432 NOTES, CASES AND INSTRUMENTS

that a shot was found in the orbit. Roentgenograms taken sixteen months later showed the shot still in the orbit, and in the same position.

The indiscriminate use of air guns by children should be discouraged.

490 Post street.

SUPERIOR RECTUS SHORTEN­ING TO CORRECT CERTAIN HORIZONTAL DEVIATIONS

A report of four cases RODERIC O'CONNOR, M.D.

SAN FRANCISCO

It seems worth while to report these four cases for the following reasons : 1. To show that rule-of-thumb methods, such as "shorten and cut for the major apparent deviation," are occasionally out of order. 2. To show again that ver­tical deviations are often the sole cause of horizontal deviations. 3. To em­phasize the importance of looking for such deviations in all cases before oper­ating, and especially before cutting an inferior oblique. 4. To prove the need to have some convictions on the subject. 5. To encourage others to acquire such convictions and to act upon them by operating on the muscle found to be at fault. Similar conditions are very fre­quent in heterophorias but it was thought best, for the sake of emphasis, to report only the squints.

Case 1. Mary M., aged 3 years plus, at date of first visit in October 1920. Ex­amination : Convergent squint, O.S. fix­ing. Refraction under atropin was + 1 D.sph. in each eye. Media and fundi were normal. The patient tilted her head toward the left shoulder. Monocular ro­tations were normal. Binocular rota­tions: very high upshoot of right eye when the left turns out, both level when right eye turns out.

Diagnosis : Paresis of left superior rectus with overaction of right inferior oblique. It should be noted that on look­ing down (away from the weak muscle), the eyes became perfectly parallel as shown by the pupillary reflections from a light ; also that the patient fixed with the eye at fault.

Shortening of the left superior rectus was advised but the father, even though a medical man, could not be made to see the reason for operating on a vertical muscle of the straight eye.

She was seen again in December, 1921, and in September, 1922, by which time she was able to be tested with the Maddox rod. The results were right hy-perphoria 15Δ, left cataphoria 25Δ. This time a cinch shortening of the left su­perior rectus was permitted and a per­fect cosmetic result secured. She was shown at the 1923 meeting of the Ameri­can Medical Association in San Fran­cisco and was last seen in September 1932. With Maddox rod she then tested, in the primary position, esophoria 4*, left cataphoria 10*. Light reflections centered in all positions except left ro­tation when the right eye went higher. There were no headaches or. other symptoms even after prolonged near use. There was third degree binocular vision. Vision was 20/20 plus, each eye without any correction, none ever hav­ing been used.

Theoretically there was enough re­maining vertical deviation to call for correction but it was not advised be­cause of the entire absence of any symp­toms subjective or objective.

This case shows that good results can be secured by shortening the muscle at fault instead of cutting the opposite in­ferior oblique. Possibly even better re­sults might have been obtained had the operation been done two years sooner.

Case 2. Miss C. L., aged 25 years, was seen first in September, 1924. Refraction was unimportant, vision being 20/20 plus, each eye with low compound hy-peropic correction. The patient com­plained of losing her place in reading be­cause of vertical diplopia. Muscle tests : right cataphoria 4*, left hyperphoria 20*, which decreased markedly on look­ing down ; right and left exophoria 22Δ.

The diagnosis being paresis of the right superior rectus this muscle was shortened by my cinch method on Octo­ber 4, 1924. The tendon was very frail, being only about one half the normal width and it was displaced inward so far that its outer margin was directly above the center of the pupil. The immediate

NOTES, CASES AND INSTRUMENTS 433

over-effect was 3Δ which on the fourth postoperative day had increased to 1 ^ so the patch was removed and vertical rotations ordçjed. On October 24 she tested 3Δ over-effect and the exophoria had been reduced to 4&. On November 7 the tests were O.D. cataphoria 1Δ, ex­ophoria 5A, and she fused the red and white images in the red-glass test. On January 28,1925, she tested orthophoria in both directions with no deviation be­hind cover.

This makes a good companion case for the first, being just the opposite con­dition relieved by the same operation.

Case 3. R. W. D., aged 30 years, was seen in July, 1927. Preoperative tests showed left hyperphoria 10*, right cata­phoria 8^, lessening rapidly on looking down, esophoria 20*. On July 29, 1927, a cinch shortening of the right superior rectus gave an immediate over-effect of 6A. Healing was uneventful. One year later he tested esophoria 1Δ, vertical orthophoria, and was entirely free from symptoms. This patient used lenses of + 4 . D.sph. and + 5 . D.sph. on the right and left eyes respectively, but all tests were made while wearing them. It is, of course, possible that correction of the vertical deviation permitted the glasses to act to relieve the esophoria.

Case 4. Yvonne P., aged 4 years when

first seen in July, 1927, showed a right eye which had visibly converged prac­tically since birth. She was a patient of another oculist who asked me to oper­ate, lens correction having failed to re­lieve the strabismus. Binocular rota­tions showed a high upshoot of the right eye when the left rotated out, and out and up, while in looking to the right both eyes remained level. On looking down the eyes became perfectly parallel as shown by pupillary light reflections.

Operation on August 4, 1927, was a cinch shortening of the left superior rectus. On September 12, 1927, the eyes were parallel for near as well as for dis­tance fixation, as shown by the reflec­tion test.

In July, 1928, the right eye converged at times but with red-glass tests there was only δ4 esophoria, the vertical tests being uncertain. The mother was not satisfied with the result and so, to please her, the right externus was cinch short­ened on August 6, 1929. The internus was not touched. On January 6, 1930, the eyes were level and parallel conver­gence was maintained up to four inches. In spite of this the mother was not satis­fied because the child had to wear glasses, + 2 D. sph. =C= +1.50 D. cyl. in each eye.

450 Sutter street.