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Keratoconus
AMERICAN JOURNAL OF OPHTHALMOLOGY Published Monthly by the Ophthalmic Publishing Company EDITORIAL STAFF LAWRENCE T.
POST,
H. ROMMEL HILDRETH
Editor
824 Metropolitan Building, Saint Louis
640 S. Kingshighway, Saint Louis
W I L L I A M H . CRISP, Consulting
F. PARK
Editor
EDWARD JACKSON, Consulting
Republic Building, Denver
HANS
LEWIS
454 Franklin Street,
530 Metropolitan Building, Denver Editor
C
BARKAN
Stanford University Hospital, San Francisco
S.
Buffalo
O'BRIEN
The State University of Iowa, College of Medicine, Iowa City
M. URIBE TRONCOSO
500 West End Avenue, New York
W I L L I A M L. BENEDICT
The Mayo Clinic, Rochester, Minnesota
DERRICK V A I L
441 Vine Street, Cincinnati
GRADY E. CLAY
Medical Arts Building, Atlanta
F. E. WOODRUFF
824 Metropolitan Building, Saint Louis GEORCE A. FII.MER, Assistant Editor, Abstract Department HARRY S. GRAPLE 227 Sixteenth Street, Denver 58 East Washington Street, Chicago Editor E M M A S. B U S S , Manuscript 4907 Maryland A venue, Saint Louis
FREDERICK
C. CORDES
384 Post Street, San Francisco
Directors:
LAWRENCE
T . POST,
President,
WILLIAM
L. BENEDICT,
Vice-President,
F . E.
WOODRUFF, Secretary and T r e a s u r e r , EDWARD JACKSON, W I L L I A M H . CRISP, HARRY S. GRADI.E.
Address original papers, other scientific communications including correspondence, also hooks for review and reports of society proceedings to Dr. Lawrence T. Post, 640 S. Kingshiglnvay, Saint Louis. Exchange copies of medical journals should be sent to Dr. William H. Crisp, 530 Metropolitan Building, Denver. Subscriptions, applications for single copies, notices of change of address, and communications with reference to advertising should be addressed to the Manager of Subscriptions and Advertiseing, 640 S. Kingshiglnvay, Saint Louis. Copy of advertisements must be sent to the manager by the fifteenth of the month preceding its appearance. Author's proofs should be corrected and returned within forty-eight hours to the Manuscript Editor. Twenty-five reprints of each article will be supplied to the author without charge. Addi tional reprints may be obtained from the printer, the George Banta Publishing Company, 450-458 Ahnaip Street, Menasha, Wisconsin, if ordered at the time proofs a r e returned. But reprints to contain colored plates must be ordered when the article is accepted.
KERATOCONUS One of the most interesting papers read before the Association for Research in Ophthalmology this year was that of Terry and Chisholm on "Keratoconus," which is published in this issue. This disease has always been one of oph thalmology's puzzles as to both nature and treatment. Fortunately it is rare, al though the authors believe that it oc curs much more frequently, especially in cases of mixed astigmia of large amounts, than is generally suspected. Probably one reason for the inefficacy of treatment is that each physician sees so few of these cases and changes in them are so slow that the individual is often
lost from observation, or improvement may be wrongly interpreted as due to effective treatment. It has seemed to me that an endocrine disturbance was frequently at least par tially responsible for the disturbance, especially when associated with malnu trition. Most of my patients have been women, with onset occurring in their twenties. They have tended to be poorly nourished and frequently there was a history of irregular menses. Two of them had cystic ovaries. Two men were definitely hypothyroid and pituitary types. Appropriate treatment for these conditions has seemed to have been of definite benefit in preventing progress of
1171
1172
EDITORIALS
