SATTLER: The Surgical Treatment of Kerato-Conus. 341 one-half size lenses in grab-frames, to be worn over her distance glasses for eading and close work. With their assistance she reads, at good range, without difficulty, - Snellen, I.

THE SURGICAL TREATMENT OF KERATO-CONUS. BY DR. ROBERT SATTLER, CINCINNATI, OHIO.

Some years ago I began a study of this congenital deformity of the cornea, together with a search of the best surgical intervention for those cases of double kerato-conus in which all other methods of treatment, as well as optical aid, afforded unsatisfactory or no relief. In the selection of cases care was exercised to include only typical examples of this uncommon affection in which there was little or no question concerning the congenital origin. Those cases were excluded in which this was in doubt, or if it could with reasonable certainty be assumed that antecedent disease of the cornea, conjunctiva, and other structures had existed. The common experience was soon shared, that the various and vaunted methods of treatment were either found wanting entirely or at least proved themselves, after faithful trials, unsatisfactory. The experience gained, even from the earlier cases, forced on me the uselessness of most methods of treatment and other accessory measures, viz., absolute rest of the eyes, avoidance of all violent physical exertion, prolonged use of atropine, the use of compress-bandage alone or combined with eserine instillations, attention to the general health either by change of climate, occupation, or medicinal treatment, etc. It was found, moreover, that only through the aid of corrective lenses, assisted in most instances by stenopaic appliances, could effectual assistance be rendered. This, again, could OPH.-7

342 SATTLER: The Surgical Treatment of Kerato-Conus. be done in those cases only which remained stationary or were slowly progressive after an interval of several, or even many, years -and in those exceptional instances in which a rapid progression mysteriously starting was spontaneously arrested. Although the benefit from lenses in the progressive cases is only transitory, it is the only means by wlhich better vision, and often, also, greater comfort, can be secured, thus enabling the patient to use his defective sight to the best possible advantage. It is also surprising that one often finds that the aid which lenses afford, in raising vision to a definite numerical standard, is insignificant or not evident at all, or the combination of lenses required seems to be an impossible one; nevertheless, the patient expresses himself pleased, and proves the expediency of selecting just that particular combination by its continued use. Mydriatics, homatropine, atropine, etc., were resorted to in all my examinations to render the investigations as complete as possible. In the final selection of lenses, however, I was invariably governed by empirical tests made when the eyes were in their normal state. Such tests, to be satisfactory, require the most deliberate and painstaking attention. The rule, which appears to be one of general adoption, is to prescribe any lens or combination of lenses which may, after a trial, aid the patiepnt's defective sight or add to his comfort in the use of his eyes. In most cases, lenses may be advantageously supplemented by stenopaic devices. In some instances, the latter may afford assistance when lenses do not. . The inefficiency of the various methods of treatment and the unsatisfactory relief so far even as lenses are concerned, led to a more careful study of the different surgical methods at our dis-

posal. We know nothing definite of the pathology of this congenital lesion or malformation of the cornea. What we do know, clinical observation and experience gained from su,rgical intervention have taught us. Kerato-conus is like the higher degrees of myopia and keratoglobus, a congenital deformity. It affects the anterior pole of the

SATTLER: The Surgical Treatment of Kerato-Conuls. 343 eye, the central and immediately adjacent regions of the cornea being usually involved. In most instances, the disease affects both eyes. It may remain stationary for life. In certain cases, however, this conical deformity, or, as it has also been aptly described, staphyloma pellucida, develops, as the result of mysterious local causes (whether suddenly or insidiously, is not known), a tendency to progression. A remarkable and fortunate feature connected with this progressive increase of the deformity is, that in a certain number of instances, in which the tendency shows itself, it is spontaneously arrested, after a variable period lasting months or years. In such cases, a fraction of available vision may be preserved. In a smaller proportion the deformity, unfortunately, advances steadily, and, in consequence, vision becomes hopelessly disordered, and the eye or eyes, for all practical purposes, useless. For the latter, and smaller contingent of these uncertain progressive cases, surgical interference must be considered a justifiable and necessary venture. There is both mystery and uncertainty concerning the alleged local and general causes, as well as concerning the time of life during which this tendency may come about. There is also much speculation as to whether the general causes which affect the nutrition at large (in particular, chlorosis, pernicious anaemia, tubercular and marasmic tendencies), or the inherent latent local ones, are the more responsible factors for the destruction of sight due to an increase of this congenital deformity which up to this period has remained inactive or stationary. It is supported by the cases under observation that the tendency to progression develops, in the majority of instances, between the twelfth and twenty-fourth year, although in one case it was delayed until the thirtieth year. It was also found that the deformity is more frequently met with in women; of eleven cases which furnish the material for this clinical study, only two were males. It was impossible to determine whether the general causes

