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Practical Trial Lenses and a Trial Set
PRACTICAL T R I A L LENSES AND A T R I A L SET
middle fossa are apt to produce irregu lar or incongruous contralateral hemianopsia most frequently with macular sparing. This need not refute the idea of bisection in complete-tract lesions. In posterior-fossa or occipital-lobe growths I believe greater equality is
487
shown in vision, extent of disc edema, and fields. The latter are most frequent ly congruous quadrantic defects or hemianopsias with or without sparing of the macula. 1819 Chestnut street.
PRACTICAL TRIAL LENSES AND A TRIAL SET EDWARD JACKSON, M.D. DENVER, COLORADO
The advantages of relatively small plano-convex or plano-concave lenses are pointed out. Furthermore the virtue of simple, light trial frames is stressed.
When only spherical lenses were sold for spectacles, and these were ground and mounted in frames in the shop of the optician who sold them, the customer could look over the stock and choose those he preferred. There was then little need for anything like a trial set. But astigmatism was discovered and after its discovery was found in most eyes. It was found to vary in amount, and in the direction of its principal meridians. So there was need for trial frames and trial lenses which could be used for testing all kinds of eyes, before the necessary glasses could be prescribed. The knowledge that optical defects of the eye cause important symptoms and disability to the person compelled to use such defective eyes, greatly increased the interest in optical errors. It made their detection, measurement, and cor rection a very important branch of the work of the medical profession. When physicians and surgeons had to study and prescribe for errors of refraction, trial sets were essential. Donders in duced the opticians to supply the cylin drical lenses needed for testing astig matism. But aside from that, doctors have taken whatever opticians have called a trial set and have recommended and supplied to them. When test lenses, frames, and allied apparatus became an important part of the optical business, the number and cost of lenses and frames grew to be an element in profits; and trial sets were elaborated in the direction of making them profitable to the optician.
The medical profession was slow to recognize that correction of refractive errors was a part of its duties to pa tients. Physicians did not eagerly take to the use of the tools by which this was to be done. They took the trial sets of fered to them, without trying to make them as effective and convenient as pos sible ; and with no thought of seeking to avoid unnecessary expense from their useless elaboration. Perhaps the greater size and more striking appearance of the larger trial case was thought to make it more impressive, and therefore more de sirable. Since cylinders have come to be used with spherical lenses, it has been neces sary to have trial frames in which two or more lenses could be placed before each eye. Many, doing this kind of test ing, have realized the defects of their apparatus, and have tried to devise something better, but in trying to get what they wanted, they have been drawn away from simplicity into un desirable elaboration. Keeping in mind certain mathematical requirements and mechanical principles, it is possible to simplify our trial sets greatly; reduce their bulk and cost, and add to their con venience and efficiency. Admitting that we must have the means of trying lenses before the eyes in combinations of two and more, why should we not get the full benefit of the best lenses and simple frames for such combinations? Piano lenses are optical ly superior to the double convex and concave lenses in general use. As trial
488
EDWARD JACKSON
lenses they are far better than the menis The intervals of 0.12 D. are elimi cus lenses that are being exploited at nated because they are not useful in higher prices and by copyrighted names. any trial set. If an eye requires for its Their superiority has been urged upon correction a +1.12 sph., this fact can ophthalmologists since 1866; but not ef be established more quickly and more fectively enough to overcome the plaus certainly by comparing the effects of a ible claims and readiness of the manu 1- and a 1.25-D. lens, than by any use of facturers to supply goods from which a 1.12 sph. With cylindrical lenses inter they can get more profit. Those who are vals of one-eighth D. are still less useful to use trial sets must give enough and more confusing. thought to the subject to find out what This practical trial set must include they want; and then insist on having it. three cross cylinders, the +0.25 —0.25 ; The customary lenses are 38 mm. in the +0.50 —0.50; and the + 1 . — 1 . diameter. They are larger and heavier These will be used more than any other than are needed. But custom is hard to lenses in any trial set by one who un overcome. A lens 31 mm. in diameter, derstands the importance of astigma mounted in a flat rim, reduces by half tism, and the method of using the cross the weight of the stronger lenses. It is cylinder to determine its meridians (the large enough to handle easily and serves direction of cylinder axes) and their all purposes of testing vision. A set of strengths. such lenses is notably less bulky and The lenses furnished are only one of more convenient. each strength. The pairs