PARALYSIS OF THE SUPERIOR RECTUS AND ITS BEARING ON THE THEORY OF MUSCULAR INSUFFICIENCY. BY Dr. A. DUANE, ASSISTANT SURGEON, NEW YORK OPHTHALMIC AND AURAL INSTITUTE. Reprinted from the Archives of Ophthalmology, Vol. xxiii., No. i, 1894. PARALYSIS OF THE SUPERIOR RECTUS AND ITS BEARING ON THE THEORY OF MUSCULAR INSUFFICIENCY.1 By Dr. A. DUANE, ASSISTANT SURGEON, NEW YORK OPHTHALMIC AND AURAL INSTITUTE. PARALYSIS of the superior rectus has usually passed for a pretty infrequent affection. Mauthner in his classical work upon Paralyses of the Ocular Muscles, states that of 108,000 cases of eye diseases of all sorts, collected by Mooren, there is not a single case of isolated paralysis of the superior rectus recorded, while in Graefe's 40,000 cases there are 9, in Schubert's 20,000 cases 8, and in Schbler's 20,000 cases 3. On the other hand, Hulkeout of 19 cases in which the oculomotor nerve was affected found isolated paralysis of the superior rectus in 5. This last result, Mauthner says, is opposed to all our experience, and he adds that one would rather expect to encounter twenty cases of total oculomotor paralysis in succession before meeting with one in which only a single branch of the nerve was affected. In spite of this dictum from so eminent an authority, I must say that my experience is quite in accord with Hulke's; and, in fact, among the cases that I have examined, isolated paresis of the superior rectus stands next in order to that of the external rectus, surpassing even paralysis of the superior oblique in frequency. I have, that is, in examining a com- paratively limited number of unselected cases both in private ' Read before the Section of Ophthalmology and Otology at the N. Y. Academy of Medicine, Feb. 19, 1894. • Reprinted from the Archives of Ophthalmology, Vol. xxiii., No. 1, 1894. 62 A. Duane. and dispensary practice, seen six in which there was un- doubted paresis of the superior rectus unaccompanied by any other form of paralysis, or by any heterophoria not directly attributable to the affection of the superior rectus itself ; and I have seen four others in which it was associated re- spectively with esophoria, insufficiency of the externi, paresis of the internal rectus of the other eye, and a con- comitant divergent squint-complications which have ob- viously no real etiological connection with the condition in question. In addition, I have noted some half dozen other cases in which the muscular conditions were more complex, but in which various circumstances pointed to the part played by the affection of the superior rectus in the production of the attendant symptoms ; so that from these and the cases just mentioned, a fairly complete symptoma- tology can be evolved, together with data regarding the etiology and treatment. For convenience of inspection I have presented the histories of these cases in the appended tabular form. Be- fore seeking to draw any inferences from them, however, I would like to invite your attention for a few moments to a consideration of the nature and diagnostic features of the condition which we are studying. The superior rectus is an elevator and adductor of the eye, and rotates the upper extremity of the vertical meridian of the latter inward. Its elevating action is most marked when the eye is abducted ; its adducting and rotating actions, on the other hand, increase as the eye is rotated inward. Hence, when this muscle is paralyzed, the eye to which it is attached lags below when the two eyes are lifted up, and owing to the unbalanced action of the other muscles di- verges somewhat from its fellow, and undergoes torsion, so that the upper end of its vertical meridian diverges from that of the other eye. Moreover, the deficiency in elevation of the eye is most pronounced in abduction, while the rela- tive divergence and the torsion of the vertical meridian are particularly marked when the eyes are carried inward to the median line and beyond it to the nasal side. Or, vertical diplopia occurs in looking up, which diplopia increases as Paralysis of the Superior Rectus. 63 the eyes are carried up, and increases particularly in the upper and outer part of the field of fixation. In the very slightest cases, vertical diplopia may occur only in the last- named region ; in more pronounced paresis, it will also be present both when the eyes are directed straight upward and when they are abducted in the horizontal plane; and in complete paralysis, it will be marked when the patient is looking straight to the front and will even be apparent for a short distance below the horizontal plane. The diplopia, besides being vertical (with the image which corresponds to the paretic eye higher) is also crossed ; and the lateral diver- gence of the images is greatest when the eye is directed straight forward or when it is somewhat adducted. Both the vertical and the lateral diplopia may vary in amount from two or three to many degrees ; and in those parts of the field where, owing to its small amount or to the com- pensating action of other muscles, the separation of the eyes fails to produce actual diplopia, its presence can be made out by the insufficiency tests, and we hence find a hyperphoria or an exophoria. The exophoria produced by paresis of the superior rectus amounts to three or four degrees even in the slight cases, and is distinguished from ordinary exophoria by the fact that the diverging power (abduction) of the eyes instead of being increased is either normal or slightly diminished. In typical cases of paralysis of the superior rectus the tilt- ing of the vertical meridian produces an apparent tipping of the false image which is in consequence inclined toward the side of the .sound eye. This tipping is never recognized by the patient spontaneously, and, according to Mauthner, can scarcely be said to occur in practice. But its presence was noted in at least five of my cases-in three of them beyond the shadow of a doubt, in the others with reasonable certainty. The curious