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St. Louis Ophthalmic Society
826
SOCIETY PROCEEDINGS
would be as accurate as the occlusion test described by O'Conner and Mar lowe. It would seem that the shorter periods of occlusion should be as satis factory for the test as the longer periods. The ideal occlusion, Dr. Camp believed, would be one of both eyes; if the test could be made after the pa tient had been asleep for two or three hours. This would preclude not only any attempt at fusion, but also any at tempt at fixation. The muscular tonus and nerve stimulus would be at a minimum. DR. F. N. KNAPP (Duluth) asked Dr. Berrisford how he could consider exophoria and divergence insufficiency with asthenopic physiology. H e had been interested in Marlowe's work be cause of symptoms of asthenopia that were not relieved by correction of re fractive error. Sometimes prisms were prescribed for the correction of exophoria. On re-examination of the pa tient with the correction, the degree of exophoria was as much as on a previous examination without correction. A more accurate measurement of the exophoria might be obtained in this type of case by covering one eye for several days. Patients suffering from asthenopia due to exophoria were often relieved of their symptoms by covering one eye for from two to five days. The occlu sion test would demonstrate to the physician as well as to the patient that the symptoms were caused by muscu lar imbalance. DR. J. F. FULTON (St. Paul) said that he did not often use occlusion as a diag nostic measure believing that careful and repeated testing by prisms brought about satisfactory results. An artificial heterophoria might be brought about by prolonged occlusion. He did resort to occlusion in distressing cases of asthenopia, and by so doing gave cour age and hope to the patients and im pressed upon their minds that the symptoms they complained of were due to the maintenance of binocular vision in the presence of heterophoria. DR. H. W. GRANT (St. Paul) recalled the case of a professor at the Univer sity, who, while chopping a piece of
wood, was struck in the right eye abrading the greater portion of the cornea. This healed without scar in about ten days but, after removal of the pad, the patient nearly collided with two or three cars while trying to drive. On returning to the office the same day it was found that he had ten degrees of hyperphoria, which finally adjusted itself to one degree after several days. Occasionally, when this eye was oc cluded, the hyperphoria would return. One peculiar thing about this patient was that he was without asthenopia. In prescribing he was given one degree of prism for the hyperphoria which was manifest. Dr. Grant doubted if it would have been possible to give this man a full correction for the vertical devia tion for he doubted if the patient would have accepted it. H e had seen many pa tients with a high degree of hyper phoria wearing only partial correction and yet entirely comfortable. Several patients were wearing ten degree prisms and had three or four degrees of uncorrected error without asthen opia. DR.
WALTER
H.
FINK,
in
closing,
stated that in collecting a series of per fectly normal cases occluded for ten days, refracted with cycloplegia, and reexamined, he found high degrees of hyperphoria. Many oculists might con fuse these physiological conditions and prescribe prisms for cases when they were not needed. He had difficulty in getting patients to have the eye covered for a week. He suggested correcting the hyperphoria by the use of prisms. Most men agreed that the lateral muscle imbalance might be disregarded. WALTER M. CAMP,
Recorder.
ST. LOUIS OPHTHALMIC SOCIETY February 27, 1931 DR. M. H. POST presiding
Evaluation of pseudoisochromatic tests for color blindness DR. J. ELLIS JENNINGS read a paper on this subject which will be published
SOCIETY PROCEEDINGS in the American Journal of Ophthal mology. Discussion.
DR. M. L. GREENE had
used Stilling's test in some 1,500 cases and found it confusing and of value only when checked by Jennings' self recording or Holmgren's test. DR. J. H. GROSS has used the Adler colored pencils as a test satisfactorily. He made marks of red, green, blue, etc., on a blank card and asked the patient to make marks of the same color along side, having first tried out the pencils on a different paper to find the right color. Error in naming colors was thus avoided and the card was filed for record. DR. HARVEY J. HOWARD had found the Jennings' self recording test most satis factory. He did not find any defect in color sense not elicited by it, follow ing hesitant decisions with a request to name color and shade of yarn dis played. He believed color testing a test of intelligence of the examiner. DR. WIENER thought Dr. Jennings' ob jection to the Ishihara test could be overcome by making control plates on each of which the color blind might see the same figure but the normal eye a different one. DR. JENNINGS, closing, emphasized the need of having more than one test. The study was made to find the best of the isochromatic tests. The patients were cautious and careful and often con fused through fear of losing their jobs. He concluded that Stilling's test was best and with lantern and worsteds should suffice to detect color blindness. He believed a color blind person could be taught to read Ishihara's test as the number he saw was a clew to the num ber seen by the normal color sense. No control plates existed but might be made. Annular scleritis with report of a case DR. C. W. TOOKER read a paper on this subject which will be published in the American Journal of Ophthal mology. Discussion.
