ON SYMPTOMATIC HETEROPHORIA. BY JUSTIN L. BARNES, B. S., M. D., Assistant Surgeon to the Manhattan Eye and Ear Hospital j Adjunct Professor of Otology, University Medical College; Fellow of the New York Academy of Medicine, etc. REPRINTED FROM THE Xeto York jftteUical journal for April 28, 18'Jf Reprinted from the New York Medical Journal for April 38, 189f ON SYMPTOMATIC HETEROPHORIA. By JUSTIN L. BARNES, B. S., M. D., ASSISTANT SURGEON TO THE MANHATTAN EYE AND EAR HOSPITAL ; ADJUNCT PROFESSOR OF OTOLOGY, UNIVERSITY MEDICAL COLLEGE J FELLOW OF THE NEW YORK ACADEMY OF MEDICINE, ETC. My method of dealing with muscular anomalies, as ex- hibited in a study of some two hundred and fifty recent consecutive cases, leads me to urge a fourfold plan in deal- ing with symptomatic heterophoria : First, correct any re- fractive error; second, wait; third, experiment with prisms ; fourth, tenotomy. In precisely this order were managed these two hun- dred and fifty cases ; and, while endeavoring to make due allowance for personal error, it is not unreasonable to claim that, occurring in private work alone, greater weight should be attached to the evidence they carry than would naturally be the case in hospital studies, where the care and responsibility are divided. It is well known that there is an intimate relation be- tween accommodation and adjustment in all binocular vision. This relation is interdependent and interinfluen- tial. Any interference with the one function entails, it is logical to assume, disturbance in the action of the other ; and this relation, so evident, is of such importance that Copyright, 1894, by D...ArTXE'r<jrrAND Company. 2 ON SYMPTOMATIC HETEROPHORIA. we can scarcely fail to conclude that heterophoria, with its accompanying asthenopia, depends chiefly upon an inhar- monious action on the part of these two elements due to fault in the one or in the other. It is my belief that the primal fault lies in an existing ametropia in the vast ma- jority of instances. Assuming at all events these premises to be correct, it will be my purpose here to set forth certain observations and conclusions pertaining to the muscle question, gath- ered, as has already been noted, from personal experience alone, and to submit them without bias, yielding at all points to their logic. I shall not weary the reader with statistics, although the basis of this paper rests upon a most painstaking and elaborate schedule of these two hundred and fifty cases, for it is my wish to present conclusions rather than figures. Nothing may be more misleading than " statistics " ; for, as in the story of the man who when asked to make out a table of data inquired as to which view of the question he was desired to prove, so we are in great danger of molding our statistics much after the manner of our faith. Behind the cold table of statistics are the many subtle details and opin- ions which make the analytical deductions the more valu- able when the statistician and the observer are, as under the present circumstances, one and the same. Much might be said of symptoms and consequences at- tending heterophoria, but in this connection the methods of diagnosis and management are alone strictly pertinent. In the determination of the kind and degree of muscu- lar error, I invariably use that< instrument of precision the phorometer, which I consider to be as essential here as I do the ophthalmometer in refractive studies, for no one can eliminate with certainty his personal error in holding prisms. In the management of the phorometer I have for ON SYMPTOMATIC IIETEHOPHOPJA. 3 years taught classes in ophthalmology these cautions: (a) To invariably test first for hyperphoria, for this is a deli- cate test as a rule, involving a fine skill in detail, which is most liable to be erroneously determined when the muscles are fatigued from having undergone what I term the grosser tests. (6) To test in direct succession only alter- nate pairs-i. e., at one time a vertical pair, then a horizon- tal pair-never, for instance, testing abduction and adduc- tion one immediately after the other, because at least four muscles are involved in the test for any two, and fatigue of an opposing pair enters here as a vitiating influence; in other words, I allow rest to take place, and gain this end by this alternate method of testing, (c) To never take an im- mediate answer, but to allow a short period of time, neither too long nor too short, and averaging about ten seconds, to elapse, in order to permit of such readjustment of the mus- cles as the latter are capable of exhibiting. (cZ) To make certain of the kind of diplopia phorometrically produced, using for this purpose a red-colored glass, this point being highly essential in observations of hyperphoria, (c) To ex- plain carefully to the patient the idea of fusion ; two lights must fuse to make a test; extinction of one light does not constitute a test. To do this I hold two ignited matches, one in each hand, before the subject, and, making their flames coincide, explain that fusion is taking place; then, while again separated, I blow out the light of one match, which, leaving one burning, I explain constitutes extinction and not fusion ; and then I call attention to the fact that it is fusion-like the former-that I am after, and not ex- tinction. I have often in