POMEROY: Tenotomies of Recti Muscles.
SOME TENOTOMIES OF RECTI MUSCLES FOR INSUFFICIENCIES. By OREN D. POMEROY, M.D., NEW. YORK CITY.
The subjoined cases are reported in order to study the value of tenotomy in certain eye symptoms, not, however, losing sight of the importance of correcting the ametropia before operating on the muscles. CASE I. - Mrs. H. T. G., aet. 53, has had considerable pain across the eyebrows for several years. She also experiences difficulty in looking down while walking or in riding. On the right eye she is wearing constantly, except for reading, +.50 D. Sph. 3 +.75 D. cyl. axis go9. In the left eye she has a correction of +.75 D. Sph. + 1.25 D. cyl. axis I35°. She has, at distance, an exophoria (tendency to turn outwards) of 20. Hyperphoria (tendency of one eye to turn upwards), 30 +. Some conjunctivitis in each eye, but more in the right, which is the more uncomfortable. On January 25th, four days after the first observation, the hyperphoria was 30, the exophoria 2'. January 29th, hyperphoria 3°. February Ist, the hyperphoria was between 30 and 4°. On February 4th, the.hyperphoria showing no signs of diminution, I divided the sup. rect. of the right eye under cocaine. It required four distinct efforts to divide the tendon sufficiently to produce the desired effect. The patient then saw double and the over-effect of the operation amounted to 20+. On February 6th, there was diplopia and the same over-effect as before, but it does not annoy her in looking downwards. The diplopia grew less until February igth, when it had disappeared entirely, unless occasionally when she looked upward; still 20 of over-effect by the prism test at distance. On March 15th, the eyes are in equilibrium, except that the image of the left eye is slightly lower than the right, whereas, before the operation, the image of the left was the higher. The headaches are gone and the patient has no more difficulty in looking down. I
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regard this as a case where correction of the ametropia was unsuccessful in relieving the faulty muscular balance, and that tenotomy succeeded. CASE 2. - Bennie B., aet. i6, shows a tendency to convergent strabismus of right eye. The vision of the right eye is 20-XX with +6 D., and of the left 20-XL with +5.50 D. Has esophoria of I6°-I8°. On May 3d, 1889, the tendon of the right internus was divided and an over-effect of IO0 was obtained. After placing a suture in the conjunctiva, there was slight esophoria remaining. After a few days, much of the esophoria had returned, and on May 22d tenotomy of the left internus was done. After the operation there seemed to be some hyperphoria. On May 24th there still remained 8° of esophoria. On June 28th a large-sized granulation was removed from the site of the last tenotomy. There was no more tendency to convergent strabismus and the muscular balance seems about normal. This case presents many of the features of convergent strabismus. The sense of binocular vision was not strong, and frequently the patient only used the left eye. On account of the excessive insufficiency of the externi, I did not try to correct it by the use of glasses alone. CASE 3. - Miss T. L. C., aet. 45, by occupation a school teacher. She has had asthenopic symptoms for several years, headaches, pain in the eyeballs, etc., whenever the eyes are used for any considerable length of time. In addition to this she has been overworked for a number of years. Her manifest hypermetropia is + 1.25 D., and so far there is no presbyopia. The adjustment of glasses afforded some temporary relief. She complained especially of the right eye. She had an exophoria at the far point, of I8°, the right internus showing less power than the left internus. I divided the tendon of the right externus in a very thorough manner; several attempts were made before a sufficient effect was produced, the tendon being divided as thoroughly as in a strabismus operation. At the time, the balance of the eyes at the far point seemed perfect. After two weeks there was found to be about 9° of exophoria. There was some relief to the symptoms, but the case
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could not be followed up. I heard from her two years subsequent to the operation to the effect that the right eye gave her very little trouble and that she reg-arded the operation as of benefit. It was my purpose to have divided the externus of the left. The fact that the patient had been used up by years of overwork, operated unfavorably towards the accomplishment of as much good as might otherwise have been hoped for. CASE 4. - Anna T., aet. 24, has headaches and pains in the eyes, whenever she attempts to use them. She entered the hospital Aug. 26, I889. She has esophoria of 60-7° and hypermetropic as. of 0.75 D. in each, V=2o-xx +. This correction afforded no relief after being used several weeks and the esophoria remained as before. The ifiternus of the right, and subsequently that of the left was divided, but after a few days the esophoria was unchanged. On Feb. I2, I890, six months after commencing treatment, the right externus was advanced after the modified Prince method, under cocaine. This seemed to produce little effect after a few days, and in one week (Feb. igth) the left externus was advanced in the same manner. On Feb. 24th the esophoria was 20. March 17th, esophoria the same as before the operation, and there was no improvement. Prisms of 20, bases outwards, were ordered for each eye in addition to the first correction, and were worn without benefit for one month. May 7th, esophoria 5°°90, adduction 320, abduction 30, at the far point. The right internus was then completely divided, with considerable dissection of the conjunctiva; the patient was tested and two other essays were made to measure the effect of the operation, until an over-effect of 80 was reached and crossed diplopia resulted. On the next day there was binocular single vision, with esophoria of 30. On May i6th the esophoria was one or two degrees. Until last seen, on Aug. 23d, she had periods of apparently perfect balance of the eye muscles alternating, with some esophoria, diplopia, vertigo, headaches, etc. The last examination showed esophoria of 40. This was a most persistent case of esophoria in which the symptoms failed to give way by any nearer approach to perfect balance of the eye muscles resulting from operations. Prisms were also inoperative.
