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 -77 
 
 [Reprinted from the Ophthalmic Review, December, 1897.] 
 
 ANOMALIES IN THE FUNCTIONS OF THE 
 EXTRINSIC OCULAR MUSCLES.^ 
 
 By F. BuLLER, M.D., Montreal. 
 
 The complex phenomena which constitute the act 
 of vision have been so thoroughly elaborated in the 
 science of physiological optics, that the ophthal- 
 mologist justly claims for his work a greater exactness 
 than pertains to any other department of medicine or 
 surgery. 
 
 Certain well defined laws enable him to detect and 
 successfully contend with abnormal conditions in 
 refraction and accommodation. An absolute standard 
 of visual perfection, both for form and colour, serves as 
 a guide in every functional examination of vision, and 
 the ophthalmoscope enables him to discover the most 
 minute pathological lesions in the interior of the eye 
 itself. A complete and methodical examination will 
 often enable him to determine, with surprising pre- 
 cision, the nature and gravity of morbid conditions 
 beyond the eye and even in other organs of the body. 
 When, however, he comes to investigate the compli- 
 cated problems presented in the function of binocular 
 vision which, in the presence of a multitude of dis- 
 turbing influences, may be rendered hopelessly difficult, 
 he feels that he is still treiiding upon uncertain ground. 
 Since the majority of eyes possess a normal refraction, 
 
 ' Read before the Ophthalmological Section at the Meeting of the 
 British Medical Association held at Montreal, August and September, 1897. 
 
 1*- 
 
a definite power of accommodation and acuity of 
 vision which varies but Htt'e in different subjects, 
 though in all these particulars a certain physiological 
 variation is recognised, it would be strange if the 
 muscular movements of the eyes did not correspond- 
 ingly follow approximately definite laws. In all 
 probability they do, and it is not unlikely that estimated 
 rotating power of the different muscles, as determined 
 by innumerable examinations of the normal muscular 
 functions, is fairly correct as regards both monocular 
 and binocular vision. It is also probable that very 
 considerable variations from the alleged physiological 
 standards of motility thus obtained are consistent with 
 easy and accurate vision. Since, however, slight 
 errors in refraction in certain subjects unquestionably 
 give rise to intense visual disturbance, there seems 
 no reason why the same rule should not apply in cases 
 of defective or faulty motility, except that in so compli- 
 cated a piece of machinery it may fairly be assumed 
 that the physiological limit is still more variable than is 
 the case with any of the other factors which contribute 
 to the act of vision. However this may be, there is no 
 question as to the existence of serious visual and even 
 systematic disturbances due to faults in the extrinsic 
 muscles of the eyes, especially those which render the 
 function of binocular vision difficult and wearisome. 
 
 The series of observations which form the basis of 
 this communication relate, indeed, only to this class of 
 cases. 
 
 To begin with I have relied chiefly upon the 
 equilibrium tests made at the standard distance of six 
 metres and assumed that the normal for this distance 
 is the status known as orthophoria. Allowing for 
 physiological variation from this, I have attached little 
 or no importance to lateral deviations of two or three 
 prism-degrees, and I am quite certain there are many 
 persons who present much greater deviations than 
 
.:> 
 
 this (latent squint) without experiencing the least 
 discomfort. 
 
 I have also neglected all cases of hyperphoria which 
 could not be shown to exceed one degree. 1 am not 
 prepared to assert that one degree or less of hyper- 
 phoria may not in some persons cause more or less 
 discomfort. If so this should be relieved by wearing 
 a correcting prism, and I am under the impression 
 that I have succeeded in relieving a few of these cases 
 in this way. 
 
 The objections charged against prisms of two or 
 more degrees do not hold good in prismatic action so 
 feeble as this, and it may be that the mere mental effect 
 of wearing glasses accounts for the apparent benefit, as 
 there must be a strong neurotic element in all cases 
 that experience distress from very slight perturbing 
 influences, otherwise we should meet with an infinitely 
 larger number of people disturbed by wearing im- 
 properly centred glasses than is actually the case. This 
 statement must not be construed in such a way as to 
 minimise the importance of wearing properly centred 
 glasses in all cases. It is merely intended to point out 
 the incontrovertible fact that there are vast numbers of 
 persons who can and actually do overcome slight 
 artificial deviations without difficulty. 
 
