258 Ν. Α. W I N E A N D P. Κ. BASU

T H E F U N C T I O N A L R E S U L T S IN C A S E S O F C O N V E R G E N T S Q U I N T *

TREATED BY OPERATION

BASIL A . WARD, F.R.C.S., AND ANN HUGHES, D . B . O . ( T ) London, England

The development of binocular single on at Moorfields Highgate annex were com-vision following the surgical treatment of pared. All these cases had a good prognosis convergent squint is irregular and depends for binocular single vision, on many factors, in addition to the accuracy In order to assess the functional results both of the planning and of the execution of of operation, the cases were divided into the the operation. The reported incidence of sat- following categories: isfactory results varies widely after different GROUP 1. Orthophorie or with fully con-operations, trolled heterophoria.

The results of a series of cases operated GROUP 2. Heterophoria intermittently breaking down to manifest deviation.

* From Moorfields Eye Hospital. GROUP 3. Manifest deviation.

site of injury can be transformed into fibro- wounds of rabbit cornea in vitro was stud-blasts. Despite this, there was no apparent ied. The edges of the wound in a full-thick-collagen formation. This may be due to a ness cornea were united by epithelium. The derangement of the physiologic mechanisms epithelial growth interfered with stromal of the cells or absence of an essential nutri- cell proliferation in the wound. In absence ent in the tissue-culture medium. of the epithelium, stromal cells migrated into

areas of injury and took on the morpho-SuMMARY ¡Qgj^^j appearance of fibroblasts.

The process of healing of penetrating Banting Institute (2).

REFERENCES

1. Dunnington, J. H., and Smelser, G. K.: Incorporation of S" in healing wounds hi normal and devitalized corneas. A M A Arch. Ophth., 60:116, 1958.

2. Dunphy, J. H., and Udupa, K. N.: Chemical and histochemical sequences in the normal healing of wounds. New England J. Med., 253 :847, 1955.

3. Weimar, V . : Polymorphonuclear invasion of wounded corneas. J. Exper. Med., 105:141, 1957. 4. Wolter, J. R.: Reactions of the cellular elements of the corneal stroma. A M A Arch. Ophth., 59:873,

1958. 5. Robb, R. M., and Kuwabara, T.: Corneal wound healing. A M A Arch. Ophth., 68:636, 1962. 6. Arey, L. B., and Covode, W . M . : The method of repair in epithelial wounds of the cornea. Anat.

Ree, 22:6S8, 1943. 7. Matsimoto, S. J., and Ishimaru, H . : A contribution to the study of epithelial movements : The corneal

epithelium of warm blooded animals in tissue culture. Acta Schol. Med. Imper. Kioto., 5:167, 1923. 8. Dunnington, J. H., and Weimar, V . : Influence of the epithelium on the healing of corneal incisions.

Am. J. Ophth., 45 :89, 1958. 9. Maumenee, A. E., and Komblueth, W . : Regeneration of the corneal stromal cells. Am. J. Ophth.,

32:1051, 1949. 10. Weimar, V. : The transformation of corneal stromal cells to fibroblasts in corneal wound healing.

Am. J. Ophth., 44:173, 1957. 11. Pullinger, Β. D., and Mann, I.: Avascular healing in the cornea. J. Path. & Bact., 55:151, 1943. 12. Retterer, K.: Cicatrization of wounds of the cornea. J. d'Anat. & Physiol., 29:453, 1903. 13. Salzer, P.: (a) On the regeneration of rabbits cornea. Arch. f. Augenh., 69:272, 1911. (b) On the

regeneration of rabbits cornea: II. Arch. f. Augenh., 70:167, 1912. (c) On the regeneration of rabbits cornea: III. Arch. f. Augenh., 71:221, 1912. (d) Comparative anatomical studies on the regeneration and the wound healing of the cornea. Ztschr. f. Augenh., 79:61, 1915.

RESULTS IN C O N V E R G E N T SQUINT 259

T A B L E 1

TYPES OF DEVIATION

Accommodative squint with convergence excess Intermittent convergent squint with divergence

weakness Partially accommodative squint Nonaccommodative squint

TABLE 2

LIST OF OPERATIONS

(mm.)

