DYNAMIC SQUINT, INSUFFICIENCY OF THE INTERNI AND MUSCULAR ASTHENOPIA.
The habit of binocular single vision, when it has once reached its normal development, governs the movements of our eyes to a great degree; the desire to avoid double images makes itself continually felt; and where this is not possible, an uncomfortable feeling of uncertainty arises at every movement of the body. Double images are prevented as far as possible by movements of the eyes, which we must designate as voluntary when we are conscious of their occurrence.
If we follow a moving object with the eyes, the latter make corresponding movements in order to keep the image in the centre of both retinæ. For example, if we look at a distant object which approaches in the direction of one visual axis, this eye will necessarily remain still, while the other will be put into convergence in proportion as the object advances. If this did not happen, if this eye remained also immovable, the retinal image would deviate outwards more and more from the macula lutea and diplopia would arise. In order then to avoid diplopia the macula lutea moves to where the retinal image is formed. We can, however, move the images on the retina by the aid of prisms without movement of the object. If, for example, we hold a prism before the eye so that the base lies towards the temporal side, the retinal image will be displaced towards the base of the prism, outwards then from the macula, and double images will occur, which are at once removed by a distinctly perceptible inward movement of the eye. In this way, by means of a prism applied with the base inwards, outward deviation may be produced, and even in a modified way deviations in height of the visual axes by means of prisms with the base upwards or downwards. Here the force of habit is apparent, for in the daily use of our eyes we continually practise the inward movement of the visual axes; we can also easily restore the customary degree of convergence by means of prisms with the bases outwards; physiologically indeed, it is quite immaterial whether an object is in a proximity to our eyes attainable by convergence, which causes double images until it is binocularly fixed, or whether by the aid of prisms we bring the retinal images of a distant object to parts of the retinæ which do not correspond. If we look at a distant object fixed with parallel visual axes, under normal circumstances, prisms of 6° to 8° with the base inwards can be overcome, that is to say, as in weak prisms the deviation is equal to about half of the prism, an absolute divergence of the visual axes of 3° to 4° may be produced by which the double images are blended. It is immaterial whether we apply a prism of, say 8° to one eye, or prisms of 4° with the bases inwards to both. The facultative divergence thus attainable remains the same, which speaks for the fact, that this monolateral movement attainable by prisms is also combined with double innervation; and of course in the eye remaining in unmoved fixation, with impulses to innervation which are reciprocally abolished.
In the physiological use of our eyes we certainly never have occasion to practise absolute divergence, but we constantly practise the transition from the inward to the outward movement of the eyes, and experiments with prisms teach us, that the innervation of the externi therewith connected may even be carried somewhat beyond the physiological limits of parallelism. Moreover, the extent of the "facultative" divergence attainable by prisms shows a considerable latitude.
The case is similar with deviation in height of the visual axes. In looking upwards or downwards the innervation of both eyes is usually precisely the same, but on looking at any point when holding the head obliquely, the difference in height of the eyes then present must be balanced by a corresponding difference in the direction of the visual axes. The same thing happens, if we hold a vertically deviating prism in front of one eye in binocular vision; prisms of 2° to 3° may then be overcome by difference in height of the eyes; rarely is a much greater difference in height of the visual axes attainable. I have seen this particularly in those cases where facultative divergence also was greater than usual.
It happens especially in myopia that prisms of considerably more than 6° to 8° are overcome by divergence, and certainly without causing any inconvenience. Among the cases presented for examination, those, of course, are most numerous where the patients have some complaint to make, even if this have quite a different cause. In any case a divergent position of the axes of vision corresponds to the balance of the muscles, and this does not generally occur, for this reason, because retaining binocular single vision necessitates a parallel or convergent position of the eyes. Frequently, however, even a slight impediment to binocular fusion, such as the application of a red glass to one eye, suffices to procure preponderance in the elastic tensions of the muscles, and to cause the fixed point to appear double. We can put a stop to binocular single vision still more surely by applying to one eye a prism with the base upwards or downwards. If the double images of a point 4 to 5 meters distant show a crossed lateral position besides the difference in height caused by the prism, we may assume that an absolute divergent position of the eyes corresponds to the elastic tension of the muscles; and the measure of the deviation will be given by those prisms which, placed with the bases inwards before one or both eyes, bring the double images perpendicularly over one another. As a rule, in these cases the degree of divergence which occurs on cessation of binocular single vision, is almost as great as the facultative divergence, which may be reached in the interest of binocular single vision.