the disease. However, my cases are too few for purposes of argument and the intention of this editorial is not to dis cuss them but to refer to the treatment suggested and used by Terry and Chisholm. No originality is claimed by these writers for the idea of pressure therapy but only for the method of its applicacation. Most ophthalmologists who have employed pressure have done so spas modically and for brief periods. These authors advocate systematic and pro longed pressure. They state that this treatment "does reduce the deformity in some instances and gives permanent cure of the disease if the pressure is main tained sufficiently long (at least 10 weeks) to allow scar-tissue repair to ma ture enough to hold the newly attained more or less normal thickness of the cor nea." The authors advise restricting pressure treatment at present to patients who have keratoconus of considerable amount, with reduced vision not much improved by contact glasses. This brings up the sub ject of the use of contact glasses in this disease and here the contact glass comes into its own. If this type of glass had no other value, its usefulness in kerato conus alone would give it an important place among therapeutic devices. Like many another with whom I have talked, there have been moments when I have been so heartily sick of efforts to fit con tact glasses that I have wished that they had never been invented. So often many hours are spent in adjusting them and trying futilely to satisfy oneself as well as the patient; and even after countless attempts it is sometimes impossible to attain success. (Frequently when one suc ceeds the time spent cannot be adequately paid for.) This reaction usually follows the attempt to supply these lenses, at the earnest behest of the patient, for only a
moderate myopia in lieu of glasses, and only for cosmetic reasons. But for kerataconus—"that is another story" ! To improve vision from 5/200 more or less to 20/40 or even better, when other lenses are of almost no help, seems al most magical. Patients in these circum stances are so elated by the improved vision that they are not critical and will make every effort towards cooperation in the fitting and wearing of the lenses. Only today I waited on one of this sort whose life has been made over by the fitting of contact glasses which can be worn for 12 hours. In the acute type of case, in which there is sudden loss of vision due to apical edema and cloudiness, I have tried with astonishing success the method of X-ray treatment described by Henry Hilgartner, Jr., before the Association for Research in Ophthalmology, a few years ago. Prob ably prolonged pressure bandage would be valuable in such cases. Certainly Terry and Chisholm have given us much food for thought and ex perimentation. Their further reports and those of others who may employ this procedure will be awaited with interest. Lawrence T. Post.
DIATHERMY PUNCTURE FOR OBSTINATE GLAUCOMA One has only to look through the eye journals of thirty-five or forty years ago to realize how greatly the surgical treat ment of glaucoma has advanced since the days when iridectomy was virtually the only available operation for this dis ease. But although the average prognosis in glaucoma has been vastly improved, and although the great majority of glaucoma patients can now escape from the threat of blindness, every eye surgeon encount-
POST,
H. ROMMEL HILDRETH
Editor
824 Metropolitan Building, Saint Louis
640 S. Kingshighway, Saint Louis
W I L L I A M H . CRISP, Consulting
F. PARK
Editor
EDWARD JACKSON, Consulting
Republic Building, Denver
HANS
LEWIS
454 Franklin Street,
530 Metropolitan Building, Denver Editor
C
BARKAN
Stanford University Hospital, San Francisco
S.
Buffalo
O'BRIEN
The State University of Iowa, College of Medicine, Iowa City
M. URIBE TRONCOSO
500 West End Avenue, New York
W I L L I A M L. BENEDICT
The Mayo Clinic, Rochester, Minnesota
DERRICK V A I L
441 Vine Street, Cincinnati
GRADY E. CLAY
Medical Arts Building, Atlanta
F. E. WOODRUFF
824 Metropolitan Building, Saint Louis GEORCE A. FII.MER, Assistant Editor, Abstract Department HARRY S. GRAPLE 227 Sixteenth Street, Denver 58 East Washington Street, Chicago Editor E M M A S. B U S S , Manuscript 4907 Maryland A venue, Saint Louis
FREDERICK
C. CORDES
384 Post Street, San Francisco
Directors:
LAWRENCE
T . POST,
President,
WILLIAM
L. BENEDICT,
Vice-President,
F . E.
WOODRUFF, Secretary and T r e a s u r e r , EDWARD JACKSON, W I L L I A M H . CRISP, HARRY S. GRADI.E.
