 1883,with atropia -0. D.-i8 D. 0 and 0. S. -i6 D. R. P- 4i. July, I892, with -i6 and reads No. i Sn. at 4". Uses eyes freely without discomfort. No increase in M. or diminution in V. in seventeen years. CASE III. H. S., school-girl, age I 2, April, 1877, 0. D. and 0. S., with -8 D. It. Can't read with full correction. Atrophic crescents about j d. wide and some thinning of choroid beyond. Macula sound. Rx. -5 D. for present. One week later Rx.-6.5o D. Three weeks later, Rx.-8 D. with which P. 4" and V-=2. No mydriatic used at this time. April, I883, 0. D. with atropia -9 D. -I 50c 40° . 0. S. with atropia8.25 _75C, 300$--o No change in fundus. After wearing -8 D. constantly for six years, there was very slight increase of M. with development of a low degree of As., and an improvement in V. CASE IV. Mrs. J. M. P., aet. 25, Nov., I877. 0. D. (atropia) -5 -_I ax. I VV20 0. S. -5 -IC ax. 20 Sharp, narrow, crescents out. Otherwise normal. P.=4f', but some fatigue and strain in use. Rx. -3i constant; a month later -4; six weeks later, full correction; no asthenopia. Jan., I892, 0. D. -5 D. 2c ax. I5 . 2DQ 1 Jan., 1892, 0. S.-5 D. -.c ax. 20 After wearing -5 D. constantly for fifteen years the sphericaj correction remains exactly the same. There is a very slight (doubtful) increase in As., and rather an improvement in V. CASE V. Miss E. T., aet. 20, Dec., I877. 0. D. (atropia) -5 - 3. 0. S. " 4-I.25c ax. 30j. P =4". Eyes very irritable. Fundi normal. Rx. -2.75; a month later full correction. Sept. I890, 0. D. -5 V.=-2-T 0. S. -3.25 -2.25c ax. 30f. After wearing -5 in one eye and -4 with I.25c in the other for thirteen years, the refraction of the former is unchanged, and in the latter there is rather less myopia and a little increase in As. Vision decidedly improved.I
376
HARLA-N: Constant Correction of Higk Myopia.
CASE VI. B. McC., school girl, aet. I 3, March, I 883. Always short-sighted. Has been wearing 6 D. 0. D. (atropia) -9 D. do, Extensive atrophic crescent down and out, and general thinning of choroid. 0. S. -I3 D. not used; diverges. Fundus much same as 0. D. Rx. -9 D. with which P = 3". Nov. I884, with -9 D. IC -ax. II5, some of 40 Rx. May,. I890, (Homatropia) -.9 D. -I.5oC ax. I15 2f? After using 9 D. constantly for seven years, there is no increase in M. and slight improvement in V. CASE VII. Miss M. R., school teacher, aet. 20, Feb., '78. Always short-sighted; comes on account of severe and almost constant pain in eyes, forehead, and occiput. No asthenopia, under atropia, 0. D. -4.50 -.75C ax. 170 and 0. S. _4 -50C ax. I65 V. -2 P. = 4". Fundus in each normal. Rx. Full correction for constant use. Oct. I885, nearly eight years afterwards, no increase in M.; no diminution of V. CASE VIII. Miss A. F. W., student, aet. i8, April, i88i. Always short-sighted. Has been using glasses for six or seven years. Has -5 for distance and occasionally uses them for near; covered eye deviates in near V. without glass -fixation perfect with glass. Fundi normal. Under atropia 0. D. and 0. S. - 5.50 -22l? P=6" with correction. Rx. full, constant. July, I892. Without mydriatic 0. D. -6 D. 0. S. -7 D. 20 z After more than eleven years an increase of about .50 D. in -one eye and of I.50 D. in the other and V. stationary. Has used eyes very freely. CASE IX. Miss A. T., aet. i8. April, I882. Always short-sighted. Has been wearing glasses for five years; constantly for two years. Has - io. With atropia 0. D. and 0. S. -8 Ic ax. I8o0-. Corrected,P=5". Oph.appearancesnormal. Rx. Full, constant. May, I 889, -with homatropine: 0. D. -7.75 D. -1.25 DC. i8o2-0. 0. S.-7.25 D.-I.75 DC. i8o!. July, I892, with same correction !Q some of I5, P. -5". In ten years no increase M. and decided improvement in V. (possibly from more perfect correction).
HARLAN: Constant Correction of High Myopia.
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CASE X. H. R. C., school boy, aet. i6, Sept., I883. Always short-sighted, and M. has progressed rather rapidly. Got present glasses a year ago. 1 V 2o Has 0. D. -3.25 -4c ax. IO C C 0. S. -3.25 -3.5oC ax. I80 With atropia, 0. D. -6 -4.5oC ax. 10 20 0. S. -6 4.5C ax. I70 Oph. normal except very narrow crescent to temporal side of disc. P. (corrected) with either eye, 4", with both, 6". Right hyperphoria = 120, apparently from congenital paresis inf. rectus. When fixing object is approached within 9" 0. D. turns upwards. Rx. Full, constant. Dec. 1887, with atropia-7.50 4.50C 25. Hyperphoria as before. Declines operation. Rx. Full, combined with 50 vertical prism on each eye. March, I892, some asthenopia with glasses: 0. D. with duboisia -8.50 -4.5oc ax. 15 8 0. S. ' -4.5oc ax. I65 2 ' Slight increase in atrophic crescents. Free section of superior rectus followed by left hyperphoria=2'. A month later a return of 40 right hyperphoria - but no asthenopia with full correction without prisms. After nine years of full correction, no diminution of vision. In four years without prisms an increase of M. of 1.5O D. In subsequent five years with prisms an increase of i D. in one eye, and .50 in the other. The moderate increase of M. probably due chiefly to muscular strain. CASE XI. C. A. W., clerk, aet. 35, March, I887. Always short-sighted. Has been wearing glasses since about fourteen years of age. Has two pairs -6 D. for distance and 5 D. for near. Considerable asthenopia With homatropine 0. D. -6 -I.5oc ax. 6o .20 0. S. -6- 2cax. go 20 With full correction P = 6.5" Rx. Full, constant. July, I892, with correction 20, P. = 8i". Uses eyes freely with perfect comfort. No change in V. or M. in five years. CASE XII. N. J. T., age 20, broker, November, i875.
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HARLAN: Constant Correction of-High Myopia.
