In periodic squint, the first care must always be to determine the condition of refraction, if possible with atropine, and to neutralise or over-correct hypermetropia if present. If squint is absent during the use of convex glasses, which happens frequently under these circumstances, the operation offers no further advantages, as the constant use of convex glasses afterwards can hardly be avoided. If the periodic deviation continues to exist, the operation can be carried out according to the above rules and so as to cause a slight effect.
The final result is usually attained after two to three weeks in convergent squint; it is better to allow a slight degree of convergence to exist, as divergence, however slight, existing at this time, brings with it the fear of a gradual increase. It happens occasionally, that after years, convergence asserts itself again; I have observed it in spontaneous (see Case 39) as well as in operative cure of squint; still, this is so unusual, that I should like to give an illustration of the latter observation on account of its rarity.
Case 44.—Hedw. von L—, æt 10, came under treatment in April, 1874, for convergent squint on the left side which arose in her seventh year, with occasional alternation. Emmetropia, determined with atropine on both sides and good visual acuteness. Diplopia was present at the commencement of the squint. Patient can only be rendered conscious of double images by the help of a red glass and vertically deviating prisms. Double tenotomy of the internal recti effected a normal position, and at the end of December, 1874, the continuance of the same could be proved as well as binocular fusion with prisms. At the beginning of 1880, I was informed that from time to time periodic squint had occurred with diplopia. In the middle of March, I had an opportunity of seeing the young lady. Myopia 2 D. had meanwhile developed on both sides, visual acuteness almost = 1. The position of the eyes was perfectly good, slight convergence occurred during covering, homonymous double images with a red glass which, at a distance of 5 m., were joined by a prism of 8°; stereoscopic fusion was not perfectly certain. A true squint could not be proved. On April 3rd, as patient stopped for a few hours on her journey through, a striking convergent squint of the left eye was seen. The deviation amounted to 4 to 5 mm. Single vision existed at a distance of 15 to 20 cm., then homonymous double images appeared, which did not correspond to the objective deviation; the double images were however corrected by a prism of 6° (base outwards) for an object 5 m. distant.
We cannot conclude the consideration of the operative treatment of convergent squint without once more returning to the relation between the line of vision and the position of the cornea. The angle [Greek: a] still deserves mention in a few thankful words—hic mihi angulus praeter omnes ridet—it is a very useful guide in tenotomy. In tenotomy we may count as gain the apparent divergence which it causes in hypermetropes who do not squint. We obtain a perfect cosmetic result, while a convergence, objectively determinable, but not otherwise easily visible, continues to exist. It would be folly to exceed this; and for cases where binocular fusion does not exist, and where diplopia is not present, to wish to remove this covered convergence due to the angle [Greek: a], the cosmetic result would be impaired by it.
Those cases where it is a question of uniting homonymous double images are very instructive when considering tenotomy. Only when squint arises after childhood (after the fifteenth year) does it cause troublesome diplopia, this accords naturally with the laws of normal binocular fusion learnt meanwhile. (On the other hand those cases, which sometimes occur after tenotomy, with the double images in a position which does not correspond to the normal physiological laws and which cannot therefore be united by prisms, are naturally unsuitable for the operative removal of diplopia.) Cases in which convergent squint is followed by troublesome double images, appear, with the exception of the hysterical form mentioned on p. 41, chiefly in myopia, more seldom in emmetropia, and very rarely in hypermetropia; for if the conditions contained in the ocular muscles are coincident with hypermetropia, squint usually arises in the course of childhood, before normal binocular vision has become a fixed habit.
As the cases here under consideration are not very common, I will relate a few from which conclusions may be derived as to the effect of tenotomy.
