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ametropia, its imme- 
diate AND REMOTE 
CONSEQUENCES 

BV 

HOMER E. SMITH, M.D. 

NORWICH, N. Y. 

[Read before the Sixth District Branch Medical 
Society of the State of New York, September 24, 1907-] 



reprinted from the 

NEW YORK STATE JOURNAL OF MEDICINE 

Published Monthly by the 
Medical society of the State of New York 
December, 1907 



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AMETROPIA, ITS IMMEDIATE AND 
REMOTE CONSEQUENCES. 



By HOMER E. SMITH, M. D. 

NORWICH, N. Y. 

I T is a reprpach to the medical intelligence of 
to-day that a paper with this title should 
find a place on the program of a meeting of 
medical men. The truths which it presents (for 
they are truths, verified in a thousand instances) 
should be so familiar that any repetition of them 
should be unnecessary. The immediate and re- 
mote consequences of ametropia should be known 
to every physician. That they are not, is the 
reason of this paper ; what they are, the results 
and the remedy, will be my endeavor to present. 
Ametropia simply means an eye with incorrect 
measurements. It means that such an eye, in 
the state of rest, does not bring parallel rays of 
light to a sharp focus on the retina. That is a 
little thing to cause trouble to its owner, too lit- 
tle in the opinion of many physicians to be re- 
garded at all. Let us see what are the facts in 
the case and how intimate is the relationship 
of this simple thing to the health, happiness and 
habits of the individual. Let us take up seri- 
atum the three grand divisions of ametropia, 
myopia, hyperopia and astigmatism. 

It is interesting to note how opposite are the 



effects of near- and far-sightedness upon the 
growing child. Myopia is a condition in which the 
far point of distinct vision is at a finite distance. 
Degrees so low as even a half diopter will mean 
for a child inability to participate in any of the 
out-door games. This means a deprivation of 
exercise in the open air, an ill-developed muscu- 
lature and a disproportionate development of 
the brain at the expense of the body. Such 
children become solitary in their habits. In dis- 
position they become morose. In school they 
are inattentive to blackboard work and are re- 
proved for that which is no fault of theirs. All 
these have their marked influence on the growing 
mind and !x)dy, and character is altered there- 
from. Hyperopia is the opposite of myopia, and 
produces opposite but no less marked results. 
In this condition parallel rays of light can be 
brought to a focus on the retina only by an ef- 
fort of accommodation. In other words, distinct 
distant vision is secured only by constant muscu- 
lar action and near vision only by a still greater 
effort. Children with this condition detest study, 
are thought to be indolent and can only be driven 
to close application. They delight in out-door 
games, are physically robust and ill-developed 
mentally. They are truants from school, and 
fall into bad habits. The criminal class finds 
many recruits from the hyperopes. It is not ap- 
preciated how irksome, if not impossible, be- 
comes continued use of the eyes for near work; 
and such children are not infrequently punished 
for their infirmity. 

It is little short of marvelous to note the 
change which properly fitted lenses work in both 
these cases. Children possess the same qualities 
the world over. They are eager to learn and 
they rejoice in out-door sports as well. With 



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corrected vision the myope takes his share of 
play with his fellows, the hyperope his share of 
school work without complaint, and that natural 
balance which should exist between brain and 
brawn ensues to the perfect development of a 
sound mind in a sound body. It is almost an 
axiom that a backward child is a defective, phy- 
sically and not mentally. Sometimes it is his 
hearing, but more often his vision is at fault. 

Civilization is making giant strides in progress 
and is daily making greater demands upon the 
accuracy of our faculties. Daily are the condi- 
tions for success becoming more difficult to 
meet, and it is not fair to the child that he 
should start handicapped in the race of life. 
School work, while it should not be, is graded 
for the highest intelligence. The defective lags 
behind and becomes discouraged. The State 
gives every year more and more attention to per- 
fecting the courses of study which shall, in its 
judgment, best fit its students for their future 
lives and shall meet the demands which a pro- 
gressive civilization is to entail upon them, but 
H, does nothing to insure that the student shall 
be in the best possible condition to attain the re- 
sults aimed at or to start out fully equipped 
with those faculties which shall render their at- 
tainment possible. There should be a State 
Board of Physical Examiners for the primary 
student, whose duties should be to inquire into 
the .physical condition of such students, to sug- 
gest the remedy for defects and with power to 
compel its application. So long, however, as the 
. State neglects this it devolves upon you and me 
to de-,rt>issionary work along these lines. We 
should preach to every parent the need for the 
examination, under atropine, of the eyes of all 
children of school age. That there is need for 

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this is shown by statistics which demonstrate 
that 35 per cent, of all school children have de- 
fective vision to a degree sufficient to hamper 
them in their work. Were these children fitted 
with proper lenses we would hear less of inat- 
tention to study, of headaches and poor vision, 
and the average of health and attainment would 
become markedly higher. 

