myopia: 
By Albert R. Baker, M. D., Cleveland, O. 
Prof, of Ophthalmology, Otology and Laryngology in the Medical De- 
partment of Wooster University. 
There is no subject which demands the same careful 
consideration of the thoughtful physician or student of 
sociology as that of myopia. It is a disease peculiar to 
civilization, and one that is rapidly on the increase. It is 
somewhat doubtful whether the ancients ever suffered from 
myopia. Probably the earliest myope of whom we have 
any record was the Emperor Nero, who used a concave 
glass so that he was enabled better to see the gladitorial 
contests. 
Observations have proven that all animals are hyperme- 
tropic and that myopia is peculiar to man, and as Landott 
has well said, the disposition to myopia is therefore found 
in the development of the human race, and the determining 
cause in what is more particularly called civilization. 
The rapid and uniform increase of myopia in school 
children is remarkable. In the primary grades of many of 
our city schools not more than two or three per cent, of 
myopia will be found. In the grammar grades from ten 
to fifteen per cent, will be met. In the high schools from 
twenty to thirty percent., while in many of our colleges 
the percentage of myopia will be increased to forty or 
even seventy per cent. The influence in producing 
* Read before the Mississippi Valley Medical Association, Louisville, 
Kentucky, October 9, 1890. 2 
Baker : Myopia. 
myopia, as the result of the close application which is 
demanded of the eyes in school work, is best seen by com- 
paring it with the following table of examinations of sol- 
diers in France by Tscherning.—Arch. F. Opth., xxix., 
p. 201, 1883. 
Day Laborers, Peasants and 
TOTAL. 
MYOPES. 
PER CENT. 
Sailors, ... 
2326 
5 7 
2.45 
Mechanics of various kinds, 
Mechanics engaged with 
2861 
150 
5.24 
near work, 
Artists, Engineers and Ar- 
566 
66 
11.66 
chitects, - 
270 
36 
13-33 
Merchants, 
1009 
159 
15.76 
Professional Men, 
491 
159 
32.38 
We are greatly indebted to Von Graefe and Donders for 
our knowledge of the pathology of myopia. It was held 
for many years that myopia was due to an increased con- 
vexity of the cornea or of the lense, or both, or else due 
to opacities or changes in the vitreous, but it has been 
fully settled that myopia, practically speaking, in all cases 
is due to an elongation of the eye-ball at its posterior 
pole and is due to a great variety of causes, heredity play- 
ing an important role in its production. It is probable 
that the myopia itself is not hereditary, but the dyo-ce- 
phalic form of head and face is markedly so, and thus pre- 
disposes the individual to myopia. 
The exciting causes are found in reading and using the 
eyes on small objects near the eye, bad light and holding 
the book too close to the eye, stooping posture in schools, 
improper arrangement of seats, bad typography, opacities 
of the cornea or media, astigmatism. 
But these alone are not sufficient to account for the 
production of myopia, and we must seek for some condi- 
tion of the eye itself, which may be found in a weakened 
condition of the coats of the eye, so that they are not 
enabled to withstand the intra-ocular pressure. A reference 
to the anatomical condition will show that the part of the 
eye least able to resist this pressure is the posterior part Baker : Myopia. 
of the eye-ball. It is already weakened by the entrance 
of the optic nerve, and it does not have the support of 
the muscles and lids which the anterior portion and sides 
have. 
The myope not being able to see objects beyond his 
range of accommodation, closes the lids tightly over the 
ball, leaving only a small slit so as to get stenopaic vision, 
and thus the injurious pressure continues when he looks at 
a distance as well as near by. 
But we must still seek farther than to a merely weakened 
condition of the coats of the eye and increased pressure, 
to arrive at a clear understanding of the cause of myopia. 
There is in these cases a choroiditis which I believe is the 
important pathological condition in the production of the 
posterior staphyloma and resulting myopia. And this is 
always to be found in the early history of the disease. 
Although the sclerotic is the principal envelope (the 
skeleton) that gives support to the eye-ball, it can easily 
be understood that an inflammation of the choroid may 
also involve the sclerotic. Why this inflammation should 
in these cases always involve the posterior part of the eye- 
ball may be explained by the fact that this is the part that 
is always subjected to brightest light and where almost all 
the labor of seeing is performed, and consequently subject 
to the greatest irritation. It performs the most physi- 
ological labor and consequently is the first to suffer when 
abused. 
Among our school children will always be found a num- 
ber who are said to have “ naturally weak sight.” Their 
eyes are subject to irritation, black spots are complained 
of, photophobia and pain, together with various other 
subjective symptoms of inflammation. 