344 SATTLER: The Surgical Treatment of Kerato-Conus. were more than associate disturbances. In two cases, both young women, protracted ill-health was present. In both cases, it was certain that this influenced unfavorably the progression of the ocular deformity. A study of the cases under observation upholds a clinical resemblance to kerato-globus. Still, distinctive differences separate the former from the latter, even more unfortunate lesion. A congenital origin must be assigned to both, but the subsequent course is different. Kerato-globus, buphthalmus, and excessive myopia, are recognized more readily during the earlier months or years of life, because of the more striking deformity and, in most instances, abnormal dimensions of the globe. These congenital malformations are furthermore characterized by the subsequent pathological changes which invade such eyes and terminate in optic nerve atrophy and excavation, under the clinical picture of chronic glaucoma, hydrophthalmus, detachment of the retina, etc. In kerato-globus, as has been stated, the principal disturbances due to defective and disordered vision, occur before the tenth year, although the graver complications may be delayed until after the thirtieth year. With typical cases of kerato-conus this is different. The malformation of the cornea is often not recognized before the tenth year, and in many cases it is not discovered until unmistakable progression with increasing failure of vision has resulted. It was during the period following puberty, or between the twelfth and twenty-fourth year, that the disturbance became marked in the cases under observation. Funct'ional distress was pronounced and persistent in some of the cases, but serious complications of the optic nerve and retina, glaucoma, hydrophthalmus (such as occur in the allied affections of keratoglobus, etc.), did not manifest themselves. A complication confined to one case was abrasion and ulceration of the prominent apex of the deformity, arising from traumatism, exposure, or irritating atmospheric causes. Another case complained that every prolonged effort of the eyes produced excessive muscular weariness and that the prominence of the cornea impeded the movement of the lids.

SATTLF:R: The Surgical Treatment of Kerato-Conus. 345 In five out of eleven cases of congenital kerato-conus, surgical intervention was advised and practiced only after all other methods had been tried and lenses and stenopaic. appliances had been discarded as useless, and the patient, in consequence of the uncontrollable progression and its attending blindness, was reduced to a state of helplessness-in other words, when vision was so reduced that even with the best optical correction and stenopaic appliances less than O.I could be claimed and the reading of the large type was no longer possible even at the closest range. The surgical treatment of kerato-conus, which has for its purpose to bring about an arrest of the increasing deformity, and also the possible betterment of sight, is, in every instance in which it can be considered, a justifiable intervention. It is, however, a tedious undertaking, beset with dangers and difficulties. Nor is the object accomplished in all cases by one method or by surgical interference on the part of the cornea alone, but this must often be supplemented by operations on the iris and lens. It is a question of choice, which experience only can determine, which one of the several methods shall be selected for the most important interference, so far as the deformed cornea is concerned - whether it shall be cauterized, partially excised, or abscised with the knife. The supplementary surgery on the part of- the iris or lens is of little concern compared with the probable dangers so far as the cornea is concerned. If the selection of one or the other methods depends on preference without previous experience, that one which involves the least traumatism should be selected. In five out of the eleven cases which furnish the material for this contribution, the methods resorted to. were as follows: I. Partial abscission of the pellucid cone without penetrating through the thickness or thinness of the cornea. II. Crucial excision of narrow wedge-shaped pieces of tissue from the prominent central region without penetration. III. The placing of a number of intersecting (stellate) linear excisions through the ectactic region. IV. One or other of the first three methods, supplemented

