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The Traumatic Ophthalmoplegias as a Workmen's-Compensation Problem
T H E TRAUMATIC OPHTHALMOPLEGIAS AS A WORKMEN'S-COMPENSATION PROBLEM M. DAVIDSON, M.D. NEW YORK
From his experience in making 10,000 examinations for compensation purposes, the author states that for ascertaining functional loss in traumatic ophthalmoplegia on a percentage basis, objective tests are indispensable in checking and coordinating results obtained from tests in which the subjective element is inherent. He advocates the use of four methods as a routine procedure: his adaptation of the Perlia test, the Hess method, the screen test, and the charting of diplopia. The seventy-one cases of traumatic ophthal moplegia discovered in these examinations fall into three categories; namely, those result ing from basal fractures, orbital injuries, and psychogenic conditions. Read at the New York Academy of Medicine, Section of Ophthalmology, on December 17, 1934.
The examination of eyes for compen sation purposes has aspects not in volved in the practice of ophthalmol ogy. It is a medico-legal examination, and the ophthalmologist's findings have to be defended before lay referees and commissioners. Account has to be taken of other medical observers' findings, which may be based on different meth ods and may represent different stages of a pathological process. The exami nation is performed without the com plete cooperation of the patient who is also a claimant for compensation. Fi nally, there is the demand for an ex pression in terms of a percentage re garding any functional loss that may have been incurred. These conditions call for a standard procedure,in the ex amination with emphasis on objective or objectivized methods which lend themselves to graphic registration. An attempt to meet these aspects of traumatic ophthalmoplegias is there fore presented. It has grown out of deal ings with a considerable number of such cases in the course of 10,000 ex aminations for compensation purposes at the New York State Bureau of Workmen's Compensation during the past four years. The tabulation of the material has incidentally disclosed some clinical data of interest. The problem of the procedure in examination Compensation in traumatic ophthal moplegias can be awarded only in terms of permanent loss of normal motor field. There are, to be sure, two other functional impairments involved in an ophthalmoplegia. In addition to the
manifest loss of motor field, that is, the field of heterotropia and diplopia, there is an intermediate zone of latent im balance or heterophoria separating it from the zone of binocular single vi sion. This is easily demonstrated by comparing a diplopia chart obtained by proceeding from the field of single vi sion to the field of diplopia with one obtained by examining from the oppo site direction. Recovery is also liable to leave a heterophoria. Stereoscopic acui ty or depth perception likewise is liable to impairment, even in the field of sin gle vision, and surely in that of the zone of heterophoria. It is of course entirely abolished in the field of diplopia. Neither of these two conditions, how ever, can be dealt with in practice, and we have to limit ourselves to com pensation in terms of loss of motor field, of a field of diplopia. The method currently used for ap praising the loss of motor field is that of charting the diplopia. However reli able it may be made in examining pa tients for therapeutic purposes, diplo pia charting is far from satisfactory for purposes of compensation. A red glass which breaks up whatever fusion im pulses may be operating in overcom ing a muscle paresis and converts a heterophoria into a heterotropia, must enormously enlarge the field of diplo pia. It can be employed only as an aid in diagnosis of eye and muscle, not for charting the diplopia. Even without the red glass, one has to contend with in cidental organic or psychogenic or simulated monocular diplopias and polyopias. Suppression makes it entire ly inapplicable. Diplopia charting is af-
1030
TRAUMATIC OPHTHALMOPLEGIAS ter all a subjective method and has all the weaknesses of such methods. The screen method is objective but does not lend itself to graphic registra tion and therefore to the determination of the extent of loss of motor field. Prism measurement of a heterotropia or
1031
has been a valuable addition to our available methods, and is objective. It cannot, however, be used as a basis for compensation, since, like the red glass, it excludes all fusion impulses and gives what may be called the static or total deviation, i.e., the manifest plus the
Figure 3 Fig. 1 (Davidson). Positive Perlia. For purpose of photography the subject is placed sidewise instead of to face the tangent cur tain which forms the background. Fig. 2 (Davidson). Negative Perlia. Left eye occluded. Fig. 3 (Davidson). Negative Perlia. A 10diopter prism, base down, on the right eye.
a heterophoria could hardly be used as a basis for estimating the functional loss. The Hess method of graphic registra tion of binocular motor incoordination* * Fuchs, E. Diseases of the eye. Trans lated by E. V. L. Brown from the fifteenth German edition, Philadelphia, J. B. Lippincott Company, 1933.
