INSUFFICIENCY 
OF THE 
OCULAR MUSCLES 
DUE TO 
Errors of Refraction. 
Read before The Ophthalmic Section of the 
New York Academy of Medicine, 
May 18 th, 1893. 
BY 
S. M. PAYNE, M. D , 
Lecturer on Ophthalmology in New York Polyclinic; Surgeon to the 
Hackensack Hospital ; Assistant Surgeon to Man- 
hattan Eye and Ear Hospital. 
Reprinted from Tin-: Nkw York Poi.vci.inic, Jit.v, iSgs INSUFFICIENCY OF THE OCULAR 
MUSCLES DUE TO ERRORS OF RE- 
ERA ('TION. 
BY S. M PAYNE, M. D., 
Lecturer uu Ophthalmology in New York Polyclinic; 
Surgeon to the Hackensack Hospital; Assistant Sur- 
geon to Manhattan Eye and Ear Hospital. 
Mr. President and Gentlemen: This is a 
subject that perhaps more has been written 
upon, and which has been discussed more than 
any other in ophthalmology; but notwith- 
standing, I believe it is one in which the pro- 
fession is more at sea than any other in the 
list of eye troubles. I say so because we differ 
so widely in our methods of treatment. Some 
cut the muscles, some prescribe prisms, and 
others correct the refraction of the eye which 
has the lesser error and leave the other uncor- 
rected, or give the same glass for both eyes, 
when the difference of the two eyes is very 
great. 
I have the pleasure of presenting to you to- 
night my investigations, and my conclusions 
drawn from them. I have used the word in- 
sufficiency in the title of this paper because 
it is the one commonly used, and not because 
I believe it to be the right one. I believe the 
only insufficiencies we have are paralysis, 
paresis, and permanent squint; all of which 
are excluded from this paper, except squint 
that is due to an error of refraction. I use the 
Stevens nomenclature because it is the true 
definition of the tendency of eye deviations; 
but I do not accept his theory, that a vertical 2 
tendency to deviate is due to malformation of 
the orbit. 
The main object of this paper is to show that 
when both eyes have the same error of refrac- 
tion the tendency to deviation is either inward 
or outward, and that when the error of re- 
fraction is different in the two eyes there is 
a tendency to deviation upward or downward, 
and in the majority of the eases inward or out- 
ward at the same time. When both eyes are 
equally hypermetropic, or have the same 
amount of hypermetropic astigmatism, the ten- 
dency to deviation, as a rule, is inward. Where 
both eyes are equally myopic, or have the same 
amount of myopic astigmatism, the tendency 
to deviation, as a rule, is outward. Where the 
two eyes have a different degree of hyperme- 
tropia, or hypermetropic astigmatism, the ten- 
dency of the eye that has the greater error of 
refraction is downward and inward. Where 
the two eyes have a different degree of myopia, 
or myopic astigmatism, the tendency of the eye 
that has the greater error of refraction is down- 
ward and outward. 
Having found as a rule that the above ten- 
dencies existed with their relative errors of 
refraction, the next thing was to find out the 
cause. I concluded that the superior and in- 
ferior recti played a part in accommodation as 
well as the internl and ciliary muscles. Ad- 
mitting this to be the fact, for the sake of argu- 
ment, we know that the inferior recti, which 
pull the eyes down and in, are attached nearer 
the cornea than the superior recti, which pull 3 
the eyes up and in. This would give the eyes 
a tendency downward as well as inward in 
accommodation. 
The eyes being emmetropic, they would show 
no tendency to deviation at the distance, and 
in looking at a point thirteen inches from the 
eyes, each ciliary muscle would contract so as 
to increase the strength of the crystalline lens 
to the amount of 3 D., and in the same ratio 
each eye would turn in and down. The same 
rule holds good with two eyes having the same 
amount of hypermetropia. That is to say, if 
each eye had a hypermetropia of 3 D. and had 
vision og or each crystalline lens would be 
increased in strength 3 D. by the contraction 
of the ciliary muscles, and in consequence the 
interni superior and inferior recti muscles are 
stimulated to contract, but a counter effect of 
the opposing muscles keeps the eyes straight 
until double vision is produced by a prism, 
base up or down in front of one eye, which will 
show the tendency inward. 
