PROGRESSIVE MYOPIA 
AND ITS 
OPERATIVE CURE. 
BY 
RICHARD H. DERBY, M. D., 
OPHTHALMIC SURGEON TO THE DEMILT DISPENSARY ; LATE ASSISTANT OP PROP. YON 
GRAEPE IN BERLIN. 
[REPRINTED FROM THE NEWYORK MEDICAL JOURNAL, fUNE, 1873.] 
NEW YORK; 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1873. PROSPECTUS FOR 1873. 
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D. APPLETON & CO., 549 & 551 Broadway, U. Y PROGRESSIVE MYOPIA 
AND ITS 
OPERATIVE CURE. 
BY 
RICHARD H. DERBY, M. D., 
OPHTHALMIC SURGEON TO THE DEMILT DISPENSARY; LATE ASSISTANT OP PROP. YON 
GRAEFE IN BERLIN. 
[REPRINTED FROM TEE NEWYORK MEDICAL JOURNAL, JUNE, 1873.] 
NEM1; YORK: 
D. APPLETON AND COMPANY, 
519 & 551 BEOADWAY. 
1873. PRO GEES SI YE MYOPIA AND ITS OPERATIVE 
CURE. 
It is not uncommon to hear from near-sighted people the 
belief expressed that their eyes are stronger than those that 
can see well in the distance. They are able to recognize very 
minute objects by weak light, and they congratulate them- 
selves that at the time of life when others need a convex glass 
for reading, they will be able to work with ease without any 
glass. 
How utterly without foundation this so generally-accepted 
prejudice is, I shall endeavor to show in the course of this pa- 
per. 
We must distinguish between two forms of near-sighted- 
ness. The one has been called stationary, the other progres- 
sive myopia. In the former the near sight remains unchanged. 
With the proper glass, distant objects are seen distinctly, near 
objects are clearly seen without any glass, and the near-sight 
does not increase in degree. Indeed, between the fortieth and 
fiftieth year, when the power of accommodation becomes less, 
there is an apparent diminution in the amount of the myopia. 
These cases are the exceptions. The progressive myopia is a 
very different affection. It is a disease, and a disease fraught 
with many dangers to the eye. In the near-sighted eye there 
is more than a simple error of refraction. Its optical character 
may lie in this; its anatomical lies in a distention of the eye 
and increased length of its visual axis, and this depends upon 4 
PROGRESSIVE MYOPIA 
a pathological distention of its membranes. When this disten- 
tion has reached a certain point, the membranes become at- 
tenuated, and their power of resistance so much diminished, 
that the distention no longer remains stationary, especially as 
the intraocular pressure in the myopic eye is generally in- 
creased. The myopia increases with this progressive disten- 
tion, and this is a real disease of the eye.1 
What are the dangers of high degrees of myopia ? In the 
first place there is the tension of the inner membranes of the 
eye, and the ophthalmoscope shows the limited crescent at the 
border of the optic disk, but in many cases we see other 
changes that are not to be explained as the results of tension; 
small isolated patches lie about the disk—evidences of cho- 
roiditis. These circumscribed, patches appear in the region of 
the macula lutea, sometimes only changes in the choroidal pig- 
ment, but often in the form of haemorrhages presenting the 
appearance of a chorio-retinitis circumscripta, and in these 
cases the patients can no longer read as before; objects appear 
of an irregular form, and a central scotoma soon follows. 
Later opacities appear in the vitreous humor, and, if these are 
diffuse and become organized, there is great danger for the eye. 
Opacities in the lens occur too, and the saddest and unfortu- 
nately not an infrequent fate of these eyes, separation of the 
retina and subsequent blindness. 
One word with regard to the frequency with which this af- 
fection occurs, before we pass on to a consideration of the con- 
ditions of its development. 
Dr. Cohn, of Breslau, published in 1867 the results of an 
examination of the eyes of 10,060 school-children. He found 
a constantly-increasing number of myopic pupils from the 
lowest to the highest schools. The following table gives the 
percentage of near-sighted pupils in the various schools: 
Elementary school 6.7 per cent. 