feature about these cases is that, while theoretically the tilting should have been most pro- nounced when the affected eye was strongly adducted, it was actually observed mainly when the eye was directed up and very slightly in. When the paralysis is bilateral-and it was so, at least ap- 64 A. Duane. parently, in nearly all of the uncomplicated cases which I examined,-the tendency to crossed diplopia is even more marked than in the unilateral variety. On the other hand, the tendency to vertical diplopia in the primary position and when the eyes are carried straight upward, is diminished, or, if the muscles are about equally affected, is altogether absent. It is present, however, quite as before, in the upper and right-hand and the upper and left-hand portions of the field of fixation, and also in extreme abduction in the hori- zontal plane, so that the diagnosis of the bilateral is quite as easy as that of the unilateral variety. In making repeated examinations of these cases of bilateral paresis, I have noticed that the relative strength of the two paretic muscles seems to vary from time to time, so that in the primary position we sometimes get right hyperphoria, sometimes left hyperphoria, and sometimes absolute freedom from any tendency to vertical insufficiency. There is no other condition which presents precisely the features just described except an isolated spasm of the in- ferior oblique. But the unchanging character of the phe- nomena observed, and the absence of any cause that could produce so unique a variety of a spasm render it extremely improbable that this can really be the sole condition present. Nevertheless, I am strongly inclined to believe that, in the bilateral form of the affection, spasm does play a part and that those cases which appear to be due to paresis of both superior recti are actually cases of paresis of one superior rectus associated with compensatory spasm of the inferior oblique of the same eye. This is probable on a priori grounds, since it is likely that in the endeavor to lift both eyes equally when there is paresis of one superior rectus, a specially strong nervous impulse is sent to both elevators of the paretic eye. If now this impulse affects both elevators equally, it would, if sufficiently strong to cause anything like a normal action of the paretic superior rectus, produce actual spasm of the unimpaired inferior oblique. This would in one way be an advantage, as tending to overcome the hyperphoria ; but it would cause vertical diplopia in the opposite sense in the upper and inner part of the field of fix- Paralysis of the Superior Rectus. 65 ation, and would increase the tendency to lateral divergence. This action then would be only partially compensatory. My chief reason for thinking that this sort of compensa- tion actually takes place is that in these bilateral cases the first examination often shows that the affection is strictly unilateral, while subsequent trials reveal involvement, more or less marked, of both sides. Moreover, as already stated, this secondary involvement is evidently a variable condition, since the effects it produces will in the same case at one time equal, at another time exceed, and at another again fall short of those produced by the primary paresis. This is precisely what we should expect in a case of compensatory spasm which must necessarily be variable in amount. With this reservation then, that the diagnosis of bilateral paresis is open to question, we may say that the differentia- tion of these cases is easy, provided that we can establish with certainty the existence of diplopia having the char- acteristics given above. The determination of this latter, however, requires the intelligent co-operation of the patient, and may be rendered difficult by his stupidity and inattention or by a perverted imagination which makes him see things as they are not. Hence no diagnosis should be regarded as final unless established by the concordant results of several examinations in which the conditions have been varied so that deception, conscious or unconscious, is im- possible. This has been done in all of the cases here re- ported, and, in nearly all, the examinations have been repeated at intervals of several weeks or months ; and no case so examined has been adduced unless the results ob- tained were uniformly accordant. Moreover, in all these cases the influence of complicating conditions has been taken into account, and wherever possible has been eliminated-e. g., in the case of refractive errors by the use of the proper correcting glass. It is hoped therefore that these cases, few as they are, will suffice to illustrate, with reasonable fulness, the main symptoms attributable to paresis of the superior rectus. 66 A. Duane. These symptoms appear on the whole to be but slight. The most constant and characteristic is spontaneous diplopia (both lateral and vertical). This is generally transient, but while it lasts causes a disagreeable sense of blurring and confusion. Other symptoms in the order of their frequency are headache, pain, and a sense of weariness in the eyes, and a state of chronic irritation of the conjunctiva and lids which resists local treatment. In one of the uncomplicated cases a variety of scotoma scintillans was present, and the same or a similar phenomenon occurred also in one of the complicated cases. In one or two instances there has been spasm of accommodation, but whether this condition had anything to do with the paresis I cannot say. All the symptoms are aggravated by use of the eyes for close work, and remit when close work is abandoned ; and the most fre- quent complaints came from school-children, musicians, and seamstresses who were obliged by their occupation to look long and steadily at near objects, but in whom no deficiency of accommodation and in most cases no notable error of refraction could be made out to exist. The way in which the symptoms are produced seems tolerably certain. In the slight cases vertical