Always short-sighted. Has been wearing-I2 D. for six years. Reads with some strain at 5" with correction. 0. D. with atropia -i8 D. T%DW. " 0. S. " 14 D. 420. Condition of muscles not recorded. Extensive choroidal atrophy in each eye, surrounding disc, and extending outward to macular. Choroid stretched, vessels straightened. Rx. -14 distance-; continue -I2 near. August, I89I. Has been using distant glasses constantly for the last four years. V. = 2 8 with glasses and with -i D. added, 3. This case is not included among those of full correction because even during the last four years when he was wearing -14 constantly, there was probably -i D. of increased M. not neutralized. It is of interest on account of the length of time the patient was under observation, and the very discouraging appearance of the fundus. Including the six years during which he wore glasses, before the first examination, he used -I2 for reading for eighteen years, and afterwards for four years preferred the constant use of -14. Sixteen years after the first examination there had been an increase of only i D. in myopia and no diminution of vision. CASE XIII. W. C. McB., aged 12, May, I883. Eyes always "weak." Dimness of distant vision, asthenopia, and chronic blepharitis. 0. D. and 0. S., under atropia, with -4 D. 26 . Fundus in each eye normal. With full correction, has a near point of three inches. Rx. -4 D. constant. July, i886, 0. D., under homatropine - V. 2 8? " -6 , some of 20. 0. S., " S. Rx. O0. D. -5. O. "-5-5. July, I892, with above correction V. = 2 8. P= " Eyes quite healthy. Though comparatively few these cases offer considerable va. riety in the ages of the patients, the degrees of M., and the con*dition of the fundus when the full correction was ordered. The ages vary from 12 to 35 years, the degrees of M. from 4 D. to i6 D.- with an average of about 8 D. - and while in some the fundus was normal, some had moderate myopic crescents, and in 4
HARLAN: Constant Correction of Higii Myopia.
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others there were extensive choroidal changes. No case is noted in which the patient had not worn the correction for more than five years, and the period of time extends from that to seventeen years. In no case was there the slightest diminution *of vision and in most the vision became more acute. In eight the M. was stationary. In four cases there was a slight increase of M.; from .50 to 1.50. In one case only was there a considerable increase -2.50 D. - after constant correction for nine years, and this occurred chiefly during the first four years when there was an uncorrected hyperphoria. In some cases the patients were able to wear the full correction at once, and in others not until after a gradual increase in the strength of the glass for several weeks or months; and this does not seem to depend on the degree of the myopia. Some patients with comparatively low myopia have very little accommodative power at first, while, on the other hand, I have often been astonished at the -high degree- sometimes even beyond the normalpossessed by high myopes who have never worn glasses and have had little or no use for their ciliary muscles. To avoid the danger of over-correction, the refraction should be tested under thorough mydriasis. Several of these patients had marked insufficiency, which was relieved at once by the correction of the myopia. The convergence will generally fall into line when the accommodation is put to work, or, if it does not, it can usually be made to do so by prisms or tenotomy. Exophoria that exists, with the correction decided upon, in distant vision should receive attention at once. Of course I don't wish to be understood as claiming that every case of myopia should receive full correction, and attempting to solve this difficult and important problem by finding out the degree of the optical defect and clapping on the glass with the corresponding focal distance; but only that the degree of comfortable accommodation that exists at the time, or can be acquired by practice with gradually increasing lenses, should be the chief guide in deciding upon the glass to be used. Complete correction of the optical defect with full restoration of the normal relation between accommodation and convergence is the
380
HARLAN: Constant Correction of High Myopia.
ideal condition, but an ideal that cannot always be reached. The acuteness of vision, the effect of strong concaves in diminishing the size of the retinal image and the nature of the patient's occupation should of course have due consideration; and persistent sense of strain and discomfort in near work should suggest a compromise. As to the nature of this compromise, I think that it should rarely consist in the ordering of two pairs of glasses, but that the lenses habitually worn by the patient should become a permanent part of his optical system. Other considerations aside, the mental worry and accommodative disturbance involved in the incessant changing of glasses is a factor by no means to be disregarded. This fact was well illustrated by the case of a young lawyer who consulted me a few years ago. His myopia had been carefully and accurately corrected by a very well known ophthalmic surgeon who had given him glasses for distance and for near. He could read -f-airly well with his near glasses, but cornplaimed that when he wanted to look for a book on his shelves the glasses had to be changed, and when he changed again and resumed his work it was some time before his eyes adjusted themselves comfortably to reading or writing. Then when he went into the street with his distance glasses he was always uncomfortable and sometimes so dizzy that he reached home with difficulty. He had almost constant headache and got into such a nervous and irritable condition that some obscure cerebral or neurotic trouble was suspected and he was referred to a general practitioner for treatment, but without result. The symptoms disappeared entirely and at once under constant correction. When it is not practicable to use full correction for near work, the easiest way out of the difficulty is often to sacrifice something of distant vision, and patients with very high degrees of myopia - say from IO to i8 D. - are usually content with the distant vision that they get with from I to 3 D. deducted from the fully neutralizing glass, or, if desired, distant vision can be sharpened occasionally by holding weak concaves in front of the habitual correction by means of "fronts," lorgnettes, or even a single glass. Some patients prefer to wear the distant correction constantly and add a -weak convex for reading.
HARLAN: Constant Correction of High Myopia.
38I
Better than either is the use of bifocal lenses. The practical genius of Franklin appreciated the fact that life is too short to spend so much of it in taking off one pair of glasses and putting on another, and invented the well known "slit glasses" which still bear his name; but in young subjects the bifocal glass is often more than a mere convenience and has a distinct therapeutic value. DISCUSSION.
DR. 0. F. WADSWORTH, Boston. -I should like to add my testimony to that of Dr. Jackson and Dr. Harlan as regards the advantage of full correction in many cases of myopia. It has been my practice for many years to give full correction in cases where there was no serious disturbance in the fundus, where vision came up practically to normal and where accommodation was good. While I can give no statistics, it has been my impression that there were great advantages in that practice. There have been a good many instances where patients have come to me using partial correction and who were at an age when myopia is likely to continue to progress, whose myopia ceased to progress as soon as they used full correction, whether in consequence of this or not, it is difficult to say. Theoretically, I think it an advantage that the ciliary muscle should be exercised, just as much as that other muscles should be exercised. No one would think of preventing any other muscle from acting in order to improve its condition. There is one point which I do not remnember hearing touched upon b3i the readers which I think is an objection to partial correction, or to one correction for distance and another correction for near use. It is, that with such correction the patient is obliged to learn and practice two different methods of association between accommodation and the external muscles. That must be a disadvantage. DR. D. B. ST. JOHN RooSA, New York. -Some years ago I was led into full correction of myopia from what might seem an empirical method of observation. I studied as far as possible all myopes who were at the same time ophthalmologists, and I found that these men without exception corrected their myopia fully. They used one pair of glasses for all work, and I reasoned that a myope also an ophthalmologist would know much more about the subjective sensations from full correction than any hypermetrope or hypermetropic prekbyope. From experience I soon found that my patients did as well as I could expect with full correction, and I have approximated
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HARLAN: Constant Correction of H:igh Myopia.