Intermediate school 10.3 “ 
High-school (Realschule) 19.7 “ 
Colleges (gymnasia) 26.2 “ 
In the high-schools one-half of the first class were found 
to be myopic. 
1 Bonders, “Refraction nnd Accommodation des Auges,” p. 288. AND ITS OPERATIVE CURE. 
5 
In the colleges the statistics were more dreadful. Here in 
the sixth class 12,5 per cent, of the pupils are near-sighted, 
while in the first class there is the enormous percentage of 
55.8 of myopic students. 
Lately, Erismann1 has published carefully-prepared statis- 
tics of the refraction of pupils in the schools of St. Petersburg. 
Four thousand three hundred and fifty-eight scholars were ex- 
amined. Of these 30,2 per cent, were myopic. Here, as in 
Cohn’s tables, a comparison of the different classes shows a 
startling increase from year to year in the number of myopes. 
Among children of eight years of age, 10.2 per cent, were 
found to be myopic. Among the pupils of twenty years, my- 
opia was found in 40 per cent, of all examined. 
The value of these statistics, taken from so large a number 
of pupils, must not be underrated. They establish the fact of 
the very great frequency of myopia, and show in most alarm- 
ing figures the rapidity of its progress. 
Let us now consider the factors concerned in the develop- 
ment and progress of myopia. We are told® that these are: 
1. Pressure of the muscles on the eye during great conver- 
gence of the visual axis. 
2. Increase of the intraocular pressure, produced by accu- 
mulation of blood in the eye through bending the head for- 
ward. 
3. Conditions of congestion in the fundus, which lead to 
softening of the tissues, and even when the intraocular press- 
ure is normal, but still more when it is increased, produce 
distention of the membranes. 
The most potent of these factors is undoubtedly the first. 
Coccius3 regards the convergence of the visual axis as a most 
important element in the development of myopia. He says: 
“The external muscles may give the eye a somewhat different 
shape at the same time that the ciliary muscle is engaged in 
accommodation.” Giraud Teulon4 considers that the act of 
convergence alone in the horizontal plane must through mus- 
1 “Archiv. f. Ophth.,” xvii., 1, pp. 1-79. 
2 Bonders, “Refraction und Accommodation des Auges,” p. 288, 
8 Ooccius, p. 87. 
* Annales d'Ooulistique, November, December, 1866. 6 
PEOGEESSIVE MYOPIA 
cular pressure increase the intraocular pressure, and especially 
would this be the case where there was insufficiency of the 
internal recti muscles. The staphyloma posticum he regarded 
rather as an evidence of the insufficiency than of the myopia. 
One word with regard to the relation between this insuffi- 
ciency of the interni and the increase of the myopia. If the 
insufficiency exists for all points of the visual range, the mus- 
cle of accommodation is never at rest. On examining binocu- 
larly the degree of the myopia of such a patient for the dis- 
tance, we find it too great, and not until either the muscular 
equilibrium is restored by aid of a prism of abduction or one 
eye is closed do we obtain the actual degree of the myopia. 
As Yon Graefe1 further points out, this apparent increase of the 
myopia through the muscular insufficiency is entirely analo- 
gous with what we find in latent hypermetropia—it is a limita- 
tion of the range of accommodation. Just as the prism with 
its base inward sets free a portion of the accommodation for 
binocular vision, so we need not be surprised that the patient 
who has formerly used concave 12 in order to see distinctly in 
the distance, after the tenotomy sees just as well with concave 
14, 16, or even 18. 
Yon Graefe3 considers insufficiency of the interni a most 
important factor in the progress of the myopia, and pointed 
out most clearly the beneficial action of a tenotomy of the ex- 
ternal rectus in these cases. In a very large proportion of the 
cases of progressive myopia, perhaps in nine-tenths of all the 
cases, there is insufficiency of the interni, and, in an operation 
for the relief of the muscular difficulty, we are assured that we 
have a means of preventing the further increase of the myopia. 