Address original papers, other scientific communications including correspondence, also hooks for review and reports of society proceedings to Dr. Lawrence T. Post, 640 S. Kingshiglnvay, Saint Louis. Exchange copies of medical journals should be sent to Dr. William H. Crisp, 530 Metropolitan Building, Denver. Subscriptions, applications for single copies, notices of change of address, and communications with reference to advertising should be addressed to the Manager of Subscriptions and Advertiseing, 640 S. Kingshiglnvay, Saint Louis. Copy of advertisements must be sent to the manager by the fifteenth of the month preceding its appearance. Author's proofs should be corrected and returned within forty-eight hours to the Manuscript Editor. Twenty-five reprints of each article will be supplied to the author without charge. Addi tional reprints may be obtained from the printer, the George Banta Publishing Company, 450-458 Ahnaip Street, Menasha, Wisconsin, if ordered at the time proofs a r e returned. But reprints to contain colored plates must be ordered when the article is accepted.
KERATOCONUS One of the most interesting papers read before the Association for Research in Ophthalmology this year was that of Terry and Chisholm on "Keratoconus," which is published in this issue. This disease has always been one of oph thalmology's puzzles as to both nature and treatment. Fortunately it is rare, al though the authors believe that it oc curs much more frequently, especially in cases of mixed astigmia of large amounts, than is generally suspected. Probably one reason for the inefficacy of treatment is that each physician sees so few of these cases and changes in them are so slow that the individual is often
lost from observation, or improvement may be wrongly interpreted as due to effective treatment. It has seemed to me that an endocrine disturbance was frequently at least par tially responsible for the disturbance, especially when associated with malnu trition. Most of my patients have been women, with onset occurring in their twenties. They have tended to be poorly nourished and frequently there was a history of irregular menses. Two of them had cystic ovaries. Two men were definitely hypothyroid and pituitary types. Appropriate treatment for these conditions has seemed to have been of definite benefit in preventing progress of
1171
1172
EDITORIALS
the disease. However, my cases are too few for purposes of argument and the intention of this editorial is not to dis cuss them but to refer to the treatment suggested and used by Terry and Chisholm. No originality is claimed by these writers for the idea of pressure therapy but only for the method of its applicacation. Most ophthalmologists who have employed pressure have done so spas modically and for brief periods. These authors advocate systematic and pro longed pressure. They state that this treatment "does reduce the deformity in some instances and gives permanent cure of the disease if the pressure is main tained sufficiently long (at least 10 weeks) to allow scar-tissue repair to ma ture enough to hold the newly attained more or less normal thickness of the cor nea." The authors advise restricting pressure treatment at present to patients who have keratoconus of considerable amount, with reduced vision not much improved by contact glasses. This brings up the sub ject of the use of contact glasses in this disease and here the contact glass comes into its own. If this type of glass had no other value, its usefulness in kerato conus alone would give it an important place among therapeutic devices. Like many another with whom I have talked, there have been moments when I have been so heartily sick of efforts to fit con tact glasses that I have wished that they had never been invented. So often many hours are spent in adjusting them and trying futilely to satisfy oneself as well as the patient; and even after countless attempts it is sometimes impossible to attain success. (Frequently when one suc ceeds the time spent cannot be adequately paid for.) This reaction usually follows the attempt to supply these lenses, at the earnest behest of the patient, for only a
moderate myopia in lieu of glasses, and only for cosmetic reasons. But for kerataconus—"that is another story" ! To improve vision from 5/200 more or less to 20/40 or even better, when other lenses are of almost no help, seems al most magical. Patients in these circum stances are so elated by the improved vision that they are not critical and will make every effort towards cooperation in the fitting and wearing of the lenses. Only today I waited on one of this sort whose life has been made over by the fitting of contact glasses which can be worn for 12 hours. In the acute type of case, in which there is sudden loss of vision due to apical edema and cloudiness, I have tried with astonishing success the method of X-ray treatment described by Henry Hilgartner, Jr., before the Association for Research in Ophthalmology, a few years ago. Prob ably prolonged pressure bandage would be valuable in such cases. Certainly Terry and Chisholm have given us much food for thought and ex perimentation. Their further reports and those of others who may employ this procedure will be awaited with interest. Lawrence T. Post.
DIATHERMY PUNCTURE FOR OBSTINATE GLAUCOMA One has only to look through the eye journals of thirty-five or forty years ago to realize how greatly the surgical treat ment of glaucoma has advanced since the days when iridectomy was virtually the only available operation for this dis ease. But although the average prognosis in glaucoma has been vastly improved, and although the great majority of glaucoma patients can now escape from the threat of blindness, every eye surgeon encount-