When we call the ophthalmoscopic diagnosis of refraction objective, we
only mean to say that we count the subjective opinion of the patient to
be of less value, than that of the physician who examines him. The
determination of the glass even, with which we believe we are able
distinctly to see the fundus of the eye, is also an objective one.
Whoever, for instance, is firmly convinced that convergent strabismus
depends on hypermetropia, will, in doubtful cases, very easily carry his
subjective conviction into the objective examination, and will still see
clearly the fundus of even an emmetropic eye with a weak convex
glass--the objective signs for the clearness of the image have no
absolutely defined limits. But apart from this, other sources of error
are possible. A person using the ophthalmoscope, for instance, who,
without knowing it--and such a thing may happen--possesses a slight
degree of latent hypermetropia, will find his own hypermetropia
everywhere, just also as a myope, who deceives himself slightly about
the degree of his myopia in the calculation of the ophthalmoscopic
diagnosis of refraction, lays rather too high a value on his own myopia.
Finally it must be added, that if the ophthalmoscopic estimation of
refraction is to be exact, mydriasis by atropine is required, when, as
is known, even emmetropic eyes may show a slight degree of
hypermetropia. Enough, we must not over-rate the value of the objective
determination of the error of refraction, and I would estimate the limit
of error at half a dioptre at least. If the examination is rendered more
difficult, as is frequently the case with children, by a restless and
impatient demeanour of the patient, even the objective diagnosis may
afford very doubtful results; such cases were, of course, excluded from
the statistics. Moreover, ophthalmoscopic determination of the error in
convergent strabismus is specially difficult, for one cannot advise the
patient as to a suitable direction for the eye not under investigation.
It is generally best to keep the eye not under investigation closed.
In practice it is immaterial whether emmetropia or a minimum degree of
hypermetropia is present; for statistics essentially devoted to
theoretical questions it seemed more suitable to unite these cases in a
separate group.
Accurately taken, the statistics should give the condition of refraction
at the age at which the squint begins. But, if there is a thankless
task, it is that of examining the erect image in children from two to
three years of age. To furnish accurate results this method requires a
certain tractability on the patient's side, which is never present at
this age, and not always in adults. A number of the cases surveyed in
the following table also came under observation long after the squint
commenced, and in some short-sighted persons in particular, the degree
of myopia at the time when squinting began, may have been less than it
was at the time of the examination.
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