Discussion of Miss Kramer's Paper
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1124 ERNEST . W. SHEPPARD DISCUSSION OF M ISS KRAMER'S PAPER
ERNEST A. \'. SHEPPARD, M . D .
Miss Kramer has given briefly the characteristics of the different types of the vertical anomalies. While the final responsibility of the diagnosis of the type or types (there may be more than one type or more than one muscle involved either in one or both eyes) rests with the ophthalmologist, the interested orthoptic technician will try to see in how many
Fig. 1 (Sheppard). Case 1. This sliows a paralysis of the right inferior oblique. The eye with the paralyzed muscle is the fixating eye. A recession of the left superior rectus was performed. The good result is due to a correct differential diagnosis and to good fusion (preoperative photographs).
cases her diagnosis agrees with that of the ophthalmologist. If they are not in accord, it is definitely to the benefit of the patient that an agreementnot a compromisebe reached. And let not the ophthalmologist stand upon his dignity and
not be advised by an observant, experienced orthoptic technician. After all, she sees the patient for a much longer time than does he. There are few physicians who will not be advised by an observing, well-trained, and experienced nurse why then should they not be advised by a similar orthoptic technician?
One test and one examination is not sufficient to make a diagnosis. This is particularly applicable to those cases which have strong fusion.
CASE REPORTS CASE 1
History. P . S., a man (fig. 1 ) , aged 32 years, was seen on August 13, 1938. His chief complaint was that the left eye deviated up and out (fig. 1 ) .
Examination: Uncorrected vision, O.D., was 20/20 correctable to 20/15 with a -hO.SOD. cyl. ax. 60. Uncorrected vision, O.S., was 20/30 correctable to 20/15-iii with a -l-l.OOD. cyl. ax. 90. The cover test showed: Exot. 20, L H 40 diopters; Xt ' . 18, L H ' 18 diopters, Pcb, 8 cms. The rotations showed paralysis of the right inferior oblique with overaction of the agonist, the left superior rectus, and of the antagonist, the right superior oblique. The fusion was poor but when he did fuse he did so at orthophoria.
Treatment. On October 6, 1938, a recession of the left superior rectus was performed. Tests made on the next day with the Maddox rod in front of the right eye showed: R H 1-3, R H ' trace to L H ' 4 ; Maddox rod in front of the left eye: L H 6-8, R H ' 8. The cover test showed: L H 8, X 16 L H ' O, Xt ' 25. The red-glass reading w a s : R H 5, R H ' 8. Six days later the red glass in front of the right eye gave: L H 2^,, L H ' 2 ^ .
- VERTICAL MOTOR ANOMALIES 1I2S The Maddox rod in front of the right eye showed: L H 2>
im ERNEST . \V. SHEPPARD right inferior obHque was secondary to paralysis of the right superior oblique or of the left superior rectus or both, or pseudoparetic, was never definitely determined. There was also a marked upward deviation of the left eye when adducted. No fusion was present.
Operations. 1. A Jameson recession of the right medial rectus was performed on April 28, 1936.
2. On January 19, 1937 a myectomy was done on the right inferior oblique.
Fig. 3 (Sheppard). Case 3. This woman, aged 52 years, had had a convergent strabismus since the age of seven years. A Jameson recession of the left medial rectus and a Worth advancement and resection of the left lateral rectus were performed. An old paralysis of the right inferior oblique was also present. The good result achieved in this case was due to a correct differential diagnosis and to good fusion (postoperative photograph).
3. A myectomy was done on the left inferior oblique on October 26, 1937.
4. A Reese resection was performed on the right lateral rectus on May 17, 1938.
5. On July 5, 1938, a Jameson recession was done on the left inedial rectus.
6. On June 18, 1940, an advancement of the left inferior rectus was done.
7. An advancement of the left inferior rectus was done on July 30, 1940.
8. On the same date an advancement was performed on the right lateral rectus.
Examination on February 20, 1945, showed abnormal retinal correspondence both vertically and horizontally. The measureinents were : Et 35, E t ' 50, L H
30, L H ' 25, with alternation and preference for fixation with the left eye.
Summary. 1. Surgery on the vertically acting muscles may well be deferred until one is absolutely sure of the diagnosis.