Figure 4 Fig. 4 (Davidson). Negative Perlia. Convergent strabismus.
latent deviation, and does not separate a heterotropia from a heterophoria. It is inapplicable in the presence of suppres sion. I t also has some problems of a mechanical nature yet to be solved, such as the visibility of the rod guiding the green thread and the difficulty with neu tralization of the red marks and green
1032
M. DAVIDSON
thread by the red and green niters. The Perlia test (Klin. M. f. Augenh., v. 12, p. 492), based on the Hering rod test and designed originally for measur ing depth perception, has been modified and adapted by me for exploration of the integrity of the motor field on the principle that binocular depth percep tion should be lost in the field of diplopia or suppression. It is thus an objec tive-performance control test in chart ing the diplopia or suppression field. As a preliminary demonstration of what is expected of him, the subject is given a 4-mm. white, spherical test ob ject (veil pin mounted in a black hold er), and is asked to hold it in front of him at his arm's length (or 50 cm.) and bring it up from some distance in the transverse vertical plane, to touch a similar test object held by the exami ner. The performance is then repeated before a tangent curtain, but a few inches in front of it, with the subject's head immobilized, at intervals of 5 de grees from the primary or straight-for ward position. The whole of the normal field of binocular stereopsis, that is, to a thirty-degree radius, is thus explored. The results are recorded on a tangent curtain record form as plus or success, and minus or failure. By shifting the position of his test object for each per formance, the examiner eliminates and controls the subject's muscle sense. By first helping the subject to touch it and then retaining it for several successive performances in the same position, the examiner can detect any lack of co operation by the persistence of failure to perform by muscle sense alone. For a positive Perlia, the test objects should be made to meet in the transverse verti cal plane without fumbling and neither from the front nor from behind. A few experiments on normal individuals should enable one to recognize the strik ing difference between a positive binoc ular Perlia performance and a negative monocular Perlia performance. In the negative Perlia, the test objects are missed anteroposteriorly by 1-2 en*, at least. Figures 1, 2, 3, and 4 illustrate a positive and various negative Perlia performances. A positive Perlia can be repeated indefinitely. Occasionally a
performance is accidentally positive. This cannot be repeated. Three per formances at each point are therefore advisable for the beginner in order to the avoidance of errors. Past-pointing, ataxias, and coarse tremors would seem at first glance to offer a difficulty, but these have not pre sented themselves in practice as a prob lem. The Perlia is not, as some believe, a test for eye-and-hand coordination, but for binocular coordination essential to binocular single vision and depth per ception. Purely horizontal concomitant heterotropias of low degree will give an occasional positive Perlia either in the upper or lower motor field in relation to decrease of convergence in elevation and increase of convergence in depres sion, as controlled by the screen test. This is particularly frequent in diver gent strabismus. It is to be borne in mind that the Perlia test is a powerful stimulus to fusion and stereopsis. Al lowance for this feature is made in the adoption of a radius of 15 degrees from the primary position as a normal mini mum of motor field, instead of 10 de grees as recommended by the American Medical Association Committee on Compensation for Eye Injuries. The 4-mm. test objects provide for visual acuities as low as 20/600 and for stereoscopic acuities as low as 200 sec onds of arc. With increasing experience, I have found the use of a 2-mm. test object just as practical. This corre sponds to a minimum of 20/300 visual acuity and one hundred seconds of arc of stereoscopic acuity. The former may be regarded as too low theoretically, but because of pseudoscopy inherent in the method, it is not seriously objectionable in practice. The latter is certainly with in the normal variations of binocular stereoscopic acuity. A 2-mm. test ob ject at 50 cm. would be the equivalent of a 25-mm. spotlight for testing diplo pia at 6 meters. Theoretically a 1-mm. test object would be ideal but I have not experimented with its practicality. Coarseness of hand movements may be a handicap. Because of the short dis tance at which the Perlia test is per formed, 7 degrees or less of divergence
1033
TRAUMATIC OPHTHALMOPLEGIAS Binocular Motor Field Chart for Hess,modified Perlia,and Diplopia tests at 50cm. Name and Diagnosis: T.P. O.D.Superior Oblique Paralysis. Summary of History: Male, 34, 6/6/34-Fell 15 feet. Right temporal skull fracture
Exam. 7/23/34.
r~j-*" = -:
S
S
Hess(green on O.D.) Modified Perlia Diplopia Each square: 5 degrees Chart as seen by patient,his right and left corresponding to those of charts / and - = presence or absence of depth perception on Perlia chart. D-S=position of O.D.and O.S.images on the Diplopia chart. Hess(green on O.S.)