How great an advance such an operation as this would be, 
needs but a moment’s reflection. If, by a simple tenotomy, 
we can, besides relieving the very distressing symptoms of 
muscular asthenopia, moreover prevent any further increase of 
the myopia, does it not deserve our most earnest attention ? 
We have endeavored to depict some of the dangers to which 
1 Zebeuder, 1869, p. 280, 
2 “ Ueber die Operation des dynamischen Auswartsschielen, besonders 
in Rucksicht auf progressive Myopie.” Klin. Monatsblatter far Angen- 
heilkunde, yii., August and September. AND ITS OPERATIVE CUKE. 
7 
the near-sighted eye is liable. We have seen that such an eye 
is exposed to a chain of lesions that terminates not infrequent- 
ly in blindness. Experience has shown us that in nearly all of 
these cases of progressive myopia there is an insufficiency of 
the internal recti. Many of the most acute observers have re- 
garded this insufficiency as the most important factor in the 
development of the myopia, and one has gone so far as to call 
the staphyloma posticum the evidence of the insufficiency of 
the intemi. 
Let us now see what evidence there is in favor of tenotomy 
in these cases, and how far experience has shown that it has 
fulfilled what its advocates have claimed for it. Let us refer 
again to the previously-cited article of Yon Graefe. Out of 
eighty cases of progressive myopia after tenotomy of the exter- 
nus, only six remained markedly progressive, and four slightly 
so. All of these eighty cases were such as in the last two 
years before the operation had grown decidedly worse: for ex- 
ample, an increase of the myopia from \to from -fa to 
from Jjj- to These were all cases observed during a period 
of at least four vears. 
In a recent number of Yon Graefe’s “ Archiv.,” Mannhardt 
publishes two cases of progressive myopia, in which the arrest 
of the disease after tenotomy was very marked. The first case 
was one of a girl ten years of age. The myopia of the right 
eye was -fa; of the left eye, to- Six months later, myopia of 
the right eye Tt > of the left eye Six months after this 
the myopia had increased to on the right eye, and T*g- on the 
left. There was marked insufficiency of the interni. The 
power of abduction was represented by a prism of 11°. A 
tenotomy of the right externus, and a month later of the left, 
was made. Three months after operation, the myopia, which 
had been so steadily increasing before, was now found to be 
only -jY on the right eye, and on the left, and decreased 
steadily afterward. 
In the second case, patient twenty-nine years of age, on 
the right eye myopia ;on the left eye y There was facul- 
tative divergence of 6°. Tenotomy of the left externus was 
made. Fourteen days after operation, the myopia of the left 
eye was y Four weeks later it was and at the end of ten 8 
PEOGEESSIYE MYOPIA 
weeks it was The myopia of the right eye was reduced 
from \ to In the course of his paper on this subject, Mann- 
hardt states his conviction that the inflammatory processes 
which we call sclero-choroiditis posterior, with all their con- 
sequences, that the myopia itself, at least the progressive form, 
owe their origin to a purely mechanical cause, which we can 
correct or completely overcome. 
The following five cases, all of progressive myopia, and in 
all of which a tenotomy of the external rectus was made to 
stay the disease, I have selected from my own records: 
Case I.—Sigismund Wroblewski, twenty-five years of age, 
student of philosophy. Latterly myopia markedly progressive. 
Eight eye, myopia £, v. f; left eye, myopia v. -J. Insuffi- 
ciency of the interni, in 10", of more than 18°. Insufficiency 
of interni, in 15', of 9°. 
On November 30, 1869, the right externus was cut. No 
suture was applied. 
Prism of abduction 18°. 
On June 11, 1870, a tenotomy of the left externus was 
made, and a suture, to limit the effect, inserted. A subseqiient 
examination of the refraction showed no increase in the my- 
opia. The muscular asthenopia was relieved, and patient re- 
ceived concave prismatic reading-glasses. 
Case II.—Felix Gerloff, aged twenty-one. Eight eye, my- 
opia i, v. =i; left eye, myopia v. =£. 
