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Prolonged Monocular Occlusion as a Test for the Muscle Balance
PROLONGED
MONOCULAR
OCCLUSION AS
A TEST FOR T H E
MUSCLE BALANCE F. W.
MARLOW, M.
D.
SYRACUSE, N. Y.
This paper describes the method of occlusion and emphasizes the need for making it complete and prolonged. It reports graphically striking results in the unmasking of heterophoria not discovered by other methods. Read before the American Ophthalmological Society, June, 1920.
The method to which the title of this paper refers is an extension in point of time only of the screen or cover test. It has been put in practice by replac ing one of the patient's lenses by a ground glass, it being found necessary occasionally, on account of the annoy ing glare from the latter, to paste a piece of dark paper over the back of it, or to substitute a black patch for it. The ground glass is used on account of its comparative inconspicuousness, but a black patch is much less annoying to wear. A full refractive correction is worn over the other eye. The object of the test is explained in detail to the patient, and it is scarcely necessary to state that only those who combine sufficient intelli gence to understand it with a realiza tion that the problems presented by their cases are obscure, and a genuine desire to give all possible assistance in solving them are fit subjects for it. As a matter of fact patients of this class are very numerous. I have been sur prised at the willingness, even eager ness, with which it has been accepted by patients, and at the conscientious ness with which it has been almost in variably carried out. The directions given to the patient are that he shall put the glasses on in the morning before opening his eyes, that he shall not look over or under them, that if he wishes to remove them for any purpose during the day he shall close his eyes, or at least one of them before doing so, and replace the glasses before reopening them, and that he shall wear them until after he has closed his eyes at night. In other words, that one eye shall not be al lowed to associate with the other dur ing the whole period of the test. Strict continuity is apparently a very impor
tant detail. It was my good fortune to come across a case previously in the hands of one of my colleagues, in which sufficient emphasis had not been laid upon this point. Thru his courtesy I am able to give the results of a seven and also a fourteen-day occlusion test in which the patient did not put his glasses on until after dressing. Before the first occlusion test exam ination showed an exophoria of onehalf degree and no hyperphoria. After the seven-day test the exopho ria rose to one and one-half degrees, and there was a left hyperphoria of one and one-quarter degrees. After the fourteen-day test the exo phoria was two degrees, and the hyper phoria three degrees. A ten-day test without any break in the continuity gave exophoria seven de grees, and L. hyperphoria three degrees. At the end of the period of occlusion, or whenever a test of the muscle bal ance is made during it, a full correc tion of the refraction is placed in a trial frame, with a Maddox rod or whatever other means is selected for the test, the patient is directed to close his eyes, his glasses are removed and replaced by the trial frame. He is then directed to open his eyes, and the test is made, without any break in the continuity of occlusion. It is my usual practice to use the Maddox rod for the vertical, and the phorometer or vertical diplopia test for the lateral de viations, with the screen or parallax test as confirmatory. The difference between these tests is not always in favor of the screen test, and is negligi ble compared with the changes occur ring under prolonged occlusion. The choice of the eye to be covered is usually determined by finding out
238
OCCLUSION TEST FOR MUSCLE BALANCE
239
4. Those in which there is a reversal which eye the patient uses for point ing or aiming at a distant object, and in the form of deviation, right chang occluding the other, or if one eye is ing to left hyperphoria, or esophoria to exophoria. defective, by occluding that. 5. Those in which there is a reduc I have used this method occasion ally for about twenty-five years, with tion in the amount of error. What changes take place in exopho increasing frequency during the last ten or twelve years and have notes of ria are in the direction of increase. In the majority of cases the near point about five hundred cases. In the earlier cases the observations of convergence is normal before, and were limited to the changes in the po remains normal after occlusion. Esophoria sometimes diminishes or sition of rest for 6 meters, but in some of the later ones have been extended even changes to exophoria, and some also to the abduction, near point of times increases. convergence, and the balance at 1/3 In hyperphoria the changes may be meter before and after occlusion, and in the direction of increase, decrease, also to the distribution of the hyper- or reversal. When reversal takes phoria over the field, chiefly after oc place, it is usually accompanied by the clusion. development of exophoria. The youngest patient in whom the In the majority of cases the muscle balance