Case 45.—Miss von B—, æt. 14, came under treatment on May 1st, 1875, for diplopia, which made its appearance about a year previously. Emmetropia and full visual acuteness exist on both sides. The double images are homonymous and further apart on both sides of the visual field. At first single vision existed only to about 0·75 m.; gradually, however, the area of single vision was extended by practice of the outward movement, supported by the use of prismatic spectacles, so that after a year patient could see singly to a great distance. This improvement was not maintained. At the beginning of 1879, diplopia was again present to a troublesome degree, particularly on looking downwards; on looking straight forwards the left eye showed a slight convergent deviation, amounting at most to 2 mm. During various examinations the distance of the double images was stated to be now less, now greater, a prism of at least 5°, at most of 9°, was requisite for correction. Diplopia was at once removed by tenotomy of the left internal rectus, with very slight loosening of the conjunctiva, and has not appeared since.
Case 46.—Miss A—, æt. 17, suffered from diplopia for a few weeks, a year and a half ago; for the last half year the diplopia is continuous, and striking squint is stated to be sometimes present. Myopia 2 D. on both sides, visual acuteness = 5/9. On fixation of an object about 4 m. distant, the left eye deviates inwards at most 2 mm.; homonymous double images, with a red glass and on correction of the myopia, which were united by means of prism 14° at a distance of 5 m., without red glass (with retinal images alike on both sides) prism 8° sufficed to unite them. If a vertically deviating prism is held before one eye, the double images stand just above one another when looking at an object 20 cm. off, on nearer approach they are crossed. On May 3rd, 1879, tenotomy of the left internal rectus with small conjunctival wound without loosening of the conjunctiva, and union of the conjunctival wound by a suture. On May 8th, single vision, also with correction of the myopia and with red glass. Facultative divergence = 2°. On May 14th, with correction of the myopia, there was still single vision for distance; however, with red glass double images occurred again; and at the end of May the condition of the double images was just the same as before the operation. On vertical shifting of one visual field by a weak prism the double images are brought into a vertical line by means of prism 16°, with the base outwards. Therefore, on July 1st, the right internal rectus was also divided, with small conjunctival wound without loosening of the conjunctiva and without suture. The evening after the operation slight divergence on covering. On July 24th, binocular single vision is present; with red glass homonymous double images at 5 m., corrected by prism 4°. This time the result was final; for in the middle of October, three months after the operation, the report was exactly like the one of July 24th above stated.
Case 47.—Mrs. A—, æt. 33, has suffered for six months from alternating convergent squint with diplopia, for a short time even a parallel position is still possible. On the right myopia 4 D., V. = 6/12. On the left myopia 4 D., V. 6/9. Single vision occurs to 22 cm., at a greater distance homonymous double images, whose mutual distance remains the same when looking to one side. On correction of the myopia a prism of at least 32° is necessary for the union of the double images for an object at 4 m. Two days after tenotomy of the internal recti on both sides, the facultative divergence amounted to 7° (at 4 m.) on correction of the myopia. Single vision was also present when looking strongly to one side, and with differentiation of one retinal image by a red glass.
Case 48.—Mr. B—, æt. 32, first observed the occurrence of diplopia at the beginning of April, 1877. Myopia 6 D. is present in both eyes, visual acuteness on the right 1/2, on the left rather more than 1/2 (5/9). The double images are homonymous and sometimes (not always) move farther apart at the limits of the visual field. Patient could only decide after two years, in July, 1879, on the operative treatment then proposed. Diplopia continued to exist; single vision was only now and then possible for a short time. On correction of the myopia (if one eye is provided with a red glass) prism 12° suffices for union of the double images. If one visual field is moved in a vertical direction by a prism of 5° during the trial of convergence, prism 38° is necessary in order to equalize the lateral deviation of the double images, and to place them perpendicularly above one another for an object 5 m. distant. On July 14th, tenotomy of the internal rectus of the left eye; single vision next day on correction of the myopia, prism 6° is overcome by divergence; if, however, double images are produced by a vertically deviating prism of 5° they immediately show homonymous lateral deviation, which is corrected by prism 18° at a distance of 5 m.