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Correction of Cross-Eye Deformity
124
ROBERT VON DBR HEYDT
Fundus vessels seen with the redfree light are black on a light back ground due to the absence of the dif fuse red of the choroid. Of particular interest are some of the findings in the macular region. Here very minute vessels may be followed over the edge of the macula into its depression until they are lost in the foveal reflex. A well-defined, small granulation of the macular surface is seen. Small macu lar hemorhages are easily discernible and larger hemorrhagic and exudative zones in choroiditis quite easily located even through a diffusely clouded vit reous. The foveal reflex ordinarily found only in youthful individuals can often be observed with the red-free light in old age. The macular zone is of a radiant yellow color and its diameter about one-third that of the disc. It is therefore easily visible and can be located in pathologic fundi in cases where this would be impossible with ordinary light. It has been conceded and especially emphasized by Haab that the darker red of the macula is due to increased pigmentation. With the red-free light all pigment appears black. There is, however, no black mottling in the macular zone, consequently no pig ment. As the macula is now definitely
known and seen to be yellow, its darker red contrast found with ordi nary illumination can only be ascribed to an intensification by the yellow col oration. This can be easily shown by placing a yellow lens over part of a red zone the color of the fundus. The red under the yellow lens will be of a more intense red. We have therefore with the red-free light the first absolute demonstration of the yellow coloring at the macula in the living eye. A new explanation of why this zone is more intensely red with ordinary illumination. The ability to measure this zone more accurately, comparing it with the usually larger size of yellow discoloration found after death. W e can note new details of the macula as respects its size, reflexes and surface, absence of pigmentation (ex cept secondary to disease), vascularization and the direction of vessels. W e can also with it measure and by com parison in various eyes study the yel low discoloration of the lens in age. Most important is the ability to fol low minutely the direction of the nerve bundle and fibre layers in the retina— a matter of great importance; as I will endeavor to show in the near future by presenting some new and intensely interesting findings by Vogt in patho logic fundi as shown with the red-free light.
CORRECTION OF CROSS-EYE DEFORMITY. J. A. KEARNEY, M.
D.
NEW YORK.
This is a review of the author's practice and teaching in the New York Polyclinic Med ical School and Hospital, based upon 175 consecutive operative cases. The chief concern of cross-eyed pa tients is the correction of the de formity. C r o s s - e y e (Strabismus Squint) cases as a rule are seen in con sultation by the eye surgeon at certain ages and under certain conditions and it is always interesting to note the com pelling cause of the first visit.
The child in arms is seen by us when a worried mother notices the infant's eyes are crossed, next period when as a sensitive youth he suffers deeply the gibes of his school companions, some what later on when he is chagrined to find that because of this deformity he is unable to secure a position for which
CORRECTION OF CROSS-BYE DEFORMITY
125
he has trained and is perfectly capable is generally a history given of difficult of filling, still later on in life when he or instrumental delivery of the child discovers that the operation for the and subsequent occasional convulsions. correction of squint is not a serious Spasticity and other neurologic dis one and that it is possible to obtain a orders are the usual sequellae of birth good result at any time from nine years hemorrhages, unless the clot is re of age onward. Certain other com moved and intracranial pressure re pelling conditions are familiar, the lieved by a decompression operation. young girl who is not invited to parties If this procedure is deemed necessary given by her friends on account of her the earlier it is done the better. Often appearance, the young person during we find in the fundi of cross-eyed in courtship for obvious reasons, and the fants optic discs that are decidedly pale cross-eyed who are avoided by super thruout (atrophic), as the result of stitious people. No other case is faulty development in embryo and more gratifying than when a client ap sometimes associated with stigmata plies for the correction of a squint de (high palatal arches, cleft palates etc.) formity referred by a patient upon elsewhere from the same cause. These are neurologic cases also. whom you have operated. Mentally normal children with stra Strabismus is paralytic (partial, com plete), or concomitant (monocular, al bismus, in which no changes are noted ternate). In complete paralytic squint in the eye