V. Graefe designates as "dynamic squint" that condition in which the position of divergence corresponding to the state of tension of the muscles does not occur because binocular vision is retained. Without clearly defined limits these conditions pass on into periodic squint, when either diplopia occurs together with the divergence, or the habit of binocular fusion becomes less frequent or is quite forgotten, while, however, according to the varying state of the muscles sometimes normal position, sometimes divergence, is present. A correct position of the eyes is quite possible even without binocular fusion, then only the regulator is wanting, which, in the varying play of the muscular forces, ensures the balance of position and movement.
The older ophthalmologists had a parallel strabismus and probably understood by that, what we now designate as relative divergence. The connection between relative divergence and myopia, pointed out by Donders, is universally admitted; on the other hand, in more modern literature we scarcely find any intimation of the fact that a parallel squint occurs, which is quite independent of myopia, and rests solely on the fact that the impulse of innervation for convergence is lost. A few examples may explain this condition.
Case 13.—Auguste T—, æt. 28. On the left emmetropia, V. 12/20. On the right the visual acuteness is variously given, but certainly does not amount to more than 1/5 nor less than 1/10 of the normal. Ophthalmoscopic report normal. The left eye is naturally the fixing one, the right always remains parallel—for near objects double images are present. A convergent movement is not attained, either for near objects, or by means of prisms with bases outwards for distant ones. Prisms with the bases inwards are not overcome; with vertically deviating prisms the double images of distant objects stand perpendicularly above one another.
Case 14.—Ludwig v. K—, æt 32, has complained of diplopia repeatedly for fifteen years. Statement in August, 1877: Convergence to a pencil held before patient on the median line is only retained to about 50 cm., nearer, crossed diplopia occurs. In reading, binocular fixation is possible with an effort at a nearer point. The facultative divergence does not amount to more than 3°; even by convergence to a distance of 4 mtr. prisms of 3° only are overcome. Emmetropia and full visual acuity on both sides. In Sept., 1880, three years after, the statement remained unaltered. Patient has only used the prismatic spectacles then prescribed off and on, as the symptoms are sometimes more troublesome, sometimes less so, and he exerts his eyes but little on the whole.
A restriction of movement of the internal recti did not exist in these cases; the absence of the convergent movement is not then to be set down to the interni not possessing the proper power for acting, but only to the fact that the impulse for their simultaneous innervation was wanting. We frequently find this absence of innervation in divergent squint, and then generally consider it to be a consequence of the squint, which, however, as the above cases show, need not necessarily be the case. If preponderance of the externi is at the same time present, absolute divergence is the result, but not always permanent squint, frequently only the periodic form. The anomaly of innervation may also usually be proved in such cases, in that after the removal by operation of the absolute divergence it continues to exist in the relative form; it can indeed happen that for a few days after the operation convergent squint is present for distance, together with relative divergence for near objects.
The highest phases of this anomaly, as represented in Cases 13 and 14, are seldom seen. Slighter degrees, which, like so many other things, are usually designated as "insufficiency of the interni," are more frequently met with and are combined with asthenopia. On the one hand, in looking at near objects a tendency exists to the formation of double images, which are removed by the action of the interni; on the other hand, however, the habit of binocular single vision is relinquished on account of the frequent diplopia. In all forms of squint we see that binocular fusion is forgotten; still it seems more natural to assume this to be the result, and not the cause of the squint, as Krenchel does.