diplopia is of constant occurrence only in extreme elevation of the eyes or in extreme abduction. Even in more marked paresis the tend- ency to vertical diplopia in looking straight ahead is slight, and it is absent altogether in convergence and when the eyes are depressed. That is, it is pronounced in those parts of the field of fixation which are practically never used, and is little marked or absent in those positions of the eye which are habitually employed. It is therefore neither a constant nor a very troublesome symptom. This is especially the case in the bilateral form. On the other hand, the exo- phoria produced by the condition, being quite pronounced when the eyes are directed straight forward and when they are moderately adducted, is constantly present. It is, more- over, particularly marked when the affection is bilateral. Even in slight cases this exophoria amounts to 30 or 40 for the distance, and to an equal or greater quantity for near Paralysis of the Superior Rectus. 67 points. This is a considerable amount when it has to be overcome constantly, and the exophoria consequently must be the cause of more or less eye-strain, particularly when the eyes are- employed for close work, which implies accu- rate definition of images and consequent necessity for the absence of diplopia. The other symptoms-headache, pain in the eyes, and conjunctival and palpebral irritation-so far as they are attributable to this condition, are in all probability reflex phenomena due to the strain incurred in overcoming the exophoria. The causal relation between the paresis and the chief symptoms seems certain. Other causative factors, such as refractive errors, insufficiencies, disorders of accommoda- tion, etc., have been eliminated either by their non-exist- ence or by the fact that their correction had afforded no relief. In regard to the course pursued by these cases I can pre- sent no definite data, as but few of them have been under observation long enough to enable me to speak with cer- tainty upon this point. But in those cases which I have been able to examine at long intervals, the vertical diplopia has remained unchanged in character and apparently also in amount, each examination being in this regard simply a repetition of the one before. The lateral diplopia and the exophoria seem too to be pretty stable factors, not varying much from one time to another, except that there seems to be on the whole a tendency for the exophoria to show a slow progressive increase. It would seem, therefore, that the condition which underlies the diplopia and exophoria must itself be comparatively stationary, and corresponding to this assumption is the fact that the symptoms also show very little alteration, except as they are affected by such disturbing factors as the entrance upon new occupations which throw additional work upon the eyes, or the use of faulty glasses, particularly prisms. The treatment of these cases may be briefly dismissed. In marked paralysis with a constant vertical diplopia of many 68 A. Duane. degrees, it will be proper, if we can be sure that the condition is a stationary one, to perform advancement of the paretic muscle. The operation theoretically indicated, namely tenotomy of the inferior oblique of the other eye, is both practically inapplicable and can also be demonstrated to be unsound in principle. Tenotomy of a depressor muscle- inferior rectus or superior oblique-is, of course, out of the question, since it would produce a worse condition than that which it is designed to relieve. Tenotomy of the superior rectus of the other eye may replace the operation of advancement when the paresis is combined with esoph- oria. It is only a few cases, however, that present symp- toms marked enough to justify operative interference of any kind. Only one such has occurred among those that I have examined, and in this advancement of the superior rectus was performed with satisfactory results. In other cases prisms may be resorted to. Here, as the exophoria is the principal disturbing factor, prisms of two or three degrees before each eye, with base directed inward are indicated. If in addition there is any considerable amount of hyperphoria, a prism base down (or preferably base up) may be employed ; but in this case we must recol- lect that if the glass is to be used for near work (in which the eyes are naturally cast down somewhat), the vertically deviating prism must either be left out altogether or much diminished, because, with the eyes directed even a little below the horizontal line, the tendency to ver- tical diplopia decreases rapidly and soon disappears. Prisms were employed with quite satisfactory results in three cases; in two others, in which they were prescribed the patients did not get them, and in one case the result of their application was unknown, as the patient did not return. To supplement muscular deficiencies with prisms, however, is like giving a lame man a crutch; it helps but does not cure his lameness, and in some instances by favoring mus- cular inaction really retards recovery. A more rational plan, it seems to me, is to exercise the internal recti. This Paralysis of the Superior Rectus. 