Can Hypermetropia 
BE 
Healthfully Outgrown? 
B. ALEX. RANDALL, M.D., 
Philadelphia, Pa. 
f.Reprinted from Proceedings American Opkthalmological Society, 1890.] 
HARTFORD, CONN : 
Press of The Case, Lockwood & Brainard Company. 
1890. [Reprinted from Proceedings American Ophthalmological Society, 1890] 
CAN HYPERMETROPIA BE HEALTHFULLY 
OUTGROWN ? 
B. ALEX. RANDALL, M.D., 
PHILADELPHIA, PA. 
In the study of refraction and its anomalies, it might be 
claimed that little advance has been jnade, in spite of the im- 
mense amount of work that has been done in this direction, 
since the era inaugurated by the treatise of Donders. That 
treatise marks a stage to which some of the ophthalmologists 
of to-day have not yet attained ; and while progress, real and 
considerable, has been achieved at many points, there is a large 
part of the profession which seems to close the eyes to this,-and 
persists in holding views no longer sustained by the facts. One 
of the views thus adhered to is that of the general prevalence of 
emmetropia, an assumption that has its comfortable side, and 
its long list of authoritative upholders, yet is surely in conflict 
with the experience of every careful student. We have outlived 
Jaeger’s teaching, that infants are born myopic ; and have quite 
generally accepted the showing of all later investigators, that 
they are, almost without exception, hypermetropic. Yet the 
investigations which show hypermetropia in the majority of 
school-children have met less acceptance ; and studies which 
even define emmetropia as “having normal vision” are offered 
as competent to prove the contrary ; while the known preval- 2 
Randall: Can Hypermetropia be Healthfully Outgrown? 
ence of H. after loss of the accommodation is explained by a 
theory of “hypermetropia acquisita,” backed by the great name 
of Donders. 
Much as we have received from that master which seems 
destined to remain an enduring monument of his labor and 
insight, there is danger that admiration may go much too far in 
upholding hypotheses which he framed to fill the wonderfully 
few gaps in his knowledge of this difficult subject. Surely his 
pupils have ill-learned the lessons which he taught, if they in- 
sist upon the points which he himself held only tentatively, and 
try to maintain his unsupported dicta in the face of strong 
evidence. It is as a most admiring follower of Donders 
that I wish to call in question some of the views which to-day 
pass current largely upon the authority of his name; for I be- 
lieve them to be erroneous, and would wish that his sanctioning 
of them should be forgotten. In a previous paper (read before 
the Ophthalmic Section, American Medical Association, May, 
1890) I have endeavored to show that he did not hold the view 
generally adduced from his much misused paragraph as to 
“ tone of accommodation,” which undermines his formal defini- 
tion of emmetropia; and in the present instance I would call 
attention to another misunderstood passage of his treatise — 
that on the frequency of the occurrence of myopia, page 341. 
He here gives a diagram, based principally on his case-books, to 
indicate the relative frequency of the various degrees of refrac- 
tion-error in the Dutch population — a diagram which might be 
understood to indicate that Em. is about as common as the low- 
est grades of M. or H., were it not expressly stated that the 
lines representing these are only 1/10 of their proper length. 
In fact, then, he distinctly states that Em. constitutes less than 
2.5$ of the population, although he had made outside observa- 
tions in order to correct the possibly erroneous indications 
obtained from eye-cases only. M. = i/96 or less, he reckons at 
37.Si—the corresponding grade of H. at 45$ ; and it is only by 
counting these as practically emmetropic that the percentage 
85$ Em. is obtained. Donders is far from teaching, therefore, 
that Em. predominates ; and although he indicates a larger 
proportion of myopes than of hypermetropes in his experience, Randall: Can Hypennetropia be Healthfully Outgrown? 
3 
and that the medium grades of H. are not very common, his 
results are not extremely different from those which I would 
urge as correct. 
In previous publications (“American Journal Medical Scien- 
ces,” July, 1885 ; Transactions VII, International Ophthalmolog- 
ical Congress, 1888) I have brought together as completely as 
possible all the investigations, to date, of the refraction of the 
eyes of school-children and others, in the endeavor to learn what 
is the prevailing refraction of the human eye; with the result 
of showing a decided preponderance of IT, a small percentage 
of Em., and a varying proportion of M., depending upon the age, 
class, and education of those examined. Divergent as were the 
results which had been obtained by various investigators, the 
consensus of them all gave distinct pointings ; and critical study 
of the methods used in each examination rarely failed to give 
full explanation for the deviations from the average result. 