In 8" insufficiency of intend of more than 22°. 
In 14/ insufficiency of interni of 10°. 
Prism of abduction of 10°. ' 
January 6,1870.—A tenotomy of the right externus, with 
a suture to limit the effect, was made. Six months later, on 
June 2d, the myopia of the right eye was found to be the 
same; that of the left was ■£. 
Case lll.—Marie Zalenska, seventeen years of age. My- 
opia of right eye v. =f. Myopia of left eye v. = 
In 8" dynamical divergence of 18° and more. 
In 10' dynamical divergence of 9°. 
After correction of a slight difference of height in the two 
eyes, prism of abduction found to be 10°. 
May 18, 1870.—A tenotomy of the left externus, with a AND ITS OPERATIVE CERE. 
9 
limiting suture, was made, and on the 18tli of June a partial 
tenotomy of the left superior rectus. 
June 26th,—Myopia remains the same as before'the opera- 
tion. 
Case IY.—Ernst Siegfried, student, seventeen years of age. 
Latterly rapid increase in the myopia, which is now on the 
right eye, v. =|; left eye, myopia v. = 
In 8" insufficiency of interni of 12°. 
In 10' insufficiency of interni of 2°. 
Prism of abduction 12°. 
May 28, 1870.—A tenotomy of the left externus, with lim- 
iting suture, was made. Patient subsequently received weak 
concave prismatic glasses for his work, and the myopia re- 
mained the same as at the first examination. 
Case Y.—Hermann Simon, weaver, aged eighteen years, 
came to the clinique on account of rapidly-increasing near 
sight. Had never worn a glass. 
On both eyes myopia ■§•, v. = 
In 6" insufficiency of the intend of 10°. 
Prism of abduction, after correcting a difference of height 
in the two eyes, 14°. 
July 4, 1870.—Tenotomy of the left externus was made, 
and a limiting suture inserted. Patient subsequently received 
concave glasses Ho. 6 for his work. A later examination of 
his refraction was not made. 
How is it that an operation that promises so much should 
not have been generally adopted and found its proper place in 
operative surgery % One reason for this has undoubtedly been 
the fact that neglect of the rules for the regulation of the effect 
of the operation has caused either real convergent strabismus 
or a most troublesome and persistent temporal diplopia, and, 
in consequence of this unfortunate issue, a distrust has grown 
up in the minds of the surgeons who have practised this meas- 
ure. 
That there is no danger of an excessive result from the op- 
eration if the effect of the tenotomy is accurately measured, my 
own experience and the careful observation of a large number 
of cases, operated upon by my late teacher, Yon Graefe, have 
taught me. 10 
PROGRESSIVE MYOPIA 
I propose now, as briefly as possible, to review the method 
of examination of these cases, and indicate the precautions to 
be taken both at the time of operation and during the subse- 
quent treatment. 
The first and most commonly-employed test consists in di- 
recting the patient to fix with both eyes an object, which is 
advanced on the median line, until the nearest point of binocu- 
lar fixation is ascertained. The power of maintaining binocu- 
lar fixation for a near object is no proof that there is no insuffi- 
ciency of the intend, for the punctum proximum is the result 
of fusion, and in cases of most marked dynamical divergent 
squint the punctum proximum is often excellent. The exami- 
nation of the binocular near point reveals real relative diver- 
gent strabismus, if that be present, but the dynamical condition 
of the lateral muscles must be ascertained by other means. 
Another test consists in momentarily interrupting binocu- 
lar vision by covering one eye, and then watching the rotation 
that the eye makes while under cover, as well as the rotation 
required in order to regain fixation when the screen is removed. 
The great difficulty in measuring slight excursions of the eye 
prevented this test from fulfilling all the demands made upon 
it. 