Figure 5
Binocular Motor Field Chart for Hess,modified Perlia,and Diplopia tests at 50cm. Name and Diagnosis: T.P. O.D. Superior Oblique Paralysis Summary of History: Inferior Oblique Spasm Male,34,6/6/34-Fell 15 feet. Right temporal skull fracture.
Re-Exam. 11/20/34.-(evolution with contracture of antagonist).
Hesstgreet on O.D.) Modifitd Perlia Diplopia Each square : 5 degrees Chart as eeen^by patient,his right and left corresponding to those of charts. rand - = presence or absence of depth perception on Perlia ohart. D-Ssposition of O.D.and O.S.Images on the Diplopia chart. Hess(green on O.S.)
Figure 6 Figs. 5 and 6 (Davidson). These charts show the results of tests made on the same patient, the first (fig. S) almost seven weeks following the accident, the second (fig. 6) approximately four months after the first. The early onset of the contracture of the antagonist is illustrated.
M. DAVIDSON
1034
weakness at the extreme periphery might not be disclosed from a theoreti cal standpoint. This objection applies however to any method of exploring the motor field for near. The simultaneous use of the other methods would reveal the error, should the fatigue of the mus cle involved resulting from the test it self not make it manifest. Finally, the Perlia test has the advan tage of being applicable to the deaf and dumb and to persons of low intelligence. It may be described as a dynamic meth od of exploring binocular motor co ordination. It has proved in my hands
half of the field at two thirds of the loss of an eye, and sectors in proportion. Some clinical observations on traumatic ophthalmoplegias Seventy-one cases of traumatic oph thalmoplegias figure among ten thou sand examinations for compensation purposes, exclusive of old traumatic cases accidentally discovered, nontraumatic cases which came for observation, those due to symplephara and those diagnosed as congenital anomalies. They were tabulated on the following basis:
Table 1 TABULATION OF RELATION OF ACCIDENTS TO INJURY
MotorVehicle Accidents
Airplane Accidents
Falls from Heights
Missiles, Assaults, Falls on Level
Basal fractures, 52
25
2
10
15
Orbital injuries, 17
1
Accidents Injury
Psychogenic, 2
a most useful method in dealing with ophthalmoplegias for compensa tion purposes. To sum u p : four methods should be regularly employed in the examination of ophthalmoplegias for compensation purposes. The order of their usefulness in my experience has been the follow ing: The Perlia test, the Hess method, the screen test, and diplopia charting. The three which lend themselves to charting have been incorporated in a single form for recording. For the sake of uniformity the Hess chart has been limited to 15 degrees from the primary position. Because of the small scale of the form, the hyperbolic curve of the lines marking the degrees has been ig nored. Generally, all four methods em ployed are found to agree in their re sults. The practice in New York State has been to consider the loss of 80 percent of the minimum motor field the equiv alent of the loss of an eye. The upper half of the field is compensated for at one third of the loss of an eye, the lower
16 2
A. As basal fractures were consid ered all those with a positive skull frac ture by X ray, or a palpable orbital fracture regardless of the X-ray report, or a substantiated history of uncon sciousness. B. As orbital injuries were included all orbital penetrating injuries and periorbital injuries without demonstrable fracture. C. Psychogenic cases were those without evidence of either a basal frac ture or orbital injury. Table 1 indicates the high frequency of motor-vehicle accidents as the cause of basal fractures, and that of missiles, assaults, and falls on the level as causes of orbital injuries. Table 2 is an attempt to find a re lation between type of injury and fre quency of special muscle involvement. Traumatic enophthalmos and exophthalmos and third- and sixth-nerve paralysis can be seen to belong ex clusively to the basal-fracture syn drome. The most frequent basal-frac ture syndrome is a combination of en-
TRAUMATIC OPHTHALMOPLEGIAS ophthalmos, paresis of one or both ele vators, and mydriasis. A simultaneous tabulation of thirty traumatic optic atrophies observed for the same period disclosed only one positive and' one doubtful apex syndrome in the com bined series of 102 cases. The former exhibited a well-marked Argyll Robert son pupil. Posterior-pole lesions have been observed only once in the series of ophthalmoplegias. With two exceptions in all the traumatic ophthalmoplegias