referred to, are There can be a great reduction in the one convex and one concave of equal number of such lenses required for a strength. By the possible combinations complete trial set, by using lenses in this allows of placing lenses of equal combination. Piano lenses so combined strength before the two eyes. Suppose are practically accurate, and as light as each eye has hyperopia 4.75 D. Before when the two surfaces are ground on a one eye is placed a + 4 . with a +0.75 single piece of glass. Such a combina D.; and before the other eye + 5 . with tion avoids the inaccuracy of all com —0.25 D. This will be found true for all, binations of double convex and concave except for the highest and rarest errors. lenses. We could not provide for a pair of my The possibilities of such a set of small opic eyes, if each required —30 sph. lenses are best understood by consider with —9. cyl. But there is no reason ing what can be done with 12 pairs of to suppose that such a pair of eyes ever spherical and 8 pairs of cylindrical existed. Even after bilateral cataract ex lenses. These include 0.25, 0.50, 0.75, traction, the two eyes never require 1, 2, 3, 4, 5, 10, 15, 20, and 25 D. for the exactly the same combinations. sphericals; and the same up to, and in Trial frames adapted for the purpose cluding 5 D. for the cylindrical. By are essential for the use of such lenses combining two of these we have any in clinical testing. The best thus far spherical, with 0.25-D. intervals, to 6 found are the simple steel wire frames D.; and by 1-D. intervals, a series to of proper size, carefully adjusted. The 30 D. For the cylinders there are 0.25- spring of the wire must hold the cylin D. intervals to 6-D., and 1-D. intervals ders at the axes selected. The width be to 9-D. This is a more extended series tween centers may be 61 or 62 mm. The than is commonly furnished by the temples should be straight, holding to larger sets of trial lenses that are not the sides of the head, in any position to adapted like the piano lenses to combi give the lenses the proper angle. A pro nation. The two-cell trial frame, each tractor is needed to determine the di cell taking two piano lenses, makes easy rection that has been selected for the the placing of any strengths of the axis of the correcting cylinder. Such a spherical and cylindrical series together, protractor is larger and more accurate before an eye, with as much accuracy of than the graduated scales on many trial strength as is obtainable with the usual frames. The wire hooks should hold the trial sets. lenses securely by their mountings,
PRACTICAL TRIAL LENSES AND A T R I A L SET
without catching the edge of the glass, when this is thick, as in concaves and near the axis of a strong convex cylin der. These hooks should be so placed on the eye wire that they hold a little more than half the circumference of the lenses. For convenient use they must be kept in shape or adjusted when they get out of shape. Placing the temporal hooks lower than the nasal, facilitates introducing, or removing lenses, when the frame is on the face. Habitual use of such frames has convinced the writer, and others who have tried them, that frames of this kind are to be preferred to any of the heavier, more elaborate and more expensive frames that do vari ous things that are commonly not worth doing. The diagnosis of ametropia with trial lenses is best made by frequent changes and comparison of lenses held before the trial frames and the lenses that are placed in them. Such supplementary lenses better serve the purpose than changes of the lens in the trial frames. The instantaneous change of the lenses before the eye is the best form of sub jective testing, and is impossible when each lens has to be removed and an other substituted in the trial frame. The instant reversal of effect, possible with supplementary lenses, gives a more rapid and reliable method of subjective testing than any other. It also compels close attention to the testing, and builds up the examiner's conception of what is going on in the eye tested. It secures speed, accuracy, and alertness on the part of both patient and examiner. Such a trial set can be easily carried anywhere that it may be desired to de termine a patient's vision. The real ca pacity for vision can be known only when errors of ocular refraction have been corrected or compensated. This is true for the ophthalmologist or any physician who wishes an exact record of the visual acuity. It is also conveni ent to have such a set in the dark room of the completely equipped office, where refraction is to be measured by skiascopy. When it is desirable to let a patient keep his correcting lenses be fore his eyes, before prescribing them, such a set will furnish the lenses needed
489