2. The differential diagnosis should be made, if possible, before any surgery is performed. The postoperative findings may not be characteristic, probably due to adhesions, scar tissue, or innervational factors.
3. In this case probably more than one type of deviation was present and both eyes were involved.
4. The unsatisfactory outcome was due to : ( a ) Not making a complete and correct diagnosis, (b) Operating before the diagnosis was made, (c) Abnormal retinal correspondence, both vertically and horizontally.
History. J. O'D., a woman (fig. 3 ) , was first seen on June 16, 1923, when she was 30 years of age. She had an alternating convergent strabismus of each eye which had first been noted at the age of seven years. She had had no treatment other than glasses. Vision was 20/15 in each eye.
Examination. On April 8, 1937, cover-test findings were : E t 60, E t ' 80D., with preference for fixation with the O .D. ; on August 2, 1939, they were : Et 65, E t ' 7 5 ; and on August 13, 1945, when the patient was 52 years of age, they were : Et 75D. Fusional amplitude on the Synoptophore was from Et 70 to Et 95. There was normal retinal correspondence. A Jameson recession of the left medial rectus was done.
On April 20, 1945, the cover test showed: Et 40, E t ' 40, L H 4-10. Rotations suggested an old right inferior oblique paralysis with overaction of the right superior oblique and the left superior rectus. Examination with the Mad-
VERTICAL MOTOR ANOMALIES 1127 dox tangent scale showed concomitant esotropia and concomitant L H .
Treatment. A Worth advancement and resection of the left lateral rectus was done on September 18, 1945. On September 25, the cover test showed: Xt 20, X t ' 25, Pcb remote. On October 6, 1945, the findings were : X 4, X ' 4, L H 22, L H ' 15, Pcb 15 cms. On October 15th, 2, E ' 2, L H 4, L H ' 8, Pcb 10 cms. The following prescription was ordered: O.D., -f lOOD. sph. = 20/15-i ; O.S., -f-1.50D. sph. = 20/15-iii, Prism 3D., base down. Add -I-2.25D. sph. bifocals.
Orthoptic training was started on October 15, 1945. There was very marked suppression of the left eye, complete macular suppression. O n March 4, 1946, the patient was comfortable without glasses for distance. The Worth-dot test showed fusion for near and distance; the cover-test findings were : 2, E ' 6, no hyperphoria ; tests with the Maddox rod were : 10, E ' 15, L H 3-8, L H ' 2-10; with the Maddox wing : 13, L H 4 ; and with the troposcope: 18, no L H , third-grade fusion.
On October 27, 1946, the troposcope showed: 12, L H 2>^; the Maddox wing : 11, L H 4 ; the Maddox r o d : 6, E ' 10-15, L H 2-7, L H ' 4-7 ; the cover test : 0, E ' 6, +v .d . 3D., - v . d . 7D. The following correction was prescribed: O.D., +1 .25D. sph. = 20/20-hi i i ; O.S., + 1.25D. sph. = 2 0 / 2 0 - i i ; add -f2.00D. sph., bifocals. Glasses for near work only. The Worth-dot test showed fusion for near and distance, without correction.
Summary. 1. A high horizontal deviation may mask a low vertical deviation.
2. The patient had good fusion even after squinting for 45 years. The successful outcome was due to the strong fusion which was able to compensate for an L H of 0-7.
3. There was a marked psychologic improvement in the patient following the surgery. This undoubtedly had a favorable influence on the general nervous system which in turn favorably influenced the ocular nervous mechanism.
The vertical deviations present many more difficulties than the horizontal deviations because of:
1. The greater difficulties in diagnosis. 2. The lesser fusional amplitudes. 3. The greater difficulty in deciding
upon what muscle to operate, what operation and how much.
Fo r these and other reasons, orthoptic training in the vertical anomalies is essential. There is no material diflFerence between orthoptic treatment of the vertical and the horizontal motor anomalies. The principles are the same; namely, differential diagnosis, correction of amblyopia and abnormal retinal correspondence, elimination of macular and foveal suppression, development and stimulation of fusion and fusional amplitudes and, lastly, good binocular stability for distance and near vision. The establishment of the last mentioned skill, good binocular stability, is the keynote for good results, orthoptically, in the vertical motor anomalies, more perhaps than in the horizontal motor anomalies.
1801 Street, N.W. (6).