that as near as possible. If you do not use atropia, it is impossible to remove a certain quantity of -artificial myopia in some instances, but that is not always present and then you may use atropia where you are particularly anxious to exactly correct the myopia. As to the influence of correction of the full measure of myopia in diminishing the progress of the myopia, I am an agnostic on that point, - I do not know. I am satisfied that my patients are more comfortable with full correction, and that the argument that has been advanced in the paper is a very strong one against the use of two kinds of glasses, until ,one is actually compelled to do so. I wish simply to refer to another point. Dr. Harlan in his paper evidently lays stress upon the correction of latent insufficiencies of the muscles. Of course you know, if you have done me the honor of reading anything of what I have lately written, that I have no faith in correcting latent insufficiencies of the ocular muscles, except in so far as can be accomplished by correcting errors of refraction. With the general principle of the full correction of the myopia, I am in accord. I have found in my experience that a few of my myopic patients with a high 'degree of myopia and a considerable quantity of corneal astigmatism sometimes will not accept in the time that they have been under my observation cylinders in addition to the concave glasses, nor is their vision sometimes markedly improved by them. It seems to be true, since I have been using Javal's methcod of measuring astigmatism, that in myopia ,of high degree a considerable astigmatism is quite well tolerated, and that the patients decline the cylinders and are perfectly comfortable without them. We all know that this is always different in hypermetropia. DR. SAMUEL D. RISLEY, Philadelphia. - I feel like thanking our President and Dr. Jackson for bringing this subject of the full correction of myopia to our attention. The management of progressive near sight has always seemed to me to be one of the most important and difficult branches of ophthalmic practice. In all essential particulars the tenets of the papers are in accord with my views and practice, since it has from the first been my habit to fully correct the myopia and to search for and correct even low grades of associated astigmatism. Reasoning a priori from the physiological facts in our possession, I feel sure this is correct practice, and in my hands has borne well the test of a steadily increasing experience. The majorit;y of young persons will be able to wear with both comfort and safety fully correcting glasses both for distant and near vision. Special corrections for the reading distance must
HARLAN: Constant Correction of Hig1k Myopia.
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of course be allowed for those who have reached the age of presbyopia. It is not only in presbyopia, however, that special corrections for reading and all continuous work at a near point are required, but also in many young peqple with progressive near sight, if the progress of the disease is to be arrested, and the eyes used with safety and comfort. This is especially the case where there is associated pathological conditions of the fundus, e.g., a woolly choroid and beginning pigment absorption; dilated anterior perforating vessels and thinning anterior sclera, even if the characteristic changes at the posterior pole are not present. These are the conditions which in my judgment disturb the nutrition of the eye, and both permit and are active in causing stretching of the eyeball. While in use the vascular choroid becomes engorged with blood, the intraocular tension is thereby increased and further distention of the ball favored. Rest is therefore an essential factoi in the treatment of these tender eyes, but since this cannot be rigidly insisted upon, all strain should as far as possible be avoided, by relieving the tension upon the ciliary and converging muscles during work at a near point. This is in large measure accomplished by glasses calculated for an artificial far point, which shall approximate the ordinary working distance, combined with prisms, base toward the nose. With this end in view I have therefore ordered for such patients a full correcting glass for distance and under-corrections with prisms for protracted near work. The prisms are combined with the working glasses as a compromise with the discordance introduced between the accommodation and convergence by the under-correction, and this I consider a point of great importance. Young eyes with progressive myopia are not liable to be painful eyes for the reason that the intraocular pressure is relieved by the stretching of the globe. The absence of pain may therefore be delusive. It is the resisting eyeball that is painful, as we constantly see demonstrated in the asthenopia set up by the hypermetropic eye with astigmatism in the more rigid eye of adult life. My experience has differed from that of Dr. Roosa, in the correction. of the astigmatism in myopic eyes. I believe it is very rarely absent in myopia. I have for a long time contended that probably the most essential factor in the etiology of myopia is the existing astigmatism, and that the myopia is progressive until the astigmatism is carefully corrected. The low degrees of astigmatism are important since these are readily overcome by the accommodation, and therefore do not cause a serious impairment of the acuity of vision, but nevertheless cause great irritation and set up the pathological states underlying the distending eyeball. The careful correc-
384; HARLAN: Constant Correction of Hig-h Myopia. tion of myopic astigmatism in the manner I have outlined so briefly has been on the whole very satisfactory. The corrections have been uniformly made under mydriatics which have not only been employed to set aside the accommodation, but for their therapeutic value, often for many days,- in a word, until the turgid condition of the intraocular tunics had subsided. I have unfortunately been unable to complete in time for this meeting a study of upwards of eighteen hundred cases of myopia which I have in process of tabulation, but I was gratified in looking over the incomplete tables to see how small a percentage of them had suffered any considerable increase in their myopia. To sum up I therefore agree with the authors of these papers that the myopia and astigmatism should be fully corrected, the corrections being made under a mydriatic, and in young persons the glasses should be worn both for distant vision and near work. In all presbyopes, and in young people with progressive myopia with the associated pathological states, special formula for reading and near work should be given, and the want of harmony thus introduced between accommodation and convergence met by the addition of prisms combined with the sphero-cylindrical correction. DR. D. B. ST. JOHN ROOSA, New York. - I do not mean to say that I do not usually correct the astigmatism in the cornea made manifest by the ophthalmometer. What I mean to say is that I found certain cases of high degrees of myopia where the ophthalmometer showed an astigmatism of X D., in which the patient would not accept the correcting glass, and where they had good vision with the, correction of the myopia and were comfortable. I agree with what Dr. Risley has said in regard to the general importance of correcting the astigmatism. DR. B. ALEXANDER RANDALL, Philadelphia. - I have always had a certain amount of suspicion of the ophthalmometer results, but I did not expect Dr. Roosa to give such a black eye to the ophthalmometer as he does. It more than confirms my impression in regard to it. It was not surprising to me after seeing the methods of work in many foreign clinics that progressive myopia was so common and so important a matter in the minds and writings of many of our European confreres, who have written more than ourselves upon the subject. Viewing the matter from the standpoint of the, correction or mal-correction which I saw commonly made in German clinics, it struck me that it was a happy thing that under-correction was the rule which they adopted, or else they would have over-corrected and habitually given overcorrections to their myopes. It has been an exception to me
HARLAN: Constant Correction of Aiglt Myopia.
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to see progressive myopia even in cases where I had every -reason to expect that the myopia would progress. I have followed the same lines as Dr. Risley, and it has been surprising to note how little as well as how rarely the myopia has increased. Instead of confirming the statement made by some writers that myopia is usually progressive, I have found in the majority of cases well and fully corrected, particularly with the mydriatic rest which these eyes usually require, that progress was the great exception and was generally brought under control, if promptly and rationally taken in hand. DR. W. S. DENNETT, New York. -We occasionally have cases of myopic astigmatism where the cylindrical glasses are not worn, but where the patient adds the astigmatic feature by tipping the myopic glasses in the manner that Dr. Green has described. I have two patients who do that habitually. One has an astigmatism of i D. and the other of 3 D. DR. HENRY D. NOYEs, New York. -What I intended to say has practically been said by Dr. Risley. It has for years been my practice to give full correction for myopia with certain limitation. The first is the age of the patient; second, the degree of visual acuity possible after careful correction, and this of course determined by conditions giving rise to amblyopia, alterations of the membranes at the bottom of the eye; third, the conditions of muscularity must always be recognized when you give full correction. There must be a careful study of these muscular conditions to decide whether the patient can wear the glasses with comfort. I have used prisms for many years past. I shall never forget a woman whom I saw many years ago to whom I had given full correction for myopia with a prism of 7° and correction for astigmatism, and it was the first glass with which she could see things approximately cor-
rectly.