69 can be done by systematic practice with prisms placed base out before the eyes. Such exercise, even if it does not in- crease the actual power of the internal recti, at least enhances the facility with which these muscles work; and whether because of this or because of the stress that is at the same time thrown upon the accommoda- tion, the result of such exercise at all events is that the exophoria diminishes or disappears altogether, at least temporarily. In many cases the symptoms are too trifling to call for any form of special treatment. The administration of tonics and the enforcement of proper hygienic regulations will fulfil all the therapeutic indications. A word finally in regard to the etiology of these cases may not be amiss. In the first place they are incontestably much more frequent than they have been supposed to be. Otherwise it is inconceivable that in a small number of unselected cases I'should have hit upon so large a propor- tion in which the superior rectus was the only muscle affected ; and while I believe that a more careful examina- tion of all cases will show that paresis of the ocular muscles (particularly of the inferior rectus), is much more frequent than has been supposed, yet the preponderance of instances in which the superior rectus was paretic is still quite re- markable. Moreover, I am convinced from a consideration of the symptoms which they presented that many cases of hyperphoria which I examined before my attention was called to this subject and to the necessity of testing for diplopia in all parts of the field of fixation, were really instances of this affection. Another noteworthy fact bearing on the etiology is that the affection is one pre-eminently attacking young persons. All the individuals examined were under thirty, and six were under fourteen. The mere statement of the ages at which the affection was observed, however, gives a very inadequate idea of its real prevalence among the young ; for not only is there nothing to show in this series of cases that the paresis had developed at or shortly before the time of 70 A. Duane. observation, but, on the contrary, everything points to its having been in existence an indefinite time. Nay, more, there is nothing to indicate that the condition, in the uncom- plicated cases at least, has not been of life-long existence, and in fact I have been led to believe that the paresis is really congenital or at least dates from infancy. In none of the uncomplicated cases could any cause be assigned to produce the paresis. They have not, for example, been uniformly associated with errors of refraction, such as have been thought to be efficient factors in the causation of these muscular troubles. Four of the cases were practically emmetropic and nearly all the others had a moderate amount of hypermetropic astigmatism. None showed anisometropia of any amount. Only one case pre- sented a large refractive error. In this there was mixed astigmatism of 5.50 D.; and it is rather a noteworthy fact that this was the only case in which there were no symp- toms referable to the paresis, which therefore seemed to have occasioned no trouble. This is readily explainable, since the vision which the patient got, did not suffice to produce sharp definition, and hence a slight tendency to diplopia might exist without causing any appreciable addi- tion to the blurring already present. It is a significant fact that it was not till this patient's vision began to improve under glasses that the tendency to compensatory action (evinced by the development of bilateral diplopia) began to be apparent. Lastly it appears extremely improbable, from the age of these patients and the history which they present, that the paresis can be due to either a nuclear or an orbital lesion of the nerve-twig supplying the superior rectus. I am there- fore driven to conclude that the condition in question is the result of a weakness of the muscle itself, due to con- genital malformation or, more likely, to arrest of de- velopment. When we reflect how little occasion we have, comparatively speaking, to use the superior rectus for making any extensive movements of the eyes, the exist- ence of a species of non-development from non-use seems not improbable. Paralysis of the Superior Rectus. 71 BEARING OF THESE CASES UPON THE THEORY OF HETEROPHORIA. In addition to the interest attaching to the etiology of this condition, it has, it seems to me, an important bearing upon the vexed subject of hyperphoria and indeed of in- sufficiencies in general. To one who has paid any attention to the problems relating to the muscular defects of the eyes the current theories of insufficiency contain much that is unsatisfactory. The tendency of the eyes to deviate when the temptation to preserve binocular vision is taken away- that tendency which we call insufficiency or by the better term of heterophoria-has been ascribed to various causes. Some write as if the faulty position were due to a want of power in the muscles (insufficiency in the proper sense of the word), and cite under this category cases in which muscles supposed to be weak are actually more powerful than their antagonists. Others regard insufficiency as due to the anatomical disposition of the parts, so that a con- dition obtains quite analogous to that which occurs in a con- comitant squint. Others have signalized the importance of an excess or deficiency of accommodative effort in produ- cing muscular deviations. But no one, it seems to me, has in an adequate and satisfactory way correlated all these different possible causes and pointed out that all or any of them may be operative, and that, just as we have a paralytic squint, a spastic squint, an accommodative squint, and a concomitant squint, so we may have and should distinguish between a heterophoria due respectively to paralysis, spasm, accommodative anomalies, and an excessive relaxation or tension of the muscles induced by faulty anatomical con- ditions. In emphasizing the difference between heterophoria and strabismus-a difference which, as far as symptoms are concerned, is, of course, most pronounced-we are apt to forget the fact long ago enunciated, that after all hetero- phoria is latent squint, and that consequently the same means of diagnosis and the same principles of treatment apply to the one as to the other. All of us recognize the fact that the means appropriate for the relief of a paralytic 72 A. Duane. squint and a concomitant squint are different; and we would not think therefore of attempting to remedy a visible deviation of the eyes without inquiring into the precise nature of the condition producing it. If this is so in the case of a manifest deviation or squint, it should be equally true of a latent deviation, or heterophoria; and my conten- tion therefore is that in the latter condition we shall not employ our tenotomies or our prisms until sure of its precise nature and of its underlying cause. In other words, we must neither consider nor attempt to treat an insufficiency simply as an insufficiency, but must take into account and try to rectify the often complex causes which lie at the root of it. To this end we should, I conceive, in every case of hetero- phoria, in the first place eliminate the effect of accommoda- tive errors by correcting the refraction ; then determine by careful and repeated examinations of the diplopia and the tendency to deviation in the different parts of the field of fixation whether the heterophoria is a concomitant one (?