POMEROY: Tenotomics of Recti Muscles.
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CASE: 5. - Bertha P., aet. 20, has always had headaches when using eyes excessively. The vision is 20-XL with - 5 D. She has exophoria of 120. On June i8, I890, the left external rectus tendon was divided with exact correction of the insufficiency. On June 25th, the exophoria was 6° 8°. July i6th, she has been wearing the correction constantly and with comfort; few headaches; exophoria 30. September igth, no asthenopic symptoms, exophoria I°-40. In this case it is not conclusive, whether the myopic correction relieved the asthenopia, or the tenotomy, or whether both shared in the relief of the patient. CASE 6. R. L. R., aet. i8, a student, complains of headaches in the temples and occipital region most of the time. He has been wearing-.5o D. which seemed for a time to better his condition. He showed a tendency to turn his eyes to the right. I found exophoria of 160 for distance with hyperphoria 40. Four days subsequently the exophoria was I90, hyperphoria as before. The eyes were both emmetropic under homatropine (4 per cent. solution used six times before examination). I divided the external rectus of the right, which seemed the stronger of the two externi, and the balance of the eyes was completely restored as far as the externi and interni were concerned. Previous to the operation he had noticed a painful sensation about the right eye, as though it was being drawn outwards; this has completely left him. On September 22d, three days after the tenotomy, the patient has diplopia when looking to the right, although in the middle line there is 50 of exophoria; the hyperphoria has nearly disappeared. On September 27th there was 60-70 of exophoria, but his symptoms have all disappeared, and he has returned to his studies. On October i8th, there was no diplopia when looking to the right; exophoria 9°. December igth, sees double if he looks sharply to the right, or if he fixes on a very near point; exophoria 60, hyperphoria I0; uses his eyes from 9 A. M. to IO P. M. March 7, 189I, has 120 of exophoria, with few asthenopic symptoms. From overwork he has had what his doctor called a bilious fever; there were some conjunctival symptoms. On March i6th there was IO0 + of exophoria, and I divided the externus of the left eye, and at
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first there was homonymous diplopia and an over-effect of 90, which was corrected by a suture, when the balance was perfect. On March igth there was exophoria of 50 when the conjunctival suture was removed. On March 23d, the exophoria was 30. When looking sharply to the right or to the left, there is diplopia, but it gives him no trouble. His eye symptoms are relieved and he has gone on with his studies. The operative procedures here may seem bold, but I have in mind the fact that the effect of a tenotomy tends to grow less after a time. It is also worthy of note that the hyperphoria has nearly disappeared as a consequence of the operation. CASE 7.-Sarah F., aet. twenty-eight, applied to the hospital June 8, i888, complaining of headaches. At. first no glass was accepted. At distance there was an exophoria of I0 and the adduction was 120 with abduction I 0. Under atropine she accepted + I.5o D. and after the atropine +.75 D. There was then found to be exophoria of 30 at the far point. The t.75 D. glasses were worn for two months without relieving the headaches, and on September 26, I888, the left externus was divided, and an over effect of 90 was obtained, when a stitch in the muscle restored the balance to about one or two degrees of esophoria, and for one day there was some diplopia. On October I th the exophoria was 40, with abduction IO1, and adduction 90. On October 31st I did a tenotomy of the right external rectus, correcting 30 of the 40 of exophoria. November 5th, no insufficiency at the far point; adduction, 120, abduction, 9°. The headaches are reported to be diminished. It will be noticed that in this last tenotomy the effect was greater after a few days than at first. CASE 8. -Miss M. T., aet. I 7, has -3 D. of myopia. Has had asthenopic symptoms with mild palpebral conjunctivitis, which showed a disposition to recur from time to time. She used a partial correction of her myopia with some benefit for two years. There was also some blepharitis marginalis. I found difficulty in convergence, and at the far point there was exophoria of 5°. The left eye showed the greatest difficulty in convergence. There was now considerable pain in the eyes, but more in the left, when reading for only a few minutes.