has been determined at the be test was made, showing a latent error, ginning and end of the period of was eleven years old, and the oldest occlusion only; but in a number, daily seventy-eight. In another case there observations have been made for the seems little doubt that the error was purpose of getting information as to present at five years of age and caus how long it takes for the muscles to ing symptoms, tho the test was not relax, and to arrive at stability. Some made until nine years later. of the cases seem to suggest that this I present a series of 73 charts, ten of happens within a week, but repetition which are herewith reproduced, show of the test in others shows that a ing at a glance the main changes which week's occlusion may leave a good have taken place in the cases they rep deal of error latent. A study of the resent. charts to be shown will leave but little The chief conclusions suggested by doubt that a period of several days at the observations made by this method least is necessary to bring about a suf is that the period of time for which the ficient relaxation of the muscles. binocular function is usually annulled In most cases the period of occlu during tests for the muscle balance is sion has been for seven days. It should too short to permit the desired relaxa be stated that this method has been tion of the muscles to take place. The used only in those cases in which the length of time necessary to bring out correction of the refraction, and such the error seems to vary in different faults in the muscle balance as can be cases; but it is evident that in many a detected by the ordinary methods, has seven-day period is enough to furnish failed to relieve the symptoms or has valuable information. aggravated them. In the second place it is evident that The cases may be divided roughly the tests as ordinarily used may not into the following groups on the basis only fail to show how much error is of the results obtained: present, but may also be misleading as 1. Those in which no change occurs to its character. in the relative position of rest. Third, that the paralytic or nonpar2. Those in which an error is found alytic nature of a hyperphoria becomes that was not demonstrable before oc much more apparent after the test than clusion. before, a very large majority being of 3. Those in which the error found the former character. In many cases, before is increased to a greater or less even in those in which there is a nor extent after occlusion. mal equilibrium in the primary posi-
240
F. W. MARLOW
tion, evidence is found in the oblique positions of insufficiency of one, and somewhat commonly of both inferior recti, and the same applies, perhaps less frequently, to the other muscles. Fourth, that there is no constant re lation between the prism duction and the muscle imbalance, at any rate so far as abduction and exophoria are concerned; as the latter after occlu sions frequently exceeds, sometimes very greatly, the abduction as meas ured before occlusion. Fifth, that the opinion that the con stant wearing of prisms tends to in crease a deviation receives no support from these observations, far more rapid and extensive changes being brought about by prolonged annul ment of the binocular function. Sixth, that the frequent failure to re lieve symptoms by the constant wear ing of prisms is explained in part by the fact that the total error may great ly exceed the manifest, and that such prisms as can be worn offset too small a fraction of the total error to make any appreciable difference.
Seventh, a few observations seem to indicate that the effect of prism exer cises is to obscure or render latent an error previously manifest, this error being easily brought out again by an occlusion test. Eighth, that the effect of a tenotomy cannot be measured without an occlu sion test both before and after opera tion. EXPLANATION OF CHARTS
X indicates a lateral deviation; above the zero line, exophoria; below, esophoria. O indicates a vertical deviation; right hyperphoria above; left below the line. X O on zero line, orthophoria. P P C, punctum proximum of con vergence, measured from base line. Occ. Occlusion. Hyp. Hyperphoria. In the measurement of abduction the higher number indicates the point at which diplopia occurs, the lower the point at which fusion returns.
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Fig. 1, Case 1. Mr. H. J. H., aged 33. Asthenopia, photophobia, constant sense of strain. Has consulted eight oculists without benefit. Wearing: Right + 1. sph. + 1.25 cyl. axis 95°; left + 1. sph. + 1.00 cyl. axis 75°. Accepts under scopolamni: R.ght + 1. sph. + 1.37 cyl. axis 100°; left + 1. sph. + 125 cyl. axis 67.5 . Obtained great relief by prism correction.
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Fig. 3, Case 3. (52.24). Mr. S. R. M., 44. Headaches and nervousness. When first seen in 1901 showed Esophoria 3°, and R. Hyperphoria YT."'. Refraction 1919: Right + 1. + 0.12 cyl. axis 150°; left + 1. + 0.12 cyl. axis 55°. Note that occlusion of twenty-four hours produced no change in muscle balance that it took three days to bring out 2° of Exophoria, and twelve days to arrive at stability. Also ' H t the final Exophoria is at least double the primary abduction.