Such results have hardly received wide acceptance, reiter- 
ated though they have been by many of the best students of 
the subject; and they have been given little of their due weight 
in practice. Theoretically it is generally conceded that all child- 
ren, as well as the new-born, are usually hypermetropic ; yet it 
is constantly being rediscovered as a new fact, peculiar to some 
special group of individuals, and is employed as a positive proof 
of any theory that needs support. The importance of refraction- 
errors in many cases is incontestible, and will be little weakened 
by such misuse of the facts ; yet it does not speak well for the 
judgment of the profession that they are so prone to ignore or 
try to explain away these teachings, except when they have 
special employment to make of them. 
Most of the investigations referred to were undertaken in 
order to throw light upon the etiology of myopia. They showed 
a disquieting rise in the percentage of this defect from the 
lower to the higher classes in the schools, and of course there 
were enthusiasts to raise a hue and cry, thunder at the over- 
burdening of the scholars, and draw all sorts of wide-reaching 
conclusions from ill-determined and insufficient data. Reaction 
was inevitable; and Donders, whose dictum, “a myopic eye is a 
diseased eye,” had been the war-cry of the crusade against 
myopia, led the recoil toward the view that myopia is a mere 4 
Randall : Can Hypermetropia be Healthfully Outgrown ? 
evolutionary adjustment of the eye to its environment, and 
wrote, “ Were it ip my power to eradicate all myopia, I would not 
do it.” To-day Cohn and others are contending that myopia is 
a curse of civilization, to be fought by the “school-physician ” 
and his hygienic dictatorship ; while Stilling and others regard 1 
all except the high grades with equanimity—rather proud of 
its prevalence in Germany, as a proof of the national evolution 
into special fitness for the highest civilization. Hypermetropia, 
it is held, is a condition of under-development common to the 
brute, the infant, the savage, and the idiot — it is put off with 
other childish things when the full stature of manhood is 
attained. 
This view, with various modifications and corollaries, is quite 
widely held, having gained ground since it was advanced, es- 
pecially by Landolt and Dor, some twelve years ago, and it is 
to it particularly that I wish to draw attention on this occasion. 
The short hypermetropic eyeball has always been regarded 
as in a condition of under-development; yet it is a newer and 
less prevalent view, that hypermetropia is merely a stage of in- 
completeness. It is quite natural that further growth toward 
the emmetropic standard should be expected of this, as of other 
infantile organs ; and this a priori view gains strength from 
the fact that, as Jaeger has shown, the infantile eye lacks some 
six mm. of its adult axial length. Add that infants are almost 
invariably H., often in considerable degree — while adults are 
assumed to be Em.—and the position seems hardly open to 
attack. Further, it has been claimed by some investigators 
that they have demonstrated this progressive decrease of the 
juvenile H.<—as when Germann found the average H. to be 
5.3 D. in the first month of life, only 3.3 in the second month, 
and 2.3 in the earlier years. Hansen also found an average 
H. = i_75 in the tenth year, declining to 0.75 D. at the fifteenth. 
Increase in the refraction of eyes, especially of children and 
young adults, has been frequently observed, not only in cases 
of progressive myopia, but in a considerable series of hyperme- 
tropic eyes, as has been recorded by Drs. Risley and Norris. 
Yet I fail to find in any of the instances any reason to believe 
that such a change has been brought about by a physiological 
growth; all have presented clear evidences of pathological pro- Randall: Can Hypermetropia be Healthfully Outgrown? 
5 
cesses; and the combatting of these by the usual therapeutic 
measures for reducing intra-ocular inflammation has been fol- 
lowed by a relief of the distressing symptoms usually present, 
and by a cessation of the change in the refraction. Many of 
the cases alluded to I have had the privilege of studying, and I 
have had others in my own practice, so that I have some experi- 
ence of the pathological form of change. But of an increase 
which could be regarded as healthy, I have met no single in- 
stance among many thousand cases. 
