Reprinted from the 
CHICAGO MEDICAL JOURNAL AND EXAMINER, 
For April, 1878. 
THE RELATION OF AMETROPI^ TO BLEPHARITIS 
CILIARIs/ 
By F. C. 
In a great many cases of blepharitis ciliaris* which present 
themselves for treatment, the disease has persisted for a period of 
several months, if not years. Perhaps the patient has never had 
any treatment for his lid trouble and thus its persistence is not to 
be wondered at. But often ive are informed that the patient has 
been under the care of experienced oculists^; that the lids improv- 
ed and seemed to get well; but that sooner or later the inflamma- 
tion recurred. Such patients of course, become rather discouraged 
by this experience and physicians who have occasion to observe 
their frequent relapses are misled into the belief that blepharitis 
iss a very intractable disease. And yet it is far from being so. 
Its obstinacy is more apparent than real, and can, I think, be 
easily accounted for. We must only remember that the patient 
does not consider the disease dangerous because it does not 
directly impair his sight; that it is the unsightly appearance of the 
ulcerations and crusts upon his lids for which he seeks medical 
advice. By a few local applications these ulcers are so nearly 
healed that the edges of the lids do not become crusted over any 
longer. The defacement is removed, although the disease is not 
eradicated. But as the patient was concerned only about the 
disfigurement, he abandons treatment as soon as the cause? of his 
anxiety is removed, and before a thorough cure can be accom- 
* This term is now commonly used to designate the eczematous inflammation which shows 
itself along the edges of the eyelids and involves the follicles of the eyelashes (cilia). It is also 
called ophthalmia tarsi. 2 
plished. The lids remain in a morbid state, and the most insig- 
nificant irritation suffices to rekindle the inflammation. This is 
not likely to occur if the treatment is properly continued until 
the lids do not show any infiltration or congestion or desquama- 
tion. But these are exceptional cases, and therefore a perman- 
ent cure of blepharitis is seldom recorded. 
This explanation is not invalidated by the fact that many 
patients have used one or another remedy for blepharitis many 
months without any lasting benefit. I lay great stress upon this 
one point: that the surgeon himself must attend to the treatment, 
if it is to be efficient. For I have been convinced by numerous 
observations that to leave the local treatment of the lids to the 
patient or, if it is a child, to the parents, amounts to little or no 
treatment. Parents are too kind-hearted to insist upon thor- 
oughly cleansing the crusted lids when at their first attempt 
the little darling begins to scream; and they are too timid to 
apply the ointment to the very edge of the lid. The remedy is 
either rubbed upon the crusts or smeared all over the cutaneous 
surface of the lid except its edge. And in either case it will be 
of just as much benefit as if it had not been used at all. 
Under these circumstances it would be surprising, indeed, if a 
relapse of the disease were less frequent when the affected tissues 
have neither recovered their sound molecular structure nor re- 
sumed their normal functions. The untimely interruption, and 
the insufficient mode of the treatment, therefore, seem to me to 
fully explain, in the majority of cases of blepharitis, the unsatis- 
factory results so commonly obtained in private and hospital 
practice. And I do not think it is necessary to look beyond 
these very plain causes and attribute to the refraction of the 
eye any great influence upon the development of blepharitis 
ciliaris. This view of a direct relation between refraction and 
tarsal inflammation was first entertained by Dr. D. B. St. John 
Roosa, of New York. Before the International Ophthalmological 
Congress, held in New York, September, 1876, he undertook to 
show that ''ametropia (anomalous refraction) seems to be the 
condition of most eyes affected with blepharitis ciliaris;" that 
" hypermetropia is the error of refraction most frequently asso- 
ciated with blepharitis ciliaris;" and that "when blepharitis is 3 
associated with errors of refraction, the cure of the edge of the 
lids is very much facilitated by, and sometimes depends upon, the 
correction of the ametropia." * 
In support of these views Roosa presented a statistical report 
of 31 cases of blepharitis, of which 26, or 83^ per cent., had re- 
fractive errors (13 hypermetropia, 5 myopia, 8 astigmatism) and 
only 5, or 16^ per cent., had emmetropic eyes. 
Dr. P. D. Keyser, of Philadelphia, confirmed Roosa's views by 
a reportf of 31 cases, of which 25 had hypermetropic eyes, and 
6 were astigmatic. But while Roosa is inclined to believe that 
ametropia only predisposes to the outbreak and favors the con- 
tinuance or relapse of the lid trouble, Keyser goes a step further, 
and thinks that "accumulations of experience may show the fact 
of ametropia being in many, if not all cases, the direct cause of 
blepharitis." t 
On the other hand, Dr. Ad. Alt, resident surgeon of the New 
York Ophthalmic and Aural Institute, says § : 
" Since Dr. D. B. St. John Roosa, at the meeting of the 
international ophthalmological congress, held in New York in 
September, 1876, has advanced the idea that blepharitis ciliaris 
was, in about 83 per cent, of the cases, connected with ametropia, 
and holds ametropia a frequent cause of conjunctivitis and 
blepharitis, 48 patients have been especially examined with regard 
to that statement; 39 of them had emmetropia, 5 myopia, 3 
hyperopia, 1 astigmatism - certainly no striking prevalence of 
ametropia." 