PoMRcOY':; Tenotomies of RUcti -Musdes445k I accordingly divided the ext. rect. of the left; getting the tendon wholly on the hook at the first essay. There was 30. of over-effect, and some diplopia for three or four days, when it completely disappeared. On looking to the left, however, there was some diplopia, which gave her no annoyance. Ten days subsequently there was found to be an exophoria of 30 at distance, but she converged fairly well, and the asthenopia seemed to have completely disappeared. The first effect of the tenotomy was less than half maintained. CASE 9. -Mary B., aet. i8, was referred to me from the department of nervous diseases by Dr. Booth, to have her eyes examined to determine whether -the headaches depended on their faulty condition. The vision is 20-Xv in each, and the patient accepts no glasses. The exophoria varied from 10 to 40, but after several examinations there seemned to be. 30 On January 29th, I divided the externus of the right and produced an esophoria of I8°. This was removed by a conjunctival stitch. January 3I, orthophoria, with abduction 40 and adduction 7°. The patient. is a, dressmaker, and reports that she has no more headaches and that. her eyes may be -used without the discomfort at first experienced. Note the apparent absence of .refractive. error in this case. CASE IO. Alice H., aet. 22, a servant, has complained of her eyes for several years, especially after, sewing or reading.; also has headaches. -Dr. C. H. Calkins of Springfield, Mass., who referred her to me, had previously divided each 6f her externi with considerable temporary benefit (six months). Her correction is for right t-I.75 D. .50 c. axis I350° Left1.50 D. 2 I C. axis 150. Vision of right is 20.-xv, left 20xxx. She has exophoria of ;;60. I divided the ext. rect. of the right. Two or three essays were made before a sufficient effect had been produced; that is, there was esophotia of abou.t 30 Three days subsequently the eye balance seems normal. She was discharged March 26th, much improved. I have heard from her since and the improvement seems fairly well maintained. CASE I I. - Mrs. G., aet. 38, has a myopia of -3 D., which she has had corrected since four years. In spite of this, she has had various asthenQpic symptoms, as headaches, pain in the OPH.- 29
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eyeballs, vertigo when viewing near objects, with nausea and inability to use the eyes for near work long at a time. She has an exophoria of 40 at the far point, the left internus showing the lesser power of the two interni. The externus of the left was divided on April I i, I872, and exact balance was obtained after two essays at tenotomy. After one month, however, there was 20 of exophoria. This condition has continued without material change, although many years have elapsed.. For several months the patient could elicit diplopia by looking sharply to the left, but this has given her no annoyance. All the symptons of asthenopia have disappeared. In I884 she again had asthenopic symptoms, when it was found that she had a slight amount of astigmatism, which on being corrected relieved all the symptoms. At the present she is comfortable, although she has an exophoria of 30 at distance. The left eye converges readily at 6"', which was not the case at first, and the right eye still converges less readily than the left. I had advised her to have the right externus divided if she had more asthenopic symptoms. It seems clear enough that the tenotomy was of undoubted benefit. CASE I2. Henry G., aet. 65. The vision in the right eye is 20-XXx, corrected by + 1.20 D., and of the left 20-XXX, corrected by + I.50 D. He has exophoria of IO1 and hyperphoria of 5°. Abduction I2°, adduction 80. Has some diplopia. On. Nov. I9, I889, I did a tenotomy of the left ext. rect. and corrected half the exophoria. On the next day there was 10 esophoria (slight over-correction), and only I0 of hyperphoria. Diplopia relieved. Patient was not observed after this, but the operation not only corrected the exophoria but also the hyperphoria, which has, as will be seen, resulted in other cases here reported. CASE I3. Maggie C., aet. 23, applied for treatment August 30, 1889, stating that whenever she held her head up or towards either side she saw double. After many careful examinations + she was fitted to the following glasses: right eye -+ I D., 1.50 c. axis go', with vision 2o-xxx; left + 1.50 D. _ + 1.50 c. axis 9go, with vision 20-XXX. These not sufficing to correct the diplopia, it was dsecided to do tenotomy. The esophoria