this way excluded error, and have been able to account for the great discrepancies be- tween various observers of the same patient. (/) To have the candle-light and the eyes of the patient on the same level, and within reasonable limits not to mind the exact 4 ON SYMPTOMATIC HETEROPHORIA. adjustment of the head; for when adjustment of the head makes a considerable difference in the tests, I consider the condition present as indicative of paresis rather than of in- sufficiency. (</) To secure like conditions of light, time of day, etc., in a series of tests. (A) To determine if the tests for powers and for insufficiencies bear harmonious or con- tradictory relations; if they are of the latter, I conclude that I have by no means reached the bottom of the mat- ter. (i) To never consider as final a single set of experi- ments, for repeated examinations are imperative; indeed, this inquiry is not one easily satisfied. (7) To confirm the tests by no one method alone, but by various other researches, such as by the use of the Maddox prism, the Maddox cylin- der, and enlarged copies of the Graefe " dot and line " test placed at twenty feet distant, both horizontally as well as vertically. This latter test I have used for several years, and I can not recall that I have seen this idea anywhere mentioned or described. Recently I have had constructed a Maddox cylinder carried in a frame for use on the phorometer, and made so that it can be revolved on its axis into exactly vertical and horizontal positions ; it yields very accurate results by this means. My method of management, when I have determined the diagnosis of symptomatic heterophoria, may be further discussed under three heads : (u) Refractive ; (6) prismatic; (c) operative. Of emmetropic heterophoria I have nothing to say in this paper. (a) Refractive.-Non-operative symptomatic ametropic heterophoria is, as a rule, successfully managed by a care- ful correction of the existing error of refraction and by time. And in this connection I wish to lay stress again upon the very great value and assistance of the ophthal- mometer in connection with the older methods of detect- ON SYMPTOMATIC HETEROPIIORIA. 5 ing and correcting astigmatism. The ophthalmologist to whom this instrument is a stranger can not realize, until he has used it, its accuracy and labor-saving character. The conditions of refractive correction and lime ful- filled have resulted most favorably in fully two hundred of the cases of my present collection. I can not, therefore, lay too much stress on the value of correcting ametropia. The result in these two hundred cases, or eighty per cent, of the whole, is a most cogent argument in support of my belief that errors of refraction are most commonly at the bottom of symptomatic errors of muscular adjustment. Certainly this procedure is highly conservative, and there- fore commendable, appealing to our common sense and satisfaction. It is also an eliminative feature in the selec- tion of cases capable of further amelioration only through prisms or operative measures. It goes without saying that very great pains must be taken not alone with the selection of suitable lenses, but also with the correctness of their grinding, centering, and adjustment. An invariable rule of mine is to inspect both the lenses ordered and their adjustment, requiring patients to report for this purpose. The question of how fully ametropia is to be corrected has no invariable solution. Tn children, I generally order full, or very nearly full, correction ; in young people, I de- cide upon correcting as much as is " accepted," encroach- ing upon the " latent " ametropia as far as possible and with the expectation of a fuller correction in a few months. It is well known that the relative accommodation being less than the absolute, a patient will very often accept more cor- rection over both eyes simultaneously than singly, and I always try to take advantage of this fact. In adults, the accommodation, being less elastic, renders the problem far simpler than in earlier years, and it is often to be noted 6 ON SYMPTOMATIC HETEROPHORIA. that patients of mature years will comfortably accept full correction for near work, if not for distance. (6) Prismatic.-In connection with symptomatic hete- rophoria, I have been led to conclude that prisms serve chiefly as the means of temporary relief afterward to be discarded, or as a medium of diagnosis. For a long time I have ceased to prescribe them for permanent use. They serve somewhat in the same capacity as do crutches-i. e., they give support to weak muscles for a time, while the latter are recuperating from a period of overexertion, and in this connection I always order prisms of low degree, cor- recting but a portion of an insufficiency. In diagnosis I use them in preparation for contemplated operations, con- ceiving that they may be worn with great aid in determin- ing the amount of heterophoria which gives rise to symp- toms ; for without their employment eyes are often in so strained a condition that we can not accurately determine exactly what is the true degree of the insufficiency, while by their action in giving support the eyes assume a state of calmness in place of irritability, and then we may dis- cover that the degree of the prisms worn is a guide to the amount of heterophoria underlying the mischief. It might then be inquired, why not order these prisms to be worn constantly ? Indeed, it might be a good plan to do so; but I am of the opinion that we should, wherever consistent with good results, discard our crutches, and I am further convinced that we have the means at hand for so doing-namely, in judicious surgery. Already, I have touched on the value of prisms used in office work. Upon their value in connection with the phorometer I need not further dwell. As for their value in calisthenics I am much in doubt, though I am sure that they have served in this manner favorably in a number of these cases. ON SYMPTOMATIC HETEROPHORIA. 