In the foregoing nothing has been said of as- 
tigmatism because only the immediate conse- 
quences of ametropia have so far been dealt 
with. The immediate consequences of astigma- 
tism, if of high degree, may be taken, for brev- 
ity’s sake, to be identical with the other forms 
of ametropia. While this is not wholly true it 
is allowed to pass in order that the remote, re- 
flex and damaging results of ametropia may be 
given their due consideration. In closing this 
phase of the subject permit me to quote from 
the report of Dr. Gulick, Physical Director cf 
the New York Public Schools. He says: “How- 
ever perfect may be the arrangements of the 
school building in lighting, heating and ventila- 
tion, the central difficulty of school life remains. 
It is a difficulty which is dependent upon the fact 
that the treasures of civilization are stored in 
print, in minute black marks upon a white sur- 
face which must be held relatively close to the 
eyes. This involves a constant attention and 
strain of the ocular apparatus to which it was 
not adapted during the long ages when it was 
being developed. Even under the most favor- 
able conditions the strain of civilization rests 
most heavilv upon the child with reference not 
merelv to the eye but also to the nerve centers 
hack of the eye and to that very great symptom- 
complex which is associated, as we have recent- 
ly discovered, with eye strain.” 



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Brief space will be given to the remote results 
of myopia and hyperopia. Whatever may be 
the cause of the former condition it is certain 
that its remote effects are expended on the eye 
itself, low forms of choroiditis result and vision 
is damaged. Incidentally it may be remarked 
that the best preventive of this disease is early 
and accurate correction of the refractive error. 
Of simple hyperopia it is also true that the eye 
suffers. If of high degree, sustained near work 
is impossible; if of low, only with advancing 
years does trouble come. 

In considering the remote and reflex disturb- 
ances due to ametropia we should take into con - 
sideration two things. The first is that our 
bodily mechanism has given it a certain quantity 
of nerve-force to energize its various organs. 
If one draws too largely on this supply others 
must suffer, and the organ of least resistance 
will show disturbed function. The second is 
that every instant of our waking existence the 
eyes are in constant action, that such activity 
calls for nervous energy in large amount even 
when the eyes are normal, and if these eyes be 
the seat of hyperopia or astigmatism the drain 
of nerve-force is enormous and exhausting. 
Bearing these things in mind it is- evident that it 
is only a question of time when the whole econ- 
omy must suffer. 

Cohen, in his “System of Physiologic Thera- 
peutics,” says: “As a causative factor in the 
production of headache eye strain is most impor- 
tant. Anorexia, dyspepsia, constipation, heart- 
burn, nausea and repeated attacks of vomiting 
represent some of the gastric reflexes. Amen- 
orrhea, dysmenorrhea, are menstrual anomalies 
sometimes caused by eye-strain. Insomnia, 
nightmare, chorea, nocturnal enuresis and even 



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epileptiform seizures have owed their existence 
and perpetuation to uncorrected eye-strain in 
some form.” Every word of this is true and has 
been proved true in many instances, but it is not 
a strong enough statement nor is it sufficiently 
comprehensive. Any organ or the nervous sys- 
tem as a whole may suffer or may cause to ensue 
any of the protean disturbances, which for lack 
of causal recognition is termed neurasthenia. 

What is the reason these patients are not 
cured? The answer is easy. Simply because 
the remedy is not applied. Patients with symp- 
toms which may be referable to eye-strain are 
sent for examination. Vision is found to be bet- 
ter than the average, lenses of any kind blur 
vision, and the patient comes back with the re- 
port that the eyes are not at. fault. Let me here 
interpolate just one illustration. A woman forty 
years old — note the age — came to me some years 
ago in a pitiable condition with symptoms refer- 
able to eye-strain. She had 20 /-XV vision in 
each eye and the weakest cylinder or spheric 
blurred vision. I told her that the eyes were 
not the cause of her troubles. She had more 
sense than her oculist, for she came back insist- 
ing on a second examination. Under cyclo- 
plegis her error was found to be an hyperopia 
of two diopters with a half diopter of astigma- 
tism at axes 180 in both. Glasses on that basis 
were ordered. She had the satisfaction of being 
cured. I had the mortification of admitting my 
mistake. 

Have any of you doubts about the evil effects 
of eye-strain? If you have, give yourself an arti- 
ficial hyperopic astigmatism by putting before 
your own eyes a pair of weak minus cylinders. 
Wear them half a day. You will certainly lose 



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your doubts and probably your dinner. It should 
be set down as an axiom, that in proportion to 
the visual acuity are the disturbances due to eye- 
strain. It is the little astigmatic errors which 
cause trouble. The large ones cause poor vision, 
there can be no attainment of a sharp focus, the 
eye gives up the struggle and with no effort there 
can be no strain. For the same reason glasses 
which are not altogether right are altogether 
wrong. A patient with an astigmatic error of 
one diopter will suffer less with no correction 
than he will with an .87 or with a 1.12 cylinder. 