1035
of one eye for a lime burn for two weeks. I t could not be established whether there existed an old concomi tant convergent strabismus or not. The condition was relieved after six months of observation by the use of prisms of 10 diopters, base out, for each eye. The patient has been wearing them with comfort and complete restoration of normal depth perception for over a year. In general, prisms have been rather suc cessful in relieving the distress of a
Table 2 TABULATION OF RELATION OF INJURY TO MUSCLE INVOLVEMENT
Involvement Injury
3d 3d Su and and External perior Supe rior 4th 6th Rectus Ob Rectus Nerves Nerves lique
Basal fractures, 52
4
1
8
13 Enophthalmos 2 Exophthalmos
(1)
(1)
(1) (1)
Orbital injuries, 17 Psychogenic, 2
9
4
Infe rior Ob lique
Supe rior Rectus Infe Inter Levator and nal Palperior Infer Rectus Rectus brse ior Ob lique
8
5
9
(3)
(2)
(5)
7
3
2
(1) 1
2
— 1 Hysteri cal ptosis
1 Diver gence paralysis
vision was 20/20. The frequency of in volvement of the elevators, particularly of the superior rectus, is noteworthy in both the basal and orbital groups. The vulnerability of the elevators accords well with the frequency of their involve ment as a congenital anomaly, presum ably from birth injuries, and with the frequency of their initial involvement in nontraumatic third-nerve paralysis. While diplopia is a prominent com plaint in the basal-fracture group, it is often masked by complaints of dizzi ness, headaches, and blurring in the or bital group, and the ophthalmoplegia and the diplopia often have to be looked for. Among the psychogenic cases, di vergence paralysis followed bandaging
6
permanent ophthalmoplegia, and would seem to be more often indicated and worthy of consideration when surgery is not resorted to. The other psycho genic case was a unilateral hysterical ptosis. The bad prognosis of the rather fre quent superior-oblique involvement is disclosed by the early onset of contracture of the inferior oblique. The Perlia test indicates a frequent early onset of suppression in the field of diplopia. This alone makes it a val uable addition to the other methods for purposes of accurate diagnosis and re cording of the evolution of an ophthal moplegia. 80 Centre Street.
From his experience in making 10,000 examinations for compensation purposes, the author states that for ascertaining functional loss in traumatic ophthalmoplegia on a percentage basis, objective tests are indispensable in checking and coordinating results obtained from tests in which the subjective element is inherent. He advocates the use of four methods as a routine procedure: his adaptation of the Perlia test, the Hess method, the screen test, and the charting of diplopia. The seventy-one cases of traumatic ophthal moplegia discovered in these examinations fall into three categories; namely, those result ing from basal fractures, orbital injuries, and psychogenic conditions. Read at the New York Academy of Medicine, Section of Ophthalmology, on December 17, 1934.
The examination of eyes for compen sation purposes has aspects not in volved in the practice of ophthalmol ogy. It is a medico-legal examination, and the ophthalmologist's findings have to be defended before lay referees and commissioners. Account has to be taken of other medical observers' findings, which may be based on different meth ods and may represent different stages of a pathological process. The exami nation is performed without the com plete cooperation of the patient who is also a claimant for compensation. Fi nally, there is the demand for an ex pression in terms of a percentage re garding any functional loss that may have been incurred. These conditions call for a standard procedure,in the ex amination with emphasis on objective or objectivized methods which lend themselves to graphic registration. An attempt to meet these aspects of traumatic ophthalmoplegias is there fore presented. It has grown out of deal ings with a considerable number of such cases in the course of 10,000 ex aminations for compensation purposes at the New York State Bureau of Workmen's Compensation during the past four years. The tabulation of the material has incidentally disclosed some clinical data of interest. The problem of the procedure in examination Compensation in traumatic ophthal moplegias can be awarded only in terms of permanent loss of normal motor field. There are, to be sure, two other functional impairments involved in an ophthalmoplegia. In addition to the
