Forcible movements of the eye made seizing the conjunctiva over the insertion of the paralyzed muscle with the fixation forceps, and strongly turning the eye in the direction of action of the weakened muscle and then in the directly opposite direction, has proved of very great value in my hands. Under Cocaine this causes no pain.
As a last resort, after the condition has existed sufficiently long to render all hopes of improvement by other means impossible, careful tenotomy of the opposing muscle may be performed, with or without advancement of the paralyzed muscle, according to the degree of deviation.
To overcome the annoying diplopia in hopeless cases, spectacles with a ground glass before the paralyzed eye may be employed.
Causticum.-Paralysis of the muscles resulting from exposure to cold. It has been especially successful in paralysis of the sphincter pupillae (mydriasis), of the ciliary muscle, levator palpebrae superioris (ptosis), orbicularis, and external rectus.
Gelsemium.-A valuable remedy in all forms of paralysis of the ocular muscles, especially of the external rectus. Paresis from diphtheria, or associated with paralysis of the muscles of the throat.
Rhus tox.-A remedy often indicated in paralysis of the ocular muscles resulting from rheumatism or exposure to cold, wet weather and getting the feet wet. Causticum is very similar in its action, though it is more especially adapted to those cases resulting from exposure to cold, dry weather.
Aconite.-Paresis from exposure to a draught of cold air.
Kali iodata.-The iodide of potassium is more commonly indicated than any other drug in paralysis of the muscles of syphilitic origin. Appreciable doses are usually employed.
Euphrasia.-Paralysis of the muscles, particularly of the third pair of nerves, caused from exposure to cold and wet; especially if catarrhal symptoms of the conjunctiva, blurring of the eyes, relieved by winking, etc., are present.
Senega.-Want of power of the superior rectus or superior oblique, in which the diplopia is relieved by bending the head backward. The other muscles may be complicated in the trouble.
Arnica.-Paralysis of the muscles resulting from a blow or injury.
Chelidonium.-Paresis of the right external rectus. Distant objects are blurred, and on looking steadily two are seen. Pain in the eye on looking up.
Cuprum acet.-Insufficiency or paralysis of the external rectus muscle.
Mercurius iod. flav.-Paralysis of the third pair, especially if syphilitic in origin.
Nux vomica-Paresis or paralysis of the ocular muscles, particularly if caused or made worse by the use of stimulants or tobacco.
Paris quad.-Paralysis of the iris and ciliary muscle, with pain drawing from the eye to the back of the head; or pain as if the eyes were pulled into the head. Eyes sensitive to touch.
Phosphorus.-Paralysis of the muscles caused or accommodation by spermatorrhoea of sexual abuse.
Spigelia.-When associated with sharp, stabbing pain through the eye and head.
Alumina, Aurum, Conium, Hyoscyamus and Sulphur have also been used with advantage.
The Localizing Value of Paralyses of Orbital Muscles in Cerebral Disease.
PARALYSIS OF THE THIRD NERVE.-Ptosis may be present in cortical lesions without any other branch of the third nerve being paralyzed. Ptosis on the same side as the lesion indicates a disease of the pons, if on the opposite side a lesion in the crus cerebri. Paralysis of the third nerve as a whole is usually present in lesions of the cerebral peduncle. Paralysis of the whole or part of the third nerve on the same side as the lesion, coming on at the same time as crossed hemiplegia, indicates a disease of the crus cerebri. The most frequent causes of oculomotor paralyses are basal lesions and usually affects all of its branches. Complete paralysis of all the branches of this nerve with no other paralysis present is always basal. Lesions in the interpeduncular space may also cause total or partial paralysis of the third nerve. Thrombosis of the cavernous sinus invariably produces paralysis of the third nerve, but all the orbital nerves and the fifth may also be affected.
PARALYSIS OF THE FOURTH NERVE alone is extremely rare, one case on record where due to tumor of the pineal gland, but is more apt to be of basal origin, and is frequently double. May occur in meningitis, from exudation between corpora quadrigemina and the splenium of the corpus callosum according to Pfungen.
Wien. Medorrhinum Blatt, Nos. 8-11, 1883.
It has been found with paralysis of the third in lesion of the cerebral peduncle.