346 SATTLER: The Surgical Treatment of Kerato-Conus. by tapping of the anterior chamber with the hope of securing a firmer scar. V. Simple iridectomy with and without interference on the part of the cornea, tatooage, but without excision of tissue. VI. The use of the galvano, or actual cautery, or the cauterization with escharotics. VII. Supplementary operation on the iris: iridectomy, iriden cleisis, for optical purposes only. VIII. Supplementary operation on the part of the lens, in those cases complicated with high myopia. IX. Supplementary operation on the part of the cornea: tatooage. Of these various methods, separate and combined, partial abscision of, and placing of linear intersecting excisions through the pellucid ectasia without opening the anterior chamber, accomplished in my cases the desired object with the least traumatism, and secured the firmest scar without too great a loss of time. The average time in which this was accomplished was eleven months. In every one of the cases, one eye was selected for surgical treatment. Cauterization with the greatest caution, in those cases in which it was tried, was more tedious and unsatisfactory. This was due to the almost uniform occurrence of necrotic changes which invaded the injured area and left the eye irritable for months and unnecessarily delayed other interference. This applied in particular to the escharotics, lunar caustic, etc., and to the most discriminate use of the actual and galvano-cautery as well. An iridectomy was necessary in most cases for optical purposes. It was found really essential that destruction and cicatrization should embrace also the regions nearer the central ones, in order to secure greater tissue-firmness and resistance. This necessarily resulted in a larger central scar. Tapping of the anterior chamber through the deformed region from which the tissue was abscised or excised was found an unwise supplementary measure.

SATTLER: The Surgical Treatmeent of Kerato-Conus. 347 The following brief reports of cases furnish evidence that surgery was adopted as a last and necessary resort, and in two cases only, both desperate ones, was it rewarded by a favorable outcome. CASE I. Miss Eloise K., Lebanon, 0. In this patienit, a young woman, wet. I9, useful vision was restored in both eyes. Until surgical interference was resorted to, she was helpless and her sight reduced to 5/200 in the right eye, and 6/200 in the left eye. Formerly, lenses had afforded some relief, but these, as well as stenopaic devices became useless and were discarded. She had been under observation for two years, and during this time every available method of treatment, general and local-eserine, compress-bandages, absolute rest, repeated adjustment of lenses,f stenopaic appliances-were faithfully tried, only to be abandoned as useless. The history conclusively upheld the congenital origin. At the age of twelve, lenses were given her which brought the sight of her better (left) eye to 0.4, and 0.3 in the right eye. She was enabled with much difficulty to complete her education. During the last two years, however, vision commenced to fail rapidly with a visible increase of the pellucid staphyloma on both eyes. The only complaint was the confusion which light produced, nor were there any evidences on the part of the internal structure which might suggest any other pathological condition except the visible one of progressive increase of the central ectactic area of the cornea. The patient's health about this time began to break down; she was anaemic, and it was feared that a tubercular tendency was about to manifest itself. A change of locality brought with it no improvement in the general health, and she returned for advice more than ever concerned about the increasing failure of sight and the marked progression of the pellu-ectasia of the cornea. She was no longer able to read the largest type and could not move about without an attendant. In spite of the disturbed state of her general health, surgical interference was advised as an imperative necessity. The more