manifest loss of motor field, that is, the field of heterotropia and diplopia, there is an intermediate zone of latent im balance or heterophoria separating it from the zone of binocular single vi sion. This is easily demonstrated by comparing a diplopia chart obtained by proceeding from the field of single vi sion to the field of diplopia with one obtained by examining from the oppo site direction. Recovery is also liable to leave a heterophoria. Stereoscopic acui ty or depth perception likewise is liable to impairment, even in the field of sin gle vision, and surely in that of the zone of heterophoria. It is of course entirely abolished in the field of diplopia. Neither of these two conditions, how ever, can be dealt with in practice, and we have to limit ourselves to com pensation in terms of loss of motor field, of a field of diplopia. The method currently used for ap praising the loss of motor field is that of charting the diplopia. However reli able it may be made in examining pa tients for therapeutic purposes, diplo pia charting is far from satisfactory for purposes of compensation. A red glass which breaks up whatever fusion im pulses may be operating in overcom ing a muscle paresis and converts a heterophoria into a heterotropia, must enormously enlarge the field of diplo pia. It can be employed only as an aid in diagnosis of eye and muscle, not for charting the diplopia. Even without the red glass, one has to contend with in cidental organic or psychogenic or simulated monocular diplopias and polyopias. Suppression makes it entire ly inapplicable. Diplopia charting is af-
1030
TRAUMATIC OPHTHALMOPLEGIAS ter all a subjective method and has all the weaknesses of such methods. The screen method is objective but does not lend itself to graphic registra tion and therefore to the determination of the extent of loss of motor field. Prism measurement of a heterotropia or
1031
has been a valuable addition to our available methods, and is objective. It cannot, however, be used as a basis for compensation, since, like the red glass, it excludes all fusion impulses and gives what may be called the static or total deviation, i.e., the manifest plus the
Figure 3 Fig. 1 (Davidson). Positive Perlia. For purpose of photography the subject is placed sidewise instead of to face the tangent cur tain which forms the background. Fig. 2 (Davidson). Negative Perlia. Left eye occluded. Fig. 3 (Davidson). Negative Perlia. A 10diopter prism, base down, on the right eye.
a heterophoria could hardly be used as a basis for estimating the functional loss. The Hess method of graphic registra tion of binocular motor incoordination* * Fuchs, E. Diseases of the eye. Trans lated by E. V. L. Brown from the fifteenth German edition, Philadelphia, J. B. Lippincott Company, 1933.
Figure 4 Fig. 4 (Davidson). Negative Perlia. Convergent strabismus.
latent deviation, and does not separate a heterotropia from a heterophoria. It is inapplicable in the presence of suppres sion. I t also has some problems of a mechanical nature yet to be solved, such as the visibility of the rod guiding the green thread and the difficulty with neu tralization of the red marks and green
1032
M. DAVIDSON
thread by the red and green niters. The Perlia test (Klin. M. f. Augenh., v. 12, p. 492), based on the Hering rod test and designed originally for measur ing depth perception, has been modified and adapted by me for exploration of the integrity of the motor field on the principle that binocular depth percep tion should be lost in the field of diplopia or suppression. It is thus an objec tive-performance control test in chart ing the diplopia or suppression field. As a preliminary demonstration of what is expected of him, the subject is given a 4-mm. white, spherical test ob ject (veil pin mounted in a black hold er), and is asked to hold it in front of him at his arm's length (or 50 cm.) and bring it up from some distance in the transverse vertical plane, to touch a similar test object held by the exami ner. The performance is then repeated before a tangent curtain, but a few inches in front of it, with the subject's head immobilized, at intervals of 5 de grees from the primary or straight-for ward position. The whole of the normal field of binocular stereopsis, that is, to a thirty-degree radius, is thus explored. The results are recorded on a tangent curtain record form as plus or success, and minus or failure. By shifting the position