In a lecture recently published, MacNamara urges that young 
hypermetropes, even those with absolute H., should not be given 
their correcting glasses, or even under-correcting lenses, for 
more than absolutely necessary use at near work, much less for 
constant wear ; claiming that the normal development of the eye, 
whereby the H. would be outgrown, might thus be interfered 
with, and the defect rendered permanent. The same idea had 
previously occurred to me and led me to give under-correcting 
glasses to cases of high H.; for I had seen enough cases of this 
kind in which five years had brought no change in the refrac- 
tion to feel confident that under the frill-correcting glasses 
hypermetropia did not tend to decrease. I have since found 
occasion in some of these instances to increase the convex 
lenses, because the patient gave evidence of requiring fuller 
correction. In no case have I observed decrease in the hyper- 
metropia ; and I am now wholly skeptical as to it, and shall 
rarely repeat the experiment. 
Inclining to reject this view, then, as unsupported by any 
facts derived from my own experience, and conflicting with much 
that I have observed, it remains to be seen if it is tenable in 
the light of the studies of the eyes of the children in the schools. 
Some supporting results have been already cited. Are they cor- 
roborated by the general result, or by other reliable investiga- 
tions ? My answer must be in the negative, since the small 
decline in the H. observed seems quite fully accounted for by 
the causes of pathological distension, which are known to be at 
work during childhood. 
The study of the average refraction of children will be best 
begun by examining the findings as to the eyes of new-born 
infants, as to which five investigations are wholly available : 6 
Randall : Can Hypermetropia be Healthfully Outgrown ? 
Examiner. 
II. Eyes 
o-S 
1.0 
1.25 
‘•5 
2.0 
2-5 
3 0 
3'25 
3-5 
3-75 
4.0 
4-5 
. 
5.0 
5-5 
6.0 
6.25 
7-0 
8 0 
9 0 
10.0 
11.0 
12.0 
? 
Ag.H 
Av. H. 
Germann, . 
220 
4 
4 
6 
14 
14 
10 
8 
4 
7 
34 
16 
25 
10 
11 
34 
12 
2 
2 
3 
1073- 
4.87 
Ulrich, 
204 
30 
132 
8 
16 
2 
2 
14 
406. 
2.14 
Bjerrum, . 
122 
34 
88 
420. 
3-44 
Schleich, . 
3°° 
6 
27 
4i 
68 
68 
00 
31 
1 
1368. 
4.56 
Horstmann, 
88 
16 
16 
36 
14 
4 
2 
244. 
2.79 
Total, . 
934 
4 
56 
6 
22 7 
14 
95 
8 
4 
7 
220 
iS 
72 
25 
72 
I I 
65 
1 
12 
2 
2 
3 
14 
35H- 
3 80 
Examiner. 
H. Eyes. 
o-S 
•75 
1.0 
!-25 
i-5 
2.0 
2-5 
2-75 
3-o 3-25 
3-5 
4.0 
LO 
5-o 
5-5 
6.0 
7-° 
8.0 
9.0 
! Ag. H. 
Av. H. 
Koppe, . . . 
61 
1 
15 
20 
3 
7 
7 , - 
2 
6 
06 
n 
2.19 
Horstmann, 
74 
18 
21 
14 
r3 
5 • • 
2 
1 
1 
111.0 
1 37 
Horstmann, 
84 
24 
32 
18 .. 
6 
4 
194.0 
2.31 
Germann, . . 
119 
10 
22 
3 
16 
17 
22 
2 
1 2 
2 
8 
7 
2 
2 
1 
1 
1 
276.2 
2.32 
Total, . . . 
338 
28 
1 
82 
3 
5° 
65 
29 
2 
31 2 
4 
22 
7 
5 
2 
3 
1 
1 
1 
7100 
2.10 
Table I. — REFRACTION GRADES OF NEW-BORN INFANTS. 
Table II. —REFRACTION GRADES OF UNSCHOOLED CHILDREN. Randall: Can Hypermetropia be Healthfully Outgrown? 
7 
Some caution is probably necessary in accepting as general 
the results of several of the investigations, even though they 
give evidence of rather special accuracy. Their discordance 
with others, presumably as well done, brings their weight some- 
what into question, and indicates that they may, though per- 
fectly accurate, be accidental. Thus Germann found 19=11$ 
of infants to have H. = 9— 12, and 50$, H.=4.5 — 8 in the first 
month ; while later there were none over 8, and only 14=24$ 
over 4 D. In his young children he found three eyes with H. 