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after repeated examinations was found to be from 30 to 5°. The hyperphoria was about the samr. On S ptember 20-h the left sup. rectus was divided, which corrected the insufficiency within one degree. After a week, the hyperphoria seemed about as before. On October i ith the esophoria was about 40 at the far point, and a tenotomy of the right inter. rect. was done, correcting the esophoria. No further complaint of diplopia was made. CASE 14. -Mr. A. E. L., aet. 35, a druggoist by occupation. He has been much troubled by diplopia and an inability to use his eyes without great pain, although he has worn properly fitting glasses. In the right he has a + i D. in the vertical meridian and +2 D. in the horizontal, and in the left +i D. in the vertical meridian and + 1.75 in the horizontal. The vision of the right is 30-cc and the left is 20-LXX. The double images were crossed. On November 27, i888, the exophoria was at distance 70. On the next day the exophoria varied from 5° to I8°. A hypeiphoria of 90 was also noticed. I then divided the externus of the right without at first accomplishing anything, but after repeated efforts, and doing all that could be done at one operation, the insuffiCiency was nearly corrected. Two days subsequently there was vertical diplopia requiring a prism of 80 ang,le downward over the right eye to fuse the two imaoes. There was, however, considerable swelling of the conjunctiva, which might temporarily modify the result, and the patient's answers were somewhat uncertain. I felt sure, however, that there was not too much effect from the operation. I also intended to correct the hyperphoria by tenotomy unless the operation already done should accomplish that purpose. It became necessary for him to go a considerable distance to his home. March 8, I889, the patient writes that complete relief from his symptoms resulted from the operation. I saw him on December 9, I889, and there was an exophoria of 70 and no hyperphoria. He uses his eyes from i6 to i8 hours daily with ease! and there is no more diplopia. On DCcember 3, i89r, still doing as well as ever. I feel in this connection bound to make the statement, that ibn spite of. the fact of great and undoubted benefit from teno-
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tomy as shown by these cases my experience has led me to believe that most cases of insufficiency may be relieved by careful correction of the ametropia. In dividing the tendon of the mnuscle, several methods have been practiced, including the making of an aperture in the centre of the tendon near its insertion and passing a very small hook in and successively dividing first one-half of the tendon, then the other half. This is a difficult manceuvre and, in the opinion of the writer, not at all necessary. I have for most of the time, caught up the tendon on the hook at its insertion, after dissecting up as little of the conjunctiva as possible, and then dividing it, not being particular to do it too thoroughly for fear of over-effect, then testing by prisms to see if a sufficient effect has been obtained. The record of cases will show that repeated efforts were often made to accomplish an adequate result. Sometimes extensive separation of the conjunctiva with division of every particle of tendon which could be found, became necessary. I am inclined to the belief that it cannot certainly be determined by inspection, whether all the tendinous fibres have been divided. In doing an ordinary tenotomy for strabismus under cocaine it is a frequent experience that apparently the whole tendon has been divided without any effect, when, on further persistence in the operation, the eye suddenly becomes restored to a proper position. I believe that in some instances a -very small number of tendpn fibres suffice to hold the eye in its original position. From considerable experience in tenotomies, I have concluded that the effect of a tenotomy is almost certain to become less after a time than at first, that is, what has been called a "latent insufficiency" of the weaker muscle. To meet this condition, I am in the habit of doing more than simply to overcome the insufficiency; vide the cases where diplopia continued for several days after the operation. In a few cases where a too considerable over-effect had resulted, a suture placed in the divided tendon and attached to the conjunctiva opposite has sufficed to annul the excessive
effect. In some of these cases where the muscles have been very weak, there has been diplopia when looking sharply towards a divided tendon; but this has been unimportant.