of his test object for each per formance, the examiner eliminates and controls the subject's muscle sense. By first helping the subject to touch it and then retaining it for several successive performances in the same position, the examiner can detect any lack of co operation by the persistence of failure to perform by muscle sense alone. For a positive Perlia, the test objects should be made to meet in the transverse verti cal plane without fumbling and neither from the front nor from behind. A few experiments on normal individuals should enable one to recognize the strik ing difference between a positive binoc ular Perlia performance and a negative monocular Perlia performance. In the negative Perlia, the test objects are missed anteroposteriorly by 1-2 en*, at least. Figures 1, 2, 3, and 4 illustrate a positive and various negative Perlia performances. A positive Perlia can be repeated indefinitely. Occasionally a
performance is accidentally positive. This cannot be repeated. Three per formances at each point are therefore advisable for the beginner in order to the avoidance of errors. Past-pointing, ataxias, and coarse tremors would seem at first glance to offer a difficulty, but these have not pre sented themselves in practice as a prob lem. The Perlia is not, as some believe, a test for eye-and-hand coordination, but for binocular coordination essential to binocular single vision and depth per ception. Purely horizontal concomitant heterotropias of low degree will give an occasional positive Perlia either in the upper or lower motor field in relation to decrease of convergence in elevation and increase of convergence in depres sion, as controlled by the screen test. This is particularly frequent in diver gent strabismus. It is to be borne in mind that the Perlia test is a powerful stimulus to fusion and stereopsis. Al lowance for this feature is made in the adoption of a radius of 15 degrees from the primary position as a normal mini mum of motor field, instead of 10 de grees as recommended by the American Medical Association Committee on Compensation for Eye Injuries. The 4-mm. test objects provide for visual acuities as low as 20/600 and for stereoscopic acuities as low as 200 sec onds of arc. With increasing experience, I have found the use of a 2-mm. test object just as practical. This corre sponds to a minimum of 20/300 visual acuity and one hundred seconds of arc of stereoscopic acuity. The former may be regarded as too low theoretically, but because of pseudoscopy inherent in the method, it is not seriously objectionable in practice. The latter is certainly with in the normal variations of binocular stereoscopic acuity. A 2-mm. test ob ject at 50 cm. would be the equivalent of a 25-mm. spotlight for testing diplo pia at 6 meters. Theoretically a 1-mm. test object would be ideal but I have not experimented with its practicality. Coarseness of hand movements may be a handicap. Because of the short dis tance at which the Perlia test is per formed, 7 degrees or less of divergence
1033
TRAUMATIC OPHTHALMOPLEGIAS Binocular Motor Field Chart for Hess,modified Perlia,and Diplopia tests at 50cm. Name and Diagnosis: T.P. O.D.Superior Oblique Paralysis. Summary of History: Male, 34, 6/6/34-Fell 15 feet. Right temporal skull fracture
Exam. 7/23/34.
r~j-*" = -:
S
S
Hess(green on O.D.) Modified Perlia Diplopia Each square: 5 degrees Chart as seen by patient,his right and left corresponding to those of charts / and - = presence or absence of depth perception on Perlia chart. D-S=position of O.D.and O.S.images on the Diplopia chart. Hess(green on O.S.)
Figure 5
Binocular Motor Field Chart for Hess,modified Perlia,and Diplopia tests at 50cm. Name and Diagnosis: T.P. O.D. Superior Oblique Paralysis Summary of History: Inferior Oblique Spasm Male,34,6/6/34-Fell 15 feet. Right temporal skull fracture.
Re-Exam. 11/20/34.-(evolution with contracture of antagonist).
Hesstgreet on O.D.) Modifitd Perlia Diplopia Each square : 5 degrees Chart as eeen^by patient,his right and left corresponding to those of charts. rand - = presence or absence of depth perception on Perlia ohart. D-Ssposition of O.D.and O.S.Images on the Diplopia chart. Hess(green on O.S.)
Figure 6 Figs. 5 and 6 (Davidson). These charts show the results of tests made on the same patient, the first (fig. S) almost seven weeks following the accident, the second (fig. 6) approximately four months after the first. The early onset of the contracture of the antagonist is illustrated.