It is not uncommon to find an inequality in the eyes of young people. This is usually corrected by an advance of the myopia in the less myopic eye during a period of five or ten years, so that the patient will accept approximately the same glass in each eye. In looking over a series of cases of myopia with Dr. Hunter he remarked that it is astonishing to see how few cases of myopia have been corrected by a simple spherical lens. Most of them have a cylinder. Not more than ten per cent. receive pure spherical glasses. DR. WILLIAM THOMSON, Philadelphia. - I have for twenty years given the full correction for myopia wherever possible.
386
HARLAN. Constant Correction of High Myopia.
I had concluded that the theory that progressive myopia was dependent on the use of the accommodation was a fallacy. If myopia progressed simply by strain of the accommodation the time would come when it would cease to progress; and if from persistent use of the ciliary muscle there would be elongation of the eyeball, we could hope that hyperopia might disappear. But we know that it does not. In very high degrees of myopia I frequently find that people who lead a town life are better satisfied to have i D. of myopia uncorrected, simply as a matter of
convenience. DR. HENRY D. NOYES, New York.- There is a progressive myopia which is a choroiditis. That is congenital. It is seen in the peasantry, in negroes, and in illiterate people. That is choroiditis. There is another class where people do not want perfectly clear vision for distance because they have a horror of seeing objects so clearly. I have had such cases particularly in advanced life come to me repeatedly. I know a man in New York, a distinguished politician, who said to me that if I gave him glasses to read with, he did not care what was in the rest of the world. I have also seen nervous or hysterical women who would not wear glasses. DR. ED. B. ST. JOHN RoOSA, New York. - In regard to the "black eye" that the ophthalmometer is said to have received by what I last said. The ophthalmometer does not tell what glasses to prescribe. It does not interfere with the accuracy of the observations of Dr. Noyes or Dr. Thompson in myopia to say that they cannot always cause the patient to wear the glasses that they should wear. It does not interfere with the accuracy of the ophthalmometer that the patient will not tolerate the correction indicated. The gentleman misconceives the idea of the ophthalmometer. Mental capacity and judgment are to be used with the instrument. All that it does is, to tell how much astigmatism there is, and that it will tell as certainly as anything can be told,- as certainly as the mariner at sea can tell by his quadrant where he is. After we have found out how much corneal astigmatism there is, there is much latitude as to the glasses to be prescribed. The ophthalmometer can receive no black eye as a scientific instrument. DR. SAMUEL B. ST. JOHN, Hartford.- There is a moral to be drawn from what Dr. Noyes has said as to the unwillingness of high degree myopes to receive the proper glasses, that is that we should catch these cases younger, so that they will be trained to appreciate images. They will not then be
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startled by the too clear images. Myopes should be treated like other people. If there is asthenopia, take that into consideration. If there is insufficiency of the ocular muscles, take that into consideration. Correct the myopia, with reference to the other conditions. In an emmetrope who has asthenopia and has insufficiency of the recti muscles, you would give certain glasses. Do the same thing with the myope after correcting the myopia. I have myself worn full correcting glasses for the last thirty years, and during the last twenty-seven years my myopia has not increased. I am one of the exceptions that Dr. Roosa may note, where a considerable degree of astigmatism (1.5 D) is corrected and accepted with pleasure. My myopia is now 9 D. I have never had the slighest trouble with my eyes. Until the last year, I have not shown any presbyopic symptoms. Between the ages of I7 years and 2I years the myopia advanced from 5.5 D. to 9 D. DR. SAMUEL D. RISLEY, Philadelphia. -During the years of the increase of the myopia, did you have the astigmatism corrected ?
DR. ST. JOHN. -No. DR. RISLEY. -The correction of the astigmatism is of importance in preventing the increase of the myopia. After careful correction of the astigmatism, increase of the myopia is very rare. DR. H. F. HANSELL, Philadelphia. -I have been a myope as long as I can remember, and since the age of I3 years, now twenty-three years, I have worn glasses. During the first fifteen years the astigmatism was not corrected. During that time I wore spherical glasses giving full correction. While I cannot say what the exact degree of the myopia was at the timte I began to wear glasses, I judge it was 3 D. or 4 D. Ten years ago I had the astigmatism corrected. Up to that time the myopia had increased to 8 D. After that it increased much more slowly, until now full correction equals 9.5 D with 2 D. of astigmatism. Visual acuity is perfect. For the last ten years I gave myself a near glass which was 2.5 D. less than full correction. In that way I have been able to read many hours in the day or night as I want to. Reading with full correction for five minutes will give dizziness and headache and the print is difficult to see, but with partial correction I can see at ten or thirteen inches with perfect comfort. The relative accommodation in myopia must be considered from a different basis than the relative accommodation in emme-
tropia or hypermetropia. OPH. -25
373-
correctinglenses, no longer exists; but is liable to be-excited consensually by efforts at accommodation. As this class includes many high myopes its exception is an important one. In this connection it should be mentioned that the inconvenience and even pain excited by the first attempts to wear strong correcting glasses are not a contraindication to their continued use. These may be tempered to the impatience or skepticism of the patient by partial correction or interrupted use of the glasses; but they are of precisely the same significance as the cramp or soreness produced by any other unfamiliar exertion and co-ordination of muscular effort. They are -always temporary, and usually trifling in comparison to the benefit soon realized from persisting in the effort.
CONSTANT CORRECTION OF HIGH MYOPIA. BY GEORGE C. HARLAN, M.D., PHILADELPHIA, PA.
Perhaps I should hardly have dared to bring so trite a subject as the correction of myopia before this meeting, but when Dr. Jackson assured me recently that he had the temerity to do this thing, it occurred to me that my private records might furnish, as illustrations, the cases of some patients who had worn strong glasses for a good many years. I remember, when a member of the International Congress in New York in 1876 intimated a desire to know the practice of his colleagues as to the constant correction of myopia, hearing a youthful ophthalmologist sitting near me mutter contemptuously, " Why does he take the time of the Congress with that? Why don't he go read his text-books ?" It is probable that that was just what he had been doing, and that it was the unsatisfactory result of his investigation that induced the question. He did not take up much of the time of the Congress, however, as the question was ignored. There seemed to be a general impression that it was finally settled, though if each one had given his opinion as
-374
HARLAN: Constant Correction of Hig1z Myopia.