DR. HARVEY J. HOWARD
had seen the case and observed a re
827
semblance to plasmoma of the conjunc tiva due to color of the elevated area; possibly the fact that the predominant cell in brawny scleritis was the plasma cell might warrant one so mistaking it. He believed the injection of atropin might have stirred up a latent infection in the ciliary body causing it to spread to the sclera. Divergence paralysis DR. HARVEY J. HOWARD presented the
case of a patient who had this condi tion, published in this number of the Journal, p. 736. Discussion. DR. F. E. WOODRUFF asked whether the internal and external recti had been tested separately by prisms and whether decentration of the glasses worn might have increased the esophoria. DR. C. W. TOOKER had had a similar
case; a woman aged fifty years, who had a homonymous diplopia beyond one meter but normal binocular vision within one meter. No pathological con dition was found and no cause for her divergence insufficiency which was of sudden onset and continued for many years. He felt that Dr. Howard's case was one of divergence insufficiency. DR. HOWARD, in closing, stated that "divergence insufficiency" was not an etiological diagnosis but might refer to several defects. The significant data in the case reported were, sudden per sistent diplopia; history of carcinoma with intracranial metastases; eye move ments unrestricted and coordinated in the six cardinal directions; twenty de grees of esotropia for distance with diplopia which disappeared at one meter; this being sufficient for diag nosis of paralysis of divergence. Tests showed at least twenty diopters of con vergence power. The glasses were properly fitted and worn. Although presence of the divergence center had not been proved he believed this case was brought about by metastasis to such a center. B. Y. ALVIS,
Editor.
SOCIETY PROCEEDINGS
would be as accurate as the occlusion test described by O'Conner and Mar lowe. It would seem that the shorter periods of occlusion should be as satis factory for the test as the longer periods. The ideal occlusion, Dr. Camp believed, would be one of both eyes; if the test could be made after the pa tient had been asleep for two or three hours. This would preclude not only any attempt at fusion, but also any at tempt at fixation. The muscular tonus and nerve stimulus would be at a minimum. DR. F. N. KNAPP (Duluth) asked Dr. Berrisford how he could consider exophoria and divergence insufficiency with asthenopic physiology. H e had been interested in Marlowe's work be cause of symptoms of asthenopia that were not relieved by correction of re fractive error. Sometimes prisms were prescribed for the correction of exophoria. On re-examination of the pa tient with the correction, the degree of exophoria was as much as on a previous examination without correction. A more accurate measurement of the exophoria might be obtained in this type of case by covering one eye for several days. Patients suffering from asthenopia due to exophoria were often relieved of their symptoms by covering one eye for from two to five days. The occlu sion test would demonstrate to the physician as well as to the patient that the symptoms were caused by muscu lar imbalance. DR. J. F. FULTON (St. Paul) said that he did not often use occlusion as a diag nostic measure believing that careful and repeated testing by prisms brought about satisfactory results. An artificial heterophoria might be brought about by prolonged occlusion. He did resort to occlusion in distressing cases of asthenopia, and by so doing gave cour age and hope to the patients and im pressed upon their minds that the symptoms they complained of were due to the maintenance of binocular vision in the presence of heterophoria. DR. H. W. GRANT (St. Paul) recalled the case of a professor at the Univer sity, who, while chopping a piece of
wood, was struck in the right eye abrading the greater portion of the cornea. This healed without scar in about ten days but, after removal of the pad, the patient nearly collided with two or three cars while trying to drive. On returning to the office the same day it was found that he had ten degrees of hyperphoria, which finally adjusted itself to one degree after several days. Occasionally, when this eye was oc cluded, the hyperphoria would return. One peculiar thing about this patient was that he was without asthenopia. In prescribing he was given one degree of prism for the hyperphoria which was manifest. Dr. Grant doubted if it would have been possible to give this man a full correction for the vertical devia tion for he doubted if the patient would have accepted it. H e had seen many pa tients with a high degree of hyper phoria wearing only partial correction and yet entirely comfortable. Several patients were wearing ten degree prisms and had three or four degrees of uncorrected error without asthen opia. DR.