for any case. They are also needed where several workers in a clinic are engaged in correcting refraction. The ready use of such a trial set with economy of time, may require a de veloped understanding of lenses and lens combinations. This may not always be needed by the optometrist or the technician who is primarily trying to sell a pair of glasses that will not at once demonstrate their unfitness for the eyes of the customer. But such an under standing is essential to the eye physi cian; and there is no better way to ac quire it than by actual work with such a trial set of piano lenses, and the simple trial frame and protractor. A real understanding of refraction and a knowledge of anatomy and of the general symptoms, causes, and results of disease are the true foundation for the claim that a physician, rather than a lens salesman should be entrusted with the care of the eyes. A school trial set The extension of public education, and the increase of occupations depend ing on constant guidance by accurate vision, have made it essential that the majority of children and adults shall have accurate measurement and correc tion of optical defects. This situation demands that the instruments of optical diagnosis shall be made as efficient as possible, and cheaply enough so as to bring them within the reach of physi cians who may spend but a small part of their time in correcting errors of re fraction. The time has come when every school child should be relieved of the handicap of poor vision, or of seeing clearly at the cost of nerve strain, which must impair health and lower future productive capacity. If the school children in isolated country districts are to have the benefits of real health examinations, every such district must have the service of a set of trial lenses, adequate to test all sorts of eyes with convenient speed and ac curacy. This practical need has de veloped from our school system and from the new ideals of health that make it important to consider what can be done to make the trial set more efficient,
490
ABRAM B. BRUNER
more generally accessible, at the mini mum of necessary cost. The Joint Committee of the Ameri can Medical Association and the Na tional Education Association upon Health Problems in Education, has made a sharp discrimination between health inspection of pupils, that may be made by teachers, principals, school nurses, and other laymen, and the health examinations to be made by physicians who have a medical education. The for-
mer can point out which children need the health examination; but only the health officer, or school physician, can decide what should be done for each child to prevent disease or maintain health. The use of a set of trial lenses in the testing of vision would fall to the duty of the school physician. The need for glasses or treatment of the eyes is a medical question to be decided by the physician. 1121 Republic building.
MALINGERING TESTS ABRAM B. BRUNER,
M.D.
CLEVELAND
This discussion was presented before a class for instruction at a meeting of the Ameri can Academy of Ophthalmology and Otolaryngology in Boston, September 19-22, 1933.
It would appear to be an almost uni versal human failing that most people should, honestly or dishonestly, at tempt to explain many functional dis turbances in limbs or organs on a basis of injury. With the possible exception of the spine, the visual apparatus prob ably offers the malingerer his best op portunity. Several terms in common use, in dis cussing malingering, should be clearly defined. By Simulation we mean the feigning of an ocular injury or disease which does not at all exist; by False Attribution is meant the ascribing of an untrue cause to an existent injury or disease; by Exaggeration, the claim that a certain injury or disease is of greater severity or more disabling than is actually the case. Brief mention should be made here of Dissimulation, or the pretense that an actual disease or disability does not exist. This attitude is mostly encoun tered in workmen when they attempt to secure employment. It is apparently an inevitable outgrowth of Workmen's Compensation Laws both in Europe and the United States. The psychology of the malingerer is important, and a few of his characteris tics, if known and observed, will be a great aid in detecting his deceit. It is surprising to note how many people
find it justifiable to magnify the extent of their ocular injuries. They think that either their employer, or his insurance company, could pay any exorbitant claim, disregarding its honesty. Another common trait of malingerers is their conceit. Regardless of whether they have been previously coached or not, nearly all malingerers attempt to give you the impression that their an swers to your tests are unusually prompt and intelligent. This is quite to be expected, as we know that the aver age working man is not as smart as he thinks he is. It is really a great help to diagnosis, however, if your patient will fool himself rather than if you must do it all. Do not, however, fail to recognize the malingerer of high intelligence. A classic example of such a case was that of a physician, examined in our office some years ago. This type of patient will probably make one grave mistake; he will attempt to act very unintelligent while at the same time he will perhaps volunteer the flattering news that you have a great reputation, a splendidly equipped office and a most thorough and comprehensive method of examina tion. In the general routine of examina tion, special emphasis should be placed on a few procedures. I consider it very
middle fossa are apt to produce irregu lar or incongruous contralateral hemianopsia most frequently with macular sparing. This need not refute the idea of bisection in complete-tract lesions. In posterior-fossa or occipital-lobe growths I believe greater equality is
487
shown in vision, extent of disc edema, and fields. The latter are most frequent ly congruous quadrantic defects or hemianopsias with or without sparing of the macula. 1819 Chestnut street.