 It is not an uncommon experience that weak prisms, 
 worn for the correction of faulty equilibrium, afford 
 relief for some time and then lose their effect. I have 
 come to regard this as an indication for operative 
 interference in some cases where the proper course to 
 pursue was difficult to determine. 
 
 The equilibrium tests were made in distance (6 
 metres) with prisms, Stevens' phorometer and the 
 compound Maddox rod coloured red. I regard this 
 instrument as not less reliable than the Stevens' phoro- 
 meter, but have habitually used both. 
 
 It was essential to have some standard of fusion 
 
power, and the following was accepted as normal. Ab- 
 duction 5° to 8", adduction 25" to 50°, sursumduction 
 2° to 3'. 
 
 This standard is not absolute, and is chiefly useful 
 for purposes of comparison. In every case where 
 there is binocular vision, the range of fusion may be 
 temporarily increased in any direction by systematic 
 exercise of the muscles. I have seldom known this 
 apparent increase in power to be long maintained after 
 the exercises had been discontinued. 
 
 Equal exercise of all the muscles will sometimes 
 develop a preponderating power in a sense that did 
 not exist before. This fact, when it occurs, is more 
 significant than the original latent tendency. An 
 habitual abduction of 5° and adduction of 25° (in the 
 absence of hyperphoria) could hardly be regarded as 
 abnormal, but an abduction of 5° with an adduction 
 of 60° or more, and esophoria of more than 2° or 
 3° would probably be sufficient justification for opera- 
 tive interference. 
 
 When there is binocular vision with a latent ten- 
 dency in any direction, and a considerable relative 
 excess of power in the muscles acting in that direc- 
 tion, the fault may safely be corrected by operation — 
 tendon relaxation or tendon shortening. Relief from 
 headaches, asthenopia, and neurasthenic symptoms 
 often follows such operations ; they are, therefore, not 
 only justifiable, but positively indicated under such 
 circumstances in the absence of refractive error, or 
 where the refraction has been corrected without afford- 
 ing relief. A careful investigation of every case of 
 muscular anomaly during a number of years in private 
 practice has furnished from a material of 8,000 patients 
 no cases that seemed suitable for operative inter- 
 ference, i.e., about 1*4 per cent.; they may be classified 
 as follows : — 
 
 * 
 
Esophoria 
 
 37 
 
 Exophoria 
 
 31 
 
 Hyperphoria 
 
 30 
 
 Hyper-exophoria 
 
 10 
 
 Hyper-esophoria 
 
 2 
 
 no 
 
 
 A tabulated statement showing the principal features 
 of each case may be of some interest. The figures 
 showing the degrees of tendency and fusion power are 
 the average of several, sometimes of many measure- 
 ments in each case. 
 
 It will be seen that the number of cases operated upon 
 for the three principal forms of deviation are nearly 
 equal, i.e., 37 cases of esophoria, 31 of exophoria and 
 30 of hyperphoria. There were only 12 cases requiring 
 operation for the correction of both horizontal and 
 vertical deviation, and only 2 of these were for an 
 upward and inward deviation. 
 
 I desire to call attention to this fact, as it is a 
 striking commentary on the contention of those who 
 claim that the chief factor in the aetiology of con- 
 vergent squint is to be found in the presence of 
 hyperphoria. 
 
 A study of the tabulated results shows t';-l there 
 were 39, or 35*4 per cent, of cases which may fiirly be 
 classed as cured ; 37, or 33*6 per cent., greatly bene- 
 fited ; 20, or 18 per cent., somewhat benefited ; 8 
 unimproved, and in 6 the result was unknown. 
 Leaving out these last 14 cases the operations would 
 appear to have benefited in 87 per cent, of all the 
 cases so treated. This is perhaps as good a result as 
 attends most surgical operations, and in this connec- 
 tion I may add that I am not aware of any instance 
 which the result was actually injurious to the 
 
 m 
 
 patient. I am therefore justified in claiming that the 
 usual operations performed for the relief of persons 
 
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 suffering from the various annoyances due to faulty 
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 not only harmless, but in a very large percentage of 
 such cases they are followed by satisfactory results in 
 as large a percentage as are obtained, according to 
 most statistics, in the operations for removal of 
 cataract. 
 