If we should have a hypermetropia of 3 D. 
in one eye, and 2 D. in the fellow eye, with 
vision each, we would have a tendency in- 
ward and downward of both; but as the interni, 
superior and inferior recti, contract in accord 
with the ciliary muscles, the eye which has the 
hypermetropia of 3 D. would turn in and down 
a little more because the ciliary muscle con- 
tracts to overcome the 1 D. more than its fellow 
eye; or the eye having the 3 D. would have a 
tendency to converge to a point thirteen inches 
from the eyes, while the one having the 2 D. 4 
would have a tendency to converge to a point 
twenty inches from the eyes, and in the same 
ratio the eyes would have a tendency to turn 
downward. The same rule applies to hyper- 
metropia with astigmatism, and hypermetropic 
astigmatism. 
We have three reasons for a tendency to 
divergence, or a divergence, in myopia. The 
main reason is, a want of stimulus to the 
interni, because of the ciliary muscles not con- 
tracting in accommodation. The second is, 
that the optic and visual axes are nearer the 
same than an emmetropic or a hypermetropic 
eye; and in consequence has to begin farther 
away, and more convergence is necessary at a 
given point. The third is that it has to turn 
on its long axis. 
Where the myopia of two eyes is different, 
the one having the greater error turns outward 
and downward. First, because the vision is 
not so good; second, to prevent double vision, 
as the image on the retina is larger and neces- 
sarily received by the brain as a second object. 
Why the eye turns down as well as out is either 
because the superior oblique acts with the ex- 
ternus against all the rest of the muscles, which 
are supplied by the third nerve, or because it 
simply swings out on a line of the position 
it would have if it had the power of accom- 
modation, which would be downward and in- 
ward. 
Tendency to deviate outward in hyperme- 
tropia, in the majority of cases, is found in 
patients who have reached the age of pres- 5 
byopia, and sometimes in high decrees of 
hypermetropia. The amount is seldom more 
than 30, which is due to giving up accommoda- 
tion for the distance, consequently a tendency 
to divergence. Why some myopic eyes have 
a tendency to turn in, I am not able to explain, 
unless there is a marked difference between the 
optic and the visual axis, as in a hypermetropic 
eye. 
I object to cutting the ocular muscles for 
tendencies to deviation. When a muscle is cut 
it either attaches itself back to its former place, 
and the same amount of tendency exists, or it 
is attached farther from the cornea, which is 
liable to produce double vision, especially if 
the patient looks in the direction of the cut 
muscle. When patients are operated upon and 
nothing is said to them about using their eyes, 
they are afraid to attempt to use them so long 
as there is blood under the conjunctiva, which 
generally lasts three or foiir weeks. During 
that time their asthenopia disappears, and the)' 
report to the surgeon that they have had no 
more trouble, and the surgeon thinks that the 
operation has made a cure. The case is then 
reported as cured. As soon as the patient be- 
gins to use his eyes he returns saying that his 
same old trouble has come back. An examina- 
tion is made and the same tendency is found 
to exist that did exist before the operation, 
showing that the muscle had attaehed itself 
precisely as before. Probably another opera- 
tion is performed or a number of them. If, 
after the final operation is performed, the 6 
muscle is found to be attached to its former 
place, which is shown by the same tendency 
to deviation, the cure is finally effected by 
giving the right glasses. The patient, and 
probably the surgeon, thinks that the operation 
has had something to do with the cure. If the 
muscle fails to attach itself to its former place, 
binocular single vision is lost and may never 
be restored. 
Those who operate for vertical tendency, cut 
the superior rectus, which is almost always the 
superior rectus of the eye that does not have 
the tendency to deviate, and the one that has 
the lesser error of refraction, which is the one 
the patient depends upon, instead of cutting 
the interior rectus of the eye that has the ten- 
dency to deviate downward. 
The advantage prisms have over muscle cut- 
ting, is that you can take the prism off and 
leave the patient in no worse condition than 
when first prescribed for. 
When prisms are prescribed without cor- 
recting the error of refraction, the patient will 
return with the same complaint; an examina- 
tion will show that the eyes have the same 
degree of tendency to deviation with the pre- 
scribed prisms on, or twice the amount that 
they had in the beginning; if the prisms are 
increased they will still have the original 
tendency in addition to what was prescribed 
the last time If the error of refraction is cor- 
rected and along with it prisms to correct the 
existing tendency to deviation, the eyes will 
show, when the patient returns, a less degree 7 
than was corrected by the prism, with only the 
correction of the refraction before the eyes; 
because the tendency to deviate is corrected in 
part or in whole by the correction of the error 
of refraction. 