to just how it was settled, there would probably have been considerable diversity. At any rate, after sixteen years more of ophthalmological progress, comparison of text-books, papers that appear from time to time in medical journals, discussions in societies, talks with colleagues, and the occasional examination of floating patients who have been under treatment at home and abroad, show that there is far from being a general consensus of opinion on this important practical subject and that it is still one, like Sancho Panza's puzzling legal case, "concerning which many things may be said on both sides." For myself, a rather careful experience of a good many years has convinced me that excessive convergence without accommodation is the most important factor in progressive myopia, and that our most valuable therapeutic measure is the restoration, as nearly as possible, of the normal relation of these two
functions. As I have included only cases which I have chanced to have an opportunity to examine after a full correction of from 4 D. upward had been worn constantly for more than five years, I have been greatly disappointed with the smallness of the number, but have taken some comfort from the reflection that no news is, to a certain extent, good news, as patients are not only likely to return' if their glasses prove unsatisfactory, but are prone to attribute a great variety of ills to the delightfully tangible cause of a pair of spectacles. These may at least serve as a text and an excuse for expressing my opinion. CASE I. P. N., school boy, aet. I4, Dec. 23, '74.' Has never worn glasses. 0. D. and 0. S. with -7.5 D. 2B. With correction can read only 4.5 Sn. and not nearer than 20". Slight partially atrophied crescents to outer side of discs. Otherwise normal. Rx. -4 D. in spectacles for constant use and -4 in eyeglass to be added occasionally for distance. June 6, I875, has a near point of 8" with full correction and V.= -2Q Rx. Franklin glasses. Julyg, 1875,has now P.=3i"
with full correction, Rx. -7.50 D. constant. June, i886, V.=-2Q sharp- and no' increase M. after eleven years. CASE II. D. S., female, age I3, Oct. I875. Has never worn glasses. 0. D.-20 D. and 0. S.-i8 D. -2-8- (without
HARLAN: Co;zstanit Correction of High Myopia.
375
mydriatic) atrophic crescents, with -I6 D. reads at 6", Rx. -t6 D. constant. Nov., 1883,with atropia -0. D.-i8 D. 0 and 0. S. -i6 D. R. P- 4i. July, I892, with -i6 and reads No. i Sn. at 4". Uses eyes freely without discomfort. No increase in M. or diminution in V. in seventeen years. CASE III. H. S., school-girl, age I 2, April, 1877, 0. D. and 0. S., with -8 D. It. Can't read with full correction. Atrophic crescents about j d. wide and some thinning of choroid beyond. Macula sound. Rx. -5 D. for present. One week later Rx.-6.5o D. Three weeks later, Rx.-8 D. with which P. 4" and V-=2. No mydriatic used at this time. April, I883, 0. D. with atropia -9 D. -I 50c 40° . 0. S. with atropia8.25 _75C, 300$--o No change in fundus. After wearing -8 D. constantly for six years, there was very slight increase of M. with development of a low degree of As., and an improvement in V. CASE IV. Mrs. J. M. P., aet. 25, Nov., I877. 0. D. (atropia) -5 -_I ax. I VV20 0. S. -5 -IC ax. 20 Sharp, narrow, crescents out. Otherwise normal. P.=4f', but some fatigue and strain in use. Rx. -3i constant; a month later -4; six weeks later, full correction; no asthenopia. Jan., I892, 0. D. -5 D. 2c ax. I5 . 2DQ 1 Jan., 1892, 0. S.-5 D. -.c ax. 20 After wearing -5 D. constantly for fifteen years the sphericaj correction remains exactly the same. There is a very slight (doubtful) increase in As., and rather an improvement in V. CASE V. Miss E. T., aet. 20, Dec., I877. 0. D. (atropia) -5 - 3. 0. S. " 4-I.25c ax. 30j. P =4". Eyes very irritable. Fundi normal. Rx. -2.75; a month later full correction. Sept. I890, 0. D. -5 V.=-2-T 0. S. -3.25 -2.25c ax. 30f. After wearing -5 in one eye and -4 with I.25c in the other for thirteen years, the refraction of the former is unchanged, and in the latter there is rather less myopia and a little increase in As. Vision decidedly improved.I
376
HARLA-N: Constant Correction of Higk Myopia.
CASE VI. B. McC., school girl, aet. I 3, March, I 883. Always short-sighted. Has been wearing 6 D. 0. D. (atropia) -9 D. do, Extensive atrophic crescent down and out, and general thinning of choroid. 0. S. -I3 D. not used; diverges. Fundus much same as 0. D. Rx. -9 D. with which P = 3". Nov. I884, with -9 D. IC -ax. II5, some of 40 Rx. May,. I890, (Homatropia) -.9 D. -I.5oC ax. I15 2f? After using 9 D. constantly for seven years, there is no increase in M. and slight improvement in V. CASE VII. Miss M. R., school teacher, aet. 20, Feb., '78. Always short-sighted; comes on account of severe and almost constant pain in eyes, forehead, and occiput. No asthenopia, under atropia, 0. D. -4.50 -.75C ax. 170 and 0. S. _4 -50C ax. I65 V. -2 P. = 4". Fundus in each normal. Rx. Full correction for constant use. Oct. I885, nearly eight years afterwards, no increase in M.; no diminution of V. CASE VIII. Miss A. F. W., student, aet. i8, April, i88i. Always short-sighted. Has been using glasses for six or seven years. Has -5 for distance and occasionally uses them for near; covered eye deviates in near V. without glass -fixation perfect with glass. Fundi normal. Under atropia 0. D. and 0. S. - 5.50 -22l? P=6" with correction. Rx. full, constant. July, I892. Without mydriatic 0. D. -6 D. 0. S. -7 D. 20 z After more than eleven years an increase of about .50 D. in -one eye and of I.50 D. in the other and V. stationary. Has used eyes very freely. CASE IX. Miss A. T., aet. i8. April, I882. Always short-sighted. Has been wearing glasses for five years; constantly for two years. Has - io. With atropia 0. D. and 0. S. -8 Ic ax. I8o0-. Corrected,P=5". Oph.appearancesnormal. Rx. Full, constant. May, I 889, -with homatropine: 0. D. -7.75 D. -1.25 DC. i8o2-0. 0. S.-7.25 D.-I.75 DC. i8o!. July, I892, with same correction !Q some of I5, P. -5". In ten years no increase M. and decided improvement in V. (possibly from more perfect correction).
HARLAN: Constant Correction of High Myopia.
