Those cases deserve special consideration in which emmetropia is present in one eye, in the other myopia. Slight degrees of one-sided myopia reconcile themselves with the continuance of a normal binocular act of vision. If the far point of the myopic eye lies at an inconvenient proximity even for reading, then, as a rule, the emmetropic eye is used for near as well as distant objects; if, on the contrary, the degree of myopia answers to a range of vision convenient for working, and visual acuteness is normal, then the temptation to use the emmetropic eye only for distance and the myopic one only for near objects is so overpowering, and the advantages on the other hand which would be offered by clinging to binocular vision so slight, that a convenient monocular vision is generally preferred. Even for objects which lie nearer the eye than the far point of the myopic, and at the same time farther than the near point of the emmetropic eye, for which, therefore, both eyes could secure clear retinal images, binocular vision is not used. In cases in which the patient can read with proper binocular fixation, if one covers all but one line and then makes with prisms double images standing one above another, it is the myopic eye alone which almost invariably shows a clear retinal image.
The usual result of this is, first a relaxing of binocular vision, and as together with this the motive for convergence, namely, the effort of the accommodation ceases, the conditions for the commencement of divergence are produced. Still the elastic tension of the ocular muscles decides even here; if the interni preponderate, convergent squint results, when the myopic eye is used for near objects, the emmetropic for distant ones. If the externi preponderate, then permanent or periodic divergent strabismus is caused. Nevertheless, in a remarkable minority of cases the elastic tension of the ocular muscles is so regulated that, despite relaxation of binocular fusion, neither convergent squint nor absolute divergence occurs, but simple relative divergence remains with employment of the myopic eye for near objects.
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.