>., is presumably due to anatomical conditions), or varies in away to indicate muscular paralysis or spasm. When in this way we have found the cause of the condition and the muscle which is at fault, and are convinced that the condition itself is a stationary and not a variable one, we are ready to rectify the anomaly, supposing always that it still presents symp- toms worth rectifying. This seems to me the conservative course, and it is one which I have myself pursued for several years past with very satisfactory results. In closing I may say that in my own experience paretic heterophoria, of which the condition chosen as my subject is a type, constitutes a fairly large proportion of the total number of cases of insufficiency-a larger proportion cer- tainly than I should have expected to find. They are not, however, nearly as numerous probably as the cases of con- comitant (or anatomical) heterophoria in w,hich an eye tends to deviate because one of its muscles is faultily attached and is consequently in a state of undue tension or relaxation. Cases of spasmodic heterophoria are probably not un- common, occurring much oftener apparently than does true spastic squint. Accommodative heterophoria, although re- Paralysis of the Superior Rectus. 73 garded by many as the most common variety, is not so in my experience; indeed, it is a rare thing for me to find that the correction of a refractive error, even when kept up per- sistently for weeks, has influenced at all the muscular balance of the eyes or the heterophoria which is its result. 74 A. Duane. TABLE OF CASES. Note.-In preparing this table the following abbreviations, which the writer has employed constantly for the last four years, and which have proved very serviceable in recording cases of muscular trouble, have been used : D, diplopia. D', diplopia at near points. D//, homonymous diplopia. DX, crossed diplopia. DR, " right diplopia" ; diplopia with image corresponding to right eye below. DL, " left diplopia " ; diplopia with image corresponding to left eye below. SV, single vision. LH, left hyperphoria. RH, right hyperphoria. S, esophoria. S', esophoria at near points. X, exophoria. X', exophoria at near points. P//, homonymous parallax.1 PX, crossed parallax. PR, parallax with image of right eye lower. PL, parallax with image of left eye lower. Ef, " eyes-front " ; both eyes di- rected horizontally forward. Er, " eyes-right " ; both eyes di- rected horizontally to right. El, "eyes-left"; both eyes directed horizontally to left. Eu, "eyes-up" ; both eyes directed up. Eu & r, " eyes-up-and-right " ; both eyes directed up and to right. Eu & 1, " eyes-up-and-left " ; both eyes directed up and to left. Ed, " eyes-down " ; both eyes di- rected down. Ed& 1, " eyes-down-and-left " ; both eyes directed down and to left. Ed & r, " eyes-down-and-right " ; both eyes directed down and to right. >, more than. > > , steadily increasing. <, less than. <<, steadily diminishing. = =, constantly the same. Thus the formula for marked paresis of right superior rectus would be : Ef, DL & X or LU & X, PL and PX. Er, DL (or LH) > >. El, DX. Eu, DL & X > >. Eu & r, DL > >, DX < <. Eu & 1, DL < < to SV. Ed, Ed & 1, Ed & r, SV. The characteristic feature, however, is contained in the expression Eu & r, DL > >, which alone is sufficient to make out the presence of the condition. 1 By parallax is meant a change in the apparent position of the object of fixation when a screen is shifted from one eye to the other. If, for example, the patient fixes his gaze upon a mark made upon a flat surface (so that the mark cannot be projected upon any plane behind it), and upon carrying the screen from the right eye to the left this mark appears to move to the right, the patient is said to have homonymous parallax (P//) ; if it moves to the left, he has crossed parallax (PX) ; if it moves down, he has right parallax (PR); if it moves up, he has left parallax (PL). Parallax in this sense is only diplopia obtained by a special artifice, and, like any other form of diplopia, can be measured in terms of the prism which causes its abolition. Paralysis of the Superior Rectus. 75 This Diagram represents a case of paresis of both Superior Recti, the muscle of the left eye being the one mainly affected ; or a paresis of the left Superior Rectus with spasm of the left Inferior Oblique. Red glass placed before left eye. Nomenclature as upon pre- ceding page. No. Date when FIRST Seen. Name and Occupa- tion. Age. Sex. Muscle Affected Other Muscular Affec- tions. Resulting Heterophoria and Diplopia. Refraction. Symptoms. Treatment. Course and Results. Date when LAST Seen. I Nov. 5, 1891. H. F., school- boy. • 12 M. Both, es- pecially L. None. For distance. PX, slight. PR and PL on alternate days. X, 0° (increasing on. final test to 2°-3°). LH, i°-2° (by abducting- prism test). Abd. 6° (finally only 4°). Ad- duction (test of Feb., 1894) less than 150 even at near points. Eu, DR > > rapidly. For near. X', 5* or 6°. Eu, DR > > and DX. Eu & 1, DR > > (very ra- pidly). DX. Eu & r, DL, DX. Er, DX. El, DX marked, DR. Tilting of one or both images frequently observed. Hyperme- tropic astig- matism. [Using for reading + 0.75 D. cyl. each, pre- scribed after examination under atro- pine. Glasses given by an- other oculist 