PARALYSIS OF THE SIXTH NERVE when the only focal sign usually results from basal disease. It is also especially liable to occur from distant pressure, and Wernicke says, particularly from a tumor of the cerebellum. Paralysis of the sixth with hemiplegia of the opposite side indicates a lesion in the pons. The facial is frequently involved with the skin in the lesion of the pons.
PARALYSIS OF THE FIFTH NERVE with hemiplegia of the opposite side points to disease in the pons.
Strabismus or Squint is inability to bring the visual axes of both eyes to meet at a certain point, or when the point fixed casts its image only on the macula lutea of one eye, while in the other it falls on some eccentric part of the retina. If the squinting eye deviates inward, it is called strabismus convergens; if outward, divergens; if upward, sursum vergens, and if downward, deorsum vergens. The squint in concomitant strabismus differs from that of paralysis in the following points: The primary and secondary deviation are equal in strabismus, while in paralytic squint the secondary deviation is greater than the primary. In strabismus the extent of the movement in the two eyes is normal and equal, while in paralysis the mobility of the eye decreases in the direction of action of the paralyzed muscle. Diplopia is generally absent in strabismus, except at the commencement of the squint; but, when present, is found in all parts of the field, and in strabismus there is no particular inclination of the head.
Strabismus is usually mono-lateral, that is a faulty position of eye; or it may be alternating, when the patient will be able to fixate objects with either separately, and when doing so the other eye becomes the squinting one. In alternating squint one eye usually is used to fixate distant objects and the other for near objects. The strabismus may also be intermittant or constant. Strabismus is not observed after death, during deep sleep or in deep narcosis.
Concomitant squint is very seldom accompanied by diplopia. This is believed to be due to a suppression of the retinal image in the squinting eye, for, being that of some object with which the mind is not interested, it is simply ignored at will. Hansell Journ. Amer. Medorrhinum Assoc., Feby. 16, 1895. concludes that, “Amblyopia is congenital and not acquired; is not improved by tenotomy when high or of long duration; is always present in monocular squint; is not a factor in alternating squint; can be replaced by full acuity of vision after the hitherto good eye has been rendered by accident or disease inferior to the squinting eye.”
Binocular vision, according to von Graefe, is absent in about 90 per cent. of the cases of strabismus, that it can be produced by prisms in about 25 per cent, and exists after operation in about 50 per cent. Its presence is proved at once by the existence of binocular diplopia, and when not present it is determined by having the patient look at the flame of a candle at the distance of six or eight feet through a prism placed before one eye, when either diplopia or a corrective squint will occur, if the prism is not too strong, for the patient will endeavor to overcome the prism by squinting and fusing the images, or if neither of these effects occur, absence of binocular vision is proven. Binocular vision is frequently only lost over certain portions of the retina.
The visual acuity of the squinting eye is diminished. This may exist before the development of the squint and may be one of the reasons for squinting.
Apparent Strabismus is the condition where there is a deviation of the optic axes, and yet both eyes fixate and neither moves when the other is closed. This is due to the relation between the optic axis and the visual line. If the optic axis lies to the outer side of the visual line, we have an apparent divergent squint and, if to the inner side, may have the reverse- an apparent convergent squint.
Strabismus Convergens is the most common form of squint met with, and usually develops between the second and seventh years of life. Diplopia is generally present in all cases which develop later than childhood.
CAUSES.-In a great majority of cases it is found to exist in connection with hypermetropia. Donders first called attention to the relation of hypermetropia to convergent strabismus, and showed it to be present in about 75 per cent. of the cases; other authorities since then have placed it as high as 85 per cent. It has also been estimated that about 16 per cent. of all hypermetropes squint. It is usually the median or slight degrees of hypermetropia that most often induces strabismus. Hypermetropia causes strabismus on account of the normal or physiological relation between convergence and accommodation; that is, with an increase of convergence the relative range of accommodation approaches the eye. All hypermetropic eyes require a strong tension of the accommodation for distinct vision, and hence to aid the accommodation they are inclined to converge too much. As a result of too strong continued convergence the hypermetrope soon learns to give up binocular vision because he finds he can secure a more distinct image, with less strain on the accommodation, by monocular fixation.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.