348 SATTLER: The Snrgical Treatment of Kerato-Conus. imperfect (right) eye was selected and a small iridectomy performed downward and inwards; after an interval of several weeks, abscision of the conical protuberance of the cornea, without penetrating the thickness, was performed. Subsequently, this region wvas tattoed. One year afterwards, vision with corrective lenses was 0.4. A decided improvement having taken place in the patient's general health, the left eye was prepared for operation. The only modification was that the apex was not abscised, but instead a small wedge-shaped piece of cornea was excised horizontally, and a similar piece at right angles to it vertically. The anterior chamber was not opened. The eye resented the traumatism inflicted Jby the operation and for several months remained irritable, and it was necessary to defer tattooing until fourteen months after the operation. The final outcome in this case was satisfactory. The patient was examined recently, almost fourteen years after the first operation, and vision was found with corrective lenses to be o.6 in the right eye, which had always been the more defective one, and 0.4 in the left eye. She has been able during the last years to read and use her eyes with comfort and with not too much fatigue. CASE II. Miss B., Evansville, Ind. General health good. Small iridectomy first performed in both eyes, followed in six weeks' by tatooage without excision in the right eye. Several months later, the prominent apex of the cornea of the left eye was cauterized with the actual cautery. Both eyes remained irritable for months. Vision before the operation was less than o.i in either eye. Two years afterwards, the sight was found to be about the same, but the left eye was still irritable. Tatooage was indefinitely postponed and patient refused further interference. CASE III. Miss W., aet. 20, Wyoming. High myopia and small central pellucid staphyloma in left eye. V. = 0.2, with corrective lenses. Progressive and prominent kerato-conus in right eye, associated with high myopia. Fingers could only be counted at four feet with this eye, but by holding a book at close range, al-' most in contact with the face, large type could be read.

SATTLER: The Surgical Treatment of Kerato-Conus. 349 A small iridectomy was first performed. This was followed by the production of cataract: subsequent discisions effected complete absorption of the lens. After this, from the central region of the cornea, a series of linear intersecting pieces of tissue were excised and their scars subsequently tatooed. The reward of this case was V. = o. i, with the aid of corrective lenses and stenopaic devices. CASE IV. A. B., Cincinnati, O., aet. I 5. Double keratoconus, V. =o.i D. -not aided by lenses, but considerable improved by stenopaic appliances. The deformity was most marked in this case, and unmistakable progression was taking place. General health excellent. Double iridectomy (small), followed by application of thegalvano-cautery in the right eye. This was followed by an irritable scar and much suffering, which extended over many months and resulted afterwards in a marked diminution of vision in this (right) eye. CASE V. In contrast with the favorable outcome in the first and third cases and the negative returns for the second and fourth ones, I mention briefly my last experience with the surgical treatment of kerato-conus. Miss S., Bellefontaine, O., consulted me first about four years ago. She had never enjoyed perfect vision either for distance or at close range. I found what others had discovered before me, a well-marked conical deformity of the cornea, occupying the central and adjacent regions in both eyes. In her most defective eye (right eye), V. = o.i. Formerly, strong cylindrical comibinations improved the sight slightly, but at this time only stenopaic appliaances proved of benefit. The vision of the left eye was 0.3. She could with this eye read ordinary print, but every prolonged effort was attended with annoyance. In every other respect both eyes were found normal. The rapid decline of vision in both eyes, the imperfect aid from lenses in her best eye, and the practically hopeless state of the right one, led me to suggest an attempt to improve this hopelessly defective eye. The operation proposed consisted of the placing of a series of

350 SATTLER: The Surgical Treatment of Kerato-Conus. linear intersecting excisions of tissue through the prominent central area of the cornea, to be followed later by a small iridectomy and tatooage of the corneal scars. In order to test the susceptibility of the cornea to traumatism, I determined, as an exploratory venture, to excise a single strip of tissue, just above the center, which appeared the most prominent, parallel to the horizontal diameter of the cone. The anteritr chamber was then opened through the wound made. For forty-eight hours the eye remained bandaged and only the outer dressing removed, and there was no complaint whatever. After this, there was precipitated with incredible rapidity, on the third day, an intense reaction which foreshadowed the hopeless ruin of the eye. Complete sphacelation of the cornea, followed by panophthalmitis and orbital abscess, resulted. She opposed enucleation at first, but finally consented, and the eye, filled and surrounded with pus, was removed, only to be followed by cicatrical contraction in the cavity of the orbit. This was certainly an unhappy termination and depressing disappointment. Every possible precaution had been exercised. The operation was performed with the least possible traumatism, amidst the most favorable surroundings and the most stringent asepsis. Cocaine was instilled but once. The patient was in excellent health; in fact, everything appeared as favorable as could be wished or desired. One is almost forced to the conclusion that the greater dangers which attend surgical interference in this region are assignable to the extreme vulnerability of the central areas of the cornea to traumatism of every kind and degree. In a deformed or conical cornea, with its nutrition precarious in consequence of the distortion, and possibly, also, the greater thinness of its tissues, these dangers appear to be increased. Although serious complications need not be looked for in every case, one must be prepared to find in certain instances that the simplest surgical procedure is violently resented, and this altogether out of proportion to the injury which is inflicted. A further conclusion which suggests itself is that surgical

Discussion.