6 or 7 months before]. Severe daily protracted headaches coming on whenever eyes are used for any purpose requir- ing fixed attention. Somewhat less with glasses, but not nota- bly so. Looking up causes him great pain in the eyes, and tests with prisms, etc., cause headache. Eyes become tired very soon when close work is done. Also has often blurring of sight, with occasional spontaneous crossed and vertical diplopia (DX and DR). Once a tran- sient attack of alternat- ing hemianopsia. Tentative use of prisms cor- recting hy- perphoria andexopho- ria (cylin- ders during this time being dis- carded). Afterwards prisms pre- scribed with cylin- ders. Prisms alone, caused great relief of head- ache, blurring, and as- thenopia. By use of prisms and cylinders combined was so much improved as to be able to work all day. Head- aches not entirely re- lieved and afterwards seemed to return, when they were again re- lieved by astigmatic glasses given by an- other practitioner. Hy- perphoria had in the meantime diminished, so that now prismatic- glasses overcorrect this element. Feb. 17, 1894. 2 Feb. 18, 1893. B. A., school- girl. 9 F. Both, in almost equal degree. None. For distance. X at first only 30, afterward increasing to 8° or more. With red glass, DX changing slightly in Er and El. Abd. 8C -, but after using prisms increased to io°. Adduction (at distance) espe- cially after wearing prisms almost 0°, and very hard to train. For near. X', 6° or more ; increasing to 15° after constant use of prismatic glasses. ( Eu, DX ! Eu & r, DX and DL > >. ) Eu & 1, DX and DR >>. ( Ed, SV. [Numerous exam- inations gave absolutely con- Right eye emmetropic ; Left eye slightly hy- permetropic (+ 0.50 D). [Examina- tion underho- matropine.] Conjunctival irritation and pain and lachryma- tion ; not improved by local astringent treat- ment. Occasional lateral and vertical diplopia. No headaches. Symp- toms aggravated by schoolwork, and occur- ring chiefly when eyes are engaged in close work ; remit at other times and absent during vacation. Afterwards, when exophoria had notably increased, symp- toms more marked when using eyes for distance. Prisms (3° base in and 2° base in) given (Feb., '93) for near work ; af- terwards (Dec., '93) for far also. Training of adduction (Feb., '94). Prisms, when used for near work only, seem- ed to cause marked relief of symptoms; when prescribed for distance also, aggra- vated symptoms. Symp- toms finally relieved completely by exercise of adduction with prisms ; X finally 0° and X', 2°-3° only. March 12, 1894. I.-UNCOMPLICATED CASES. 76 3 June 29, G. M„ 26 F. Both. cordant results, except that first record taken does not reveal any involvement of R. superior rectus]. Final examination shows DX in Ed. For distance. Slight hyper- After a moment's look- Given Did not use prisms, as symptoms had in the main disappeared upon her giving up her work as a seamstress. Report- 1893. seam- stress. X, 5°. For near. X', 8°. Ef, DX (diminishing slightly in Er). Eu, DX. Eu & r, DX and DL > > . Eu & L, DX and DR >>. Ed, DX but vertical diplopia slight or uncertain. [Repeated examinations on two separate days by differ- ent observers.] metropia (+ 0.50 sph. ac- cepted). ing at any object (espe- cially when doing fine work), object blurs and becomes double. (Glass of + 0.50 sph. does not prevent this). At other times a spot followed by a light cloud floats before thesight, orshe has a sud- den attack of amaurosis. These attacks followed by headache. Sees well on first waking up, but later in day troubles come on. prism 2° base in each eye. ed by letter, Feb. 18, 1894. 4 Sept., 1893. H. G., cutter. 28 M. R. (after- wards of L. also). None. For distance. X, 2° +. LH (only a trace after affec- tion had become bilateral). Adduction, 150 (with great difficulty). For near. X', 3° +• Eu & r, DL > >. No other vertical diplopia at first examination. At second examination, showed also, Eu & 1, DR >>. Eu, DX. No other diplopia. [Examinations on 3 separate occasions several weeks apart.] Right eye emmetropic ; Left eye myo- pic (- 0.50 sph. under homatropine). Pain and irritation of eyes and conjunctival discharge, especially in evening. Not relieved by astringent treatment. Sense of straining in eyes. Headaches now and then. Given prism 2° base in each to use if symp- toms recur. Symptoms disappeared spontaneously on his giving up reading, of which he had done a good deal ; hence did not use prisms. Feb. 23, 1894. 77 No. Date when FIRST Seen. Name AND Occu- pation. Age. Sex. Muscle Affected. Other Muscular Affec- tions. Resulting Heterophoria and Diplopia. Refraction. Symptoms. Treatment. Course and Results. Date when LAST Seen. 5 Nov. ii, 1893- c. u., school- girl. 12 F. R. (mainly). None. For distance. PX, 2° + ; PL, decided. X, o°-3°, LH, o°-i°. For near. Eu & r, DL and DX. Eu (extreme), DX. Eu & 1, DX. Er, tendency to DL. El (extreme), DX. No diplopia elsewhere except in final examina- tion, when slight DR in Eu & 1 (compensatory action of inferior oblique) was observed. [7 or 8 examinations made on 4 different days.] Mixed astig. (cyl. + 5.50 D with sph. - 2.00). [Examination un- der homatropine.] Symptoms mainly those due to error of refraction-poor vi- sion and occasional headaches. Correction of refrac- tive error. Gradual im- provement of sight un- der use of glasses, V when last tested |g. 6 Nov. 17, 1893. M. B. 9 F. R. None. For distance. PX (= 2°) and PL. X, 3°. LH slight. Abd. 50. For near. Eu & r, DL. No diplopia elsewhere. Emmetropia and V normal. [Examination under homatropine.] Accommodation normal. Pain in eyes and almost constant frontal headaches for past 2 months. Can- not see well to read, and even at distance objects blur. Had scarlet fever in May, and to this mother attributes present trouble, but symp- toms did not be- gin directly after illness. Given prism 2° base in each for near work. Did not return. Did not return. 