grounds, with or without the eye is in malposition and can not errors of refraction existing, or in be voluntarily moved in the direction which recent exudative changes are ob of the paralyzed muscle; in partial served become the subsequent charge paralytic squint the eye in faulty posi of the ophthalmologist. tion can voluntarily be rotated in the Since no one cause has been ascribed direction of the paralyzed muscle, but for strabismus, the usual attending not to the normal extent. abnormal factors may be looked for In concomitant squint the eyes ro and corrected if possible, the earlier the tate equally, the affected one maintain better. Errors of refraction, amblyopia ing the same angle of deviation in all •and faulty fusion are the usual con positions. Each eye fixes alternately comitants. in alternate concomitant strabismus; If an error of refraction is present and in monocular concomitant strabis suitable lenses worn constantly give mus one eye fixes and the other con the best results in correcting a squint stantly deviates. Vertical concom deformity at a period when a child's itant strabismus is uncommon and we eyes are observed to be crossed at have to do chiefly with lateral devia times and straight at others, no matter tions, convergent and divergent con what angle of deviation obtains; or comitant strabismus. when the angle remains constant and An infant with a noticeable squint is less than 15 degrees. Glasses may requires a careful direct method oph- be worn by children as young as one thalmoscopic examination of the fun- and one-half years of age, and it is dus of each eye. They are neurologic never too early to prescribe a correc cases when we discover as we fre tion for an existing error of refraction quently do edematous changes in the in a developing strabismus. Correct fundi, that indicate an increase in the ing lenses, however, seldom have any intracranial pressure. Measurement effect upon a squint deformity of 15 of the degree of intracranial pressure degrees and over, if the eye that turns should be made and recorded at once, remains in malposition for three by a spinal mercurial manometer months or longer. at lumbar puncture to verify the funThe correction of faulty fusion is dus findings; and if it records a de rarely successful because of the imma cided increase above the normal, the turity of the patient at the time the excess1 of pressure is usually due to an treatment would avail; and even un intracranial hemorrhage at birth. There der the best conditions excessive dili-
126
J. A. KEARNEY
gence is required to get a small per grees when it exists. If the deviation centage of good results. An occasional measures 30 degrees an advancement good result is obtained in amblyopics of the externus is done first and when when the affected eye is compelled to the reaction subsides the internus of fix by placing a correcting lens before the same eye is completely tenotomized it, and shutting off fixation of the good and usually corrects. If the deviation eye by a shade, or atropinizing it. is 45 degrees an advancement of the Conservative methods have been externus of the squinting eye is done tried out usually, on all strabismic pa first followed by a complete tenotomy tients who are particular about their of the internus of the same eye when looks, before the operative age (9 the reaction of the advancement opera years) is reached; and when an eye tion subsides, and later on an advance surgeon is, consulted a review is made ment of the externus of the good eye of the history and treatments that had usually corrects. been given, and if stated nonoperative When tenotomies are indicated in methods have failed to correct the de concomitant convergent strabismus a formity then surgical measures are ad complete tenotomy of the internus cor vised. rects 15 degrees and if less than 15 Operations upon the external ocular degrees are to be corrected, partial muscles for the correction of squint tenotomies are done. When advance are advisable when the patient is 9 ments are indicated in concomitant years of age and over, and all neces convergent strabismus 15 degrees are sary nonoperative measures have been corrected by the usual placement of tried and have failed to correct the de stitches in the externus, but a little formity. The choice of procedure de more or less can be accomplished by pends* upon the character and angle of entering the stitches on either side of strabismus that exists, and the nature, the usual position. and extent of lateral rotations. Under In alternate convergent concomitant usual conditions the deformity in all strabismus advancements of the ex concomitant strabismic eyes may be ternal recti of both eyes are done and corrected to parallelism by definite sur the amount to be corrected is divided gical procedures. between both eyes. If the advance If the external lateral rotation of the ments do not correct the entire amount squinting eye is found to be normal, of squint, for the deviation remaining, in