35 I

intervention should not be resorted to in one eye which is hopelessly defective if the fellow eye still retains V. = 0.3 or 0.2, even, if it can be established that the deformity in this, the best eye, is slowly progressive. Spontaneous arrest is possible at any stage of progression, and such an arrest with a fractioin of useful vision is infinitely preferable to the risks, tediousness, and loss of time which must necessarily be incurred if surgery is resorted to for the more defective eye. My own very limited experience with these cases would prompt the suggestion to defer surgical treatment until vision is reduced to less than O.I in both eyes, and lenses and stenopaic devices are discarded as useless, and the patient is rendered helpless in consequence of the resulting loss of sight. DISCUSSION.

DR. W. F. MITTENDORF. - It is a peculiar fact that very high degrees of myopia in children, after removal of the lens, require fairly strong convex glasses in order to make them see. That would, according to my mind, show that the myopia was not exactly due to axial distension of the eye, but to the condition of the lens. I have had two cases of this kind under observation, one of which was seen with me by Dr. Roosa, and the other by Dr. Derby. Cataractous changes developed in the eye and necessitated an operation, and in both, one a child of six and the other a boy of twelve, the myopia, which had amounted to I2 Ds. and I4 Ds., was overcome, and they now required a convex lens of 7 Ds. and 8 Ds. in order to see well, showing that the antero-posterior axis was not so much at fault as was the refractive media. Often, in these cases of conical cornea, the use of a pressure bandage after the operation for the removal of the lens, or after a simple paracentesis of the cornea, may help to relieve the conical shape of the cornea. DR. C. J. KipP. - I would like to ask Dr. Sattler if his experience with other operations for high degrees of myopia is the same as in this case? DR. SATTLER. - My limited experience with other cases was not very satisfactory. I have only given the history of this case, but mention in the full report the same view as that expressed by Dr. Mittendorf. I believe that the case was one of congenital malformation of the lenses, with preservation of their perfect.

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I)iscussion.

transparency, but with changes in the indices of refraction of different parts or sections. This explains the apparent excessive myopia and the high degree of amblyopia, neither found to exist after the operations were performed, but, on the contrary, her vision was surprisingly good, the myopia moderate, and the amblyopia not at all marked. I have had other cases of excessive myopia, for which operation was undertaken, but in these marked changes at the posterior pole of the eye were present. DR. H. KNAPP. - I would like to say a word about keratoconus, for I differ with Dr. Sattler in his opinion that when one eye is tolerably 'good we should not interfere. It is just in those cases that I operate. I do not think it is correct, either, that the protrusion is central, for, so far as my experience goes, it is in the majority of cases somewhat below the center. I have not been unlucky in regard to the results of the operation. For a number of years I have stuck to one method, the galvano-cautery, and the results have been satisfactory. *The greatest protrusion is here (illustrating). The principle upon which the operation acts consists in the secondary contraction of a cicatrix, and if we fail to produce that we fail in the operation. It may be done by cauterization with silver nitrate, or the galvanic cautery, etc. If I used the latter superficially so that there was no perforation, the wound healed and the conus was not verv much reduced, so that I have lately resorted always to perforation, and in a number of cases do that with the disk-shaped electrode. Holding it a little sidewise, I get a small opening, but in other cases I have pressed it on the cone, turned on the current that produced the scar, and if there was no perforation I made one with a pointed electrode. I have not seen a case of inflammation following it, but it takes six weeks or more for the ulcer of the cornea to cicatrize. I keep the patients in the hospital and watch them very carefully. If the cicatrization takes place in four or six weeks with closure of the fistula, glaucoma is apt to follow, but it is usually combatted with eserine, as are the milder attacks of glaucoma, and if that is not sufficient, a paracentesis or an iridectomy will cut the glaucoma short. In only two cases have I been obliged to make an iridectomy. DR. THEOBALD. What happens to the iris in these cases? Do Vou have anterior synechia? DR. KNAPP. - Yes. In about one case in four, but in those cases iridectomy is not usually necessary, for often the iris frees itself afterwards.