7 Dec. J- T. 20 M. R. Insuf- For distance. Hypermetropic as- Very severe head- Advance- Final result April, 27, 1889. R. ficiency of left inter- nal rectus (?or spasm of right Eyes diverge behind screen. PL, 4°-5°. PX, 120. X very variable. LH 2°-6°. Abd. 22°. tigmatism. f R. + 1.00 sph. O 1 +0.75 cyl. 1 L. + 0.75 sph. O I +0.75 cyl. ache at times. Used to have diplopia when young, and then right eye di- verged more than ment right superior rec- tus, tenoto- myleft supe- rior rectus, of opera- tions : cor- rection of vertical di- plopia for 1890. Report by let- ter, Feb. II.-CASES COMPLICATED ONLY WITH A LATERAL DEVIATION. 78 8 Aug. 23, 1890. L. H. 11 F. L. externus). Insuffi- ciency of both ex- tern!, es- pecially L. Adduction, n°-i5°. Excursion test practically same as for near objects. Produces voluntary DX by turning out right eye. For near. Eu & r, DX >>, DL >>. Eu & 1, DL < < to SV, DX <<. Er, DXandDL. PX>>. El, PX < < to o°. Image formed by right eye tilted to left. For distance. D// and DR (inconstant). D// > > laterally, especially in El. DR >> in El. P// and PR. S, 7°-2o°. RH, slight or 0° (by abducting prisms). Abd. 5°-8°. Both eyes deviate markedly in behind the screen. For near. Eu, D// and DR. Eu & 1, DR > > and D//. El, D// and DR. Er, Eu & r, Ed, no diplopia. [Numerous examinations made on four or five separate days.] under atropine. Developed spasm of accommodation after use of cor- recting glasses. Hypermetropia and astigmatism. R. + 2.50 sph. + 0.75 cyl. L. + 2.00 sph. + 0.50 cyl. [Examination under atropine.] at present. Cannot read with right eye alone. In Jan., 1889, first treated for astheno- pic troubles (pain in eyes, difficulty in reading, etc.). Given glasses (R. + 2.00 sph. +0.75 cyl. ; L. + 1.50 sph. Q + 0.50 cyl.). Six months ago attack of diphtheria followed by paresis of laryn- geal and some trunk muscles and strabis- mus. Sight became blurred, and she de- veloped spasm of accommodation. advance- ment right internus. Correction of astigma- tism. Exercise of adduction by prisms. ment both extemi ; ex- ercise of adduction with con- verging prism. looking di- rectly for- ward and for position of conver- gence ; exo- phoria con- verted into slight eso- phoria (about i°). Adduction 38°. Head- aches reliev- ed by glasses Can now use right eye for reading, and vision in it has improv- ed (report of Feb., 1894). Nearly complete correction of conver- gent squint. 25, 1894. Jan.' 30, 1891. 79 No. Date when FIRST Seen. Name AND Occu- pation. Age. Sex. Muscle Affected. Other Muscular Affec- tions. Resulting Heterophoria and Diplopia. Refraction. Symptoms. Treatment. Course and Results. Date when LAST Seen. 9 Aug. 27, 1892. S. M. C. 25 F. R. (after- wards of both). Esophoria (? accom- moda- tive). For distance. P oJ or L and //. S, 30 or more (less with refraction corrected ; greatest when eyes are under influence of homatropine and refraction is uncorrected). LH, 1-20 (by diverging-prism test); at times o° (especially when refraction is corrected), and then S less. At last examination, RH, i°. Abd. 5°-6°. Adduction, 20° easily. D// in El, not in Er. For near. S' several degrees (o° with glass). Eu & r, DL. At last examination also showed, Eu & 1, DR and D//. Eu, D//. Ed, SV everywhere. [Several examinations at long intervals.] Hypermetropia and astigmatism. R. + 1.00 sph. + 0.50 cyl. L. + 1.25 sph. (under homatropine). Evidently some ac- commodative spasm. Range of accommo- dation good, but has transient uniocular blurring of sight in- dicative of temporary accommodative fail- ure. Daily headaches (frontal), and pain referred to back of eyes. Relieved tem- porarily by use of glasses, but recur- ring. Cannot use eyes for near work even with the glasses without speedy fa- tigue. Marked pain in eyes produced by looking up. Correction of refrac- tive error. Given R. + 0.50 sph. + 0.50 cyl. L. + 0.75 sph. for constant use. Given (Feb. 21, 1894) prisms for esopho- ria. Prisms caused no relief. Mar. 31, 1894. 10 March 20, 1893. T. K. 13 M. Both, es- pecially L. Divergent strabis- mus. For distance. Eyes diverge markedly, producing regular di- vergent concomitant squint, which usually affects R. eye. Eyes diverge behind screen, and in making movement of redress, eyes (especially right) shoot beyond the mark, and then return by jerky motion to position of fixation. DX of 6°-8°, and DR or sometimes DL. For near. Converges normally, but with much effort, and has binocular fusion near point of 3 inches. Ef, DX(with red glass) and DR or sometimes DL. Eu & 1, DR >>. Eu & r, DL > >. No diplopia in Ed. [Several examinations.] Emmetropic. V. each. Has been using a glass of + 0.75 for both far and near, prescribed Nov., 1890. Used these for a year and then stopped. Occasional spon- taneous diplopia. For 6 years has been in the habit of clos- ing right eye when he wishes to see at a distance. Screws up eyes when he reads ; eyes get tired and pain him after read- ing. Headaches rare. None. Symptoms remained same during the 11 months when he was under obser- vation. Feb. 17. 1894. 80 II1 March A. D., 27 M. L. ; (after- wards R. (trau- matic). Esopho- For distance. Hypermetropic as- Severe periodical T enotomy Partial cor- Feb., 1886. phy- sician. ria ; lately has shown involve- ment of depressors of eye. RH, i°-2° ; S, 2°-3°. Abd., 30. Adduction at first very limited. Since operations-hyperphoria 0° or only a trace. Diplopia for distance same as for near, except that in Ef gets sometimes D//, sometimes DX,and the normal tendency, unless the eyes have been used for near work, is to D// in Ef ; and the D// in Er is marked for distance and increasing. For near. X' 2°-30. Ef, SV. Er, D// slight, DL slight. El, DX marked, DR. Eu & 1, DX > > greatly, DR > > (marked.) Eu & r, DX > > slightly. DL > > . Ed, D// > >. Ed & r, DR and //. Ed & 1, DL slight. In Eu tilting of image formed by right eye. tigmatism developing into mixed astigma- tism (+ 2.25 and + + 1.75 D. cyl. with - 1.00 sph.). attacks of migraine (infrequent). Sense of straining and drawing of eyes often. R. superior rectus and repeated tenotomies of lateral muscles. Correction of refrac- tion (after first series of tenoto- mies). rection of the hyper- phoria by a prism before the tenoto- mies were done caused marked re- lief of symp- toms. Teno- tomies pro- duced simi- lar relief, although not an absolute one. 1894. 