WALTER
H.
FINK,
in
closing,
stated that in collecting a series of per fectly normal cases occluded for ten days, refracted with cycloplegia, and reexamined, he found high degrees of hyperphoria. Many oculists might con fuse these physiological conditions and prescribe prisms for cases when they were not needed. He had difficulty in getting patients to have the eye covered for a week. He suggested correcting the hyperphoria by the use of prisms. Most men agreed that the lateral muscle imbalance might be disregarded. WALTER M. CAMP,
Recorder.
ST. LOUIS OPHTHALMIC SOCIETY February 27, 1931 DR. M. H. POST presiding
Evaluation of pseudoisochromatic tests for color blindness DR. J. ELLIS JENNINGS read a paper on this subject which will be published
SOCIETY PROCEEDINGS in the American Journal of Ophthal mology. Discussion.
DR. M. L. GREENE had
used Stilling's test in some 1,500 cases and found it confusing and of value only when checked by Jennings' self recording or Holmgren's test. DR. J. H. GROSS has used the Adler colored pencils as a test satisfactorily. He made marks of red, green, blue, etc., on a blank card and asked the patient to make marks of the same color along side, having first tried out the pencils on a different paper to find the right color. Error in naming colors was thus avoided and the card was filed for record. DR. HARVEY J. HOWARD had found the Jennings' self recording test most satis factory. He did not find any defect in color sense not elicited by it, follow ing hesitant decisions with a request to name color and shade of yarn dis played. He believed color testing a test of intelligence of the examiner. DR. WIENER thought Dr. Jennings' ob jection to the Ishihara test could be overcome by making control plates on each of which the color blind might see the same figure but the normal eye a different one. DR. JENNINGS, closing, emphasized the need of having more than one test. The study was made to find the best of the isochromatic tests. The patients were cautious and careful and often con fused through fear of losing their jobs. He concluded that Stilling's test was best and with lantern and worsteds should suffice to detect color blindness. He believed a color blind person could be taught to read Ishihara's test as the number he saw was a clew to the num ber seen by the normal color sense. No control plates existed but might be made. Annular scleritis with report of a case DR. C. W. TOOKER read a paper on this subject which will be published in the American Journal of Ophthal mology. Discussion.
DR. HARVEY J. HOWARD
had seen the case and observed a re
827
semblance to plasmoma of the conjunc tiva due to color of the elevated area; possibly the fact that the predominant cell in brawny scleritis was the plasma cell might warrant one so mistaking it. He believed the injection of atropin might have stirred up a latent infection in the ciliary body causing it to spread to the sclera. Divergence paralysis DR. HARVEY J. HOWARD presented the
case of a patient who had this condi tion, published in this number of the Journal, p. 736. Discussion. DR. F. E. WOODRUFF asked whether the internal and external recti had been tested separately by prisms and whether decentration of the glasses worn might have increased the esophoria. DR. C. W. TOOKER had had a similar
case; a woman aged fifty years, who had a homonymous diplopia beyond one meter but normal binocular vision within one meter. No pathological con dition was found and no cause for her divergence insufficiency which was of sudden onset and continued for many years. He felt that Dr. Howard's case was one of divergence insufficiency. DR. HOWARD, in closing, stated that "divergence insufficiency" was not an etiological diagnosis but might refer to several defects. The significant data in the case reported were, sudden per sistent diplopia; history of carcinoma with intracranial metastases; eye move ments unrestricted and coordinated in the six cardinal directions; twenty de grees of esotropia for distance with diplopia which disappeared at one meter; this being sufficient for diag nosis of paralysis of divergence. Tests showed at least twenty diopters of con vergence power. The glasses were properly fitted and worn. Although presence of the divergence center had not been proved he believed this case was brought about by metastasis to such a center. B. Y. ALVIS,
Editor.