My own observations during the past year extended over 18 
cases, in private practice, of idiopathic || blepharitis, of which 
only 5 or 33 per cent, showed ametropia (4 hypermetropia, one 
myopia and one astigmatismus). The state of refraction was 
* " The relations of Blepharitis ciliaris to Ametropia," in the report of the fifth International 
Ophthalmological Congress; also published in the Amer. Joum. Med. Sciences, January, 1877. 
t"On some forms of inflammatory diseases of the eye being caused by defects of the refrac- 
tion and accommodation," in the Transactions of the Med. Soc. of the State of Pennsylvania, 1877. 
J Phila. Med. Tinies, 1877, p. 268. 
^"Clinical Report of 3,873 Eye-patients treated at the New York Ophthalmic and Aural 
Institute during the year 1876," in Archives of Ophthalm. and Otol., vol. vi., p. 180. 
|| I. e., not complicated by (or the sequela; of) other inflammatory affections of the eye 4 
carefully ascertained by means of the ophthalmoscope, without, 
however, the previous use of atropia, which Keyser employed in 
all, and Roosa in the majority of cases. Though the accommo- 
dation becomes pretty well relaxed in the dark room, and 
although I had frequent opportunity for testing the reliability of 
my ophthalmoscopic measurement afterwards, when the eyes had 
been atropinized, and found it confirmed by the other tests-1 
admit that the influence of the ciliary muscle is not as completely 
suspended in the dark room as by the paralysing action of 
atropia; and I concede that, had I employed the atropia, some of 
my cases might have shown a slight degree of hypermetropia, 
and consequently increased the percentage of ametropia. 
I am quite willing to make this concession ; for I hope I shall 
be able to prove that the mere statistical fact that ametropia pre- 
vails among blepharitic patients, cannot be accepted as conclusive 
evidence of any etiological connection between the two affections. 
I think I can show that such deductions are as fallacious as the 
argument of post hoc ergo propter hoc, which in therapeutics has 
so often led to deception and disappointment. 
In the first place, the high percentage of ametropia Dr. Roosa 
has found among his blepharitic cases, is nothing very extra- 
ordinary, since the examination of thousanus of atropinized eyes 
has shown that ametropia is the rule and emmetropia the excep- 
tion in the refractive state. F. Erisman,* of St. Petersburg, 
examining the refraction of the atropinized eyes of 4,358 pupils, 
aged from 6 to 20 years, found 30.2 per cent, myopia, 43.3 per 
cent, hypermetropia, 26 pei' cent, emmetropia and 0.5 per cent, 
amblyopia. In other words, 73.5 per cent, ametropia, against 
only 26 per cent, emmetropia ; a result which comes pretty near 
the statistics of Dr. Roosa. 
Those who believe in the causal 'relation between ametropia 
and blepharitis, refer, in advocating their views, to the well- 
known fact that the continued use of the eyes for near work (as 
reading, writing, sewing) often occasions a hypermmia of the 
conjunctiva and the edges of the lids. This hypersemia - they 
continue to reason-becomes chronic, produces an alteration of 
♦ Graefe's Archiv. f. Ophthalmol., xvii., 1, p. 8. 5 
the nutrition,.and finally leads to an inflammation of the tissues 
involved. Says Keyser* : 
" That ametropia of any kind or form causes in all acts of vis- 
ion a strain more or less upon the eye. which creates a hyper- 
acmic condition of the neighboring parts, is a well-known fact, as 
may be seen in many cases by red and congested conjunctiva and 
edges of the lids after use at close work or reading. In cases 
where the strain is so great as to create a continued hypersemia 
of the edges of the lids, the extremely fine ducts and external 
openings of the small sebaceous glands that are to be found in the 
canals and follicles of the cilia, become closed by pressure from 
the swelling of the tissue and vessels surrounding them, and hav- 
ing no outlet for the natural secretions, which are now increased 
by the hyperaemic condition, a choked status results, and inflam- 
mation and suppuration take place, as may be noticed by the 
little pus beads that are found encircling the cilia and extending 
down the canal to the gland." 
According to this view a great strain of ametropic eyes, during 
the act of near vision, is the primary condition which ultimately 
leads to the inflammation of the lids. 