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353

DR. T. Y. SUTPHEN.- I have within the last few years operated upon two cases of conical cornea in the same family with the galvano-cautery. One, Dr. Knapp saw with me, and advised this course. The result was a slight scar without perforation and apparent arrest of the trouble. DR. KNAPP. - I think' it is essential not to use the electrode at white heat, and this also applies in using the ordinary -galvanocautery in ulcers, etc., for it causes scarring and destruction to a greater distance than we desire. In one case where I cauterized twice, the lens was affected and I had to operate later for cataract. DR. H. D. NOYES - It is an experience that has been confirmed by many, that cases of conical cornea are often improved in vision by the employment of convex cylinders. DR. EMIL GRUENING. -The discussion being on the removal of the lens in high myopia, etc., and Dr. Sattler having said that his experience was " negative " in some cases, I would like to hear Dr. Sattler explain what he means by that. Did he lose the eye, was there detachment, was the lens not absorbed, or what was the outcome of his operatibns? DR. SATTLER. - The patients selected were all under twenty, and the surgery resorted to was not attended by unfavorable sequences, but the final results were not as satisfactory; that is, they were not benefited as much as was hoped for. They simply did not come up to the expectations, either with or without the use of lenses after the results of the operation were fully disclosed, when compared with the acuity of vision which existed before with the old lenses. DR. C. J. Kipp. - Only good results have been reported here from kerato-conus operations. I saw a case, some time ago, however, in which the operation done by a good operator was followed by panophthalmitis six weeks after the operation. The eye was apparently doing well for six weeks, when suddenly purulent irido choroiditis developed, and the end was destruction of the-eye. DR. C. S. BULL. - On the operations in high myopia it seems to me we need a great deal more information to determine the cases that are operable. I have kept a record of 347 cases of very high myopia, that is, more than I2 Ds., and in only three was the condition of the eye such that it seemed to make such an operation advisable or desirable. In only three was the fundus in such a condition as to make it at least wise to operate, and in all three

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the operation was declined when a statement of the dangers was presented to the patient. In the one case in which I have operated, a young person of eighteen, with a myopia of i8 Ds., and a fairly healthy fundus, the result was extremely unsatisfactory. The swelling of the lens was very rapid, with intense injection, so that extraction of the lens had to be done within forty-eight hours after the needling, and the result was but little improvement in vision, due to the opacity of the capsule which followed, and the condition of the eye was such that I was afraid to operate upon the capsule. DR. D. B. ST. JOHN RooSA. -What has been said by Dr. Bull agrees exactly with my own feelings on the subject. I had the opportunity in Paris to learn exactly of these operations, and I became impressed there with the belief that we need just what Dr. Bull has said, information, and exact information, as to the methods of operating and the results. I hope that Dr. Sattler will be good enough to report to this society a detailed account of each case in which the results were negative. Under the best of circumstances, the progress of the operation must be in the very nature of things tedious. The men who have had the most to do with it say that when you start out to remove the lens for high degrees of myopia, you begin a long walk and must be satisfied if within two months you have come to the end and bettered the condition of the patient. We want to know what the conditions in the background of the eye were in unsuccessful cases, and indeed we want in this comparatively new subject as much light as we can possibly get, that the few cases that come to a man in which he would operate may be treated with as much success as properly belongs to the operation. DR. S. D. RISLEY. - I think the subject of operation for myopia is one about which this society should freely speak its mind. Without wishing to prolong the discussion, I desire to place myself on record as being fully in accord with the views expressed by Dr. Bull and Dr. Roosa. After considerable experience in the management of high myopic eyes, I have not yet seen the case in which I felt like venturing upon the removal of the transparent lens. There are always pathological eyes, and I not only agree with Dr. Roosa that " it is a long walk we are taking " in attempting extraction, but wish to insist that it is one beset with many dangers. The " unsatisfactory or negative results " which Dr. Sattler has reached I think are to be anticipated in operating upon an

Discussion.