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Fig. 4, Case 4. Mrs. T. E. M., 32. (1900) Congestion of L. eye and L. sided headache one year or more. with eyes all her life. Photophobia, flatulence, nausea, insomnia. Refraction under scopolamin: Right — 0.12 sph. + 0.37 cyl. axis -j- 0.2S cyl. axis 90°. December 16. No headache or asthenopia and Note distribution of Hyperphoria at end of test, indicating paresis
More or less trouble 100°; left + 0.2S sph. less nervous. of both inferior recti.
OCCLUSION TEST FOR MUSCLE BALANCE
245
Fig. 5, Case 5. Mrs. C. A. T. (4737). Always subject to sick headache once in six weeks, requiring hypodermics. Constant head ache in the intervals. Asthenopia, photophobia. Hxamined many times and operated on in Pittsburgh in 1898, without benefit. Now glasses for several years. Under cycloplegia: Right E m ; left 0.50 sph. She had E s o p h o r i a 7°, and L. H y p e r p h o r i a V/z", and a par tial tcnotomy on the left inferior reclus and free teiiotomy of left inferior rectus. To illus trate unknown effect of teiiotomy without occlusion test.
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Fig. 6, Case 6. Miss B. I , 17'/,. (7986). Always subject to headache. R. fronto-occipital. Now constant for three weeks. Asthenopia, photophobia, blurring. Practically complete relief by partial prism correction. Note primary abduction 9° —, 8° —, and final degree of exophoria 12°. Refraction under scopolamin : Right + 0.75 sph. + 0.87 cvl. axis 90°: left -f 0.50 sph. + 0.75 cyl. axis 85°. '
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Fig. 7, Case 7. Mrs. C. R. S. (7663). Operated on for goiter seven months ago, for tonsils six weeks ago, on account of nerv ousness without much improvement in symptoms. Cannot do anything in the morning. Severe asthenopia, strained feeling, chiefly looking off. Photophobia, almost constant vertigo. Refraction under scopolamin: Right — 0.25 sph. + 0.62 cyl. axis 80°; left — 0.25 sph. + 0.62 cyl. axis 110°. Given full refractive correction and 3 base in each eye. September 26. _ Reports symptoms all gone. "Reads regardless"; no vertigo. Final Exophoria more than double primary abduction. Disappearance of Hyperphoria.
248
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Fig. 8, Case 8. Miss D. S., 20. (4162). September, 1915. Glasses cause lacrimation. Headaches, temporarily relieved by correc tion of refraction and R. Hyperphoria, but finally increasing in number. No headache while ground glass was worn (November, 1919). March 9, 1920. "The glasses have almost entirely relieved my headaches." One or two a month now instead of several a week as before. Refraction under scopolamin: Right + 0.2S sph. -f 0.12 cyl. axis 70°; left + 0.2S sph. + 0.50 cyl. axis 90°. Note that for over four years muscle tests always showed from yA° to 2" of R. Hyper phoria, and from no lateral error to Esophoria 1°.
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Fig. 9, Case 9. Prof. T. W. D., 35. Use of eyes makes him nervous all over. Glasses (practically an accurate refraction) strain eyes. Photophobia. Would have to give up work if relief could not be obtained A second occlusion test after partial tenotomy of each internus showed Esophoria 9° and no H y P e r P ? ° " a 1 . A second tenotomy of L . internus, L. Esophoria 4° and Hyperphoria 0 . Operations gave great relief.
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Fig. 10, Case 10. (8312). Miss M. N., 22, obliged to give up teaching on account of "nerves." Headache, stomach trouble, insomnia and some asthenopia. Refraction under scopolamin: Right + 0.25 sph. + 0.25 cyl. axis 60°; left + 0.12 sph. + 0.12 cyl. axis 135°. Note diminution of Hyperphoria after lateral tenotomis. After first occlusion test L. Hyperphoria was 7°, down to L.0 0° up to right On June 7th L. Hyperphoria J4° in primary position, and yi — in all oblique positions. Patient was greatly benefited by operations. Exophoria 2° at 6 m., and 0° at 13 m.