7 (c) Operative.-When a sufficient period of time under refractive correction has elapsed, and this time should not be less than six months under ordinary circumstances, with- out affording decided relief, and especially where, in addi- tion to lenses, prisms are giving relief, I am in favor of surgical readjustment of the offending muscles. Though a seeming paradox, I am also in favor of this procedure where prisms do not yield relief. Under both these cir- cumstances I am a believer in the efficiency and expediency of tenotomy. I do not believe in tenotomies first and lenses afterward, but, as I have, repeatedly asserted, in the reverse order. In these two hundred and fifty cases tenotomy was per- formed upon only twenty patients-a very small percentage. After such eliminative measures as I have outlined, the number of cases subject to tenotomy is so small that I an- ticipate favorable results with a degree of certainty in which I am seldom disappointed. In an examination of these twenty cases I found such results as justified the measure in every case without exception. The only supe- riority of this fourfold method lies in its conservatism and elimination. The technique of operation is comprised in the much- discussed "graduated tenotomy." This surgical measure has the advantages of very slight traumatism, ease of execu- tion, and absolute certainty, in connection with the pho- rometer, of accurate surgical results. Indeed, done with care, even the dreaded "stitch" is usually avoidable. When a sufficient effect can not be secured in a single operation without extensive cutting, I consider it highly detrimental to persist until the desired effect is attained, but believe that further results should be secured in a sub- sequent operation, deeming it wise that the correction of heterophoria should be divided between the muscles, instead 8 ON SYMPTOMATIC IIETEROPHORIA. of being sustained by surgery upon a single muscle. This may be done sometimes at the same sitting. It is, more- over, desirable to secure a slight overeffect in an endeavor to compensate for the contraction in healing. Much has been said and written on this operation. Much has been said of the " latent " muscular error that appears, and that the heterophoric tests yield the same re- sults after as before the operation. On account of the op- position in the associated action of the muscles and their counterbalancing influence, this may truly be a latent in- sufficiency that reveals after operation an apparent return to the original condition. Yet, on the other hand, it may be that these muscles do, in healing, become restored to their former position with unaltered leverage power. But relief is what follows the procedure when done after the eliminating processes. This relief is due either to the actual readjustment by surgery, or else to the enforced mus- cular rest, only temporary albeit, which follows the opera- tion, much in the same way that eyes, inert during atro- pinization, afterward perform their duties in a proper manner, when before their functions were accompanied by asthenopia. In the study of these two hundred and fifty cases I have certain special observations to present. In a recent paper by Dr. S. M. Payne is set forth an ingenious and plausible theory-to wit, that, where there is deviation horizontally alone, the ametropia is isometric, and conversely, where the deviation is vertical, with or without lateral tendencies, the refraction is anisometric. I have found this proposition to be true in a very large proportion of my cases, the number of exceptions being only thirty out of the w hole series, or eighty-eight per cent., according with the law as enunci- ated. The ophthalmometer, 1 believe, will, with its accu- racy and the more attentive use of the phorometer and its ON SYMPTOMATIC HETEROPHORIA. 9 various adjuncts, hereafter greatly reduce the percentage of exceptions; and, moreover, we must remember that we can not be entirely certain of the accuracy in the subjective tests of our patients. The practical value of this theory teaches the importance of very accurate work in correcting ametropia, for it is the very slight degrees of astigmatism rather than gross errors that influence the law, and of the quality of astigmatism it is the " mixed " variety which plays the leading part. And it is to be noticed that, where exceptions to this theory occur in vertical deviations, the spherical lenses were isometric, as a rule, again showing the importance of discovering small amounts of astigma- tism. Furthermore, the value of employing several meth- ods instead of one is apparent from the fact of there being so many exceptions, which