The last and conclusive test for insufficiency consists in in- 
terrupting binocular vision by means of a prism, with its base 
directed upward or downward. This, Yon Graefe called the 
test of equilibrium. The prism thus held produces of neces- 
sity vertical diplopia. Every effort at fusion now ceases, and 
the dynamical condition of the lateral muscles now manifests 
itself. Dynamical divergence shows itself by a crossed position 
of the images, and the prism that is required to bring these im- 
ages on the same vertical line represents the amount of the in- 
sufficiency for a given distance. We first measure this amount 
for the reading or working distance, to ascertain whether strong 
efforts at abduction are necessary. The usual test consists of 
a dot, through which a vertical line is traced. The patient’s 
attention is directed especially to the dot, and the fine line 
serves to aid him in his estimate of the lateral distance be- 
tween the dots. Having measured the amount of the disturb- 
ance of equilibrium for the ordinary working distance by means AND ITS OPERATIVE CURE. 
11 
of a prism with its base held vertically, the same test is applied 
to greater distances, and finally for fifteen feet. At this dis- 
tance it is customary to substitute for the point a candle-flame. 
The amount of the disturbance of equilibrium for this distance 
is measured in the same way as before. 
Before proceeding further it is proper to consider for a mo- 
ment this test. Is it sufficient ? Can we by this means detect 
ordinary cases of insufficiency of the internal recti, and meas- 
ure the degree of such insufficiency ? To this we answer un- 
hesitatingly, Yes. This method of examination has been criti- 
cised, and the infallibility of the tests questioned. We believe 
that, by a careful application of the principles so distinctly enun- 
ciated by Yon Graefe, these tests will prove in nearly every 
case sufficient. Yon Graefe especially insisted that, in the 
examination of the insufficiency for the reading distance, 
the line should be, relatively to the point, very fine, otherwise 
the patient’s attention would be occupied with the double im- 
ages of the lines, and he would therefore make constant efforts 
to fuse the two lines in one vertical plane. Of course, if such 
efforts at fusion are made, the value of the test is lost. But, 
as Yon Graefe points out, we have a means to detect this effort 
to fuse. This consists in giving the prism a slight inclination 
toward the one side or the other. If* when the prism is held 
before one eye, with its base downward, the patient sees two 
superimposed dots lying on one and the same vertical line; 
then, on turning the prism in the least about the visual axis, 
if no efforts at fusion are present, the dots will cease to lie in 
a vertical plane. If the base of the prism in this case is turned 
toward the temple, there will be crossed diplopia; and, if 
toward the nose, homonymous. If, however, efforts at fusion 
are still made, then the inclination of the base of the prism 
will have no other effect than to diminish the vertical distance 
between the dots. “ Whenever the inclination of the prism 
does not change the lateral distance between the two points, 
that is to say, when the two dots appear upon one line, not 
merely in one position of the prism, but continue so while the 
inclination of the base is changed, then the test proves noth- 
ing.” In order to avoid this disposition to fusion, Yon Graefe 
advised in this test the use of a figure where the dot was larger 12 
PROGRESSIVE MYOPIA 
and the line very fine, directing the attention of the patient 
especially to the dot. If efforts at fusion were still made, then 
the figure was used where the line was very short, or a simple 
dot alone. Yon Graefe mentions further exceptional cases 
where the minds of patients are so occupied with the idea of 
vertical contour, that even for the double images of a single 
dot they make efforts at fusion. In such cases he advises using 
a figure where the dot is very tine, or to substitute for the dot 
a short oblique line, and, while the test is applied, of turning 
the paper on which the line is traced. 
Having now ascertained the degree of the insufficiency for 
the ordinary working distance, as well as for the distance, we 
must determine the power of abduction. As we shall see, un- 
less this power of abduction or facultative divergence exceeds 
a certain limit, a tenotomy of the externus is out of the ques- 
tion. With marked insufficiency of the interni for the reading 
distance, we may find, for an object held fifteen feet away, no 
trace of dynamical divergence—indeed, there may be dy- 
namical convergence; but still, if the power of abduction be 
good, there is no contraindication to the operation. Is it a 
disadvantage to have for vision in the distance an overbalance 
of the internal recti ? Ho. The postulates for vision in the 
distance are no longer the same as for a nearer point, the 
visual act is not so fixed, is more transient. This negation 
holds as long as the patient does not really squint, so long as 
the overbalance is merely dynamical. Then, the first question 
to be answered, before we think of an operation to relieve the 
insufficiency, is, What is the power of abduction for the dis- 
tance ? What prism with its base inward can be overcome by 
divergence ? This amount of ability to abduct we can remove. 