355

organ that is already diseased. In the few instances in which 1 have undertaken to get rid of the cataractous lens in highly myopic eyes, my experience has sustained such anticipation. In extracting even the opaque lens from myopic eyes, we soon learn that the danger of a bad result is much greater than in other eyes, and that they should always be included in the group of complicated cataracts. As to the conicity of the cornea, my observation has shown that in many instances the progress of the corneal distension has not been on the lines of a cone, but presents a wave-like stretching of the cornea, the axis being approximately horizontal. Before undertaking operation in these cases, unless there is opacity at the pole of the cornea, we should make persistent and patient efforts for improvement by the use of drugs, prolonged mydriasis, or eserine in some cases, and the application for a long time of a protective bandage with the subsequent earnest endeavor to correct them by the use of cylinders. In a large group of instances which had been discouraging at first, I have been able to improve the vision greatly by very high cylinders. The cylinder glasses in our ordinary test sets are often not sufficient, e.g., I have one gentleman wearing a glass composed of crossed cylinders over one eye the formula for which is -ii D. axis IO°, + IO D. axis ioo°. With this glass he has a vision of 20/40 when the glass is fixed properly before his eye. In the first study of his case I gave him a discouraging opinion, but later, with the use of the stenopaic slit, I found good vision with a suitable glass before the slit. Patient effort resulted in ordering the glass mentioned, which he has been using for twelve years or more. Before resorting to operative interference, I am sure we should always try to correct these cases with cylinder glasses. DR. NOYES.- Have you made any use of the hyperboloid lenses? I tried them for some time in the effort to improve the vision, but had to lay them aside. DR. RISLEY.- Dr. Noyes's experience agrees with my own in the use of hyperboloid lenses. DR. NoYES. -Sometimes convex lenses will do the thing when cylinders will not. DR. WM. THOMSON. - It seems to be going back to things prehistoric to say that I called attention to this over twenty years ago, and the paper can be found in our proceedings. I have quite a number of people who have passed a lifetime of comfort by

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the use of these very high cylinders. Just before leaving home I had a letter from a grateful lady in Wyoming, a schoolteacher, who has used them for many years. Dr. Knapp says the apex of the cone is never in the center, and when you approach a case of that kind you have to do so purely empirically, but by simple perseverance I have been able to get an acuity of vision of 20/40 or 20/30, which has enabled them to go on for many years without any further treatment. In many cases you produce a monocular diplopia, so that when your patient looks at a small point of light, by putting the head in a certain position, he sees the light distinctly without any astigmatic effect, and either below or above it a large pear-shaped image of the light, which can at pleasure be thrown aside, so as not to impair the view of the light proper. To make the best use of the pupillary area is the object to be attained. DR. SAMUEL THEOBALD.-I would like to ask Dr. Risley if the astigmatism in the case he referred to was equal to the sum of the cylinders? DR. RISLEY. -Yes. It was about 2I D. DR. W. H. WILMER. - I would like to ask about the effect upon the progression of the disease where these high cylinders are used. I have a number of patients wearing them, but the disease is still progressing. DR. RISLEY. - In the case I have detailed there has been no progression, but on one occasion I found it necessary to make a slight change in the direction of the axes of the cylinder. I would like to emphasize as first in importance the treatment of these cases by mydriatics, eserine, and bandaging. Dr. Sattler has said that they are usually progressive, which is in accord with my own observation in cases where no treatment has been instituted. I think they should be treated as pathological eyes. It has therefore been my habit to treat them by mydriatics for weeks at a time, allowing them to wear smoked glasses, and using a firmly applied bandage over one or both eyes. I apply it for a few days over one and then over the other. All attempt to use the eyes is forbidden, and careful attention given to the general regimen. When the eves seem to have reached a satisfactory condition for the prescribing of glasses, I then patiently work out the problem of corneal refraction, first doing it with a dilated, and later through the normal pupil. I have in my set of test glasses an opaque disk with a central opening, 3 mm. in diameter. By fixing the patient's head firmly in the optometer in the desired position, this disk is placed before the most favorable part of the