Recession medial rectus 4 Recession medial rectus 5 Recession medial rectus 4

with resection lateral rectus 4 - 7 Recession medial rectus 5

with resection lateral rectus 5 - 7 Resection lateral rectus 5 - 7

TABLE 3

RECESSION MEDIAL RECTUS FOU R MM.

Total Num­ Groups

ber of Cases 1 2 3

Accommodative squint with convergence excess

A. Single recession 2 B. Separated recession 2 C. Bi ateral recession 1

Intermittent convergent squint with divergence weakness 1

Partially accommodative squint 1

Good prognosis for binoc­ular single vision

TOTALS

A first class result or cure was considered

to be achieved postoperatively if binocular

visual acuity was 6 /6 with and without

glasses and bar reading N5 with and without

glasses in cases in which the hypermetropic

correction was -|-3.0D or less. Where the

correction was higher, these conditions had

to be present with —3.OD. clip-ons added to

the spectacles.

A s the aim of the investigation was to an­

alyze the efi'ect of operation and, if possible,

assess the relative merits of dififerent pro­

cedures, a relatively short follow-up period

was considered adequate, namely three

TABLE 4

RECESSION MEDIAL RECTUS FIVE MM.

Total Num­ber of Cases

Groups

1 2 :

1 1 1 0

c.

Accommodative squint with convergence excess

A. Single recession 12 B. Separated recession

a. By 1 / 1 2 or less 4 b. by 6 / 1 2 to 3 yr. 3

Single recession fol­lowing on recession and resection on the other eye

a. 1 / 5 2 after first operation 1

b. l i yr. after first operation 3

Intermittent convergent squint with divergence weakness S

Partially accommodative squint Good prognosis for binocular single vision 3

Nonaccommodative squint Good prognosis for binoc­ular single vision 2

1

1 2

1 3 1

1 2

2

TOTALS 3 3 4 9 2 0

TABLE 5

RECESSION MEDIAL RECTUS FOUR MM. COMBINED WITH RESECTION LATERAL RECTUS FOUR

TO SEVEN MM.

Total Num­ber of Cases

Groups

1 2 ·

Accommodative squint with convergence excess

Partially accommodative squint Good prognosis for binoc­ular single vision

Nonaccommodative squint Good prognosis for binoc­ular single vision

1 2 1

1 2

TOTALS 2 6 1

months. Tables 1 through 8 survey the find­

ings. It is interesting to compare these results

with those of similar surveys reported in

the literature (table 9 ) :

COMMENT

The percentage of the total number of

cases which attained binocular single vision

was disappointingly small, particularly so

260 BASIL Λ, W A R D A N D A N N HUGHES

TABLE 6

RECESSION MEDIAL RECTUS FIVE MM. COMBINED WITH RESECTION LATERAL RECTUS FIVE TO

SEVEN MM.

Total Num­ber of Cases

Groups

1

Partially accommodative squint Good prognosis for binoc­ular single vision

Nonaccommodative squint Good prognosis for binoc­ular single vision

2 1 2

3 1

TOTALS 1

TABLE 7

RESECTION LATERAL RECTUS ALONE FIVE TO SEVEN MM.

Total Num­ber of Cases

Groups

1

Accommodative squint with convergence excess

Single resection a. 1 / 5 2 or less after re­

cession of medial rectus

b. 1 / 1 2 to 4 / 1 2 after recession of medial rectus

c. 1 to 7 yr. after reces­sion of medial rectus

Intermittent convergent squint with divergence weakness

A. Single resection B. Bilateral resection C. Single resection 1 / 5 2

after recession of me­dial rectus

3

1 1

TOTALS 10 — 4 6

TABLE 8

RESULTS

Total percent of patients group 1—Orthophorie or with fully controlled heterophoria, 19 percent

Total percent of patients Group 2—heterophoria intermittently breaking down to manifest deviation, 3 1 percent