If this amount be less than what is represented by a prism of 
B°, an operation is out of the question. 
In seeking the prism which for the distance can be over- 
come by facultative divergence, great care must be taken that 
too strong a one is not chosen. Want of practice on the part 
of the patient, exclusion under the prism, an actual difference 
in height of the two eyes, may lead us in one case to choose too 
strong, and in the other too weak a prism. If the power of 
abduction in proportion to the disturbance of equilibrium, as AND ITS OPEEATIYE CUEE. 
13 
found by the equilibrium test, appear very small and below 
the amount (8°) required to admit of operative interference, it 
is then often desirable to prescribe the abduction prism over- 
come to be worn by the patient for the distance for some 
time. Frequently, then, after a few hours, the power of ab- 
duction increases by 2° or 3°, and after two or three days by 
4° or s°, and then we obtain a facultative divergence of the 
amount required, its absence in the first instance being due 
alone to want of practice. Care must be taken that the double 
images stand each in the same horizontal plane. If they do 
not, it may be accomplished by a slight rotation of the prism, 
and then the facultative divergence will be found greater than 
was supposed, one image standing higher than the other hav- 
ing previously made fusion difficult. This difference in height 
may have arisen from the surgeon not having held the prism 
strictly horizontal; sometimes, however, in these cases, besides 
the disturbance in the lateral equilibrium, there is one in which 
tbe recti superior and inferior are concerned, causing the dif- 
ference in height of the double images. As soon as this differ- 
ence in height is corrected, and the double images brought 
upon the same horizontal plane, it will be found that a strong- 
er prism can be overcome. I have in mind a case where there 
was progressive myopia of a on one eye, and on the other. 
Insufficiency of the intend, in eight inches, of more than 18°. 
An insufficiency, in ten feet, of 9°. The strongest prism that 
could be overcome for the distance by divergence was s°-6°. 
Much as the operation was indicated with this small amount 
of facultative divergence, it was impossible. A careful exami- 
nation showed that the left eye stood higher than the right, 
and upon correcting this difference of height by means of a 
prism of 4° (base downward), a power of abduction represented 
by a prism of 10° was developed. Tenotomy of the externus 
was now made, with a limiting suture, and subsequently a 
partial tenotomy of the left superior rectus. The insufficiency 
was much relieved, and binocular vision secured. 
Care must be taken that the patient does not exclude un- 
der the prism. To be assured against this error, it is not suffi- 
cient that, with the least rotation of the abduction prism, di- 
plopia appears; because patients who are in the habit of peri- 14 
PEOGEESSIVE MYOPIA 
odically excluding, as is often the case, find it easy to do so 
for images which lie in the same horizontal plane, but not 
when a slight difference in the height of the image is induced; 
nor is it sufficient that the next strongest prism produces ho- 
monymous diplopia, for it often happens that for certain ex- 
centric positions the patients exclude, and not at either side of 
this. The only method of finding if the patient excludes with 
one eye is to cover each successively with a screen. If, on 
doing so, the covered eye remains in the same position as pre- 
viously, we may know that there is no exclusion active; if, on 
the other hand, one of them makes a slight rotary motion, the 
contrary is true. 
On which eye is the tenotomy to be performed? Asa 
rule, we may say on that eye which first deviates outward on 
approaching the fixation object, or it is to be performed on the 
eye with the strongest facultative divergence, or on the one 
with the worst acuteness of vision. 
If the insufficiency of the interni is considerable, repre- 
sented by a prism of 14° or 16°, then it is most desirable to di- 
vide the effect of the operation between the two eyes, making 
successively a tenotomy of each externus, and limiting such 
effect, as we shall see presently, by the conjunctival suture. 