PRACTICAL TRIAL LENSES AND A TRIAL SET EDWARD JACKSON, M.D. DENVER, COLORADO
The advantages of relatively small plano-convex or plano-concave lenses are pointed out. Furthermore the virtue of simple, light trial frames is stressed.
When only spherical lenses were sold for spectacles, and these were ground and mounted in frames in the shop of the optician who sold them, the customer could look over the stock and choose those he preferred. There was then little need for anything like a trial set. But astigmatism was discovered and after its discovery was found in most eyes. It was found to vary in amount, and in the direction of its principal meridians. So there was need for trial frames and trial lenses which could be used for testing all kinds of eyes, before the necessary glasses could be prescribed. The knowledge that optical defects of the eye cause important symptoms and disability to the person compelled to use such defective eyes, greatly increased the interest in optical errors. It made their detection, measurement, and cor rection a very important branch of the work of the medical profession. When physicians and surgeons had to study and prescribe for errors of refraction, trial sets were essential. Donders in duced the opticians to supply the cylin drical lenses needed for testing astig matism. But aside from that, doctors have taken whatever opticians have called a trial set and have recommended and supplied to them. When test lenses, frames, and allied apparatus became an important part of the optical business, the number and cost of lenses and frames grew to be an element in profits; and trial sets were elaborated in the direction of making them profitable to the optician.
The medical profession was slow to recognize that correction of refractive errors was a part of its duties to pa tients. Physicians did not eagerly take to the use of the tools by which this was to be done. They took the trial sets of fered to them, without trying to make them as effective and convenient as pos sible ; and with no thought of seeking to avoid unnecessary expense from their useless elaboration. Perhaps the greater size and more striking appearance of the larger trial case was thought to make it more impressive, and therefore more de sirable. Since cylinders have come to be used with spherical lenses, it has been neces sary to have trial frames in which two or more lenses could be placed before each eye. Many, doing this kind of test ing, have realized the defects of their apparatus, and have tried to devise something better, but in trying to get what they wanted, they have been drawn away from simplicity into un desirable elaboration. Keeping in mind certain mathematical requirements and mechanical principles, it is possible to simplify our trial sets greatly; reduce their bulk and cost, and add to their con venience and efficiency. Admitting that we must have the means of trying lenses before the eyes in combinations of two and more, why should we not get the full benefit of the best lenses and simple frames for such combinations? Piano lenses are optical ly superior to the double convex and concave lenses in general use. As trial
488
EDWARD JACKSON
lenses they are far better than the menis The intervals of 0.12 D. are elimi cus lenses that are being exploited at nated because they are not useful in higher prices and by copyrighted names. any trial set. If an eye requires for its Their superiority has been urged upon correction a +1.12 sph., this fact can ophthalmologists since 1866; but not ef be established more quickly and more fectively enough to overcome the plaus certainly by comparing the effects of a ible claims and readiness of the manu 1- and a 1.25-D. lens, than by any use of facturers to supply goods from which a 1.12 sph. With cylindrical lenses inter they can get more profit. Those who are vals of one-eighth D. are still less useful to use trial sets must give enough and more confusing. thought to the subject to find out what This practical trial set must include they want; and then insist on having it. three cross cylinders, the +0.25 —0.25 ; The customary lenses are 38 mm. in the +0.50 —0.50; and the + 1 . — 1 . diameter. They are larger and heavier These will be used more than any other than are needed. But custom is hard to lenses in any trial set by one who un overcome. A lens 31 mm. in diameter, derstands the importance of astigma mounted in a flat rim, reduces by half tism, and the method of using the cross the weight of the stronger lenses. It is cylinder to determine its meridians (the large enough to handle easily and serves direction of cylinder axes) and their all purposes of testing vision. A set of strengths. such lenses is notably less bulky and The lenses furnished are only one of more convenient. each strength. The pairs referred to, are There can be a great reduction in the one convex and one concave of equal number of such lenses required for a strength. By the possible combinations complete trial set, by using lenses in this allows of placing lenses of equal