12 Dec. 11, 1890. F. T. C., college tutor. 28 M. R. (slight consecu- tive affec- tion of L). Insuffi- ciency of right infe- riorrectus. For distance. PX and PL. DX and L in Ef. X, 40 (later 70). LH, i°-2°. * Abd. 8° -. Adduction at first small, afterwards readily performed. For near. X' many degrees. Ef, DX and alternately DR and DL. Eu, DL > > and DX > >. Eu & r, DL > >. Eu & 1, DR > > (but not marked). Ed, DX > > and DL, changing to DR. Ed & r, DR > >. Ed & 1, DR < < to SV, then DL. On final test shows tipping of both images in Eu & 1. Myopic astigmatism (- 0.25 D. cyl. axis nearly horizontal). [Examination under homatropine.] Vertical and lateral diplopia occurring spontaneously at times, and also pro- duced by voluntary relaxation of intemi. Headaches on doing close work. Blepha- ritis for many years. Correction of refractive error. Local treatment for blepha- ritis. Headaches relieved completely and blepha- ritis in part by glasses ; blepharitis recurs when eyes areused much for near work, and head- aches recur if glasses are laid aside. Exophoria has evident- ly increased during time of observa- tion. Feb. 15, 1894. 1 The interest in this case lies in the fact that it has been under observation for such a long period (8 years), during which the involvement of the left superior rectus and the condition produced by tenotomy of the right have remained essentially the same, as shown by the eyes staying on the same level. It is also of interest as showing how much relief may sometimes be given by prisms, and how the signs of a traumatic paresis are precisely those of the non-traumatic variety. 2 Hyperphoria was, according to the testimony of a competent observer, present at least two years before my first examination. III.-CASES COMPLICATED WITH OTHER VERTICAL DEVIATIONS. 81 No. Date WHEN FIRST Seen. Name AND Occu- pation. Age. Sex. Muscle Affected. Other Muscular Affec- tions. Resulting Heterophoria and Diplopia. Refraction. Symptoms. Treatment. Course and Results. Date when LAST Seen. 13 Oct. 17, 1891. N. A., school- boy. 13 M. Both (es- pecially R). Insuf- ficiency of both infe- rior recti (especially left), and esophoria. For distance. PH and FL. LH, 2o-3°. S, 2°-5°. Abd. 40. Eu & r, DL > > , D// slight. Eu & 1, DR slight. Eu, DL. El, D// > >. Er, D// > >. Ed, D// >>. Ed & 1, DL > > , D//. Ed & r, DR and D// > >. For near. Diplopia as for distance, except that in Eu & 1 gets no diplopia. Hypermetropia (R. + 0.75 sph. L. + 0.75 sph. + 0.25 cyl. 90°). Ever since measles, 2 years ago, right eye aches and burns when used for near work. Can read well if R. eye is closed, but not if L. eye is closed. Conjunctival congestion. Astringent collyrium. Marked imprpve- ment, al- though when he reads a good deal eyes still ache. Dec. 3L 1891. (Re- ports received in 1893 indi- cate that im- prove- ment has contin- ued. 14 Feb. 28, 1893. E. S., school- girl- 8 F. Both. Insuf- ficiency of both supe- rior obliq- ues (com- ing on later). For distance. X, 3°-4° (afterwardsless). No hyperphoria, but later on gets RH with di- verging prism and LH with converging prism. PL very slight. For near. S', 2°-3°. Eu & 1, DR. Eu & R, DL. At first examination no other diplopia. [Re- peated examinations.] Afterwards (Dec., '93) shows same and also : Ef, DL (inconstant). Ed & R, DL. Hypermetropia of 4- 0.50 D shown un- der homatropine. V. normal. Constant headaches over and between eyes (dated from in- jury received 3 months before-blow upon head from fall- ing down stairs-but had had the same sort of headaches before). In later examination (Dec., '93) also states that she has pain in eyes; has togoup close toobjectsto seethem; None. Symptoms same. Dec. 23, 1893. 82 Ed & 1, DR. And in Eu, image of L. eye tilted to R. Ed, image of L. eye tilted to L. (?) has occasional spon- taneous vertical diplo- pia ; sometimes red or blue lights come before eyes, clouding the sight. At times stands still and shakes i5 June, 1893. B. S. 28 F. Both. Esopho- ria. Insuf- ficiency of left infe- rior rectus (develop- ing later). For distance. S, l°-2°. Abd. 6°. Hyperphoria o° or LH 1° (on one examination). For near. S', slight. Eu & r, DL > > and DX. Eu & 1, DR > > and DX. Ed, no diplopia. [Several tests]. Examination, Feb. 17, '94, shows also Ed & 1, DL. Hypermetropic as- tigmatism (+ 0.75 sph. + 0.50 cyl. R. E., and + 0.75 sph. O + 0.75 cyl. L. E.) Given R. + 0.50 cyl. axis 20°. L. + 0.75 cyl. axis 160°. With these, V. +. [Examination of refraction made un- der homatropine.] Headaches (frontal) frequent, coming on especially in morn- ing, and associated with pains in eyes. In a bright light has to strain and screw up eyes to see well. Astigma- tism cor- rected by glasses. Headaches greatly im- proved by glasses. Feb. 17, 1894. 83 84 A. Duane. SUMMARY OF SYMPTOMS Uncomplicated Cases. Cases Compli- cated with Lateral Devia- tion. Cases Compli- cated with Vertical Devia- tion. Spontaneous diplopia I, 2, 3 7, io 12, 14 Blurring of sight I, 3, 6 - - Pain in eyes i, 6 9, io 13, 15 Conjunctival irritation 2, 4 - 12, 13 Fatigue and sense of strain in using eyes I, 4 g, io II, 15 Headache i, 3. 4, 6 7, 9 II, 14. 15 ' Scotoma scintillans 3 - 14 Spasm of accommodation - 7. 8 13 Transient hemianopsia i - - Inability to use the affected eye for reading 7 13 SUMMARY OF TREATMENT. Case. Result. Advancement superior rectus 7 Improved. Exercise of adduction Application of prisms for exophoria and hyper- phoria 2 7 I 2 II 6 3 4 Relieved. Improved. ( Improved temporarily. ) Result un- i known. 1 Did not wear - glass pre- ) scribed. Local astringent treatment 2, 4, 12 13 Ineffectual. Caused im- provement. 1 Also in 12, but here apparently due to another cause. Ube Iknfckerbocker press g. p. putnam's sons NEW YORK