Another form of relative divergence is that which is brought about in consequence of extreme myopia. The change in form of the myopic eye diminishes its mobility, associated movements of the eyes may be replaced by turning the head, but this is not possible for the movement of convergence. Further, in extreme myopia the far point is generally used for reading, &c., and sometimes even a somewhat greater distance, because on account of the close proximity of the objects the retinal images are so large that they are sufficiently clearly recognised even if they are not quite distinct. At all events accommodation certainly does not take place, hence one motive favouring convergence is removed.
Finally, however, such considerable convergence as clear vision demands in high degrees of myopia, would be difficult even for a normally movable eye. Reasons enough therefore exist for giving up binocular fixation and using only the more convenient eye for reading, without effort to the accommodation and convergence. In myopia of high degree patients almost always read with relative divergence, and these myopes do just what we must advise them to do, they avoid strain of the accommodation and convergence of the visual axes and thus keep well.
Notwithstanding that this condition necessarily results from the nature of extreme myopia, it is frequently held to be pathological, which it certainly is not in itself. At most, the short-sightedness and change in form of the eye are pathological; the relative divergence on the other hand is simply a harmless result of the above conditions.
No doubts whatever exist about this relative divergence. The theory that the demands on the working eye must be very much increased is quite unfounded. If any harmful influence were to be feared for the fixing eye, one would observe the same in convergent squint, when, as a rule, one eye only is used for fixation even after operation.
In convergent strabismus, however, no one, at least no ophthalmologist, thinks of entertaining such fears for the eye used in fixation, and where is the physiological basis of this whole idea to be found? Is the visual purple more active in monocular than in binocular vision, or what physiological activity is thereby taxed in increased degree?
I have found no confirmation of Alfred Graefe's theory that in myopia the eye chiefly used in fixation is frequently affected with choroiditis of the macula lutea, &c., but have only observed that patients to whom this happens seek the advice of a physician more eagerly than when the same intra-ocular troubles befall the other usually neglected eye in connection with myopia.
Muscular asthenopia undoubtedly occurs; it is only a question whether it is as frequent as it is diagnosed. It has its foundation in that the convergence necessary for reading, writing, &c., can only be sustained by an effort of the internal recti, which exceeds their strength, and finally results in painful fatigue of the muscles, just as accommodative asthenopia depends on painful fatigue of the muscles of accommodation. The similarity reaches still further. We occasionally find that despite considerable degrees of hypermetropia no asthenopia occurs even in persons who strain their eyes; while, on the other hand, asthenopic troubles appear in hypermetropia which are not removed by correction of the refraction and must consequently have some other motive. Yet still more is this the case with those disorders, of which muscular asthenopia may be supposed to be the cause. Notwithstanding the existence of a considerable preponderance of the externi, muscular asthenopia may be entirely absent. If we find, for example, that as soon as we do away with binocular single vision absolute divergence occurs even on looking at a distant fixed point, and that prisms of 12° to 30° are overcome by divergence, we may safely assume that the elastic preponderance of the externi must be overcome in reading, &c., in the interest of binocular, single vision by a stronger muscular effort of the interni, which is, however, very frequently accomplished without fatigue. Asthenopic disorders are also frequently present together with preponderance of the externi, which continue to exist despite the removal of the same by operation, and must consequently have some other cause. The diagnosis of accommodative asthenopia is as a rule confirmed ex juvantibus; this cannot be asserted for the muscular form.
For example, Case 15.—Mathilde F—, æt. 21, has suffered from asthenopic disorders for three years. The investigation at the beginning of January, 1880, shows: On the left, myopia 4 D., V. = 5/18, No. 0·3 is read at 10 cm.; on the right, myopia 6 D., V. 5/24, 0·3 is read with difficulty, cylindrical glasses cause no improvement. Patient converges to about 8 cm., on exclusion absolute divergence of 3 to 4 mm. follows, with slight upward deviation of the right eye.