MONOCULAR
OCCLUSION AS
A TEST FOR T H E
MUSCLE BALANCE F. W.
MARLOW, M.
D.
SYRACUSE, N. Y.
This paper describes the method of occlusion and emphasizes the need for making it complete and prolonged. It reports graphically striking results in the unmasking of heterophoria not discovered by other methods. Read before the American Ophthalmological Society, June, 1920.
The method to which the title of this paper refers is an extension in point of time only of the screen or cover test. It has been put in practice by replac ing one of the patient's lenses by a ground glass, it being found necessary occasionally, on account of the annoy ing glare from the latter, to paste a piece of dark paper over the back of it, or to substitute a black patch for it. The ground glass is used on account of its comparative inconspicuousness, but a black patch is much less annoying to wear. A full refractive correction is worn over the other eye. The object of the test is explained in detail to the patient, and it is scarcely necessary to state that only those who combine sufficient intelli gence to understand it with a realiza tion that the problems presented by their cases are obscure, and a genuine desire to give all possible assistance in solving them are fit subjects for it. As a matter of fact patients of this class are very numerous. I have been sur prised at the willingness, even eager ness, with which it has been accepted by patients, and at the conscientious ness with which it has been almost in variably carried out. The directions given to the patient are that he shall put the glasses on in the morning before opening his eyes, that he shall not look over or under them, that if he wishes to remove them for any purpose during the day he shall close his eyes, or at least one of them before doing so, and replace the glasses before reopening them, and that he shall wear them until after he has closed his eyes at night. In other words, that one eye shall not be al lowed to associate with the other dur ing the whole period of the test. Strict continuity is apparently a very impor
tant detail. It was my good fortune to come across a case previously in the hands of one of my colleagues, in which sufficient emphasis had not been laid upon this point. Thru his courtesy I am able to give the results of a seven and also a fourteen-day occlusion test in which the patient did not put his glasses on until after dressing. Before the first occlusion test exam ination showed an exophoria of onehalf degree and no hyperphoria. After the seven-day test the exopho ria rose to one and one-half degrees, and there was a left hyperphoria of one and one-quarter degrees. After the fourteen-day test the exo phoria was two degrees, and the hyper phoria three degrees. A ten-day test without any break in the continuity gave exophoria seven de grees, and L. hyperphoria three degrees. At the end of the period of occlusion, or whenever a test of the muscle bal ance is made during it, a full correc tion of the refraction is placed in a trial frame, with a Maddox rod or whatever other means is selected for the test, the patient is directed to close his eyes, his glasses are removed and replaced by the trial frame. He is then directed to open his eyes, and the test is made, without any break in the continuity of occlusion. It is my usual practice to use the Maddox rod for the vertical, and the phorometer or vertical diplopia test for the lateral de viations, with the screen or parallax test as confirmatory. The difference between these tests is not always in favor of the screen test, and is negligi ble compared with the changes occur ring under prolonged occlusion. The choice of the eye to be covered is usually determined by finding out
238
OCCLUSION TEST FOR MUSCLE BALANCE
239
4. Those in which there is a reversal which eye the patient uses for point ing or aiming at a distant object, and in the form of deviation, right chang occluding the other, or if one eye is ing to left hyperphoria, or esophoria to exophoria. defective, by occluding that. 5. Those in which there is a reduc I have used this method occasion ally for about twenty-five years, with tion in the amount of error. What changes take place in exopho increasing frequency during the last ten or twelve years and have notes of ria are in the direction of increase. In the majority of cases the near point about five hundred cases. In the earlier cases the observations of convergence is normal before, and were limited to the changes in the po remains normal after occlusion. Esophoria sometimes diminishes or sition of rest for 6 meters, but in some of the later ones have been extended even changes to exophoria, and some also to the abduction, near point of times increases. convergence, and the balance at 1/3 In hyperphoria the changes may be meter before and after occlusion, and in the direction of increase, decrease, also to the distribution of the hyper- or reversal. When reversal takes phoria over the field, chiefly after oc place, it is usually accompanied by the clusion. development of exophoria. The youngest patient in whom the In the majority of cases the muscle balance has been determined at the be test was made, showing a latent error, ginning