The proportioning of the operation to the effect desired is 
of the utmost importance, and a neglect of this will leave the 
patient in a much more unhappy condition than before the 
operation. Inaccurate measurement may leave the patient 
with a most distressing diplopia. The following rules for 
regulating the effect of the operation, based upon his own ex- 
perience, I give in Yon Graefe’s own words. A simple tenoto- 
my of the externus produces an effect equal to that of an ab- 
duction prism of 16°; accordingly, with a facultative divergence 
of 15°, 16°, 17°, or 18°, a simple tenotomy is performed. For 
one of 14° and less, a restricting suture must be applied. This 
suture, by drawing the edges of the conjunctival wound to- 
gether, prevents the too great retraction of the muscle. Its 
effect depends on its direction (horizontal), on the amount of 
conjunctiva it contains, and on the closeness with which it is 
tied. 
If the abduction prism = 14° or 13°, a slightly horizontal AND ITS OPERATIVE CURE. 
15 
suture is to be applied, containing on each side one line of con- 
junctiva, and it is to be tied so as barely to close the wound. 
If 12° or 11°, then a moderately horizontal suture, containing 
about one line on either side, the wound to be closed. If 10°, 
a moderately horizontal suture, containing about one and a 
half line, the wound to be closed. If only 9° or B°, the suture 
is to be applied as horizontally as possible, is to include two 
lines of conjunctiva on either side, and the edges are to be 
drawn tightly together. If the abduction prism amount to 
more than 18°, it is best to divide the operation between both 
eyes. 
Immediately after the operation, the effect must be con- 
trolled by means of the equilibrium test, made in what is called 
the “position of election.” The position of election lies about 
ten feet from the eyes, about 15° toward the side of the unop- 
erated eye, and 15° below the horizontal plane in which the 
orbital axes lie. Experience shows that in this position the 
immediate effect and the ultimate effect bear a much more 
constant relation to each other than in the median line. In 
the latter place the transitory operative effect comes too much 
into play. 
In this 'position of election now there must he, immediately 
after the operation, equilibrium. If we find in this position 
1° to 2° of divergence that gradually passes over to a slight 
convergence in the middle line, and a strongly-pronounced 
convergence as the object is moved over to the side of the op- 
erated muscle, we may be fully contented. Never, however, 
should we leave in the position of election a convergence of 
more than 3°, for then there is danger of strabismus, conver- 
gence, and diplopia ensuing. Should the equilibrium test not 
show a condition in accordance with these rules, an immediate 
change in the suture must be made. 
With attention to these rules, a real convergence with di- 
plopia in the median line may be avoided, but they do not 
afford protection against temporal diplopia toward the oper- 
ated side. In order to avoid this, the defect of absolute mo- 
tion produced by the operation must be subjected to control. 
A defect of motion toward the operated side of more than 
three lines must never be allowed to remain, but must be mod- 16 
PROGRESSIVE MYOPIA 
erated by a suture. If the measure of the operation was high 
(> prism 11°), a defect of 2J to 2|- lines may be left; if the 
measure was less than this, a defect of motion of even two 
lines must be moderated. A defect of 1|- line may be left, 
even with small measures of operation (8° to 9°) without any 
danger, always provided the demands in the position of elec- 
tion are supplied. Should the correction of the defect of mo- 
tion materially influence the result of the equilibrium test, 
this dilemma may be avoided by a subsequent operation on 
the other eye. 
If the condition be examined six or seven hours after the 
operation, a slight increase in the effect will be found in the 
position of election. Instead of dynamical equilibrium, slight 
(1° to 2°) dynamical convergence will be fonnd. This con- 
vergence increases until the fourth day, when it amounts to 3°, 
4°, or s°, and in the median line from 8° to 16°. According 
to their greater or less power of fusion, the patients see double 
on the other side of four or three feet, or even one and a half 
foot in the median line. This increased effect increases again 
from the fifth, sixth, or eighth day, so that the diplopia in the 
median line disappears, mostly in the second, or at latest in 
the third week, and the lateral diplopia to the side of the op- 
erated eye some weeks later. The defect of absolute motion 
usually remains the same for some days after tli£ operation, 
and then gradually decreases until, two or three weeks after- 
ward, it only amounts to half, and, in some months later, the 
quarter of its original amount. 