M. DAVIDSON
1034
weakness at the extreme periphery might not be disclosed from a theoreti cal standpoint. This objection applies however to any method of exploring the motor field for near. The simultaneous use of the other methods would reveal the error, should the fatigue of the mus cle involved resulting from the test it self not make it manifest. Finally, the Perlia test has the advan tage of being applicable to the deaf and dumb and to persons of low intelligence. It may be described as a dynamic meth od of exploring binocular motor co ordination. It has proved in my hands
half of the field at two thirds of the loss of an eye, and sectors in proportion. Some clinical observations on traumatic ophthalmoplegias Seventy-one cases of traumatic oph thalmoplegias figure among ten thou sand examinations for compensation purposes, exclusive of old traumatic cases accidentally discovered, nontraumatic cases which came for observation, those due to symplephara and those diagnosed as congenital anomalies. They were tabulated on the following basis:
Table 1 TABULATION OF RELATION OF ACCIDENTS TO INJURY
MotorVehicle Accidents
Airplane Accidents
Falls from Heights
Missiles, Assaults, Falls on Level
Basal fractures, 52
25
2
10
15
Orbital injuries, 17
1
Accidents Injury
Psychogenic, 2
a most useful method in dealing with ophthalmoplegias for compensa tion purposes. To sum u p : four methods should be regularly employed in the examination of ophthalmoplegias for compensation purposes. The order of their usefulness in my experience has been the follow ing: The Perlia test, the Hess method, the screen test, and diplopia charting. The three which lend themselves to charting have been incorporated in a single form for recording. For the sake of uniformity the Hess chart has been limited to 15 degrees from the primary position. Because of the small scale of the form, the hyperbolic curve of the lines marking the degrees has been ig nored. Generally, all four methods em ployed are found to agree in their re sults. The practice in New York State has been to consider the loss of 80 percent of the minimum motor field the equiv alent of the loss of an eye. The upper half of the field is compensated for at one third of the loss of an eye, the lower
16 2
A. As basal fractures were consid ered all those with a positive skull frac ture by X ray, or a palpable orbital fracture regardless of the X-ray report, or a substantiated history of uncon sciousness. B. As orbital injuries were included all orbital penetrating injuries and periorbital injuries without demonstrable fracture. C. Psychogenic cases were those without evidence of either a basal frac ture or orbital injury. Table 1 indicates the high frequency of motor-vehicle accidents as the cause of basal fractures, and that of missiles, assaults, and falls on the level as causes of orbital injuries. Table 2 is an attempt to find a re lation between type of injury and fre quency of special muscle involvement. Traumatic enophthalmos and exophthalmos and third- and sixth-nerve paralysis can be seen to belong ex clusively to the basal-fracture syn drome. The most frequent basal-frac ture syndrome is a combination of en-
TRAUMATIC OPHTHALMOPLEGIAS ophthalmos, paresis of one or both ele vators, and mydriasis. A simultaneous tabulation of thirty traumatic optic atrophies observed for the same period disclosed only one positive and' one doubtful apex syndrome in the com bined series of 102 cases. The former exhibited a well-marked Argyll Robert son pupil. Posterior-pole lesions have been observed only once in the series of ophthalmoplegias. With two exceptions in all the traumatic ophthalmoplegias
1035
of one eye for a lime burn for two weeks. I t could not be established whether there existed an old concomi tant convergent strabismus or not. The condition was relieved after six months of observation by the use of prisms of 10 diopters, base out, for each eye. The patient has been wearing them with comfort and complete restoration of normal depth perception for over a year. In general, prisms have been rather suc cessful in relieving the distress of a
Table 2 TABULATION OF RELATION OF INJURY TO MUSCLE INVOLVEMENT
Involvement Injury
3d 3d Su and and External perior Supe rior 4th 6th Rectus Ob Rectus Nerves Nerves lique
Basal fractures, 52
4
1
8
13 Enophthalmos 2 Exophthalmos
(1)
(1)
(1) (1)
Orbital injuries, 17 Psychogenic, 2
9
4
Infe rior Ob lique
Supe rior Rectus Infe Inter Levator and nal Palperior Infer Rectus Rectus brse ior Ob lique
8
5
9
(3)
(2)
(5)
7
3
2
(1) 1
2
— 1 Hysteri cal ptosis
1 Diver gence paralysis
vision was 20/20. The frequency of in volvement of the elevators, particularly of the superior rectus, is noteworthy in both the basal and orbital groups. The vulnerability of the elevators accords well with the frequency of their involve ment as a congenital anomaly, presum ably from birth injuries, and with the frequency of their initial involvement in nontraumatic third-nerve paralysis. While diplopia is a prominent com plaint in the basal-fracture group, it is often masked by complaints of dizzi ness, headaches, and blurring in the or bital group, and the ophthalmoplegia and the diplopia often have to be looked for. Among the psychogenic cases, di vergence paralysis followed bandaging
6
permanent ophthalmoplegia, and would seem to be more often indicated and worthy of consideration when surgery is not resorted to. The other psycho genic case was a unilateral hysterical ptosis. The bad prognosis of the rather fre quent superior-oblique involvement is disclosed by the early onset of contracture of the inferior oblique. The Perlia test indicates a frequent early onset of suppression in the field of diplopia. This alone makes it a val uable addition to the other methods for purposes of accurate diagnosis and re cording of the evolution of an ophthal moplegia. 80 Centre Street.