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cornea, when it acts as a diaphragm or artificial pupil, shutting out temporarily the more distorted area. Having reached the best correction possible, the mydriasis is allowed to disappear, the work carefully reviewed, and the glass ordered. Care must be taken to have it so mounted by the optician that the optical center of the glass shall rest before the selected portion of the cornea. The examination is very tedious and requires careful work and great patience on the part of both doctor and patient. DR. HARLAN. - Does the prolonged use of mydriatics have any effect upon the increase of tension? DR. RISLEY. - I have never witnessed any increase of tension, but, nevertheless, in some instances weak solutions of eserine have afforded better results than atropia, but us'ually the latter is to be preferred. It speedily secures the comfort of the patient and does the eye good. DR. L. H. TAYLOR. - Do you have any difficulty in getting the patients to wear such glasses? DR. RISLEY. - On the contrary, they are greatly pleased with them, if one is able to accurately correct a given portion of the cornea. The correct mounting of the glass is an important factor. The glasses are so strong that a millimeter or two of displacement of the optical center makes it difficult to wear them. DR. G. E. DEScHWEINITZ. - About ten years ago, following the methods recorded by Dr. Thomson in the paper to which he has referred, a few cases of conical cornea seen in the dispensary of the hospital of the University of Pennsylvania were fitted with high cylindrical combinations. Dr. James Wallace published these and other cases in the University Magazine, and recorded strikingly favorable results. At his suggestion, very high cylinders were added to the ordinary trial cases to be used for this purpose. Like many of my colleagues, I have often employed very high sphero-cylindrical combinations to improve the vision of patients with conical cornea. I agree with Dr. Wilmer that in young people these glasses do not always check the progress of the conicity. However, ordinary compound hypermetropic astigmatism may be progressive and changes in refraction must be met by suitable changes in the lenses. I have been particularly impressed with the visual results in a number of patients of mature years with conical cornea attained with high cylinders OPH.- 8

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Discu4ssion.

patients who had despaired of obtaining relief from optical therapeutics. In one recent patient, 59 years of age, with a I5c. axis ioo, V. = 6/20; without the glass, V. = counting fingers and reading print only when it was held almost against the nose. Operation had been advised as the only feasible plan of treatment before I tried the cylinder. Dr. Risley speaks of using mydriatics. I always employ them as part of the routine examination, but the final glass must be determined by a post-mydriatic examination. Indeed, for a week or more before ordering the glass I prescribe a collyrium of pilocarpine (gr. t-3 1) and continue its use afterwards. DR. MYLES STANDISH. -' I only rise on account of some remarks about hyperboloid lenses. My experience has been different from those given. I have ordered quite a number, and many of them are in use now, having proved very satisfactory to the wearers. One of my patients, who is a cataloguer in the Boston Library, has worn them for many years. I should not like to have them thrown into limbo with the general remark that they are of no use. DR. SATTLER. - I certainly agree with Dr. Knapp that the malformation is not in the mathematical center of the cornea, but involves the adjacent regions as well. So far as my experience with cauterization is concernedthis applies to the actual and galvano-cautery and caustic remedies like nitrate of silver - I have found that it is more painful and tedious, and more likely to be followed by necrotic changes which later keep the eye irritable for months. I wish to say once more that surgical treatment of the cases mentioned was resorted to only after vision was reduced to less than O.I, and after every other method had been exhausted. DR. 0. F. WADSWORTH. - I would like to say a word in regard to progression. My experience agrees with that of the other gentlemen, that the progression occurs in young people and is not likely to occur later in life, but I have seen one case which I remember especially, where the conical cornea came on as late as thirty years of age, the eye having been perfectly good beforehand. The conical cornea developed in the course of some two years and then remained stationary.