by their employment might have shown patients to be inaccurate judges, and the like. Ileterophoria I am in the habit of classifying, for con- venience, under two general heads-heterophoria simplex and heterophoria complex. These hybrid terms apply, the former to lateral deviation and the latter to vertical insuffi- ciency, with or without lateral tendencies. Symptomatic heterophoria naturally occurs prior to the presbyopic period as a rule. In my series of cases heterophoria complex occurs most frequently in astigmatism, as might be rationally expected, and, while far less often accompanying hypermetropia and myopia, it is to be found oftener in the latter than in the for- mer. Here, I think, the explanation lies in the assumption that hypermetropia is a nearer normal condition than my- opia. Generally, as is natural, esophoria was associated with hypermetropia and disappeared frequently under cor- rection of the latter, while exophoria was usually found in connection with myopia. It is noteworthy that hyperphoria was oftenest found 10 ON SYMPTOMATIC HETEROPHORIA. in company with exophoria, and, as I have noted in other cases, in emmetropia the latter condition also pre- vailed, in conformity with the notion that emmetropia in- clines toward myopia. In this connection it is curious to note that hyperphoria seldom occurs alone. In the matter of operative interference, attention should be called to the fact that hyperphoria very commonly dis- appeared in these cases after the reduction of exophoria or esophoria, and vice versa. The question of surgical measures in heterophoria has provoked in the past violent discussion and has led to extreme views both on the one side and on the other. I am convinced that the truth lies between these extremes. After having followed in the management of these cases my conservative eliminative plan, the remaining patients to be subjected to operation resolved themselves into what may be termed selected material, and the results of the method, as has been said, most happily justified these tenot- omies. It has been contended that there was no alteration of muscular adjustment through the " graduated tenotomy." I believe that the contention touches not so much upon the method, but upon whether the tenotomy does secure any effect upon the adjustment. Surely it would be highly un- surgical to endeavor to get an effect in any way other than in the usual " graduated " method-I. e., with cocaine (to secure the co-operation of the subject), the phorometer, light, and prisms. As to whether we can secure readjust- ment in this manner or not, I am of the opinion that it is entirely feasible. At all events the tenotomy, done accord- ing to the " graduated " method, and after my method of elimination, has afforded relief in my cases without excep- tion. I do not mean extravagant relief, but relief supple- mentary to the underlying basic principle of refractive cor- rection. It may be asserted that the correcting lenses ON SYMPTOMATIC HETEROPHORIA. 11 would have been followed by the same results. In these twenty cases of my table relief was not secured, or was but partial, although plenty of time was allowed for results, be- fore resorting to surgery. These cases, in which operation was advised and performed, were probably instances in which there had been long abuse of the eyes, or neglect, or in which an ametropia was not, until after a long period of time, the subject of concern. I noted that the amount of heterophoria was far greater in cases selected for operation than in the others. This may throw light on this point, for it is rational to assume that the longer the delay in seeking relief the greater will be the heterophoria and the more radical the remedy necessitated. I very much regret that I do not know how to test a sin- gle muscle for insufficiency. Here I ought to say that I con- sider binocular single vision as an essential in distinguishing between heterophoria and paresis. And so, though I have without avail experimented on my own eyes in order that I might judge in person of subjective tests, I must fain content myself with the conclusion that insufficiencies are not pathological, but are really defects in leverage power due to malposition or to general debility; whereas, in the attempt to study a single muscle we trench on the ground of pathology-i. e., paresis. In conclusion, I think I may say, as the outcome of these investigations, that the wise plan lies in the middle course, as I have outlined it, and that we shall seldom fail to afford relief by following this conservative method, with- out enthusiasm on the one side or prejudice on the other. 3 East Forty-first Street. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. FOSTER, M.D. THE PHYSICIAN who would keep abreast with the advances in medical science must read a live weekly medical journal, in which scientific facts are presented in a clear manner; one for which the articles are written by men of learning, and by those who are good and accurate observers ; a journal that is stripped of every feature irrelevant to medical science, and gives evidence of being carefully and conscien- tiously edited ; one that bears upon every page the stamp of desire to elevate the standard of the profession of medicine. 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