Now, in the first place, this accommodative strain does not 
place in near-sighted eyes, unless they are armed with unsuit- 
able glasses. We know that myopic persons can read or write 
almost day and night without feeling the least fatigue in theii* 
eyes, because their far point of vision is so near the eye that they 
have to make little or no effort at accommodating their focus for 
the short distance at which they wish to read or write. A per- 
son, for instance, with myopia 1-14 does not make the least accom- 
modative effort while reading books printed in the usual types at 
the distance of twelve to sixteen inches, because if the accommoda- 
tion of these eyes is completely relaxed, the farthest point of dis- 
tinct vision is at 14 inches in front of these eyes ; therefore 
if their eyes are perfectly at rest they can see distinctly 
at short distances to accommodate for which the normal 
(emmetropic) eye has to make a considerable effort. This 
exertion, if continued for hours, must necessarily exhaust 
* Transactions of the Med. Soc. State of Pennsylvania, 1877,'p. 536. 6 
the muscular force of the emmetropic eye, and produce the 
sensation of fatigue; while the near-sighted eye does not get 
tired, and on this account is often erroneously taken for a 
" strong " eye. 
In view of these facts it is impossible to recognize in myopia a 
source from which through a continued strain of accommodation 
and consequent hyperaemia of the lids, the tarsal inflammation 
could derive its origin. 
It is a different thing with hypermetropic eyes. Hypermetro- 
pia, if not corrected by convex glasses, is the source of a contin- 
ual strain upon the eyes. The accommodation of far-sighted eyes 
is never relaxed except during sleep, because they must make 
more or less effort at accommodation even when they look at dis- 
tant objects, in order to overcome the refractive error, and to 
gain a well-defined, focalized impression upon the retina. This 
same effort to correct the anomalous refraction, must be made 
during reading or writing, in addition to the amount of accommo- 
dative action which is required to change the focus from distant 
to near vision. It is evident, therefore, that hypermetropes use 
their eyes for near work under very unfavorable conditions; the 
abnormal strain upon the accommodative function must sooner 
or later exhaust the power of the ciliary muscle; the eyes be- 
come tired, heated, red and painful; the vision is obscured, and 
the patient is obliged to interrupt his work. People generally 
call such eyes " weak," and oculists use the technical term 
" asthenopia," to designate in one word all these symptoms due 
to the overwork of accommodation. 
As long as hypermetropic eyes are not employed much for 
near work, and if there is but a slight degree of hypermetropia, the 
person will not be troubled by asthenopia, because the strain 
upon the accommodation is not sufficient to produce it. The 
presence or absence of asthenopia, therefore, gives us a pretty 
sure indication as to whether or not there is any great strain 
upon the eyes. And where this strain is not sufficient to give 
rise to asthenopic trouble, it is certainly not great enough to 
affect such distant parts as the eyelids, so intensely as to produce 
blepharitis. 
Roosa found hypermetropia 1-48 to 1-30 in nine cases, and 7 
hypermetropia. 1-24 to 1-8 in four cases; Keyser reported hy- 
permetropia 1-48 to 1-30 in twenty cases, and hypermetropia 
1-24 to 1-5 in 5 cases. This preponderance of the slight degrees 
of hypermetropia, which so seldom give occasion for asthenopic 
trouble, militates strongly against the idea that they should play 
an important role in the development of the lid trouble. If we 
actually admit that these slight degrees of hypermetropia can 
have so far-reaching an influence upon the lids, we shall find it 
very difficult to account for the fact that blepharitis is so seldom 
observed in the large number of hypermetropes who consult us 
on account of asthenopia, and whose eyes decidedly labor under a 
great, continued strain. I have always observed the rule to 
record any visible morbid condition of conjunctiva, lids, etc., in 
patients who consulted me on account of refractive anomalies. 
In examining such eyes I could not fail to detect even a slight 
degree of blepharitis. And yet, looking over my memoranda for 
the past years, I find only 4 cases of blepharitis among 267 cases 
of anomalous refraction. In all these cases the error of refraction 
was so marked that it impaired the function of the eyes, and in 
the most of the hypermetropic and astigmatic eyes produced 
more or less asthenopia ; and nevertheless the nutrition of the 
edges of the eyelids was not disturbed except in four cases. 
While on the other hand, where the edges of the lids were in- 
flamed, the anomaly of refraction was as a rule so insignificant 
that under ordinary circumstances it did not give any inconven- 
ience to the patient, and it required artificial means to establish 
its presence. 
As especially conclusive evidence of the causal relation be- 
tween hypermetropia and blepharitis, Keyser referred to one 
case, with these words: " Also in the case of June 5, 1876, the 
hypermetropia was, without doubt, the cause of the blepharitis; 
as the lids of only one eye were affected, and this was the hyper- 
metropic one, while the other was normal and no defect of 
refraction could be found." * 
But this case is not so positive a proof of any direct connection 
between the two affections as it seems at first sight. In fact, it 
* Transactions of Medical Society of State of Pennsylvania, 1877, p. 536. 8 
becomes a very doubtful argument as soon as we know that 
blepharitis may be limited to one eye also under altogether differ- 
ent circumstances, as the following case may illustrate : 
On October 3, 1876, I was consulted by the parents of Felix 
M , aged 9 years, because they believed him to have become 
near-sighted. They remarked that when reading he would bring 
the book very close.to the eye, and could read but a short time. 