 It will be observed that whilst there were many 
 cases of refractive error among the no cases, there 
 were also a great many with little or no refractive 
 error, and in no case was an operation performed in 
 the presence of a refractive error in which relief was 
 not first sought by its correction. I cannot agree with 
 those who contend that the correction of errors of 
 refraction will always correct associated muscular 
 faults. If this be true, how can we account for 
 the many cases of muscular faults in which refraction 
 is emmetropic ? 
 
 It is undoubtedly true that some of the lower grades 
 of muscular faults may be benefited by wearing suit- 
 able prismatic glasses, but the usefulness of these is 
 exceedingly limited, and those who depend upon them 
 are doomed to frequent disappointment. 
 
 I have not had sufficient experience in the correction 
 of muscular faults in persons suffering from epilepsy 
 and chorea to say that they cannot derive benefit from 
 ocular therapeutics or operations to secure equilibrium, 
 but so far as my experience goes I am inclined to 
 believe that little or no relief is to be expected from 
 such treatment, at least quoad the functional nervous 
 disorder, but I would not hesitate to recommend the 
 scrupulous correction of refractive errors in such 
 persons, or of any considerable muscular fault, if 
 present, just as 1 would recommend the removal of 
 every discoverable source of nerve irritation or cause 
 of ill-health whatever it might be. 
 
 A searching analysis of the no cases 1 have tabulated 
 
17 
 
 would bring out a good many interesting facts which I 
 cannot discuss now ; for instance, among those cured 
 there were two of esophoria with normal refraction in 
 which the chief complaint was persistent vertigo, both 
 entirely relieved by tenotomy of the internal recti ; 
 in neither of these, however, was there anything 
 approaching epileptiform phenomena. 
 
 The clinical investigation of functional muscular 
 anomalies can only be undertaken at the expense of 
 enormous loss of time and the exercise of unbounded 
 patience on the part of the surgeon ; hard conditions, 
 it is true, but not too hard for him who delights in his 
 profession and feels the joy of overcoming difficulties 
 that have baffled others. 
 
 If the results I have now placed on record are 
 reliable, and I believe they are, being the outcome of 
 many years' patient observation and steady work, free, 
 I hope, from partiality of any sort, then it follows 
 that whoever ignores the injurious effects of muscular 
 faults in ophthalmic practice, fails to accord at least i 
 per cent, of his patients the benefit which a proper 
 application of his knowledge should bestow. 
 
 1 have purposely abstained from any discussion of 
 the theoretical aspects of faulty muscular equilibrium, 
 for the reason that I could not on the present occasion 
 do justice to this part of the subject, and from a clinical 
 standpoint it matters not what the cause of physical 
 distress may be so long as the means employed for its 
 relief are efficient. 
 
 In reply to some points raised in the discussion which 
 followed the paper, Mr. BuUer said : Mr. President, first 
 as to the point raised by Dr. Stevens — want of uniformity 
 in standard of measurement. I claim that it is impossible 
 to establish a definite standard for all cases, and say that 
 a man must come up to that standard or he is abnormal. 
 I think that Dr. Stevens supports me in this contention, 
 
i8 
 
 if I remember rif^htly, in his work on functional muscular 
 disturbances, the first work in which he brought this 
 subject prominently before tlie public. He admits, I 
 think, in that work, that there is a difference in individuals, 
 and that a man may be allowed a certain difference of 
 muscular power in different ocular muscles, and that what 
 may be normal for one man is not normal for another. In 
 other words, that the relative strength of the ocular 
 muscles has to be taken into account in considering what 
 is the normal standard. 
 
 I said, from five to eight degrees for abducting power 
 and twenty-five to fifty for adducting power. Now the 
 relative proportion between these is pretty much the same, 
 and if a man is comfortable with five degrees of abducting 
 power and twenty-five degrees of adducting power after a 
 good many trials as to the strength of the muscles, surely 
 that is sufficient evidence that, as far as he is concerned, 
 we may regard this as a normal condition or a fairly 
 normal condition. 
 