On correction of the myopia the facultative divergence amounts to = 26°. Here one might easily have concluded the asthenopia to be a result of fatigue of the interni, but this opinion was refuted by the effect of the treatment. The double tenotomy of the externi performed on January 2nd was first followed by convergent squint with homonymous double images, which were united by a prism of 12° with the base inwards. In the course of a few days single vision was again restored. A fortnight after the operation, on correction of the myopia, patient could see singly to 3 mtr.: towards both sides homonymous double images were still present, and in fixation to 30 cm. relative divergence on exclusion of one eye. Six months after the operation, on correction of the myopia and application of red glass to one eye, crossed double images occur close together, which become homonymous by means of a prism of 3° with the base inwards. Patient sees double images always, without being much disturbed by them, yet they cannot be united by means of prisms. The habit of binocular single vision has also gradually been lost. In reading (without correction) a movement of convergence takes place (it cannot be determined whether this answers exactly to the distance of the object). If, on the other hand, one asks the patient to fix binocularly larger objects, such as a pencil close to her, she is unable to do it, relative divergence occurs then, as well as on exclusion of one eye. The asthenopic disorders remain unchanged and are not removed even by prismatic spectacles. Despite all reasons then for the supposition the asthenopia was certainly not of a muscular nature.
The uncertainty as to diagnosis is still greater in those cases which, according to v. Graefe, were to be designated as dynamic relative divergence; cases in which with parallel visual axes a disturbed balance is not present but occurs on convergence in such a way that the interni only perform their destined work with difficulty, and are nevertheless urged on in the interest of binocular single vision, till they give way in painful fatigue.
According to v. Graefe the diagnosis of this condition must be carried out in the following way. First of all the convergence must be fixed on a near object in the median line; if one eye remains behind in the movement it may be accounted for in various ways, for example, the impediment of movement caused by the change in form of the eye in myopia or the faulty innervation of the interni mentioned on p. 54. In both cases for the most part no dynamic, but manifest relative divergence is present in viewing near objects. It may also happen that the patient does not converge sufficiently, merely because accommodation is absent. This experiment does not then prove the presence of dynamic relative convergence, and v. Graefe came to the conclusion, therefore, that a normal position of the eyes obtained only by the habit of binocular single vision must be relinquished so soon as we cause binocular single vision to cease. Just as under these circumstances dynamic absolute divergence is manifested in the observance of distant objects, so must this be the case in dynamic relative divergence in the observance of near objects. One eye is first excluded while looking at an object about 25 cm. distant, to determine whether it still remains in a proper position for fixation. We have reason to believe that the position which occurs in the excluded eye answers to the given conditions of tension of the muscles. Still it is not necessary to cause binocular vision quite to cease, it is sufficient and even more advantageous, simply to make binocular single vision impossible, which we are able to do by means of prisms. If, for example, a point be fixed lying at the usual distance for work of 25 to 30 cm., or, according to v. Graefe, a large spot intersected by a vertical line, and one then applies a vertically deviating prism to one eye, the influence of binocular single vision on the ocular muscles is removed, as the fusion of the double images standing above one another is impossible; and nothing prevents the assumption of a relative position of divergence instead of a proper convergent one; as a result of this the double images show a crossed lateral position as well as the difference in height produced by the prism. The extent of this lateral deviation may be measured by means of prisms, which being applied to the eyes with the bases inwards place the double images again perpendicularly above one another. Von Graefe holds it to be of importance to determine the strongest prisms which can be overcome for the given distance by means of convergence and by the outward movement of the eyes.
On the strength of this method of inquiry there is a prevalence of opinion that the asthenopic disorders common in myopia are caused by over-exertion of the ocular muscles; indeed people believe this so strongly that they assume the presence of muscular asthenopia even in individuals in whom the habit of working with relative divergence is already firmly rooted. Relative divergence may perchance cause annoyance through double images, though this really seldom happens, but it can never cause muscular asthenopia, for the internal recti muscles protect themselves by means of relative divergence from any stronger exertion.