Each eye showed V= 20 which was deteriorated by even the weakest 
convex glasses. But he could read large print (Jaeger 7) only, 
and had to hold the book as near as six inches to the eye. 
The ophthalmoscope detected H. 1-16 ; otherwise the fundus was 
normal. He was given convex 24 and after having these glasses 
on 10 minutes, he could read smaller print (Jaeger 3) and at a 
greater distance than he could without glasses. The right upper 
lid was covered with crusts produced by extensive ulcerative 
blepharitis, while the other lids did not show any defect. 
In this case the blepharitis was confined to one lid, but, un- 
fortunately for Keyser's theory, both eyes showed the same 
degree of II. and the same amount of accommodative strain. 
There is another fact which does not well agree with the view 
that the strain caused by ametropia is the principal cause of 
blepharitis. I refer to the fact that this disease is most frequent- 
ly met with in children ; and if it is observed in older persons, 
they can generally date the first outbreak back to childhood. As a 
rule we can say the disease is developed at a time of life when the 
acts of vision do not demand any continued efforts of the eyes. My 
experience is that the greatest number of blepharitic patients is 
observed among children under five years of age. And I was 
surprised by finding that neither Roosa's nor Keyser's list con- 
tains a single patient under five years and that both tables include 
very few patients between five and ten years. Can they really 
not have observed any such cases, or did they omit them because 
the tests of vision cannot be employed in so young children ? As 
my experience is greatly at variance with their statements, I will 
give here a statistical rdsumd from my private and hospital 
records. 
In private practice I observed during the four years, 1874 to 9 
1878, 73 cases of blepharitis ciliaris. According to the age they 
can be classified as follows: 
Under 5 years 27 cases, or 37 per cent. 
Between 5 and 15 years 22 " " 30 " 
Between 15 and 20 years 14 " " 19 " 
Over 20 years 10 " " 14 " 
The record book of the Illinois Charitable Eye and Ear In- 
firmary gives this information : 
Total number of cases of blepharitis during 1876...34. 
Under 5 years 16 or 47 per cent 
Between 5 and 15 years 11 or 32.3 " 
Between 15 and 20 2 or 6.0 " 
Over 20 5 or 14.7 " 
Total number of cases of blepharitis during 1877 55. 
Under 5 years 19 or 34.5 per cent. 
Between 5 and 15 vears 21 or 38.2 " 
•/ 
Between 15 and 20 years 9 or 16.3 " 
Over 20 years 6 or 11.0 " 
The hospital and private records agree in proving the preva- 
lence of blepharitis among children, and a careful inquiry into 
all the circumstances associated with the beginning of the disease 
would, in most cases, discover other and more potent causes than 
ametropia. 
sIn a few instances it has been mentioned that the edges 
of the lids which had been treated unsuccessfully for years, 
got-well without much treatment as soon as the refractive error 
was corrected by suitable glasses. These observations fully 
coincide with the experience so often gained in cases of conjunc- 
tivitis, that they prove to be rather obstinate to the usual topical 
treatment, but are speedily cured as soon as any anomaly of re- 
fraction has been corrected. In either case the rapid improve- 
ment in the condition of the lids must be attributed to the cor- 
rection of the ametropia; there is no doubt of that. But this* 
improvement takes place, not because by correcting the refrac- 
tion we remove the original cause of the disease, but because we 
abolish thereby a condition which is apt to aggravate and prolon- 
gate an existing inflammation of the conjunctiva or lids. Jus 
as the least amount of smoke in the air, which does not make any 10 
palpable impression upon a healthy conjunctiva, markedly irri- 
tates an already inflamed conjunctiva, so does the abnormal effort 
hypermetropic and astigmatic eyes have to exert in near vision, 
more strongly affect the eyes of the lids in the inflamed than in the 
healthy state. While any congestion produced in healthy eyelids 
will pass off without consequences, it will increase the inflamma- 
tion and retard the recovery of inflamed lids. And this, I think, 
is the real relation of ametropia to blepharitis ciliaris; the affec- 
tion of the lids may sometimes be rendered very obstinate through 
the adverse influence of hypermetropia or astigmatismus. We 
must look upon ametropia as a complication of blepharitis; and 
whenever the affection of the lids, especially in adults, does not 
readily yield to a proper treatment, we may find a certain degree 
of ametropia to be the cause of the obstinacy of the disease. If 
this is the case we should of course remove this, like any other 
complication, in order to put the lids in the most favorable con- 
dition for recovery.