and end of the period of was eleven years old, and the oldest occlusion only; but in a number, daily seventy-eight. In another case there observations have been made for the seems little doubt that the error was purpose of getting information as to present at five years of age and caus how long it takes for the muscles to ing symptoms, tho the test was not relax, and to arrive at stability. Some made until nine years later. of the cases seem to suggest that this I present a series of 73 charts, ten of happens within a week, but repetition which are herewith reproduced, show of the test in others shows that a ing at a glance the main changes which week's occlusion may leave a good have taken place in the cases they rep deal of error latent. A study of the resent. charts to be shown will leave but little The chief conclusions suggested by doubt that a period of several days at the observations made by this method least is necessary to bring about a suf is that the period of time for which the ficient relaxation of the muscles. binocular function is usually annulled In most cases the period of occlu during tests for the muscle balance is sion has been for seven days. It should too short to permit the desired relaxa be stated that this method has been tion of the muscles to take place. The used only in those cases in which the length of time necessary to bring out correction of the refraction, and such the error seems to vary in different faults in the muscle balance as can be cases; but it is evident that in many a detected by the ordinary methods, has seven-day period is enough to furnish failed to relieve the symptoms or has valuable information. aggravated them. In the second place it is evident that The cases may be divided roughly the tests as ordinarily used may not into the following groups on the basis only fail to show how much error is of the results obtained: present, but may also be misleading as 1. Those in which no change occurs to its character. in the relative position of rest. Third, that the paralytic or nonpar2. Those in which an error is found alytic nature of a hyperphoria becomes that was not demonstrable before oc much more apparent after the test than clusion. before, a very large majority being of 3. Those in which the error found the former character. In many cases, before is increased to a greater or less even in those in which there is a nor extent after occlusion. mal equilibrium in the primary posi-
240
F. W. MARLOW
tion, evidence is found in the oblique positions of insufficiency of one, and somewhat commonly of both inferior recti, and the same applies, perhaps less frequently, to the other muscles. Fourth, that there is no constant re lation between the prism duction and the muscle imbalance, at any rate so far as abduction and exophoria are concerned; as the latter after occlu sions frequently exceeds, sometimes very greatly, the abduction as meas ured before occlusion. Fifth, that the opinion that the con stant wearing of prisms tends to in crease a deviation receives no support from these observations, far more rapid and extensive changes being brought about by prolonged annul ment of the binocular function. Sixth, that the frequent failure to re lieve symptoms by the constant wear ing of prisms is explained in part by the fact that the total error may great ly exceed the manifest, and that such prisms as can be worn offset too small a fraction of the total error to make any appreciable difference.
Seventh, a few observations seem to indicate that the effect of prism exer cises is to obscure or render latent an error previously manifest, this error being easily brought out again by an occlusion test. Eighth, that the effect of a tenotomy cannot be measured without an occlu sion test both before and after opera tion. EXPLANATION OF CHARTS
X indicates a lateral deviation; above the zero line, exophoria; below, esophoria. O indicates a vertical deviation; right hyperphoria above; left below the line. X O on zero line, orthophoria. P P C, punctum proximum of con vergence, measured from base line. Occ. Occlusion. Hyp. Hyperphoria. In the measurement of abduction the higher number indicates the point at which diplopia occurs, the lower the point at which fusion returns.
OCCLUSION TEST FOR MUSCLE BALANCE
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Fig. 1, Case 1. Mr. H. J. H., aged 33. Asthenopia, photophobia, constant sense of strain. Has consulted eight oculists without benefit. Wearing: Right + 1. sph. + 1.25 cyl. axis 95°; left + 1. sph. + 1.00 cyl. axis 75°. Accepts under scopolamni: R.ght + 1. sph. + 1.37 cyl. axis 100°; left + 1. sph. + 125 cyl. axis 67.5 . Obtained great relief by prism correction.
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Fig. 3, Case 3. (52.24). Mr. S. R. M., 44. Headaches and nervousness. When first seen in 1901 showed Esophoria 3°, and R. Hyperphoria YT."'. Refraction 1919: Right + 1. + 0.12 cyl. axis 150°; left + 1. + 0.12 cyl. axis 55°. Note that occlusion of twenty-four hours produced no change in muscle balance that it took three days to bring out 2° of Exophoria, and twelve days to arrive at stability. Also ' H t the final Exophoria is at least double the primary abduction.