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CASE X. H. R. C., school boy, aet. i6, Sept., I883. Always short-sighted, and M. has progressed rather rapidly. Got present glasses a year ago. 1 V 2o Has 0. D. -3.25 -4c ax. IO C C 0. S. -3.25 -3.5oC ax. I80 With atropia, 0. D. -6 -4.5oC ax. 10 20 0. S. -6 4.5C ax. I70 Oph. normal except very narrow crescent to temporal side of disc. P. (corrected) with either eye, 4", with both, 6". Right hyperphoria = 120, apparently from congenital paresis inf. rectus. When fixing object is approached within 9" 0. D. turns upwards. Rx. Full, constant. Dec. 1887, with atropia-7.50 4.50C 25. Hyperphoria as before. Declines operation. Rx. Full, combined with 50 vertical prism on each eye. March, I892, some asthenopia with glasses: 0. D. with duboisia -8.50 -4.5oc ax. 15 8 0. S. ' -4.5oc ax. I65 2 ' Slight increase in atrophic crescents. Free section of superior rectus followed by left hyperphoria=2'. A month later a return of 40 right hyperphoria - but no asthenopia with full correction without prisms. After nine years of full correction, no diminution of vision. In four years without prisms an increase of M. of 1.5O D. In subsequent five years with prisms an increase of i D. in one eye, and .50 in the other. The moderate increase of M. probably due chiefly to muscular strain. CASE XI. C. A. W., clerk, aet. 35, March, I887. Always short-sighted. Has been wearing glasses since about fourteen years of age. Has two pairs -6 D. for distance and 5 D. for near. Considerable asthenopia With homatropine 0. D. -6 -I.5oc ax. 6o .20 0. S. -6- 2cax. go 20 With full correction P = 6.5" Rx. Full, constant. July, I892, with correction 20, P. = 8i". Uses eyes freely with perfect comfort. No change in V. or M. in five years. CASE XII. N. J. T., age 20, broker, November, i875.
378
HARLAN: Constant Correction of-High Myopia.
Always short-sighted. Has been wearing-I2 D. for six years. Reads with some strain at 5" with correction. 0. D. with atropia -i8 D. T%DW. " 0. S. " 14 D. 420. Condition of muscles not recorded. Extensive choroidal atrophy in each eye, surrounding disc, and extending outward to macular. Choroid stretched, vessels straightened. Rx. -14 distance-; continue -I2 near. August, I89I. Has been using distant glasses constantly for the last four years. V. = 2 8 with glasses and with -i D. added, 3. This case is not included among those of full correction because even during the last four years when he was wearing -14 constantly, there was probably -i D. of increased M. not neutralized. It is of interest on account of the length of time the patient was under observation, and the very discouraging appearance of the fundus. Including the six years during which he wore glasses, before the first examination, he used -I2 for reading for eighteen years, and afterwards for four years preferred the constant use of -14. Sixteen years after the first examination there had been an increase of only i D. in myopia and no diminution of vision. CASE XIII. W. C. McB., aged 12, May, I883. Eyes always "weak." Dimness of distant vision, asthenopia, and chronic blepharitis. 0. D. and 0. S., under atropia, with -4 D. 26 . Fundus in each eye normal. With full correction, has a near point of three inches. Rx. -4 D. constant. July, i886, 0. D., under homatropine - V. 2 8? " -6 , some of 20. 0. S., " S. Rx. O0. D. -5. O. "-5-5. July, I892, with above correction V. = 2 8. P= " Eyes quite healthy. Though comparatively few these cases offer considerable va. riety in the ages of the patients, the degrees of M., and the con*dition of the fundus when the full correction was ordered. The ages vary from 12 to 35 years, the degrees of M. from 4 D. to i6 D.- with an average of about 8 D. - and while in some the fundus was normal, some had moderate myopic crescents, and in 4
HARLAN: Constant Correction of Higii Myopia.
379
others there were extensive choroidal changes. No case is noted in which the patient had not worn the correction for more than five years, and the period of time extends from that to seventeen years. In no case was there the slightest diminution *of vision and in most the vision became more acute. In eight the M. was stationary. In four cases there was a slight increase of M.; from .50 to 1.50. In one case only was there a considerable increase -2.50 D. - after constant correction for nine years, and this occurred chiefly during the first four years when there was an uncorrected hyperphoria. In some cases the patients were able to wear the full correction at once, and in others not until after a gradual increase in the strength of the glass for several weeks or months; and this does not seem to depend on the degree of the myopia. Some patients with comparatively low myopia have very little accommodative power at first, while, on the other hand, I have often been astonished at the -high degree- sometimes even beyond the normalpossessed by high myopes who have never worn glasses and have had little or no use for their ciliary muscles. To avoid the danger of over-correction, the refraction should be tested under thorough mydriasis. Several of these patients had marked insufficiency, which was relieved at once by the correction of the myopia. The convergence will generally fall into line when the accommodation is put to work, or, if it does not, it can usually be made to do so by prisms or tenotomy. Exophoria that exists, with the correction decided upon, in distant vision should receive attention at once. Of course I don't wish to be understood as claiming that every case of myopia should receive full correction, and attempting to solve this difficult and important problem by finding out the degree of the optical defect and clapping on the glass with the corresponding focal distance; but only that the degree of comfortable accommodation that exists at the time, or can be acquired by practice with gradually increasing lenses, should be the chief guide in deciding upon the glass to be used. Complete correction of the optical defect with full restoration of the normal relation between accommodation and convergence is the
380
HARLAN: Constant Correction of High Myopia.
ideal condition, but an ideal that cannot always be reached. The acuteness of vision, the effect of strong concaves in diminishing the size of the retinal image and the nature of the patient's occupation should of course have due consideration; and persistent sense of strain and discomfort in near work should suggest a compromise. As to the nature of this compromise, I think that it should rarely consist in the ordering of two pairs of glasses, but that the lenses habitually worn by the patient should become a permanent part of his optical system. Other considerations aside, the mental worry and accommodative disturbance involved in the incessant changing of glasses is a factor by no means to be disregarded. This fact was well illustrated by the case of a young lawyer who consulted me a few years ago. His myopia had been carefully and accurately corrected by a very well known ophthalmic surgeon who had given him glasses for distance and for near. He could read -f-airly well with his near glasses, but cornplaimed that when he wanted to look for a book on his shelves the glasses had to be changed, and when he changed again and resumed his work it was some time before his eyes adjusted themselves comfortably to reading or writing. Then when he went into the street with his distance glasses he was always uncomfortable and sometimes so dizzy that he reached home with difficulty. He had almost constant headache and got into such a nervous and irritable condition that some obscure cerebral or neurotic trouble was suspected and he was referred to a general practitioner for treatment, but without result. The symptoms disappeared entirely and at once under constant correction. When it is not practicable to use full correction for near work, the easiest way out of the difficulty is often to sacrifice something of distant vision, and patients with very high degrees of myopia - say from IO to i8 D. - are usually content with the distant vision that they get with from I to 3 D. deducted from the fully neutralizing glass, or, if desired, distant vision can be sharpened occasionally by holding weak concaves in front of the habitual correction by means of "fronts," lorgnettes, or even a single glass. Some patients prefer to wear the distant correction constantly and add a -weak convex for reading.
HARLAN: Constant Correction of High Myopia.
38I
Better than either is the use of bifocal lenses. The practical genius of Franklin appreciated the fact that life is too short to spend so much of it in taking off one pair of glasses and putting on another, and invented the well known "slit glasses" which still bear his name; but in young subjects the bifocal glass is often more than a mere convenience and has a distinct therapeutic value. DISCUSSION.