An ophthalmoscopic examination reveales a hyperemic 
disk, a slight blurring of its outlines, a condition of the 
fundus which has been described as the “peach blow ” 
choroiditis. After a time there is a deposit of pigment 
around the disk, which is followed by staphyloma, atrophy, 
hemorrhage, detachment of the retina, cataract, opacities Baker : Myopia. 
of the vitreous and all the serious consequences of malignant 
myopia. It is altogether probable that the posterior 
staphyloma is a conservative factor which, by the relief of 
injurious pressure, prevents other more serious troubles. 
Dr. Risley has attempted to demonstrate (and his views 
have coincided with that of many observers) that cataract 
is a disease of old age, not because of the age, but because 
the sclerotic has greater resisting power, and that when 
a choroiditis is developed in an old person, injurious dis- 
turbances of nutrition are caused, resulting in cataract, 
while in younger persons, the sclerotic yields, the proper 
nutrition of the eye is preserved, the lense remains clear, 
and myopia is thus developed. 
It can not be objected to this view of the etiology of 
myopia that intra-ocular tension is not increased in 
myopia, because the yielding of the sclerotic in the pos- 
terior pole is the element that prevents the increase of 
tension. In glaucoma we have an increased tension, but 
the circumstances are entirely different. It occurs usually 
in hypemetropic eyes and at an advanced age, and the 
excavation when it occurs in glaucoma is confined to the 
papilla, because it is the weakest point. It is possible 
that not a remote connection between choroiditis, posterior 
staphyloma, cataract and glaucomatous excavation of the 
disk may yet be established, all depending on one cause, 
or the same combination of causes. Other causes which 
have an influence in the production of myopia are com- 
pressions of the globe by the extrinsic muscles of the eye- 
ball. Von Arlt’s theory that the softening of the sclerotic 
at the posterior pole is due to a venus stasis caused by 
the compression of the venae vorticose by the oblique 
muscles in convergence, is a plausable one. An arrested 
development of the sclerotic has also figured in ophthalmo- 
logical literature as a cause of myopia. There is no doubt 
but that all these may have an influence in the production 
of myopia, but a careful weighing of all the evidence and 
close clinical observation of progressive cases of myopia 
will convince the most skeptical that the process is essen- Baker: Myopia. 
tially an inflammatory one, which will be found to vary 
from a simple hyperemia to an intense disseminated choroi- 
ditis. Only a small portion of the fundus may be in- 
volved, or the entire membrane even extending so as to 
include the retina, sclerotic and other ocular structures. 
Subjective symptoms of myopia are those of indistinct 
vision at a distance and the discord that exists between 
conveyance and accommodation, which I have discussed 
in another paper.* 
But even in low degrees of myopia the patient often suf- 
fers from hyperemia of the fundus oculi, which gives rise to 
all sorts of visual trouble. He suffers from asthenopia, 
muscae volitantes, fatigue of the eyes, pain in the orbit, a 
sense of fullness and pressure in the head, or even head- 
aches. The pain often becomes more severe and is neu- 
ralgic in character. 
The dark patches dancing before the eyes are especially 
annoying to the myope, because he sees them plainer, and 
owing to the sensitiveness of the retina they cause him 
more annoyance than others. He never tires of describing 
these apparitions which assume all sorts of fantastic 
shapes, and the more he pays heed to them the more he 
can see them. Owing to his being shut out from most of 
the pleasures of sight which his defective vision de- 
nies him, he is more introspective and to a certain 
extent often becomes a monomaniac on the subject of 
these visual apparitions. As the disease progresses there 
are added to these physiological corpuscles which are 
present in the eye of every person and can be seen by 
anyone looking at a white surface, such as a white wall or 
the clear sky, pathological exudations into the vitreous, 
which are more troublesome to the patient, often interfer- 
ing greatly with vision. As the exudations take place into 
the choroid and beneath the retina, distortion of objects are 
complained of, especially horizontal and perpendicular 
lines. The patient, as Landold has said, is often placed 
in a “ vicious circle of action and re-action, for the more 
♦ Nervous diseases of reflex origin.—Journal of the Am. Med. Ass’n. Baker : Myopia. 
he pursues these phantoms the more he is harrassed by 
them, nothing being more fatiguing than the observation 
of such entopic phenomena.” 
But this is only the beginning of a long series of acci- 
dents that may befall him. Little by little he may find 
his vision failing him, or suddenly he may discover a large 
scotoma, due to hemorrhages in portions of the retina. If 
the fovea centralis be involved, all central vision is lost. 
These hemorrhages are absorbed very slowly and they are 
very liable to recur. When absorption takes place they 
almost always leave a patch of atrophy, and vision from 
this part can never hope to be restored. 