monocular concomitant convergent partial tenotomies of the interni of both strabismus that measures 15 degrees eyes are done and should be equally of deviation, a complete tentotomy of divided between them. the internal rectus of the affected eye In the divergent type of concomitant usually corrects. If the deviation strabismus, tenotomies of the external measures 30 degrees a complete ten- recti have very little effect upon the otomy of the itnemus followed by an cosmetic result but the advancement advancement of the externus of the of the internus may be regulated to squinting eye usually corrects. If the correct up to 45 degrees of deviation deviation measures 45 degrees com This is a most satisfactory procedure plete tenotomies of the interni of both on account of the good size of the in eyes usually correct. ternus muscle, and experience guides However, if it is determined that one in the placement of stitches to cor the external lateral rotation of the rect various amounts of deviation. squinting eye is not sufficient, but the Operations for the correction of amount of deficiency is made up by paralytic squints are unsatisfactory as excess of internal rotation, or in other a rule, but it is possible at times to words the lateral excursions are equal, pull and fix an eye in straight position. but the plane of rotation is advanced The usual complete tenotomy in to the nasal side, then an advancement which the aponeuroses of the muscle of the external rectus is done first and as well as the tendon are severed, and usually corrects a deviation of 15 de 'the advancement operation, a modifi-
CORRECTION OF CROSS-EYE DEFORMITY
cation of Landolt's, give the best re sults in the writer's hands. In the last 175 consecutive operations for the cor rection of squint deformity, parallelism has been obtained in all of them.
HYPERPLASTIC
EXUDATIVE
127
There were 155 monocular convergent concomitant, 16 divergent con-comitJant, 3 alternate convergent concom itant and one convergent paralytic (complete).
RETINITIS
J. W. JERVEY, M.
(NONHEMORRHAGIC).
D.
GREENVILLE, SOUTH CAROLINA.
The report of four cases and statement of reasons for grouping them as illustrating this form of retinitis. A thesis submitted, and accepted, as a candidate for membership in the American Ophthalmological Society, 1918.
True hyperplastic, exudative, non- peared to be true organized retinal ex hemorrhagic phenomena in and appar udates, nonhemorrhagic, three of them ently adjacent to the retina are rare. being confined within, or adjacent to The appearances which they present to the retinal layers, and one combining ophthalmoscopic examination are fre this type with the currently described quently similar to, and perhaps often type of retinitis proliferans extending indistinguishable from, the lesions re into the vitreous body. In none of sulting from previous hemorrhagic ex these cases was there any evidence of travasations. In fact, the ultimate re previous or present hemorrhage at the sult, subjectively and objectively, of site of the lesions, and in all except one organized hemorrhagic and nonhemor- the development of the processes was rhagic exudates might conceivably be watched from week to week and month pathologically identical, as in the le to month under ophthalmoscopic ob sions of retinitis proliferans, which servation. may have their origin in either form of In view of these observations, which exudation. are detailed below, the writer suggests This latter form of retinitis is of that proliferating or granulating or course described in all modern text chronic inflammatory (neoplastic) tis books, but the rarity of its occurrence sue may occur within as well as with may be realized by the statement of out (with an origin within) the retinal Weeks that he had seen but two cases layers; that it may occur without pre in twenty-four thousand private pa ceding hemorrhagic phenomena; and tients, and of Schobl, quoted by that whether within or without the Weeks, who observed five cases out of retinal layers these lesions may prop 179,057 patients. The common ac erly be classified as hyperplastic ex ceptance of its etiology is hemorrhagic udative (nonhemorrhagic) retinitis. extravasation from the retina into the From all that is known of retinitis vitreous. It has been pointed out, circinata, it would seem justifiable to however, that it may occur conse include this type in the above classifi quently upon the ejection of a fibrinous cation, the difference in the ophthalexudate or coagulum, with or without -moscopic picture being due merely to the presence of blood corpuscles the different arrangement of the le (Weeks). sions. Leaving out of consideration, for the The identification of hyperplastic ex present, cases of retinitis circinata, udative retinitis with the conditions which will be referred to later, the described by Coats in 1909 as a "dis writer has observed at least four cases ease of the retina, hitherto insuffi showing lesions in six eyes, of what ap ciently differentiated, which is charac-