= 7, 8, and 9 D. respectively, 2=6, 2 = 5.5, and 7=4.5 — only 
14=12$ over 4 D. Yet Schleich found but 1 in 300 as high as 
8, and 31=7 D. ; and none of the other investigators met any 
such grades. The high average hypermetropia shown by the 
table rests, therefore, upon the work of these two upon 520 
eyes ; while among 414 eyes examined by others the average 
was only 2.6 D. ; and among 756 eyes as to which the grade is 
not specifically noted, the lower grades seem to have predomi- 
nated— e. g., 2 — 2.5 among Koenigstein’s 562. Horstmann’s 
very careful work was done after the first week of life, and it is 
highly probable that just as he saw practically nothing of the 
retinal extravasations frequently met in the first week, so too he 
did not see the accompanying swollen discs, the temporary promi- 
nence of which was probably measured by the others. Thus only 
can we understand the remarkable decrease of 2 D. in the aver- 
age H. from the first to the second month of life (from 5.37 to 
3.30) found by Germann. It seems probable that the average 
hypermetropia about birth is rather below than above 3 D. 
Passing on to the results in young children not yet of school 
age (Germann’s were from iA to 10, but unschooled), the few 
available records will be found in table No. 2, page 6. 
Only Horstmann’s earlier study differs from the rather re- 
markable coincidence of the other figures, with which a further 
study of his seems to have been in close accord. We may, 
therefore, accept this average as a little above 2 D. as shown. 
Turning now to the results in the schools, and using as be- 
fore every group of figures which affords the requisite data as 
to age and grade of refraction, we obtain from the studies of 
Callan, Dennett (Hyde Park and Nantucket), Howe, Emmert, 
Risley, Collard, Van Anrooy, Hansen, and Randall : — 8 
Randall: Can Hypennetropia be Healthfully Outgrown? 
Age. 
H. Eyes. 
+ 5 
.65 
■75 
.90 
1.0 
1.25 
1.50 
1 75 
2.0 
2.25 
2-5 
2-75 
3-o 
3-25 
3-5 
3-75 
4.0 
4-5 
5-o 
6.0 
5 
Ag. H. 
Av. H. 
6 years, . 
212 
18 
11 
17 
22 
52 
24 
45 
9 
12 
2 
244 0 
7 “ • 
222 
15 
6 
18 
19 
58 
22 
43 
20 
16 
2 
2 
1 
282.5 
1.27 
8 “ . 
281 
J3 
7 
33 
4' 
95 
49 
21 
2 
17 
1 
1 
1 
3°4-5 
1.08 
9 “ • 
366 
14 
10 
62 
34 
89 
38 
45 
36 
20 
2 
5 
2 
3 
1 
3 
2 
452.6 
1.23 
10 “ 
795 
26 
21 
24 
24 
124 
75 
229 
40 
197 
3 
23 
4 
5 
1180.7 
1.48 
II “ 
955 
37 
96 
73 
47 
189 
83 
296 
29 
79 
17 
6 
3 
1186.0 
1.24 
12 “ 
I044 
54 
26 
69 
57 
300 
92 
288 
60 
52 
2 
M 
3 
10 
2 
5 
4 
5 
1 
1349 2 
1.29 
i3 “ . 
889 
39 
32 
9' 
38 
296 
96 
178 
49 
40 
12 
12 
I 
3 
2 
1156 7 
1 • 3° 
14 “ . 
849 
183 
32 
93 
44 
218 
64 
1 r5 
5* 
3' 
4 
9 
3 
1 
I 
922 4 
1.09 
15 “ • 
454 
25 
27 
48 
14 
>3i 
60 
70 
26 
20 
3 
9 
8 
1 
I 
1 
3 
5 
2 
579-4 
127 
16 “ 
381 
23 
21 
4i 
23 
1 *3 
40 
61 
23 
18 
4 
1 
3 
2 
4 
1 
1 
2 
481.3 
1.26 
17 “ 
400 
57 
10 
5i 
23 
M3 
35 
40 
7 
19 
2 
3 
4 
2 
3 
1 
434 0 
1.08 
18 “ . 