SOME TENOTOMIES OF RECTI MUSCLES FOR INSUFFICIENCIES. By OREN D. POMEROY, M.D., NEW. YORK CITY.
The subjoined cases are reported in order to study the value of tenotomy in certain eye symptoms, not, however, losing sight of the importance of correcting the ametropia before operating on the muscles. CASE I. - Mrs. H. T. G., aet. 53, has had considerable pain across the eyebrows for several years. She also experiences difficulty in looking down while walking or in riding. On the right eye she is wearing constantly, except for reading, +.50 D. Sph. 3 +.75 D. cyl. axis go9. In the left eye she has a correction of +.75 D. Sph. + 1.25 D. cyl. axis I35°. She has, at distance, an exophoria (tendency to turn outwards) of 20. Hyperphoria (tendency of one eye to turn upwards), 30 +. Some conjunctivitis in each eye, but more in the right, which is the more uncomfortable. On January 25th, four days after the first observation, the hyperphoria was 30, the exophoria 2'. January 29th, hyperphoria 3°. February Ist, the hyperphoria was between 30 and 4°. On February 4th, the.hyperphoria showing no signs of diminution, I divided the sup. rect. of the right eye under cocaine. It required four distinct efforts to divide the tendon sufficiently to produce the desired effect. The patient then saw double and the over-effect of the operation amounted to 20+. On February 6th, there was diplopia and the same over-effect as before, but it does not annoy her in looking downwards. The diplopia grew less until February igth, when it had disappeared entirely, unless occasionally when she looked upward; still 20 of over-effect by the prism test at distance. On March 15th, the eyes are in equilibrium, except that the image of the left eye is slightly lower than the right, whereas, before the operation, the image of the left was the higher. The headaches are gone and the patient has no more difficulty in looking down. I
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regard this as a case where correction of the ametropia was unsuccessful in relieving the faulty muscular balance, and that tenotomy succeeded. CASE 2. - Bennie B., aet. i6, shows a tendency to convergent strabismus of right eye. The vision of the right eye is 20-XX with +6 D., and of the left 20-XL with +5.50 D. Has esophoria of I6°-I8°. On May 3d, 1889, the tendon of the right internus was divided and an over-effect of IO0 was obtained. After placing a suture in the conjunctiva, there was slight esophoria remaining. After a few days, much of the esophoria had returned, and on May 22d tenotomy of the left internus was done. After the operation there seemed to be some hyperphoria. On May 24th there still remained 8° of esophoria. On June 28th a large-sized granulation was removed from the site of the last tenotomy. There was no more tendency to convergent strabismus and the muscular balance seems about normal. This case presents many of the features of convergent strabismus. The sense of binocular vision was not strong, and frequently the patient only used the left eye. On account of the excessive insufficiency of the externi, I did not try to correct it by the use of glasses alone. CASE 3. - Miss T. L. C., aet. 45, by occupation a school teacher. She has had asthenopic symptoms for several years, headaches, pain in the eyeballs, etc., whenever the eyes are used for any considerable length of time. In addition to this she has been overworked for a number of years. Her manifest hypermetropia is + 1.25 D., and so far there is no presbyopia. The adjustment of glasses afforded some temporary relief. She complained especially of the right eye. She had an exophoria at the far point, of I8°, the right internus showing less power than the left internus. I divided the tendon of the right externus in a very thorough manner; several attempts were made before a sufficient effect was produced, the tendon being divided as thoroughly as in a strabismus operation. At the time, the balance of the eyes at the far point seemed perfect. After two weeks there was found to be about 9° of exophoria. There was some relief to the symptoms, but the case
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could not be followed up. I heard from her two years subsequent to the operation to the effect that the right eye gave her very little trouble and that she reg-arded the operation as of benefit. It was my purpose to have divided the externus of the left. The fact that the patient had been used up by years of overwork, operated unfavorably towards the accomplishment of as much good as might otherwise have been hoped for. CASE 4. - Anna T., aet. 24, has headaches and pains in the eyes, whenever she attempts to use them. She entered the hospital Aug. 26, I889. She has esophoria of 60-7° and hypermetropic as. of 0.75 D. in each, V=2o-xx +. This correction afforded no relief after being used several weeks and the esophoria remained as before. The ifiternus of the right, and subsequently that of the left was divided, but after a few days the esophoria was unchanged. On Feb. I2, I890, six months after commencing treatment, the right externus was advanced after the modified Prince method, under cocaine. This seemed to produce little effect after a few days, and in one week (Feb. igth) the left externus was advanced in the same manner. On Feb. 24th the esophoria was 20. March 17th, esophoria the same as before the operation, and there was no improvement. Prisms of 20, bases outwards, were ordered for each eye in addition to the first correction, and were worn without benefit for one month. May 7th, esophoria 5°°90, adduction 320, abduction 30, at the far point. The right internus was then completely divided, with considerable dissection of the conjunctiva; the patient was tested and two other essays were made to measure the effect of the operation, until an over-effect of 80 was reached and crossed diplopia resulted. On the next day there was binocular single vision, with esophoria of 30. On May i6th the esophoria was one or two degrees. Until last seen, on Aug. 23d, she had periods of apparently perfect balance of the eye muscles alternating, with some esophoria, diplopia, vertigo, headaches, etc. The last examination showed esophoria of 40. This was a most persistent case of esophoria in which the symptoms failed to give way by any nearer approach to perfect balance of the eye muscles resulting from operations. Prisms were also inoperative.