ROBERT VON DBR HEYDT
Fundus vessels seen with the redfree light are black on a light back ground due to the absence of the dif fuse red of the choroid. Of particular interest are some of the findings in the macular region. Here very minute vessels may be followed over the edge of the macula into its depression until they are lost in the foveal reflex. A well-defined, small granulation of the macular surface is seen. Small macu lar hemorhages are easily discernible and larger hemorrhagic and exudative zones in choroiditis quite easily located even through a diffusely clouded vit reous. The foveal reflex ordinarily found only in youthful individuals can often be observed with the red-free light in old age. The macular zone is of a radiant yellow color and its diameter about one-third that of the disc. It is therefore easily visible and can be located in pathologic fundi in cases where this would be impossible with ordinary light. It has been conceded and especially emphasized by Haab that the darker red of the macula is due to increased pigmentation. With the red-free light all pigment appears black. There is, however, no black mottling in the macular zone, consequently no pig ment. As the macula is now definitely
known and seen to be yellow, its darker red contrast found with ordi nary illumination can only be ascribed to an intensification by the yellow col oration. This can be easily shown by placing a yellow lens over part of a red zone the color of the fundus. The red under the yellow lens will be of a more intense red. We have therefore with the red-free light the first absolute demonstration of the yellow coloring at the macula in the living eye. A new explanation of why this zone is more intensely red with ordinary illumination. The ability to measure this zone more accurately, comparing it with the usually larger size of yellow discoloration found after death. W e can note new details of the macula as respects its size, reflexes and surface, absence of pigmentation (ex cept secondary to disease), vascularization and the direction of vessels. W e can also with it measure and by com parison in various eyes study the yel low discoloration of the lens in age. Most important is the ability to fol low minutely the direction of the nerve bundle and fibre layers in the retina— a matter of great importance; as I will endeavor to show in the near future by presenting some new and intensely interesting findings by Vogt in patho logic fundi as shown with the red-free light.
CORRECTION OF CROSS-EYE DEFORMITY. J. A. KEARNEY, M.
D.
NEW YORK.
This is a review of the author's practice and teaching in the New York Polyclinic Med ical School and Hospital, based upon 175 consecutive operative cases. The chief concern of cross-eyed pa tients is the correction of the de formity. C r o s s - e y e (Strabismus Squint) cases as a rule are seen in con sultation by the eye surgeon at certain ages and under certain conditions and it is always interesting to note the com pelling cause of the first visit.
The child in arms is seen by us when a worried mother notices the infant's eyes are crossed, next period when as a sensitive youth he suffers deeply the gibes of his school companions, some what later on when he is chagrined to find that because of this deformity he is unable to secure a position for which
CORRECTION OF CROSS-BYE DEFORMITY
125
he has trained and is perfectly capable is generally a history given of difficult of filling, still later on in life when he or instrumental delivery of the child discovers that the operation for the and subsequent occasional convulsions. correction of squint is not a serious Spasticity and other neurologic dis one and that it is possible to obtain a orders are the usual sequellae of birth good result at any time from nine years hemorrhages, unless the clot is re of age onward. Certain other com moved and intracranial pressure re pelling conditions are familiar, the lieved by a decompression operation. young girl who is not invited to parties If this procedure is deemed necessary given by her friends on account of her the earlier it is done the better. Often appearance, the young person during we find in the fundi of cross-eyed in courtship for obvious reasons, and the fants optic discs that are decidedly pale cross-eyed who are avoided by super thruout (atrophic), as the result of stitious people. No other case is faulty development in embryo and more gratifying than when a client ap sometimes associated with stigmata plies for the correction of a squint de (high palatal arches, cleft palates etc.) formity referred by a patient upon elsewhere from the same cause. These are neurologic cases also. whom you have operated. Mentally normal children with stra Strabismus is paralytic (partial, com plete), or concomitant (monocular, al bismus, in which no changes are noted ternate). In complete paralytic squint in the eye grounds, with or without the eye is in malposition