338 
61 
18 
54 
6 
99 
21 
41 
4 
18 
2 
2 
2 
1 
5 
1 
1 
369 3 
1.09 
19 “ 
H3 
22 
1 
30 
7 
39 
7 
20 
2 
12 
2 
1 
M3 0 
1.00 
20 “ 
So 
J3 
6 
17 
5 
5 
4 
51-3 
1.03 
21 or more, 
I5I 
3' 
2 
3° 
39 
4 
6 
I 
4 
3 
1 
r5 
2 
10 
3 
• • 
217.0 
i-43 
Total, . 
7530 
631 
320 
740 
399 
2002 
7i5 r5°3 
1 
359 
555 
16 
96 
10 
85 
6 
19 
3 
36 
!3 
4 
6 
10 
9354 0 
1.24 
Table III.—REFRACTION GRADES IN THE SCHOOLS. Randall: Can Hypermetropia be Healthfully Outgrown? 
9 
An almost unvarying grade of hypermetropia would seem 
to be the average during this period, for the utmost variation 
is dess than .5 D., and even this may be regarded as perhaps 
accidental. Much of the variation is due to Hansen’s figures 
•—his 412 eyes, with an average H. = 1.75 at ten years and 
242 eyes with only H. = 0.75 at fourteen, change the averages 
at those ages from 1.20 and 1.22 to 1.48 and 1.09 D. A very 
slight downward tendency appears when we sum up the results 
for each five years of life, the average grade being 1.31 for the 
second period, 1.24 for the third, and 1.13 for the fourth, that 
for the whole 7,530 eyes being 1.24 D. 
Data are lacking from which to endeavor to compute the 
average H. in early adult life, Seggel’s examination of recruits 
in the Munich garrison standing about alone. He found with 
the test glasses an average H. m. = .50 in over 3,000 eyes. 
Such, then, is the evidence bearing upon our question which 
I am able to find in the literature — figures which, taken at 
their face-value, as all of equal weight, go but a short way 
toward proving any notable decline in the hypermetropia with 
the growth of the individual. Yet it requires no deep study of 
the investigations furnishing these results to convince one that 
that they are far from being all of equal value. Further, there 
are many studies which do not furnish their results in shape for 
our tabulation, yet are very distinct in their pointings, and 
probably more trustworthy than some of those used. The 
strongest case possible has been made for the view that H. is 
outgrown; and while I do not propose to undertake the invidi- 
ous task of showing the flaws in the studies cited, I will point 
out some of the investigations which seem to me of much weight 
and offsetting more or less the results above given. 
In his study at Schreiberhau under atropine, Cohn found 
the average H. of 299 eyes of children, 6 to 13 years of age, to 
be 1.20, with no relation of the grade to the age. Callan, 
among 346 eyes of negro pupils, found the average grade 1.23, 
present at all ages, from 6 to 19 years, with only accidental 
variations. Schadow, among the 240 H. eyes which he studied 
in Borchum, found an average of 1. at 7 to 8, 1.7 at 9 to 10, and 
intermediate grades at the other ages (6 to 14). Conrad found 10 
Randall: Can Hypermetropia be Healthfully Outgrown? 
an average H. about 1.26 among his youngest pupils (6 years),- 
with rather higher grades in the next years. Emmert, among 
his 3,279 hypermetropic eyes, found an average of 1.16 in the 
5 to 10 years, 1.38 in the n to 15, and 1.31-in the 16 to 20; the 
general average being 1.31 D. 
Numerous other points could readily be cited in support of 
the conclusion which I have drawn from my study, that there 
is a very insignificant decline, if any, in the grade of hyper- 
metropia during school life ; and when the occurrence of quite 
frequent pathological progression toward myopia at this age is 
taken into consideration, the surprise must be that the decline 
is so little. Before the school period there is some evidence 
that higher averages of hypermetropia are to be found than 
later; but a number of considerations more or less completely 
explain away this apparent showing. All the reliable measure- 
ments of the refraction of the very young have been made 
under a mydriatic; and while very far from believing that this 
introduces any element of error, I must hold them as not 
strictly comparable with results obtained without mydriatics. 
The grades of hypermetropia met in such work have no need 
of being scaled down for the reason sometimes urged, that the 
mydriatic must be discounted because it gives a fictitious H. 