POMEROY: Tenotomics of Recti Muscles.
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CASE: 5. - Bertha P., aet. 20, has always had headaches when using eyes excessively. The vision is 20-XL with - 5 D. She has exophoria of 120. On June i8, I890, the left external rectus tendon was divided with exact correction of the insufficiency. On June 25th, the exophoria was 6° 8°. July i6th, she has been wearing the correction constantly and with comfort; few headaches; exophoria 30. September igth, no asthenopic symptoms, exophoria I°-40. In this case it is not conclusive, whether the myopic correction relieved the asthenopia, or the tenotomy, or whether both shared in the relief of the patient. CASE 6. R. L. R., aet. i8, a student, complains of headaches in the temples and occipital region most of the time. He has been wearing-.5o D. which seemed for a time to better his condition. He showed a tendency to turn his eyes to the right. I found exophoria of 160 for distance with hyperphoria 40. Four days subsequently the exophoria was I90, hyperphoria as before. The eyes were both emmetropic under homatropine (4 per cent. solution used six times before examination). I divided the external rectus of the right, which seemed the stronger of the two externi, and the balance of the eyes was completely restored as far as the externi and interni were concerned. Previous to the operation he had noticed a painful sensation about the right eye, as though it was being drawn outwards; this has completely left him. On September 22d, three days after the tenotomy, the patient has diplopia when looking to the right, although in the middle line there is 50 of exophoria; the hyperphoria has nearly disappeared. On September 27th there was 60-70 of exophoria, but his symptoms have all disappeared, and he has returned to his studies. On October i8th, there was no diplopia when looking to the right; exophoria 9°. December igth, sees double if he looks sharply to the right, or if he fixes on a very near point; exophoria 60, hyperphoria I0; uses his eyes from 9 A. M. to IO P. M. March 7, 189I, has 120 of exophoria, with few asthenopic symptoms. From overwork he has had what his doctor called a bilious fever; there were some conjunctival symptoms. On March i6th there was IO0 + of exophoria, and I divided the externus of the left eye, and at
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first there was homonymous diplopia and an over-effect of 90, which was corrected by a suture, when the balance was perfect. On March igth there was exophoria of 50 when the conjunctival suture was removed. On March 23d, the exophoria was 30. When looking sharply to the right or to the left, there is diplopia, but it gives him no trouble. His eye symptoms are relieved and he has gone on with his studies. The operative procedures here may seem bold, but I have in mind the fact that the effect of a tenotomy tends to grow less after a time. It is also worthy of note that the hyperphoria has nearly disappeared as a consequence of the operation. CASE 7.-Sarah F., aet. twenty-eight, applied to the hospital June 8, i888, complaining of headaches. At. first no glass was accepted. At distance there was an exophoria of I0 and the adduction was 120 with abduction I 0. Under atropine she accepted + I.5o D. and after the atropine +.75 D. There was then found to be exophoria of 30 at the far point. The t.75 D. glasses were worn for two months without relieving the headaches, and on September 26, I888, the left externus was divided, and an over effect of 90 was obtained, when a stitch in the muscle restored the balance to about one or two degrees of esophoria, and for one day there was some diplopia. On October I th the exophoria was 40, with abduction IO1, and adduction 90. On October 31st I did a tenotomy of the right external rectus, correcting 30 of the 40 of exophoria. November 5th, no insufficiency at the far point; adduction, 120, abduction, 9°. The headaches are reported to be diminished. It will be noticed that in this last tenotomy the effect was greater after a few days than at first. CASE 8. -Miss M. T., aet. I 7, has -3 D. of myopia. Has had asthenopic symptoms with mild palpebral conjunctivitis, which showed a disposition to recur from time to time. She used a partial correction of her myopia with some benefit for two years. There was also some blepharitis marginalis. I found difficulty in convergence, and at the far point there was exophoria of 5°. The left eye showed the greatest difficulty in convergence. There was now considerable pain in the eyes, but more in the left, when reading for only a few minutes.