I am confident that all tendencies to devia- 
tions and believe that all deviations, caused by 
errors of refraction, can be corrected by cor- 
recting the errors of refraction, ambliopic eyes 
included. 
My method of examination and prescribing 
is as follows: having first examined with the 
ophthalmoscope, and found the total error as 
nearly as possible, I then begin with the test 
lenses. When I find that the two eyes accept 
the same strength plus glasses, I place them in 
front of both eyes at once; then the next 
stronger glasses before removing the first, and 
so on until I get the strongest before both 
eyes that they will accept. In this way the 
patient will as a rale accept very nearly the 
total amount of hypermetropia, and at the 
same time, if a tendency to deviation exists, it 
is wholly or partly corrected. 
Where only partly corrected, a few days 
wearing of the glasses will entirely correct the 
tendency to deviate. 
The majority of patients can relax the ciliary 
muscle much better with the use of both eyes 
at once. 
When the patient has the same amount of 
hypermetropia in both eyes with the same or 
different degree of astigmatism, I place that 
combination before the eyes, and then the next 8 
stronger sphericals behind the cylinders, and 
so on until I get the strongest they will accept 
in addition to the cylinders. In hypermetropic 
astigmatism I simply give what the patient 
accepts over each eye separately. 
Where the manifest hypermetropia is dif- 
ferent in the two eyes, it does not necessarily 
follow that the total is different in the two eyes, 
especially if the difference in the manifest is 
very slight. It is only in such cases with a few 
exceptions that I use atropine. It is these cases 
that show a vertical tendency to deviate, ex- 
cept the ones that prove to have the same 
hypermetropia imder atropine; because, if two 
eyes have the same amount of hypermetropia, 
and a different amount of manifest with each 
eye separately, they will have the same amount 
of manifest with both eyes together. I measure 
the tendency to deviate with and without 
atropine. If the tendency amounts to so much 
that it is almost a squint, or occasional squint, 
I prescribe the total correction; but if the de- 
gree is small, I will examine the eyes after 
they have recovered from atropine, and instead 
of giving them what each eye accepts I leave 
the same amount of hypermetropia uncorrected 
in each eye, which gives each ciliary muscle 
the same-amount of contraction to correct the 
uncorrected error. By this means the vertical 
tendency to deviate will be corrected as well 
as the horizontal tendency. 
If the same glass is prescribed for both eyes 
when the refraction is different the horizontal 
tendency may disappear in part or entirely, but 
the vertical tendency will not. 9 
I always give the total correction in all forms 
of myopia, and never use atropine, unless I 
suspect spasm of accommodation, which will 
be shown in the eyes requiring a much weaker 
glass to improve the vision, the same that is 
required in myopia, and a tendency of the eyes 
to turn in. 
When the two eyes have a different degree 
of myopia, the image on the back of each eye 
is different in size, and one object is received 
by the brain as two objects; to avoid this, the 
eye which has the poorer vision and magnifies 
the object more, deviates, as a rule, outward 
and downward, or, has a tendency in that direc- 
tion. This is always shown by placing a red 
glass before either eye. When the total cor- 
rection is placed before each eye the images 
are brought down to the same size, and if the 
deviation or the tendency to deviation is not 
corrected immediately, it is by a few hours or 
a few days wearing. 
Prisms might be prescribed or operations 
performed at intervals during the patient’s 
lifetime, and the tendency to deviate would 
never be corrected until the images were made 
the same size. 
Progressive myopia will continue to progress 
if you try to please your patients by giving 
them an under correction for reading or any 
near work, and full correction for the distance, 
or allow them to use the under correction for 
both far and near, unless they have reached 
the age of presbyopia. I believe it is the 
tendency to divergence that causes myopia to 10 
progress. By giving the full correction, the 
eyes act as emmetropic eyes; the tendency to 
divergence disappears; the ciliary muscles 
have to contract at the near point and along 
with them the other muscles of accommodation. 
