Part 12

CASE 53.--Ernest Sp--, aet. 11-1/2; divergent squint had been observed as early as his second year. The deviation amounts to 5 or 6 mm., is sometimes alternating, generally the left eye deviates. No convergent movement on fixing a pencil about 25 cm. distant; the right eye is then used for reading, the left one makes a distinct, but not a sufficient, movement inwards. Emmetropia on both sides, visual acuteness nearly perfect on the right, on the left 2/3 of the normal. Even with red glass and prisms deviating in a vertical direction, double images not perceived. On October 2nd, 1879, shortening of the left internal rectus, tenotomy of both externi. A week later divergence was no longer present. When reading, the left eye makes a distinct, perhaps rather too great, movement of convergence, and yet six weeks after the operation, distinct divergent squint was again present, even if to a slighter degree than before; the left eye deviates 3 to 4 mm., the right 2 to 3 mm. outwards. The result obtained amounted then to not more than about 3 mm. In the middle of December the tenotomy of both externi was therefore repeated. A week after the operation convergent squint of 2 mm. is present with homonymous diplopia. A pencil made to approach on the middle line is seen double to about 20 cm., on approaching nearer, double images are not perceived in spite of distinct relative divergence. Double images at a distance of 4 m. are corrected by prism 25 deg.; as, however, normal binocular vision is not present, the value of this statement is very questionable. Three weeks after the second operation the position of the eyes was normal, and the slightest convergence was perceived only on close investigation. Double images are no longer observed, however they may still be brought to view.

In periodic divergent squint, if the deviation is considerable and frequent, if at the same time the normal near point of convergence is only attained with difficulty or not at all, we can hardly combine shortening of the internus with tenotomy of the externus; more often indeed, additional tenotomy of the externus of the other eye is necessary in order to obtain a permanent cure. In exceptional cases (when it seemed to me as if the squint depended more on insufficiency of the internus than on preponderance of the externus) I have confined myself to shortening the internus without separating the externus; I will quote just one example of this.

CASE 54.--Ida K--, aet. 11. On the right, hypermetropia 3 D. with the ophthalmoscope, visual acuteness 5/24. No. 0.3 is read with difficulty. On the left, with the ophthalmoscope hypermetropia 4.5 D. with asymmetric meridian. Single letters of 3.0 m. are recognised with convex 6.5 D. Fingers are counted at about 1-1/2 m. The choroid is slightly and unequally pigmented, no ophthalmoscopically assignable reason exists for the considerable visual defect. The left eye frequently deviates outwards, convergence is attainable to 15 cm. On May 2nd, 1877, shortening of the internus (without tenotomy of the externus). Two weeks later slight convergent squint was present; in November, 1877, six months after the operation, the position of the left eye was perfectly normal.

Tenotomy of the externi suffices when the divergent deviation is inconsiderable and does not occur often, if the normal near point of convergence can still be reached, and binocular fusion is possible.

If we want to increase the effect of simple tenotomy of the externi, this may be done just as well by practice of the associated movements of the eyes as by practice of the convergence, of course for a short time only after the operation. As long as the detached tendon of the external rectus is not re-attached firmly with the sclerotic, all these movements of the eyes help to strengthen the result of the tenotomy. In order to practise convergence we can bring a suitable fixed point on to a mirror and so make it possible for the patient himself to see the position of his eyes, of course only in cases where binocular fusion is no longer present. He who possesses a normal binocular vision is troubled in these exercises by diplopia; but this is not the case in the suppression of binocular fusion so frequent as a result of squint.

Periodic divergent squint is divided by no sharply defined limits from those cases in which only a preponderance of the externi exists without insufficiency of the interni. We frequently find very considerable degrees of facultative divergence as a casual symptom, without the occurrence of manifest divergence or the presence of asthenopic troubles. If this is accompanied by weakness of the interni, absolute divergence occurs on looking at near objects, sometimes for distance also and certainly if we suppress binocular fusion by covering one eye or render it difficult by colouring one visual field with a red glass.

In these cases the indications for the operation are given either by asthenopia, by troublesome double images or by the disfigurement inseparable from periodic squint; it will depend on the degree of the facultative divergence, whether we confine the tenotomy of the externus to one eye or whether we distribute it between both eyes.

Finally, it may be desirable to still say a few words as to the most favorable period for the operation. The comprehension of the defective sight often present in squint as caused by "non-use" has resulted in the preposterous advice that tenotomy should be carried out as early as possible. I can vouch for the fact that even the earliest tenotomy of the ocular muscles is of no avail against congenital amblyopia. I have repeatedly seen children on whom tenotomy had been performed in their first year, usually with bad cosmetic result but with continuance of defective sight of the squinting eye.

The final result of the operation is almost always very unsatisfactory when performed on children before their fourth year. I can show a number of good results in children on whom I operated between their fifth and sixth year; however, the more I considered the subject, the more it seemed to me advisable to raise the tests which must be imposed on the patients. With children it is not so much a question of determining the limit of age, but whether their intelligence is sufficiently developed to render a reliable examination possible. A sufficient knowledge of letters and the power of reading is necessary to an accurate trial of vision; the entire bearing of the children must permit of the ophthalmoscopic diagnosis of the weak condition and should raise no scruples as to wearing spectacles which may be necessary after the operation. Under any circumstances no harm is done by deferring the operation until these conditions are fulfilled; the interval may be filled up by practising the mobility of the eyes, which does more good than the customary strabismus spectacles or even tying up the eye. If we tie up the fixing eye, the squinting one is certainly put into fixation, but the other squints instead, and of course it is just the same with the plan, as childish as it is antiquated, of tying on a pierced walnut shell before each eye.

Strabismus spectacles, _i. e._ those with a leather band to go round the head, provided with leaden discs which cover one eye completely and leave only a side aperture for the other, of course only induce a transfer of the squint to the covered eye, together with practice of the eye in a lateral direction; but apart from their unsightly appearance they require a constant lateral direction of the eye, which is followed even after a short time by fatigue of the muscles employed and soon becomes unbearable. This is not the case if we cause the mobility to be practised alternately and towards both sides; here we must insist that the limits of the outward movement are really reached. These exercises are at least rational and tend to increase the strength of the antagonist, on which we must depend so much in the operation and to diminish an insufficiency made worse by want of practice.

PRINTED BY ADLARD AND SON, BARTHOLOMEW CLOSE.

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