 On the other hand, there are a large number of people 
 who I am perfectly convinced cannot get an abducting 
 power of eight degrees excepting by long-continued 
 exercise of the external muscles, and I believe that the 
 abducting power, if increased by exercise, will lapse back 
 into the original condition unless the exercise is main- 
 tained, so that it is exceedingly difficult to establish an 
 absolute standard, if indeed it is possible. 
 
 As for the method of testing for deviations or the relative 
 merits of the Maddox rod or Stevens' tropometer, I must 
 say I have not found the tendency to confusion with the 
 Maddox rod that Dr. Stevens claims to exist. I have, 
 however, found a somewhat greater degree of deviation by 
 the use of the Maddox rod than by Stevens' tropometer. 
 
 Now as to Dr. Mittendorf's remarks concerning the 
 frequency of operating. I would have no objection to 
 doing frequent operations, and getting very little effect at 
 a time, and repeating the operations as often as seemed 
 necessary to achieve my results little by little ; indeed I 
 would prefer to do it in that way if I had such control over 
 
 \ 
 
19 
 
 my patients as would enable me to do it, but 1 am quite 
 sure that if I were to propose to operate upon my patients 
 half a dozen times for correction of slight degrees they 
 would leave me. I have gone on the principle of correcting 
 as nearly as possible in one or two operations any moderate 
 degree of defect, or if there is a large degree of defect I 
 have stated plainly to the patient that I might have to 
 perform several operations. Sometimes I have operated 
 upon one muscle more than once, but never more than 
 twice. That is my position. With regard to the refractive 
 question I thought I had expressed myself distinctly on 
 that point. I do attempt to correct every error of refrac- 
 tion, and correct it as absolutely and completely as I know 
 how. I cannot do more than that. I am only restrained 
 from absolute correction of a refractive error by the 
 ignorance of my patients, most of whom are too ignorant 
 to tell me the difference between a quarter and an eighth 
 of a dioptre ! 
 
 With reference to Dr. Osborne's question as to what is 
 the proportion of cases in which I have used atropine, I 
 would say I have used atropine or homatropine in all my 
 cases, as I consider that it is essential to use one of these 
 drugs. Homatropine is sufficient in some cases, but in 
 others I think that atropine is necessary, and I use it in 
 order to get absolute correction of the refraction, for I 
 know that in people less than 50 years of age you cannot 
 depend upon getting absolute correction without using a 
 mydriatic. I investigate the refractive error most scrupu- 
 lously before doing anything for the muscular faults. I 
 think Dr. Howe has misunderstood me in my statement 
 as to the large number of cases of normal eyes *n which 
 hyperphoria was discovered. I quite agree with him that 
 an absolutely normal eye, a physiologically normal eye, is 
 a rarity, and I thought I had explained that part of my 
 position sufficiently clearly in saying that I allowed for 
 physiological deviations to a slight degree, and where there 
 was no disturbance apparently resulting from abnormal 
 conditions I certainly would not be in favour of interfering 
 in any way. 
 
,■> 
 
 20 
 
 The tests as to muscular strength were made of course 
 by examinations repeated sufficiently often to justify me in 
 my own mind, in assuming that I had arrived at about 
 what was the limit of the muscular power in the individual 
 before I proceeded to operate. 
 
 I have not operated upon any of these cases where it 
 was fair to assume that the headaches were due to a fault 
 in the general health. Surely if a person comes to you 
 with a history of having headaches for fifteen or twenty 
 years, it is absurd to assume that it is due to some fault 
 in the general health which can be cured by giving him 
 some trumpery drug or other. As a general rule, long- 
 continued trouble of this kind depends upon something 
 pertaining to the individual, which cannot be so easily cor- 
 rected. If in the course of ten or fifteen years an individual 
 has not had opportunity of improving his health in such 
 a way that he can correct headaches depending on it, it is 
 certainly remarkable, but if he comes to you with head- 
 aches, and obvious errors of ocular functions are detected, 
 such as to entitle one to assume that their correction may 
 lead to some beneficial result, and after the operation your 
 patient steadily recovers from the malady which has pur- 
 sued him for ten or twenty years, surely it is fair then to 
 assume that at least your result was due to the therapeutic 
 measures you adopted. 
 

 
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