As-to the after-treatment, the operated eye is to be band- 
aged, in order that as far as possible no movement of the eye 
shall modify the immediate effect. If a suture has been used, 
the patient must be seen within six or eight hours after the 
operation, and the equilibrium test made in the position of 
election. Should the effect now be found greatly increased, 
either from the suture having come out, or through tearing of 
the conjunctiva at the point of puncture of the suture, a new- 
one must be put in place which will restore equilibrium in the 
position of election. On the other hand, if now we find the 
effect reduced (a thing that sometimes happens through an ee- 
chymosis occurring after the bandage wras applied, or through AND ITS OPERATIVE CURE. 
17 
swelling of the portion of conjunctiva contained in the suture), 
and if this reduction of the effect is as great as 5° or 6°, it 
must he corrected. At the end of twenty-four hours after the 
operation, the suture has established its effect, and may be re- 
moved. If at this period too great an increase in the effect 
be found, corresponding to a prism of 6° or 7°, then a new su- 
ture must be applied, which shall secure equilibrium in the 
position of election. If there be no increase in the effect of 
the operation, then the suture is to be removed, and the pa- 
tient directed to look to the side of the unprotected eye, by 
which means the still delicate adhesions will be stretched, and 
the operative effect increased. 
On the second day much the same principles are to be ob- 
served. If there be dynamical convergence of 2° to 1° in the 
position of election, there are no measures to be taken. If 
dynamical convergence of 7° or more, a new suture is to be 
applied, and the adhesions loosened. If there be dynamical 
equilibrium, then the eyes are to be directed strongly to the 
side of, the unoperated eye, and this can be best accomplished 
by means of the ordinary squint-spectacle, with its opening 
outward and before the healthy eye. If there be dynamical 
divergence, and the suture still in place, it is to be removed, 
and an horizontal suture, inside of the cornea, containing a large 
fold of conjunctiva, applied. 
If, in the course of the next few days, between the third 
and the sixth, it becomes necessary to increase the effect, the 
patient must be directed to persistently look toward the side 
of the unoperated eye. Should it now be necessary to dimin- 
ish the effect (an increase of 5° or 6° may be left so), the edge 
of the wound must be raised, the attachments separated, and 
a more effective suture applied. 
In the course of the second and third weeks after the op- 
eration, a decrease in the effect usually appears. Should this 
decrease not prove sufficient, then associated movements tow- 
ard the side of the operated eye are to be advised. Toward 
the end of the second week, if the effect is to be diminished, 
the patient should receive the strongest possible prisms of ab- 
duction for reading. If, on the other hand, an increase in the 18 
PEOGEESSIYE MYOPIA AND ITS OPEEATIYE CURE, 
effect is desired, a combination of concave glasses, with prisms 
of abduction, should be worn for the distance. 
In the foregoing rules for the management of the opera 
tion, free use has been made of Yon Graefe’s original articles, 
and Dr. Swanzy’s excellent resume of the subject in the Dub- 
lin Quarterly. 
I cannot leave this subject without urging upon my read- 
ers, and especially upon such as are interested in ophthalmic 
medicine, the great importance of this operation as a prophy- 
lactic measure in progressive near sight. It may be said that 
we shall have to operate upon a large class of cases where 
the patients complain of scarcely any symptoms of asthenopia, 
and where formerly a tenotomy would not have been thought 
of; but the end to be gained, and the dangers to be warded off’ 
by the operation, fully justify the measure. If I have suc- 
ceeded in drawing the attention of the profession to the im- 
portance of muscular insufficiency as a cause of progressive 
myopia, a fact first established by Yon Graefe, and rightly re- 
garded as one of his most brilliant contributions to ophthalmic 
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