Belladonna.-If accompanied by headache and hyperaesthesia of the senses.
Hyoscyamus.-Spasmodic action of the eyeballs.
Ignatia.-Morbid nictitation and spasmodic affections occurring in nervous, hysterical women.
Jaborandi, Physostig., Nux vomica, Pulsatilla and Sulph. have also been used with benefit, as may any of that class of remedies denominated our antispasmodic.
Muscular Asthenopia.-This term is applied in a general way to various tired and strained sensations about the eyes and head resulting from insufficiency of some of the extrinsic muscles of the eye. Special attention was first directed to this subject by von Graefe, which until within a few years had received but meagre attention and had been applied especially to an insufficiency of the internal recti muscles. Within the last five or ten years, however, hardly a number of our current ophthalmological literature has appeared, without containing more or less reference to some of the muscular anomalies. To Dr. George T. Stevens is due the credit of having been the one to first turn the present attention of ophthalmologists in this direction, and, while we cannot accept in full his methods of treatment, must acknowledge that by his efforts researches in this line have been greatly advanced and stimulated. An exhaustive consideration of the insufficiencies of the ocular muscles is of course impossible within the limits of an ordinary text-book, and it is for this reason, presumably, that none of the more recent works upon the eye give this subject the attention that it should receive.
It is a well recognized fact that defects of the ocular muscles can and do cause various reflex disorders, such as vertigo, general nervous excitements, gastric derangements, neuralgic pains of the back, head, etc. On the other hand, many asthenopic symptoms of the eye may be the effect of some remote disorder such as uterine disturbances, etc. In treating of muscular asthenopia we shall adopt the terms suggested by Dr. Stevens as more accurately describing the various forms of insufficiency, viz.: Orthophoria: Normal adjustment of the eye muscles. Heterophoria: Abnormal adjustment of the eye muscles. Esophoria: A tendency of one or both eyes to deviate toward the nose. Exophoria: A tendency of one eye to rise above the level of its fellow. Hyperesophoria: A tendency upward and outward. The designation “right” or “left” must be applied to these two terms.
The examination for heterophoria may be practiced by a number of methods.
Stevens’ Phorometer (Fig. 56). In this test the patient, while holding the head erect, looks at a lighted candle at the distance of twenty feet, which should be upon a level with the eyes. Then with the refractive error, if any, corrected, prisms of sufficient power to produce diplopia are placed with the base inward before each eye. The images thus produced are homonymous, and, if seen exactly on the same horizontal plane, there is no tendency to a vertical deviation. If, however, one image is higher than that of the other, there is absence of the vertical equilibrium, or hyperphoria. If the left image is higher than the right, it indicates that the visual line of the right eye has a tendency to rise above that of the left; this is hyperphoria. If the right image is seen above that of the left, it is known as left hyperphoria. The degree of the deviation is shown by the prism, which, when placed with the base up or down before one eye, brings the two images exactly on the same horizontal plane. Diplopia is again induced by placing a prism with the base up or down before one eye, and, if the two images are now exactly vertical, no deviation in the horizontal plane is shown. A prism of 7 degree is usually sufficient to cause vertical diplopia when placed with the base up or down before one eye. Say, with the base down before the right eye, if now, the upper image appears more at the right than the lower, it indicates exophoria; but, if the upper image is to the left of the lower, exophoria is shown. The degree of the horizontal deviation is shown by the degree of the prism which, when placed with the base in or out before either eye, brings and holds the images in a vertical line.
In the Steyens instrument the degree of the deviation is found by rotating the test prisms. The amount being indicated on the scale on the face of the prisms.
Examination should then be made in the same way at the distance of eighteen inches to determine the condition of the muscles in accommodation, and for this purpose a small white cross on a black background is used in the Stevens phorometer.
Many oculists claim the examination as to the muscular balance in accommodation is of no consequence. This the writer believes to be a grave error, as in the very large majority of cases the troubles complained of are only present, or at least markedly worse, when using the eyes at near vision. There is no question but that the muscular balance in the majority of instances is decidedly different in accommodation than it is in distant vision, and as the eyes are used for a large percentage of the time at near vision the condition of the muscles in accommodation is, therefore, of the utmost importance.
The Maddox Test is made by a small glass rod, which may be mounted or held in the hand, and, for hyperphoria, is held exactly vertical before one eye. A red glass may be placed before either eye to more clearly show the two different objects, the line of light and the flame. When looking at the lighted candle, a long horizontal line of light is seen by the eye in front of which the rod is held, while the other eye sees the natural light. Now, if the line of light passes exactly through the centre of the flame, as seen by the other eye, there is no hyperphoria present; but if above or below, then hyperphoria is shown, and the degree is represented by the prism which causes the line of light to pass directly through the centre of the flame. The rod is now turned horizontally in front of one eye, causing a vertical line of light which, if passing directly through the flame shows orthophoria of the lateral muscles; if the line is to the same side as the eye before which the rod is held, it indicates exophoria; if to the opposite side, exophoria, and the prism which brings the vertical line of light directly through the flame indicates the degree of exophoria or exophoria. This we believe to be the most reliable test for muscular insufficiency at present devised.
The Savage Test for Insufficiency of the Oblique Muscles.- Occasionally cases of undoubted eye-strain are met with which are not relieved even after the most careful correction of the refractive error or of any of the already named forms of heterophoria. These cases may be due to an insufficiency of one of the oblique muscles, a condition easily detected by Savage’s test; but if found, there has been at present no satisfactory suggestion offered as to treatment.
In testing, a double prism of six degrees each, base to base, is held with its axis vertical before one eye and the patient requested to look at a horizontal line on a card eighteen inches away. With the other eye covered, the line appears to be two, each parallel with the other; on uncovering the other eye, a third line is seen between the other two, with which it should be exactly parallel. If there is any loss of balance between the oblique muscles, this test will show a lack of parallelism of the middle line with the other two, the right end of the middle line will point to the lower line and the left end to the upper line, or vice versa.
With the double prism before the right eye, if the middle line is seen nearer the bottom, there is left hyperphoria; if it extends farther to the right than the other two, and not so far to the left, exophoria is present; or, if reversed, extending farther to the left and not so far to the right, exophoria is shown. If the right ends of the middle and lower lines converge, insufficiency of the superior oblique of the left eye is shown; if they diverge there is insufficiency of the left inferior oblique. By changing the double prism to the left eye, the right eye may be similarly tested.
The Harold Wilson Phorometer.- Of the many different kinds of phorometers now upon the market, the Wilson, in the author’s opinion, is far better than any other, because in the one instrument are combined the Stevens, the Maddox and the Savage tests. Its accuracy, ease and rapidity of working make it the instrument par excellence. As oftentimes the results of the examination of the muscles by the different methods very the value of having all the different tests in one instrument is at once apparent.
Hyperphoria.- By this is mean the condition of the ocular muscles in which there is a tendency of one to rise above the level of its fellow. Hyperphoria should be designated as right or left. In right hyperphoria the image of the right eye is higher than that of the left, the right eye standing lower its image is projected above that of the left and vice versa in left hyperphoria. This term does not imply that the visual line referred to is too high, but that it is higher than the other, without indicating which may be at fault.
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.