CASE 6 may serve as an example: H. B--, æt. 15, shows a considerable and
very varying periodic inward squint. Sometimes correct position is
present, sometimes strong deviation, indeed the latter only occurs on
looking at distant objects, while for near ones correct position of the
eyes generally takes place. The examination showed for the right eye
hypermetropia 1·5, for the left myopia 3·5 D.; full acuity of vision on
both sides. The squint occurring in the left eye on looking at distant
objects was therefore accommodative; the effort of the accommodation
necessary for correcting the hypermetropia united itself to an
excessively strong innervation of the interni, as the interests of
binocular vision came but slightly into consideration on account of the
myopia in the left eye. For near objects the myopic eye is used without
accommodation and therefore also without convergent strabismus of the
right. But if one caused a point about 25 cm. distant to be fixed first
with the right (hypermetropic) eye while the left was covered and then
caused fixation to be transferred to the left, the accommodative
convergent strabismus induced was alternately transferred to the left
eye and continued, although the left eye fixed without any effort of the
accommodation on account of its myopia. Double tenotomy of the interni
and correction of the hypermetropia effected the cure of the squint.
The clearest cases of accommodative strabismus are those in which
usually a correct position and sometimes even binocular fusion is
present, while squint occurs only during the strain on the accommodation
necessary for distinct vision.
CASE 7. Miss Bertha v. Pr--, æt. 27, shows strong accommodative squint
of the right eye, said to have been observed by her parents when she was
fifteen months old. Correct position of the eyes is generally present
with indistinct vision; the endeavours to see clearly immediately causes
striking convergence of the right eye. On the left hypermetropia 3·5 D.,
vision normal; on the right the same degree of hypermetropia, vision not
more than 1/12 of the normal, no ophthalmoscopic report. On correction
of the hypermetropia and with aid of a red glass crossed diplopia
immediately appears, which is corrected by a prism of 5° base inwards;
prisms of 12° with the bases inwards are overcome on fixation of an
object about 12 ft. distant by divergence. The elastic tension of the
ocular muscles necessitates then a preponderance of the externi, and an
effort of the accommodation necessary to overcome the hypermetropia,
which on account of the congenital amblyopia of the right eye unites
itself with excessive convergence. Had the elastic tension of the ocular
muscles made a preponderance of the interni a condition, permanent
convergent squint would have been the result, and one would have called
the weak sight of the right eye amblyopia from want of use.
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