combination. Piano lenses so combined strength before the two eyes. Suppose are practically accurate, and as light as each eye has hyperopia 4.75 D. Before when the two surfaces are ground on a one eye is placed a + 4 . with a +0.75 single piece of glass. Such a combina D.; and before the other eye + 5 . with tion avoids the inaccuracy of all com —0.25 D. This will be found true for all, binations of double convex and concave except for the highest and rarest errors. lenses. We could not provide for a pair of my The possibilities of such a set of small opic eyes, if each required —30 sph. lenses are best understood by consider with —9. cyl. But there is no reason ing what can be done with 12 pairs of to suppose that such a pair of eyes ever spherical and 8 pairs of cylindrical existed. Even after bilateral cataract ex lenses. These include 0.25, 0.50, 0.75, traction, the two eyes never require 1, 2, 3, 4, 5, 10, 15, 20, and 25 D. for the exactly the same combinations. sphericals; and the same up to, and in Trial frames adapted for the purpose cluding 5 D. for the cylindrical. By are essential for the use of such lenses combining two of these we have any in clinical testing. The best thus far spherical, with 0.25-D. intervals, to 6 found are the simple steel wire frames D.; and by 1-D. intervals, a series to of proper size, carefully adjusted. The 30 D. For the cylinders there are 0.25- spring of the wire must hold the cylin D. intervals to 6-D., and 1-D. intervals ders at the axes selected. The width be to 9-D. This is a more extended series tween centers may be 61 or 62 mm. The than is commonly furnished by the temples should be straight, holding to larger sets of trial lenses that are not the sides of the head, in any position to adapted like the piano lenses to combi give the lenses the proper angle. A pro nation. The two-cell trial frame, each tractor is needed to determine the di cell taking two piano lenses, makes easy rection that has been selected for the the placing of any strengths of the axis of the correcting cylinder. Such a spherical and cylindrical series together, protractor is larger and more accurate before an eye, with as much accuracy of than the graduated scales on many trial strength as is obtainable with the usual frames. The wire hooks should hold the trial sets. lenses securely by their mountings,
PRACTICAL TRIAL LENSES AND A T R I A L SET
without catching the edge of the glass, when this is thick, as in concaves and near the axis of a strong convex cylin der. These hooks should be so placed on the eye wire that they hold a little more than half the circumference of the lenses. For convenient use they must be kept in shape or adjusted when they get out of shape. Placing the temporal hooks lower than the nasal, facilitates introducing, or removing lenses, when the frame is on the face. Habitual use of such frames has convinced the writer, and others who have tried them, that frames of this kind are to be preferred to any of the heavier, more elaborate and more expensive frames that do vari ous things that are commonly not worth doing. The diagnosis of ametropia with trial lenses is best made by frequent changes and comparison of lenses held before the trial frames and the lenses that are placed in them. Such supplementary lenses better serve the purpose than changes of the lens in the trial frames. The instantaneous change of the lenses before the eye is the best form of sub jective testing, and is impossible when each lens has to be removed and an other substituted in the trial frame. The instant reversal of effect, possible with supplementary lenses, gives a more rapid and reliable method of subjective testing than any other. It also compels close attention to the testing, and builds up the examiner's conception of what is going on in the eye tested. It secures speed, accuracy, and alertness on the part of both patient and examiner. Such a trial set can be easily carried anywhere that it may be desired to de termine a patient's vision. The real ca pacity for vision can be known only when errors of ocular refraction have been corrected or compensated. This is true for the ophthalmologist or any physician who wishes an exact record of the visual acuity. It is also conveni ent to have such a set in the dark room of the completely equipped office, where refraction is to be measured by skiascopy. When it is desirable to let a patient keep his correcting lenses be fore his eyes, before prescribing them, such a set will furnish the lenses needed
489