F. W. MARLOW
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Fig. 4, Case 4. Mrs. T. E. M., 32. (1900) Congestion of L. eye and L. sided headache one year or more. with eyes all her life. Photophobia, flatulence, nausea, insomnia. Refraction under scopolamin: Right — 0.12 sph. + 0.37 cyl. axis -j- 0.2S cyl. axis 90°. December 16. No headache or asthenopia and Note distribution of Hyperphoria at end of test, indicating paresis
More or less trouble 100°; left + 0.2S sph. less nervous. of both inferior recti.
OCCLUSION TEST FOR MUSCLE BALANCE
245
Fig. 5, Case 5. Mrs. C. A. T. (4737). Always subject to sick headache once in six weeks, requiring hypodermics. Constant head ache in the intervals. Asthenopia, photophobia. Hxamined many times and operated on in Pittsburgh in 1898, without benefit. Now glasses for several years. Under cycloplegia: Right E m ; left 0.50 sph. She had E s o p h o r i a 7°, and L. H y p e r p h o r i a V/z", and a par tial tcnotomy on the left inferior reclus and free teiiotomy of left inferior rectus. To illus trate unknown effect of teiiotomy without occlusion test.
246
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Fig. 6, Case 6. Miss B. I , 17'/,. (7986). Always subject to headache. R. fronto-occipital. Now constant for three weeks. Asthenopia, photophobia, blurring. Practically complete relief by partial prism correction. Note primary abduction 9° —, 8° —, and final degree of exophoria 12°. Refraction under scopolamin : Right + 0.75 sph. + 0.87 cvl. axis 90°: left -f 0.50 sph. + 0.75 cyl. axis 85°. '
247
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Fig. 7, Case 7. Mrs. C. R. S. (7663). Operated on for goiter seven months ago, for tonsils six weeks ago, on account of nerv ousness without much improvement in symptoms. Cannot do anything in the morning. Severe asthenopia, strained feeling, chiefly looking off. Photophobia, almost constant vertigo. Refraction under scopolamin: Right — 0.25 sph. + 0.62 cyl. axis 80°; left — 0.25 sph. + 0.62 cyl. axis 110°. Given full refractive correction and 3 base in each eye. September 26. _ Reports symptoms all gone. "Reads regardless"; no vertigo. Final Exophoria more than double primary abduction. Disappearance of Hyperphoria.
248
F. W. MARLOW
Fig. 8, Case 8. Miss D. S., 20. (4162). September, 1915. Glasses cause lacrimation. Headaches, temporarily relieved by correc tion of refraction and R. Hyperphoria, but finally increasing in number. No headache while ground glass was worn (November, 1919). March 9, 1920. "The glasses have almost entirely relieved my headaches." One or two a month now instead of several a week as before. Refraction under scopolamin: Right + 0.2S sph. -f 0.12 cyl. axis 70°; left + 0.2S sph. + 0.50 cyl. axis 90°. Note that for over four years muscle tests always showed from yA° to 2" of R. Hyper phoria, and from no lateral error to Esophoria 1°.
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Fig. 9, Case 9. Prof. T. W. D., 35. Use of eyes makes him nervous all over. Glasses (practically an accurate refraction) strain eyes. Photophobia. Would have to give up work if relief could not be obtained A second occlusion test after partial tenotomy of each internus showed Esophoria 9° and no H y P e r P ? ° " a 1 . A second tenotomy of L . internus, L. Esophoria 4° and Hyperphoria 0 . Operations gave great relief.
250
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Fig. 10, Case 10. (8312). Miss M. N., 22, obliged to give up teaching on account of "nerves." Headache, stomach trouble, insomnia and some asthenopia. Refraction under scopolamin: Right + 0.25 sph. + 0.25 cyl. axis 60°; left + 0.12 sph. + 0.12 cyl. axis 135°. Note diminution of Hyperphoria after lateral tenotomis. After first occlusion test L. Hyperphoria was 7°, down to L.0 0° up to right On June 7th L. Hyperphoria J4° in primary position, and yi — in all oblique positions. Patient was greatly benefited by operations. Exophoria 2° at 6 m., and 0° at 13 m.