I have had the satisfaction of examining a 
great many patients who have had two pairs 
of glasses prescribed, one for the distance and 
one for the near, and to the best of my recol- 
lection every one had become more near sight- 
ed, except some who said they soon found that 
their eyes were more comfortable with the 
distance glasses for all purposes, and that they 
had laid their near glasses aside. 1 have ex- 
amined a number of cases after having pre- 
scribed the total correction months or years 
before, and never had to increase the strength 
of the glasses in as many as a half dozen cases. 
Some will say that patients who have a high 
degree of myopia are not able to wear the full 
correction for the near. I succeed in making 
the patients wear the full correction for all 
distances, until they have reached the age of 
presbyopia. They see much better with a 
weaker glass for the near and will object to 
wearing the total correction unless given an 
intelligent reason for doing so. I tell them 
that as they have been seeing near objects 
without the use of. the ciliary muscle it has 
become weak, that if they will be content to 
use the full correction the strength of the 
ciliary muscles will in a short time return, and 
that the tendency to deviation, which causes 
headache and pain in their eyes, will disappear 11 
A distinguished ophthalmologist said in one 
of his papers that asthenopia was due to the 
contraction of the ciliary muscles; that a myope 
who did not have the use of the ciliary muscles 
for the near, only complained of not being able 
to see well. My experience is that the majority 
complain of pain in eyes and headaches, which 
shows evidently that it is caused by contraction 
of one or more of the external muscles of the 
eye, or, a tendency to deviation. Pain or head- 
ache can be caused by the contraction of one 
muscle of the eye as well as by another. It is 
simply an over exertion that makes a muscle 
tired, and this produces pain in eyes and head- 
aches. 
Myopic patients more commonly complain 
of pain and headaches at the near point. This 
is because the vision is better at a near point, 
and the two eyes conflict on account of the dif- 
ference in size of the objects received. It is a 
common thing for patients to say that while 
riding in a car, looking out at various objects 
the car is passing, they have headaches and 
pain in eyes. I have found that all these pa- 
tients have a tendency to eye deviation. One 
eye deviates more or less in passing from one 
object to another, just as it moves in or out 
when covered by a hand. 
I believe in cases of permanent squint, that 
we should first try to straighten the eyes with 
glasses, whether one eye is ambliopic or not. 
When a muscle is cut we rarely ever get bino- 
cular single vision, but if the eyes can be 
straightened by glasses, binocular single vision 12 
will be obtained. I have straightened the eyes 
in several cases where one eye was ambiopic. 
In cases of squint due to hypernietropia atro- 
pine is used, but not in myopia. 
I have a collection of two hundred cases, 
arranged in the table following. One hundred 
and one have the same error of refraction. 
Ninety-one of these have a horizontal tendency 
to deviate. Ten have a vertical tendency to 
deviate, nine of the ten having a horizontal 
tendency as well. Of the ninety-nine cases 
having a different error of refraction of the 
two eyes, eighty have a vertical tendency to 
deviate, nineteen a horizontal tendency to 
deviate, and sixty-nine of the eighty cases have 
a horizontal tendency as well. In the eighty 
cases of vertical tendency, sixty have a ten- 
dency of one eye downward, and twenty of one 
eye upward. 
These cases were taken from our case books 
from May 1888 to May 1890, and I noticed in a 
number of them that only one examination was 
made. Since that time, I have made my ex- 
aminations with a view to proving more con- 
clusively the rule that horizontal tendencies 
only, exist in eyes having the same error of 
refraction, and that vertical tendencies exist 
in eyes having a different error of refraction. 
When the first examination failed to prove 
the rule, a second examination, especially with 
atropine, proved the rule to hold good, almost 
without exception. 
The following table will show per cent 
of exceptions. 13 
In the next two hundred cases, which I nope 
to report soon, the exceptions will I think 
amount to less than 5 per cent. 
In this paper you have my views on the 
subject of muscular insufficiencies.. I should 
be very glad to hear the result of the experi- 
ence of others. 
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The following cases may be of interest: 
Case I.—July 23rd, 1890. Mrs W., aged forty- 14 
four, has had headaches for twenty years, which 
usually begin in the morning and last for two 
or three days. The pain starts in back of eyes, 
extends over and around head to back part, 
down neck and back. For the past six months 
has had a constant ache around the eyes. She 
has been perfectly healthy in other respects. 