for any case. They are also needed where several workers in a clinic are engaged in correcting refraction. The ready use of such a trial set with economy of time, may require a de veloped understanding of lenses and lens combinations. This may not always be needed by the optometrist or the technician who is primarily trying to sell a pair of glasses that will not at once demonstrate their unfitness for the eyes of the customer. But such an under standing is essential to the eye physi cian; and there is no better way to ac quire it than by actual work with such a trial set of piano lenses, and the simple trial frame and protractor. A real understanding of refraction and a knowledge of anatomy and of the general symptoms, causes, and results of disease are the true foundation for the claim that a physician, rather than a lens salesman should be entrusted with the care of the eyes. A school trial set The extension of public education, and the increase of occupations depend ing on constant guidance by accurate vision, have made it essential that the majority of children and adults shall have accurate measurement and correc tion of optical defects. This situation demands that the instruments of optical diagnosis shall be made as efficient as possible, and cheaply enough so as to bring them within the reach of physi cians who may spend but a small part of their time in correcting errors of re fraction. The time has come when every school child should be relieved of the handicap of poor vision, or of seeing clearly at the cost of nerve strain, which must impair health and lower future productive capacity. If the school children in isolated country districts are to have the benefits of real health examinations, every such district must have the service of a set of trial lenses, adequate to test all sorts of eyes with convenient speed and ac curacy. This practical need has de veloped from our school system and from the new ideals of health that make it important to consider what can be done to make the trial set more efficient,
490
ABRAM B. BRUNER
more generally accessible, at the mini mum of necessary cost. The Joint Committee of the Ameri can Medical Association and the Na tional Education Association upon Health Problems in Education, has made a sharp discrimination between health inspection of pupils, that may be made by teachers, principals, school nurses, and other laymen, and the health examinations to be made by physicians who have a medical education. The for-
mer can point out which children need the health examination; but only the health officer, or school physician, can decide what should be done for each child to prevent disease or maintain health. The use of a set of trial lenses in the testing of vision would fall to the duty of the school physician. The need for glasses or treatment of the eyes is a medical question to be decided by the physician. 1121 Republic building.
MALINGERING TESTS ABRAM B. BRUNER,
M.D.
CLEVELAND
This discussion was presented before a class for instruction at a meeting of the Ameri can Academy of Ophthalmology and Otolaryngology in Boston, September 19-22, 1933.
It would appear to be an almost uni versal human failing that most people should, honestly or dishonestly, at tempt to explain many functional dis turbances in limbs or organs on a basis of injury. With the possible exception of the spine, the visual apparatus prob ably offers the malingerer his best op portunity. Several terms in common use, in dis cussing malingering, should be clearly defined. By Simulation we mean the feigning of an ocular injury or disease which does not at all exist; by False Attribution is meant the ascribing of an untrue cause to an existent injury or disease; by Exaggeration, the claim that a certain injury or disease is of greater severity or more disabling than is actually the case. Brief mention should be made here of Dissimulation, or the pretense that an actual disease or disability does not exist. This attitude is mostly encoun tered in workmen when they attempt to secure employment. It is apparently an inevitable outgrowth of Workmen's Compensation Laws both in Europe and the United States. The psychology of the malingerer is important, and a few of his characteris tics, if known and observed, will be a great aid in detecting his deceit. It is surprising to note how many people
find it justifiable to magnify the extent of their ocular injuries. They think that either their employer, or his insurance company, could pay any exorbitant claim, disregarding its honesty. Another common trait of malingerers is their conceit. Regardless of whether they have been previously coached or not, nearly all malingerers attempt to give you the impression that their an swers to your tests are unusually prompt and intelligent. This is quite to be expected, as we know that the aver age working man is not as smart as he thinks he is. It is really a great help to diagnosis, however, if your patient will fool himself rather than if you must do it all. Do not, however, fail to recognize the malingerer of high intelligence. A classic example of such a case was that of a physician, examined in our office some years ago. This type of patient will probably make one grave mistake; he will attempt to act very unintelligent while at the same time he will perhaps volunteer the flattering news that you have a great reputation, a splendidly equipped office and a most thorough and comprehensive method of examina tion. In the general routine of examina tion, special emphasis should be placed on a few procedures. I consider it very