Properly used, the mydriatic can only have increased the accu- 
racy of the results. But to make them really comparable, the 
averages found without a mydriatic most certainly need to be 
scaled up — increased by a considerable increment to represent 
the latent hypermetropia which escaped measurement. The 
use of the ophthalmoscope, which was all too rare in the inves- 
tigations which have been above cited, can do something towards 
this end; but only an ultra-enthusiastic ophthalmoscopist could 
shut his eyes to its numerous shortcomings, and believe that its 
results could not be decidedly improved upon. One of the 
investigators quoted above (Koppe) suggests the discounting 
of his results on the ground that with the ophthalmoscope he 
was measuring hypermetropia of his own instead of that of the 
patient; yet a comparison of his objective and subjective 
results shows that while he uncovered H. in 35 eyes which had 
no manifest H., he failed to see the hypermetropia with the Randall: Can Hypermetropia be Healthfully Outgrown? 
11 
ophthalmoscope in 105 eyes which had already revealed it to 
the test-glasses. Such results are common among the younger 
pupils; but my own study among medical students shows that 
the same holds among the elder. Not only did the ophthalmo- 
scopic measurement raise the percentage of H. eyes from 26 to 
67$, but it also increased the average grade from .57 to .85 D. 
So, too, Cohn found among his 299 atropinized eyes 98$ H., 
and an average of 1.20, where without the mydriatic there had 
been but 82$ H. m., with an average of .75 D. Reasons have 
already been given for the belief that the hypermetropia at 
birth is below 3 D.; and we here see that the 1.24 of school-life 
should be considered to represent a real average of about 2 D. ; 
so I believe we shall not go far astray if we accept a dioptry 
and a half as representing the extreme limit of the real aver- 
age decline in the refraction from birth to adult life. 
Such a change in the refraction is far from unimportant, and 
would abundantly serve the purpose of those who claim that 
hypermetropia is outgrown, could they adduce any evidence 
that it is due to physiological growth. In the utter absence of 
any such evidence, so far as I am aware, and with the all too 
probable explanation that the pathological progress towards 
myopia is alone responsible for the change in the many, as it 
undoubtedly is in the few, the position of skepticism as to any 
normal decrease in hypermetropia seems fully justified. The 
burden of proof certainly rests upon those who wish to uphold 
such a view. 
Two arguments deserve notice in closing. In twenty 
sections of the eyes of new-born infants V. Jaeger found the 
average axial length to be 17.5, as against 23.4 mm., in as many 
adult eyeballs. Yet these were by no means the shallow balls 
of high hypermetropia, for in almost every instance the axis 
was the greatest diameter of the globe, the vertical averaging 
but 16.4, and the horizontal 17.2 mm. While such an axial 
length in an adult eye might correspond with a hypermetropia 
of some 35 D., it must not be forgotten that the lens has its 
full adult thickness, although its diameter is only 6.3 instead of 
nearly 9 mm. Consequently its curvatures are such as proba- 
bly, even in its comparatively homogeneous condition, to fully 12 
Randall: Can Hypermetropia be Healthfully Outgrown? 
compensate for the proximity of the retina. Whether it has a 
proportionately forward position, as indicated by the shallow 
anterior chamber, need not be discussed until some evidence is 
brought forward to show that the other compensation would 
not be complete. If it can nearly compensate, as we know it to 
do, for so huge a grade of axial shortening, it will be difficult to 
prove that it is not fully competent — however wonderful it 
may seem that the eyeball should undergo such changes in its 
dimensions without alteration of its refraction. It is quite prob- 
able that many of the cases of myopia found at birth, some of 
which have been observed to decrease greatly in the following 
months, have been due to a forward displacement or subluxation 
of the lens. 
The other point that deserves a passing notice is the view 
that the tendency towards myopia is an evolutionary adjustment 
of the eyeball for the demands of near-work which environ it in 
modern civilized communities. Until the proof, yet lacking, is 
adduced to show that myopia is actually inherited, such a view 
has no claim to be treated as even a scientific hypothesis; and 
its demonstration is almost impossible. It has been repeatedly 
observed that scoliosis and myopia were developed together by 
the faulty positions of school-children, especially in writing; 
and whoever undertakes to champion the evolutionary value of 
myopia, may well be challenged to uphold the same view as to 
spinal curvature.