DR. 0. F. WADSWORTH, Boston. -I should like to add my testimony to that of Dr. Jackson and Dr. Harlan as regards the advantage of full correction in many cases of myopia. It has been my practice for many years to give full correction in cases where there was no serious disturbance in the fundus, where vision came up practically to normal and where accommodation was good. While I can give no statistics, it has been my impression that there were great advantages in that practice. There have been a good many instances where patients have come to me using partial correction and who were at an age when myopia is likely to continue to progress, whose myopia ceased to progress as soon as they used full correction, whether in consequence of this or not, it is difficult to say. Theoretically, I think it an advantage that the ciliary muscle should be exercised, just as much as that other muscles should be exercised. No one would think of preventing any other muscle from acting in order to improve its condition. There is one point which I do not remnember hearing touched upon b3i the readers which I think is an objection to partial correction, or to one correction for distance and another correction for near use. It is, that with such correction the patient is obliged to learn and practice two different methods of association between accommodation and the external muscles. That must be a disadvantage. DR. D. B. ST. JOHN RooSA, New York. -Some years ago I was led into full correction of myopia from what might seem an empirical method of observation. I studied as far as possible all myopes who were at the same time ophthalmologists, and I found that these men without exception corrected their myopia fully. They used one pair of glasses for all work, and I reasoned that a myope also an ophthalmologist would know much more about the subjective sensations from full correction than any hypermetrope or hypermetropic prekbyope. From experience I soon found that my patients did as well as I could expect with full correction, and I have approximated
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HARLAN: Constant Correction of H:igh Myopia.
that as near as possible. If you do not use atropia, it is impossible to remove a certain quantity of -artificial myopia in some instances, but that is not always present and then you may use atropia where you are particularly anxious to exactly correct the myopia. As to the influence of correction of the full measure of myopia in diminishing the progress of the myopia, I am an agnostic on that point, - I do not know. I am satisfied that my patients are more comfortable with full correction, and that the argument that has been advanced in the paper is a very strong one against the use of two kinds of glasses, until ,one is actually compelled to do so. I wish simply to refer to another point. Dr. Harlan in his paper evidently lays stress upon the correction of latent insufficiencies of the muscles. Of course you know, if you have done me the honor of reading anything of what I have lately written, that I have no faith in correcting latent insufficiencies of the ocular muscles, except in so far as can be accomplished by correcting errors of refraction. With the general principle of the full correction of the myopia, I am in accord. I have found in my experience that a few of my myopic patients with a high 'degree of myopia and a considerable quantity of corneal astigmatism sometimes will not accept in the time that they have been under my observation cylinders in addition to the concave glasses, nor is their vision sometimes markedly improved by them. It seems to be true, since I have been using Javal's methcod of measuring astigmatism, that in myopia ,of high degree a considerable astigmatism is quite well tolerated, and that the patients decline the cylinders and are perfectly comfortable without them. We all know that this is always different in hypermetropia. DR. SAMUEL D. RISLEY, Philadelphia. - I feel like thanking our President and Dr. Jackson for bringing this subject of the full correction of myopia to our attention. The management of progressive near sight has always seemed to me to be one of the most important and difficult branches of ophthalmic practice. In all essential particulars the tenets of the papers are in accord with my views and practice, since it has from the first been my habit to fully correct the myopia and to search for and correct even low grades of associated astigmatism. Reasoning a priori from the physiological facts in our possession, I feel sure this is correct practice, and in my hands has borne well the test of a steadily increasing experience. The majorit;y of young persons will be able to wear with both comfort and safety fully correcting glasses both for distant and near vision. Special corrections for the reading distance must
HARLAN: Constant Correction of Hig1k Myopia.
383
of course be allowed for those who have reached the age of presbyopia. It is not only in presbyopia, however, that special corrections for reading and all continuous work at a near point are required, but also in many young peqple with progressive near sight, if the progress of the disease is to be arrested, and the eyes used with safety and comfort. This is especially the case where there is associated pathological conditions of the fundus, e.g., a woolly choroid and beginning pigment absorption; dilated anterior perforating vessels and thinning anterior sclera, even if the characteristic changes at the posterior pole are not present. These are the conditions which in my judgment disturb the nutrition of the eye, and both permit and are active in causing stretching of the eyeball. While in use the vascular choroid becomes engorged with blood, the intraocular tension is thereby increased and further distention of the ball favored. Rest is therefore an essential factoi in the treatment of these tender eyes, but since this cannot be rigidly insisted upon, all strain should as far as possible be avoided, by relieving the tension upon the ciliary and converging muscles during work at a near point. This is in large measure accomplished by glasses calculated for an artificial far point, which shall approximate the ordinary working distance, combined with prisms, base toward the nose. With this end in view I have therefore ordered for such patients a full correcting glass for distance and under-corrections with prisms for protracted near work. The prisms are combined with the working glasses as a compromise with the discordance introduced between the accommodation and convergence by the under-correction, and this I consider a point of great importance. Young eyes with progressive myopia are not liable to be painful eyes for the reason that the intraocular pressure is relieved by the stretching of the globe. The absence of pain may therefore be delusive. It is the resisting eyeball that is painful, as we constantly see demonstrated in the asthenopia set up by the hypermetropic eye with astigmatism in the more rigid eye of adult life. My experience has differed from that of Dr. Roosa, in the correction. of the astigmatism in myopic eyes. I believe it is very rarely absent in myopia. I have for a long time contended that probably the most essential factor in the etiology of myopia is the existing astigmatism, and that the myopia is progressive until the astigmatism is carefully corrected. The low degrees of astigmatism are important since these are readily overcome by the accommodation, and therefore do not cause a serious impairment of the acuity of vision, but nevertheless cause great irritation and set up the pathological states underlying the distending eyeball. The careful correc-
384; HARLAN: Constant Correction of Hig-h Myopia. tion of myopic astigmatism in the manner I have outlined so briefly has been on the whole very satisfactory. The corrections have been uniformly made under mydriatics which have not only been employed to set aside the accommodation, but for their therapeutic value, often for many days,- in a word, until the turgid condition of the intraocular tunics had subsided. I have unfortunately been unable to complete in time for this meeting a study of upwards of eighteen hundred cases of myopia which I have in process of tabulation, but I was gratified in looking over the incomplete tables to see how small a percentage of them had suffered any considerable increase in their myopia. To sum up I therefore agree with the authors of these papers that the myopia and astigmatism should be fully corrected, the corrections being made under a mydriatic, and in young persons the glasses should be worn both for distant vision and near work. In all presbyopes, and in young people with progressive myopia with the associated pathological states, special formula for reading and near work should be given, and the want of harmony thus introduced between accommodation and convergence met by the addition of prisms combined with the sphero-cylindrical correction. DR. D. B. ST. JOHN ROOSA, New York. - I do not mean to say that I do not usually correct the astigmatism in the cornea made manifest by the ophthalmometer. What I mean to say is that I found certain cases of high degrees of myopia where the ophthalmometer showed an astigmatism of X D., in which the patient would not accept the correcting glass, and where they had good vision with the, correction of the myopia and were comfortable. I agree with what Dr. Risley has said in regard to the general importance of correcting the astigmatism. DR. B. ALEXANDER RANDALL, Philadelphia. - I have always had a certain amount of suspicion of the ophthalmometer results, but I did not expect Dr. Roosa to give such a black eye to the ophthalmometer as he does. It more than confirms my impression in regard to it. It was not surprising to me after seeing the methods of work in many foreign clinics that progressive myopia was so common and so important a matter in the minds and writings of many of our European confreres, who have written more than ourselves upon the subject. Viewing the matter from the standpoint of the, correction or mal-correction which I saw commonly made in German clinics, it struck me that it was a happy thing that under-correction was the rule which they adopted, or else they would have over-corrected and habitually given overcorrections to their myopes. It has been an exception to me
HARLAN: Constant Correction of Aiglt Myopia.