Detachment of the retina is another accident even more 
serious, to which highly myopic eyes are especially predis- 
posed. The liquefaction of the vitreous, which occurs sooner 
or later in cases of choroiditis, is a factor that adds greatly to 
the dangers of detachment. And these are not all the 
dangers, for not infrequently cataract is developed, which 
is slow to mature, and when ripe difficult to remove on 
account of the atrophy which has taken place of its suspen- 
sory ligament and the fluid vitreous behind it, and when 
removed, the condition of the eye is often such as to be 
of but little service. And even though he escape all the 
dangers of myopia, he may have started a chronic inflam- 
matory process in his eyes, resulting in glaucoma in later 
life. 
The diagnosis of myopia is not difficult in most cases, 
although in cases of spasm of the accommodation, we may 
have emetropia or even hypermetropia simulating myopia. 
It is not unusual to find hypermetropic patients wearing 
concave lenses fitted by some optician who advertises to 
fit spectacles scientifically, free of charge. In all cases of 
error of refraction, when there is a marked difference in 
the results obtained by the ophthalmoscope and the tests 
made by the test types and lenses, atropia should be used. 
Myopic patients suffer the least inconvenience from the 
use of atropia, as their accommodation plays a small part 
in the visual efforts. Baker: Myopia. 
But to differentiate a stationary myopia from a pro- 
gressive one is difficult, especially in the lower de- 
gres, and will require the most careful examination on the 
part of the physician. 
If the myopia be less than 2 D, and the patient past 
twenty-five, and there are no annoying subjective symp- 
toms of any kind, and vision can be improved to and 
has apparently remained stationary for some time, there is 
a probability that this patient will go through life without 
any serious annoyance other than being obliged to resort 
to the use of spectacles, for distant vision. The only com- 
pensation that may be offered is that the use of presbyopic 
glasses may be postponed for a few years, but the patient 
will be obliged to resort to two pair; one for reading and 
one for distance, in later life. There is no truth in the 
popular fallacy that near-sighted eyes are strong eyes. I 
cannot refrain from calling your attention in this connec- 
tion to M. Sarcey’s little work entitled “ Mind your eyes. 
Good advice from a near-sighted man to his fellow-suffer- 
ers.” 
With the changes which take place in the choroid 
retina, optic nerves, pupils and selera, there are certain 
changes which can be seen by the ophthalmoscope, and 
reveals to the examiner the exact condition and enables 
him to say whether there has been serious damage done, 
and whether it is temporary or not, and he will be able to 
state with considerable accuracy what the prognosis will 
be. In the lower forms myopia of 2 D or less, there 
may be no ophthalmoscopic signs visible except the error 
of refraction. If, however, the disease is progressive, there 
will be a hyperemia of the fundus or blurring of the optic 
disk, in short, a sub-acute choroiditis. The appearance has 
been described as the “ peach blow fundus.” But, if the 
case has proceded a little farther, there will be a crescent- 
shaped figure added to the papilla, at the outer side. 
If it has progressed somewhat farther there will be a 
larger posterior staphyloma which may include the entire 
disk. Baker : Myopia. 
The appearance can readily be understood if we remem- 
ber that the three coats of the eye are intimately con- 
nected, and that when the sclerotic becomes elon- 
gated, stretched, the choroid and retina must neces- 
sarily undergo a similar stretching process, and will 
become thinned and allow the white sclerotic to become 
visible through it. But this is not the only ophthalmoscopic 
appearance which may be present as the stretching of the 
coats of the eye progresses. There may be a rupture of 
one or more blood-vessels and hemorrhage into the sub- 
stance of the choroid, retina, or into the vitreous, or 
between the retina and choroid, causing a detachment of 
the retina. If seen early the hemorrhage will appear as a 
bright red clot of blood. If later it will present a darker, 
almost black appearance. As it becomes absorbed there 
will be more or less atrophy of the choroid and retina and 
the position of the clot will always be recognized by a 
white atrophic patch. The clot of blood during the 
period of absorption will be surrounded by a hazy zone, 
indicating a local choroiditis. These clots will vary greatly 
in size, from that of a pin-point, almost invisible, to that 
of many times the size of the disk. There also may be 
seen other evidence of choroiditis, such as deposits of 
pigment, stretching of blood-vessels, exudations into the 
vitreous, irridocycilits and cataract. 
Prophylatic Treatment. Much can be accomplished by 
improved hygienic surroundings, good food, plenty of out- 
door exercise, long hours of sleep, good light, large type, 
good uncallendered paper, sitting erect, holding books and 
all work at as long a distance from the eyes as possible for 
distinct vision. This implies shorter school hours, less 
reading of illy printed newspapers and trashy novels, 
less practice on the piano, more base ball, running, hunt- 
ing, fishing, walking, riding, driving. In fact, a change 
in our entire educational system as now conducted. 