This leads up to axiom number two, which is — 
nothing short of mathematically accurate correc- 
tion of the ametropia will remedy the condition. 
Just two short illustrations of this: Patient num- 
ber one got relief by changing the cylindric lens 
from a .7 5 to an .87 ; number two, by shifting the 
axis of a .62 cylinder five degrees. This seems 
like splitting hairs, and a few years ago I would 
have thought so too. I know better now. There 
are those who think they are doing refraction 
wprk who rely on the ophthalmometer and the 
correction of the manifest error without a mydri- 
atic. I was taught this method and it took me 
ten years to unlearn it. I never now refract a 
patient under forty without full cycloplegis, often 
between forty and fifty, and sometimes even later 
in life. Knowing and having practised both 
methods, I am in a position to assert without fear 
of successful contradiction that the man does not 
live, who can with accuracy determine the refrac- 
tion of an eye unless that eye is under full ciliary 
paralysis. This does not mean that this eye 
shall be given its full correction as so found, but 
that the static refraction, under cycloplegis, shall 
be the basis for the final prescription of glasses. 

There are post-cycloplegic conditions which 



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modify the findings and problems which are 
difficult of solution and even of comprehension. 
One which I might mention and which passes 
my understanding is a static refraction, less under 
mydriasis than afterward, in other words, an eye 
which will take as a post-cycloplegic correction a 
stronger plus or a weaker minus spheric lens. 
The rule is the reverse of this. Again a cylinder 
under mydriasis may be best at 90° ; after- 
ward its best axis may be 75. I think I know 
the reason for this, but its discussion here would 
be out of place. 

To group the three axioms we have : first, the 
better the vision the more the reflex troubles ; 
second, only absolutely correct refraction will 
cure the trouble; and third, no cycloplegis, no 
refraction. Let us not claim everything in sight, 
let us be ultra-conservative and admit that there 
are some headaches, some gastric disturbances 
and some obscure nervous disorders that may be 
due to eye-strain. Such are some of your cases. 
Look to it that instead of being leaders you are led. 
It is becoming a matter of common opinion, and 
the lay press is printing articles on eye-strain and 
its remote consequences. Some of your patients 
that you have been treating for nervous head- 
aches, biliousness, hysteria, neurasthenia, and such 
like occult disorders, are going without your 
knowledge or advice to the scientific refractionist 
and are finding that two little, oval, insignificant 
pieces of glass placed in front of the face cure 
the biliousness and headaches for which you have 
been drugging them for years. This does not 
inspire in them a calm acceptation of their years 
of suffering or add to your reputation. I am far 
from saying that all the ills that flesh is heir to 
are due to eye-strain. I think there are other 
possible causes of headache, but T do sav that you 

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have not done your whole duty to your patients 
until every possible causal factor has been investi- 
gated. At least give them the benefit of the 
doubt. Put them under homatropine for a few 
days. If the symptoms are due to eye-strain you 
will get speedy relief. I have seen a headache 
disappear in the office while the drops were being 
used. 

It is admitted that the treatment of functional 
disorders must be more or less symptomatic and 
in consequence more or less disappointing, but 
if there be, and there are, many and far-reach- 
ing effects from eye-strain, this etiological factor 
should receive its due consideration. If only a 
small percentage of the reflex neuroses be due to 
this cause you owe it to your patients that this 
source of trouble shall be eliminated before con- 
demning them to symptomatic treatment which 
many times means nothing else than lifelong 
dieting and drugging with, at the end, partial 
or total invalidism. Again would I repeat, you 
can not cure a disease until you apply the remedy, 
and in this case the remedy is accurately fitting 
lenses. Don’t send your patients to an oculist 
who returns them in fifteen minutes with a report 
that there is perfect vision and nothing wrong 
with the eyes. It takes hours to do the work 
properly. Many are the causes of failure, and 
many times it lies with the oculist himself. To 
do good refraction work requires so large a mix- 
ture of brains, patience and judgment that few 
men possess these qualities in sufficient degree 
to enable them to qualify for the work. There 
are many oculists, there are few refractionists. 
As for the “graduate optician.” his work would 
be laughable were it not pitiful. No one, what- 
ever may be his qualifications, can say, with even 
a fair degree of probability, what is the refrae- 



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tion of an eye without the use of atropine or 
some other cycloplegic. To work without it is 
simply to invite failure. Perfection is a matter 
of trifles but perfection is no trifle, and I assure 
you that nothing else will do in the matter of 
refraction work. 

Do not think that I am carried away with 
the enthusiasm of the specialist. I did general 
practice for many years. Do not think either that 
I hold the patient’s eye so close to my own that 
I obscure the whole medical horizon. I admit 
there may be other disorders besides eye-strain ; 
but I do assert most positively and unequivocally 
that there is nothing which is so productive of 
gastric, nervous and cephalic disturbances, and 
that nothing can be surer than, when this is the 
cause, that only can it be removed by its one 
remedy — accurately fitted and adjusted glasses. 



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