385
to see progressive myopia even in cases where I had every -reason to expect that the myopia would progress. I have followed the same lines as Dr. Risley, and it has been surprising to note how little as well as how rarely the myopia has increased. Instead of confirming the statement made by some writers that myopia is usually progressive, I have found in the majority of cases well and fully corrected, particularly with the mydriatic rest which these eyes usually require, that progress was the great exception and was generally brought under control, if promptly and rationally taken in hand. DR. W. S. DENNETT, New York. -We occasionally have cases of myopic astigmatism where the cylindrical glasses are not worn, but where the patient adds the astigmatic feature by tipping the myopic glasses in the manner that Dr. Green has described. I have two patients who do that habitually. One has an astigmatism of i D. and the other of 3 D. DR. HENRY D. NOYEs, New York. -What I intended to say has practically been said by Dr. Risley. It has for years been my practice to give full correction for myopia with certain limitation. The first is the age of the patient; second, the degree of visual acuity possible after careful correction, and this of course determined by conditions giving rise to amblyopia, alterations of the membranes at the bottom of the eye; third, the conditions of muscularity must always be recognized when you give full correction. There must be a careful study of these muscular conditions to decide whether the patient can wear the glasses with comfort. I have used prisms for many years past. I shall never forget a woman whom I saw many years ago to whom I had given full correction for myopia with a prism of 7° and correction for astigmatism, and it was the first glass with which she could see things approximately cor-
rectly.
It is not uncommon to find an inequality in the eyes of young people. This is usually corrected by an advance of the myopia in the less myopic eye during a period of five or ten years, so that the patient will accept approximately the same glass in each eye. In looking over a series of cases of myopia with Dr. Hunter he remarked that it is astonishing to see how few cases of myopia have been corrected by a simple spherical lens. Most of them have a cylinder. Not more than ten per cent. receive pure spherical glasses. DR. WILLIAM THOMSON, Philadelphia. - I have for twenty years given the full correction for myopia wherever possible.
386
HARLAN. Constant Correction of High Myopia.
I had concluded that the theory that progressive myopia was dependent on the use of the accommodation was a fallacy. If myopia progressed simply by strain of the accommodation the time would come when it would cease to progress; and if from persistent use of the ciliary muscle there would be elongation of the eyeball, we could hope that hyperopia might disappear. But we know that it does not. In very high degrees of myopia I frequently find that people who lead a town life are better satisfied to have i D. of myopia uncorrected, simply as a matter of
convenience. DR. HENRY D. NOYES, New York.- There is a progressive myopia which is a choroiditis. That is congenital. It is seen in the peasantry, in negroes, and in illiterate people. That is choroiditis. There is another class where people do not want perfectly clear vision for distance because they have a horror of seeing objects so clearly. I have had such cases particularly in advanced life come to me repeatedly. I know a man in New York, a distinguished politician, who said to me that if I gave him glasses to read with, he did not care what was in the rest of the world. I have also seen nervous or hysterical women who would not wear glasses. DR. ED. B. ST. JOHN RoOSA, New York. - In regard to the "black eye" that the ophthalmometer is said to have received by what I last said. The ophthalmometer does not tell what glasses to prescribe. It does not interfere with the accuracy of the observations of Dr. Noyes or Dr. Thompson in myopia to say that they cannot always cause the patient to wear the glasses that they should wear. It does not interfere with the accuracy of the ophthalmometer that the patient will not tolerate the correction indicated. The gentleman misconceives the idea of the ophthalmometer. Mental capacity and judgment are to be used with the instrument. All that it does is, to tell how much astigmatism there is, and that it will tell as certainly as anything can be told,- as certainly as the mariner at sea can tell by his quadrant where he is. After we have found out how much corneal astigmatism there is, there is much latitude as to the glasses to be prescribed. The ophthalmometer can receive no black eye as a scientific instrument. DR. SAMUEL B. ST. JOHN, Hartford.- There is a moral to be drawn from what Dr. Noyes has said as to the unwillingness of high degree myopes to receive the proper glasses, that is that we should catch these cases younger, so that they will be trained to appreciate images. They will not then be
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startled by the too clear images. Myopes should be treated like other people. If there is asthenopia, take that into consideration. If there is insufficiency of the ocular muscles, take that into consideration. Correct the myopia, with reference to the other conditions. In an emmetrope who has asthenopia and has insufficiency of the recti muscles, you would give certain glasses. Do the same thing with the myope after correcting the myopia. I have myself worn full correcting glasses for the last thirty years, and during the last twenty-seven years my myopia has not increased. I am one of the exceptions that Dr. Roosa may note, where a considerable degree of astigmatism (1.5 D) is corrected and accepted with pleasure. My myopia is now 9 D. I have never had the slighest trouble with my eyes. Until the last year, I have not shown any presbyopic symptoms. Between the ages of I7 years and 2I years the myopia advanced from 5.5 D. to 9 D. DR. SAMUEL D. RISLEY, Philadelphia. -During the years of the increase of the myopia, did you have the astigmatism corrected ?
DR. ST. JOHN. -No. DR. RISLEY. -The correction of the astigmatism is of importance in preventing the increase of the myopia. After careful correction of the astigmatism, increase of the myopia is very rare. DR. H. F. HANSELL, Philadelphia. -I have been a myope as long as I can remember, and since the age of I3 years, now twenty-three years, I have worn glasses. During the first fifteen years the astigmatism was not corrected. During that time I wore spherical glasses giving full correction. While I cannot say what the exact degree of the myopia was at the timte I began to wear glasses, I judge it was 3 D. or 4 D. Ten years ago I had the astigmatism corrected. Up to that time the myopia had increased to 8 D. After that it increased much more slowly, until now full correction equals 9.5 D with 2 D. of astigmatism. Visual acuity is perfect. For the last ten years I gave myself a near glass which was 2.5 D. less than full correction. In that way I have been able to read many hours in the day or night as I want to. Reading with full correction for five minutes will give dizziness and headache and the print is difficult to see, but with partial correction I can see at ten or thirteen inches with perfect comfort. The relative accommodation in myopia must be considered from a different basis than the relative accommodation in emme-
tropia or hypermetropia. OPH. -25