Whether this is practicable or even desirable must be left 
to political economists to determine. While the picture 
presented of all the evil consequences of myopia is not Baker : Myopia. 
overdrawn, the writer does not believe that there is any 
immediate danger of the race all becoming myopic. 
While statistics prove that there is a rapid progression of 
from two or three to sixty or seventy per cent, of myopia 
from the primary school through the grammar and high 
schools to the colleges, it is not probable that if all pupils 
who entered the primary schools continued their studies 
until they graduated from the colleges that the percentage 
of myopes would be so large. The myopic child is shut 
out from much of the pleasure of out-door life that the 
emetrope enjoys. His field of vision is contracted. He 
may hear the birds sing, but he does not see their bright 
plumage except as they are confined to the avery. He 
may enjoy the fragrant odors of green fields and forests, 
but his vision is limited to a few feet in circumference. He 
may be endowed with the strength of Hercules, but his 
defective vision prevents him from enjoying the boisterous 
exercises of the play-ground. Consequently he derives 
his pleasure from reading and such pastimes as he can 
enjoy with a limited range of vision. He thus naturally 
takes greater pleasure in books, and by a process of 
natural selection he continues to pursue his studies, while 
his more fortunate (some would say less fortunate) class- 
mate, with normal vision, drops out by the way and 
enters some pursuit in life more congenial. 
It is necessary to give myopic children spectacles so that 
they may be able to gain an adquate idea of the beauties 
of nature and art which surround them. It also enables 
them to sit erect and prevents the stooping posture which 
causes the congestion of the head and eyes, which is one 
of the causes of the increase of the myopia. It also, by 
placing objects at a greater distance, prevents the exces- 
sive effort for convergence and removes another fruitful 
cause of the increase of the myopia. In these cases the 
weakest glass with which vision can be brought up to the 
normal should be ordered. 
If the myopia is progressive, children should be taken 
out of school for a time, atropia used to paralyse all Baker: Myopia. 
accommodative efforts and the general health carefully 
attended, out-door sports encouraged and all efforts at 
vision for small objects interdicted. If necessary, a broad 
shade or tinted glasses may be ordered. It is a question 
in the minds of many oculists whether the error of refrac- 
tion should be corrected with spectacles. In my opinion 
it should be, as the improvement in the vision will more 
than counterbalance the injury, if any, due to increased 
accommodative efforts. 
At the end of some months, or a year, it may be per- 
missible, if the myopia ceases to be progressive, to per- 
mit the studies to be resumed, but it should be done 
guardedly and close watch kept of the eyes for a 
relapse of the malignant trouble. 
Considerable judgment and experience is necessary in 
ordering spectacles for these cases. The following remarks 
are suggestive, and cannot be followed implicitly. 
In low degrees of myopia, I D, or less, it is usually best to 
correct the myopia fully, and the same glasses may be 
worn for reading and distance or for distance only, and 
none for reading. The comfort of the patient should be 
consulted, especially in adults, as to wearing of them for 
reading. If worn for distance only, eye-glasses may be 
given if preferred by the patient. 
In moderate degrees of from 2 to 5 D it is usually ad- 
visable to wear spectacles both for reading and distance. 
If the same glass can be worn with comfort for both near 
and distant vision, it is preferable to do so, as it avoids the 
necessity of using two pair of spectacles. In many 
myopes of this class, especially if the use of glasses has 
not been commenced until after adult life, the increased 
accommodative efforts required to see distinctly near ob- 
jects causes fatigue, and may necessitate the use of a 
weaker pair for reading. In higher degrees of myopia of 
from 5 to 9 D, two pair of lenses will usually be required, 
one correcting the error of refraction fully and another of 
lower power for reading. In high degrees of myopia of 
9 D or over, it will be seldom practicable to correct the Baker : Myopia. 
11 
refraction fully, and the patient must be content to see less 
perfectly at a distance. It is usually advisable to determine 
the amount of error accurately and then deduct about 4 
D from this amount. Many patients will wear this glass 
with comfort for both near and distant work, although 
some will require a weaker lense for reading. 
If there should be a difference of more that 1 D in 
the refractive error of the two eyes, it is not advisable to 
correct both, but correct the weaker of the two, and 
give a similar lense for the other eye. If binocular vision 
has never been established, owing to a great difference in 
refraction of the eyes, one eye being used for distance 
and the other for near vision, an exception to this rule 
may be made, and each eye corrected independently of 
the other. 
If any astigmatism be presented in either eye, it should 
be corrected fully. 
[Reprinted from the Cleveland Medical Gazette, October, 1890.]