and can not errors of refraction existing, or in be voluntarily moved in the direction which recent exudative changes are ob of the paralyzed muscle; in partial served become the subsequent charge paralytic squint the eye in faulty posi of the ophthalmologist. tion can voluntarily be rotated in the Since no one cause has been ascribed direction of the paralyzed muscle, but for strabismus, the usual attending not to the normal extent. abnormal factors may be looked for In concomitant squint the eyes ro and corrected if possible, the earlier the tate equally, the affected one maintain better. Errors of refraction, amblyopia ing the same angle of deviation in all •and faulty fusion are the usual con positions. Each eye fixes alternately comitants. in alternate concomitant strabismus; If an error of refraction is present and in monocular concomitant strabis suitable lenses worn constantly give mus one eye fixes and the other con the best results in correcting a squint stantly deviates. Vertical concom deformity at a period when a child's itant strabismus is uncommon and we eyes are observed to be crossed at have to do chiefly with lateral devia times and straight at others, no matter tions, convergent and divergent con what angle of deviation obtains; or comitant strabismus. when the angle remains constant and An infant with a noticeable squint is less than 15 degrees. Glasses may requires a careful direct method oph- be worn by children as young as one thalmoscopic examination of the fun- and one-half years of age, and it is dus of each eye. They are neurologic never too early to prescribe a correc cases when we discover as we fre tion for an existing error of refraction quently do edematous changes in the in a developing strabismus. Correct fundi, that indicate an increase in the ing lenses, however, seldom have any intracranial pressure. Measurement effect upon a squint deformity of 15 of the degree of intracranial pressure degrees and over, if the eye that turns should be made and recorded at once, remains in malposition for three by a spinal mercurial manometer months or longer. at lumbar puncture to verify the funThe correction of faulty fusion is dus findings; and if it records a de rarely successful because of the imma cided increase above the normal, the turity of the patient at the time the excess1 of pressure is usually due to an treatment would avail; and even un intracranial hemorrhage at birth. There der the best conditions excessive dili-
126
J. A. KEARNEY
gence is required to get a small per grees when it exists. If the deviation centage of good results. An occasional measures 30 degrees an advancement good result is obtained in amblyopics of the externus is done first and when when the affected eye is compelled to the reaction subsides the internus of fix by placing a correcting lens before the same eye is completely tenotomized it, and shutting off fixation of the good and usually corrects. If the deviation eye by a shade, or atropinizing it. is 45 degrees an advancement of the Conservative methods have been externus of the squinting eye is done tried out usually, on all strabismic pa first followed by a complete tenotomy tients who are particular about their of the internus of the same eye when looks, before the operative age (9 the reaction of the advancement opera years) is reached; and when an eye tion subsides, and later on an advance surgeon is, consulted a review is made ment of the externus of the good eye of the history and treatments that had usually corrects. been given, and if stated nonoperative When tenotomies are indicated in methods have failed to correct the de concomitant convergent strabismus a formity then surgical measures are ad complete tenotomy of the internus cor vised. rects 15 degrees and if less than 15 Operations upon the external ocular degrees are to be corrected, partial muscles for the correction of squint tenotomies are done. When advance are advisable when the patient is 9 ments are indicated in concomitant years of age and over, and all neces convergent strabismus 15 degrees are sary nonoperative measures have been corrected by the usual placement of tried and have failed to correct the de stitches in the externus, but a little formity. The choice of procedure de more or less can be accomplished by pends* upon the character and angle of entering the stitches on either side of strabismus that exists, and the nature, the usual position. and extent of lateral rotations. Under In alternate convergent concomitant usual conditions the deformity in all strabismus advancements of the ex concomitant strabismic eyes may be ternal recti of both eyes are done and corrected to parallelism by definite sur the amount to be corrected is divided gical procedures. between both eyes. If the advance If the external lateral rotation of the ments do not correct the entire amount squinting eye is found to be normal, of squint, for the deviation remaining, in monocular concomitant convergent partial