PoMRcOY':; Tenotomies of RUcti -Musdes445k I accordingly divided the ext. rect. of the left; getting the tendon wholly on the hook at the first essay. There was 30. of over-effect, and some diplopia for three or four days, when it completely disappeared. On looking to the left, however, there was some diplopia, which gave her no annoyance. Ten days subsequently there was found to be an exophoria of 30 at distance, but she converged fairly well, and the asthenopia seemed to have completely disappeared. The first effect of the tenotomy was less than half maintained. CASE 9. -Mary B., aet. i8, was referred to me from the department of nervous diseases by Dr. Booth, to have her eyes examined to determine whether -the headaches depended on their faulty condition. The vision is 20-Xv in each, and the patient accepts no glasses. The exophoria varied from 10 to 40, but after several examinations there seemned to be. 30 On January 29th, I divided the externus of the right and produced an esophoria of I8°. This was removed by a conjunctival stitch. January 3I, orthophoria, with abduction 40 and adduction 7°. The patient. is a, dressmaker, and reports that she has no more headaches and that. her eyes may be -used without the discomfort at first experienced. Note the apparent absence of .refractive. error in this case. CASE IO. Alice H., aet. 22, a servant, has complained of her eyes for several years, especially after, sewing or reading.; also has headaches. -Dr. C. H. Calkins of Springfield, Mass., who referred her to me, had previously divided each 6f her externi with considerable temporary benefit (six months). Her correction is for right t-I.75 D. .50 c. axis I350° Left1.50 D. 2 I C. axis 150. Vision of right is 20.-xv, left 20xxx. She has exophoria of ;;60. I divided the ext. rect. of the right. Two or three essays were made before a sufficient effect had been produced; that is, there was esophotia of abou.t 30 Three days subsequently the eye balance seems normal. She was discharged March 26th, much improved. I have heard from her since and the improvement seems fairly well maintained. CASE I I. - Mrs. G., aet. 38, has a myopia of -3 D., which she has had corrected since four years. In spite of this, she has had various asthenQpic symptoms, as headaches, pain in the OPH.- 29
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POMEROY: Tenotomies of Recti Muscles.
eyeballs, vertigo when viewing near objects, with nausea and inability to use the eyes for near work long at a time. She has an exophoria of 40 at the far point, the left internus showing the lesser power of the two interni. The externus of the left was divided on April I i, I872, and exact balance was obtained after two essays at tenotomy. After one month, however, there was 20 of exophoria. This condition has continued without material change, although many years have elapsed.. For several months the patient could elicit diplopia by looking sharply to the left, but this has given her no annoyance. All the symptons of asthenopia have disappeared. In I884 she again had asthenopic symptoms, when it was found that she had a slight amount of astigmatism, which on being corrected relieved all the symptoms. At the present she is comfortable, although she has an exophoria of 30 at distance. The left eye converges readily at 6"', which was not the case at first, and the right eye still converges less readily than the left. I had advised her to have the right externus divided if she had more asthenopic symptoms. It seems clear enough that the tenotomy was of undoubted benefit. CASE I2. Henry G., aet. 65. The vision in the right eye is 20-XXx, corrected by + 1.20 D., and of the left 20-XXX, corrected by + I.50 D. He has exophoria of IO1 and hyperphoria of 5°. Abduction I2°, adduction 80. Has some diplopia. On. Nov. I9, I889, I did a tenotomy of the left ext. rect. and corrected half the exophoria. On the next day there was 10 esophoria (slight over-correction), and only I0 of hyperphoria. Diplopia relieved. Patient was not observed after this, but the operation not only corrected the exophoria but also the hyperphoria, which has, as will be seen, resulted in other cases here reported. CASE I3. Maggie C., aet. 23, applied for treatment August 30, 1889, stating that whenever she held her head up or towards either side she saw double. After many careful examinations + she was fitted to the following glasses: right eye -+ I D., 1.50 c. axis go', with vision 2o-xxx; left + 1.50 D. _ + 1.50 c. axis 9go, with vision 20-XXX. These not sufficing to correct the diplopia, it was dsecided to do tenotomy. The esophoria
POMEROY: Tenotomies of Recti Muscles.