R. V.-5; Hm.o.js D. ) 
L. V. — S; Hm. 0.75 D. ( 75 
Exophoria 3° with or without the above cor- 
rection. 
Binocular single vision with red glass. 
Sursumduction each 30, abduction 120, ad- 
duction 28°. 
+ 0.75 D., for the distance relieves the tired 
feeling she has in her eyes. 4- 1.50 D. was 
ordered for the near. 
I copy portions of two letters from Dr. W., 
husband of the patient. 
Sept. 16th. My dear Doctor: I think suffi- 
cient time has elapsed since my wife and I 
were in your office, for a report. We went 
direct to the optician and were supplied with 
glasses. She put them on at once. Up to the 
present writing she has not had the ghost of a 
headache, has gained 15 lbs. in weight and 
over 1,000,000,000 lbs. in happiness. 
Jan. 14th, 1891.—Dear Doctor: It affords me 
infinite satisfaction to be able to report that up 
to the present writing, nearly five months since 
our first visit to your office, there has been no 
return of those terrible headaches. 
Case II.—Dec. 21st, 1889. Miss C. aged 20. 
For the last year her eyes hurt and burn after 15 
using them for near work; does not think she 
sees well, especially at the distance; things look 
blurred when she looks at them long. Oph. + 
1.50 D. both. 
R. V. - g; g W. + 0.75 D. 
L. V. -S; gw. + 0.75 D. 
Esophoria 120; with + 0.75 D. 50. 
Dec. 23rd.—Homeatropine 2 per cent, 6 times 
in eyes. 
R. V. = g with + 1.75 D. 
L. V. = “; g W. x ,.75 D. 
Esophoria 8P. 
Dec. 26th—R. V. = g; Hm. 1. d. ) f D ord 
L. V. = g; Hm. 1. d. f 
Esophoria 140; W. x 1.25 D. 50. 
March 15th.—Has been wearing her glasses 
all the time since here. Eyes feel very com- 
fortable when she has the glasses on. 
Jan. 13th, 1891. — V. g W. x 1.25 D. both, 
slightly clearer than x 1.50 D. 
Esophoria 6°; W. x 1.25 D. 
Orthophoria. Glasses give entire satisfaction. 
Case III.—Miss S., aged 32. Up to twelve 
years ago had worn glasses, for five years. 
After breaking them she stopped wearing glas- 
ses. Cannot see well when reading. Has a 
sort of mist before her eyes, and they burn 
cpiite a good deal. 
R.V-=*£>; g W.—10. D. 0—1-5° D-ax r5°* l rd 
L. V. = g; g W. —1.50 D. ax 1.50. } 
Right eye moves down and out. Reads 
Jaeger No. 1 with the above combination com- 
fortably and also has with the above combina' 
lion binocular single vision, 16 
Case IV.—Jan. 14th, 1S92. This case is taken 
outside the list because of special interest. 
Mr. M., aged 25. Has worn glasses a week, 
prescribed by an oculist. The glasses ordered 
were: 
Right x 67 D. s. o 1.25 D. c. ax 90°. 
Left, plain glass. 
Three years ago he noticed that he saw im- 
perfectly at a distance and had glasses pre- 
scribed by an oculist. 
Ophthalmoscopic examination showed opaque 
nerve fibres and 2 D. ax 60 right eye. 
Left, 13 D., partly astigmatic. 
R. V. — :2°0 x W. 1.50 D. ax 60. 
L. V. = 2o0; f0 W. 9 D. O 3.50 D. ax 165. 
With the above correction the light seen with 
the left eye is above and to the right, and both 
lights are the same size. This shows that the 
left eye turns down and out. The above glas- 
ses were ordered. 
March 18th.—He now uses his glasses for 
both far and near. It took him some time to 
get used to them for the near, but they are 
now all right, and has no nausea, which he had 
all the time before wearing the above glasses. 
Now he has orthophoria. 
R. V. = “ x W. —2 D. ax Co. 
L. V. = jo x W. —9 D. o 3.50 D. ax 165 s. 
Oct. 23rd.—Orthohoria with last glasses or- 
dered. 
R. V. = 50; 20 x W. —2.50 D. ax 60. 
L. V. = a” x W. —9 D. —4.50 D. ax 180. 
At the time of the first visit the left eye 
showed a tendency downward 120. 
327 Madison Ave.