tenotomies of the interni of both strabismus that measures 15 degrees eyes are done and should be equally of deviation, a complete tentotomy of divided between them. the internal rectus of the affected eye In the divergent type of concomitant usually corrects. If the deviation strabismus, tenotomies of the external measures 30 degrees a complete ten- recti have very little effect upon the otomy of the itnemus followed by an cosmetic result but the advancement advancement of the externus of the of the internus may be regulated to squinting eye usually corrects. If the correct up to 45 degrees of deviation deviation measures 45 degrees com This is a most satisfactory procedure plete tenotomies of the interni of both on account of the good size of the in eyes usually correct. ternus muscle, and experience guides However, if it is determined that one in the placement of stitches to cor the external lateral rotation of the rect various amounts of deviation. squinting eye is not sufficient, but the Operations for the correction of amount of deficiency is made up by paralytic squints are unsatisfactory as excess of internal rotation, or in other a rule, but it is possible at times to words the lateral excursions are equal, pull and fix an eye in straight position. but the plane of rotation is advanced The usual complete tenotomy in to the nasal side, then an advancement which the aponeuroses of the muscle of the external rectus is done first and as well as the tendon are severed, and usually corrects a deviation of 15 de 'the advancement operation, a modifi-
CORRECTION OF CROSS-EYE DEFORMITY
cation of Landolt's, give the best re sults in the writer's hands. In the last 175 consecutive operations for the cor rection of squint deformity, parallelism has been obtained in all of them.
HYPERPLASTIC
EXUDATIVE
127
There were 155 monocular convergent concomitant, 16 divergent con-comitJant, 3 alternate convergent concom itant and one convergent paralytic (complete).
RETINITIS
J. W. JERVEY, M.
(NONHEMORRHAGIC).
D.
GREENVILLE, SOUTH CAROLINA.
The report of four cases and statement of reasons for grouping them as illustrating this form of retinitis. A thesis submitted, and accepted, as a candidate for membership in the American Ophthalmological Society, 1918.
True hyperplastic, exudative, non- peared to be true organized retinal ex hemorrhagic phenomena in and appar udates, nonhemorrhagic, three of them ently adjacent to the retina are rare. being confined within, or adjacent to The appearances which they present to the retinal layers, and one combining ophthalmoscopic examination are fre this type with the currently described quently similar to, and perhaps often type of retinitis proliferans extending indistinguishable from, the lesions re into the vitreous body. In none of sulting from previous hemorrhagic ex these cases was there any evidence of travasations. In fact, the ultimate re previous or present hemorrhage at the sult, subjectively and objectively, of site of the lesions, and in all except one organized hemorrhagic and nonhemor- the development of the processes was rhagic exudates might conceivably be watched from week to week and month pathologically identical, as in the le to month under ophthalmoscopic ob sions of retinitis proliferans, which servation. may have their origin in either form of In view of these observations, which exudation. are detailed below, the writer suggests This latter form of retinitis is of that proliferating or granulating or course described in all modern text chronic inflammatory (neoplastic) tis books, but the rarity of its occurrence sue may occur within as well as with may be realized by the statement of out (with an origin within) the retinal Weeks that he had seen but two cases layers; that it may occur without pre in twenty-four thousand private pa ceding hemorrhagic phenomena; and tients, and of Schobl, quoted by that whether within or without the Weeks, who observed five cases out of retinal layers these lesions may prop 179,057 patients. The common ac erly be classified as hyperplastic ex ceptance of its etiology is hemorrhagic udative (nonhemorrhagic) retinitis. extravasation from the retina into the From all that is known of retinitis vitreous. It has been pointed out, circinata, it would seem justifiable to however, that it may occur conse include this type in the above classifi quently upon the ejection of a fibrinous cation, the difference in the ophthalexudate or coagulum, with or without -moscopic picture being due merely to the presence of blood corpuscles the different arrangement of the le (Weeks). sions. Leaving out of consideration, for the The identification of hyperplastic ex present, cases of retinitis circinata, udative retinitis with the conditions which will be referred to later, the described by Coats in 1909 as a "dis writer has observed at least four cases ease of the retina, hitherto insuffi showing lesions in six eyes, of what ap ciently differentiated, which is charac-