453
after repeated examinations was found to be from 30 to 5°. The hyperphoria was about the samr. On S ptember 20-h the left sup. rectus was divided, which corrected the insufficiency within one degree. After a week, the hyperphoria seemed about as before. On October i ith the esophoria was about 40 at the far point, and a tenotomy of the right inter. rect. was done, correcting the esophoria. No further complaint of diplopia was made. CASE 14. -Mr. A. E. L., aet. 35, a druggoist by occupation. He has been much troubled by diplopia and an inability to use his eyes without great pain, although he has worn properly fitting glasses. In the right he has a + i D. in the vertical meridian and +2 D. in the horizontal, and in the left +i D. in the vertical meridian and + 1.75 in the horizontal. The vision of the right is 30-cc and the left is 20-LXX. The double images were crossed. On November 27, i888, the exophoria was at distance 70. On the next day the exophoria varied from 5° to I8°. A hypeiphoria of 90 was also noticed. I then divided the externus of the right without at first accomplishing anything, but after repeated efforts, and doing all that could be done at one operation, the insuffiCiency was nearly corrected. Two days subsequently there was vertical diplopia requiring a prism of 80 ang,le downward over the right eye to fuse the two imaoes. There was, however, considerable swelling of the conjunctiva, which might temporarily modify the result, and the patient's answers were somewhat uncertain. I felt sure, however, that there was not too much effect from the operation. I also intended to correct the hyperphoria by tenotomy unless the operation already done should accomplish that purpose. It became necessary for him to go a considerable distance to his home. March 8, I889, the patient writes that complete relief from his symptoms resulted from the operation. I saw him on December 9, I889, and there was an exophoria of 70 and no hyperphoria. He uses his eyes from i6 to i8 hours daily with ease! and there is no more diplopia. On DCcember 3, i89r, still doing as well as ever. I feel in this connection bound to make the statement, that ibn spite of. the fact of great and undoubted benefit from teno-
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POMEROY: . Tenotomies of Recti Muscles.
tomy as shown by these cases my experience has led me to believe that most cases of insufficiency may be relieved by careful correction of the ametropia. In dividing the tendon of the mnuscle, several methods have been practiced, including the making of an aperture in the centre of the tendon near its insertion and passing a very small hook in and successively dividing first one-half of the tendon, then the other half. This is a difficult manceuvre and, in the opinion of the writer, not at all necessary. I have for most of the time, caught up the tendon on the hook at its insertion, after dissecting up as little of the conjunctiva as possible, and then dividing it, not being particular to do it too thoroughly for fear of over-effect, then testing by prisms to see if a sufficient effect has been obtained. The record of cases will show that repeated efforts were often made to accomplish an adequate result. Sometimes extensive separation of the conjunctiva with division of every particle of tendon which could be found, became necessary. I am inclined to the belief that it cannot certainly be determined by inspection, whether all the tendinous fibres have been divided. In doing an ordinary tenotomy for strabismus under cocaine it is a frequent experience that apparently the whole tendon has been divided without any effect, when, on further persistence in the operation, the eye suddenly becomes restored to a proper position. I believe that in some instances a -very small number of tendpn fibres suffice to hold the eye in its original position. From considerable experience in tenotomies, I have concluded that the effect of a tenotomy is almost certain to become less after a time than at first, that is, what has been called a "latent insufficiency" of the weaker muscle. To meet this condition, I am in the habit of doing more than simply to overcome the insufficiency; vide the cases where diplopia continued for several days after the operation. In a few cases where a too considerable over-effect had resulted, a suture placed in the divided tendon and attached to the conjunctiva opposite has sufficed to annul the excessive
effect. In some of these cases where the muscles have been very weak, there has been diplopia when looking sharply towards a divided tendon; but this has been unimportant.