Asthenopic disturbances are certainly frequent in myopia, but the above method of inquiry does not at all prove that their cause lies in the ocular muscles, for those appearances from which one concludes dynamic relative divergence and muscular asthenopia, are found in almost all myopes, even when the latter have no asthenopic troubles, for they owe their origin to the nature of the myopia. Myopes learn to converge to the distance of their far point, without exerting the accommodation; if we now cause a point at this distance to be fixed and then exclude one eye, or make binocular fusion impossible by means of vertical prisms, what imaginable reason is there for the excluded eye to remain in proper fixation? In emmetropia the habitual relation between accommodation and convergence will be able to ensure that the excluded eye also remains covering the fixed object, convergently as well as accommodatively; in myopia, every discretionary relative divergence up to parallelism of the lines of vision is perfectly justified, because no effort of the accommodation takes place. How in the world can it be held to be pathological that a movement of convergence does not occur, when one has just artificially removed all those physiological conditions which could possibly have brought it about? If one now likes, as v. Graefe proposes, to determine the prisms, which can be overcome by means of the outward movement, there is no doubt about the fact, that with the aid of prisms the lines of vision may be made parallel or even divergent, the retinal images indeed, always retaining the same distinctness, in so far as they are not injured by the prismatic diffusion of colours. There is just as little reason why the convergence usually attainable should not also be restored by the aid of prisms with the bases outwards, the retinal images are not only impaired by the prisms, but the accommodation united with the convergence, no longer corresponds to the real distance of the fixed point.
Enough, all these incidents, which are to prove the presence of muscular asthenopia in myopia, occur when the investigation is carried out as usual in the region of the far point, entirely on a physiological basis, and must not therefore be held to be pathological without further proof.
The proof of muscular asthenopia in slight degrees of myopia, emmetropia, or hypermetropia, is somewhat more certain; a deviation from physiological laws is certainly present, if we find that the corresponding convergence does not unite itself with the accommodation for a near object, we must be quite sure that an exact accommodation for the fixed point is also really present. It by no means follows because one causes a large black spot to be observed at a distance of 25 to 30 cm., that an exact accommodation takes place; one can see these things even with circles of diffusion, the retinal images are already dimmed by means of the prisms, and one can easily convince one's self that, on the renunciation of clear retinal images, normal eyes can reach every attainable convergence or relative divergence by means of prisms. Insufficient accommodation and defective convergence are, however, easily caused by all painful sensations situated near the eye, which make the accommodation uncomfortable and fatiguing. This applies to every common head- or tooth-ache, and in the same manner to disturbances arising in the conjunctiva, or which depend on the stretching of the collective tunics of the eye in myopia, or which allow any other so-called "nervous" origin to be suspected.
We must place the same claims to the diagnosis of muscular asthenopia as to that of the accommodative form. Just as the latter is only detected if convex glasses really give the expected relief, so the proof of muscular asthenopia is only furnished when relief to the interni is brought about by means of the appropriate remedies. For myopes, who do not fall back on the aid of relative divergence, notwithstanding that they possess a clear field of vision only attainable with difficulty through convergence, it is the simplest plan to remove the far point to about 25 to 30 cm. by specially adapted concave glasses. If only slight myopia or none at all is present, but the relation between accommodation and convergence is disturbed, the latter can be corrected by means of prisms with the bases inwards—to be sure, only in a slight degree, as prisms of more than 4° are scarcely suited for spectacles, partly on account of their weight and partly on account of the diffusion of colours. Prisms may be ground with concave or convex surfaces, according to the requirements of refraction or accommodation.
Finally, if an elastic preponderance of the externi can be proved by means of considerable facultative divergence, the same may be lessened by tenotomy of one or both externi; still after my own experience I cannot advise the performance of this operation unless prisms of at least 16° are overcome by absolute divergence, for I have seen many patients in other practices who have acquired convergent squint and diplopia for distance as the sole result of the operation, while the asthenopic troubles for near objects continue. The proof that it is not a case of muscular asthenopia is sometimes only obtained by the operation.