TOTAL number of cases 6 8

Operation Groups

Single muscle Recession and resection

1 2 % 3 9 %

2 8 % 3 9 %

TABLE 9*

SURVEYS IN LITERATURE

1951 Scobee Total percent of patients Group I , 39.7 percent Total luimber of cases 171

Standard of Cure Eyes straight with comfortable fusion

Operation Group 1

Recession medial rectus 3 9 % Bilateral recession medial rectus 4 6 % Recession medial rectus with resec­

tion lateral rectus 3 9 %

1 9 5 2 Cashell, et al. Total percent of patients Group 1 2 7 percent Total number of cases 7 1 0 Standard of Cure

Binocular single vision with and without glasses (if worn)

Operation Group 1

Recession medial rectus Recession medial rectus with resec­

tion lateral rectus Recession medial rectus with ad­

vancement lateral rectus

3 0 %

2 1 %

3 0 %

1 9 5 4 Costenbader and Bair Stressed the importance of planning surgery to

give a concomitant result. They produced figures to show the significance of postoperative concomitance in relation to retinal correspondence and suggested that cases which were straight with normal retinal correspondence were more likely to develop adequate fusion

Operation Concomi­

tant Results

Binocular simultaneous symmetrical surgery 9 7 %

Symmetrizing surgery 82%, Monocular surgery 5 3 %

Fifty-four percent of patients concomitant post­operatively are straight with normal retinal correspondence

1 9 5 8 Dyer and Martens Total percent of patients Group 2, 5 0 - 6 5 percent Total number of cases 1 7 6

Deviations preoperatively were of less than 4 0 dioptres, the age at onset 2 - 4 yr. and the duration less than one year

(Table 9 continued on next page)

* There must be many reservations about deduc­tions made from comparisons between the reported results of different types of operations, unless the exact diagnostic grouping and the severity of each case is known. However, this review does suggest that the incidence of binocular single vision following squint surgery varies greatly.

RESULTS TN C O N V E R G E N T S Q l ' I N T

T A B L E 9 (Continued)

261

1959 Kennedy and McCarthy Total percent of patients group 2 10 percent Total number of cases 315

1961 Lyle Total number of cases 179 of nonaccommodational

nonparalytic convergent squint after a 10-yr. follow-up

Opera- Fix. Disp. Sub­

normal B.V.

No B.V.

At 18 mo. 4 to 2 yr.

2 10.3%

10 17.2%

42 72%

At 5-10 7 yr-

7 11.5%

36 29.8%

71 58.7%

effective, unless there was a fair degree of control preoperatively, that is, they were only helpful in improving control.

Perhaps this suggests that surgical results of cases of convergent squint with a gof)(l prognosis for binocular \ ision could be much improved by the more extensive use of re­cession and resection operations.

Moorfields Eye Hospital, City Road, E.C.I.

when it is remembered that they all had a good prognosis for binocular vision.

Single muscle operations were usually in-

A C K N O W L E D G M E N T S

Our thanks are due to the surgeons of Moor­fields Eye Hospital, City Road, London, for per­mission to investigate their patients, and publish this paper. W e are particularly indebted to Mr. A . G. Cross for encouragement and advice, and to Miss Celia Norton for help in orthoptic examina­tions, and the follow-up of patients.

REFERENCES

Bond, F. M. : Tr. Pacific Coast Oto-Ophth. Soc, April, 1957, pp. 38-143. Cashell, G. T. W., Douglas, T. H., Whittington, T. H., Houlton, A. C. L., and Lyle, T. K.: Tr. Ophth.

Soc. U. Kingdom, 72:367-416, 1952. Costenbader, F. D., and Bair, D, R.: A M A Arch. Ophth., 52:658-663 (Nov.) , 19.54. Dyer, J. Α., and Martens, T. G.: Proc. Mayo Clinic, 33 :6S8, 1958. Kennedy, R. T., and McCarthy, T. L.: Am. J. Ophth., 47:508-519, 1959. Lyle, T. K.: Tr. Ophth. Soc. U. Kingdom, 81:737-756, 1961. Scobee, R. G.: Am. J. Ophth., 34 :817, 1951.

S T R U C T U R E O F T H E R E T I N A L V A S C U L A R S Y S T E M *

O F THE DOG, MONKEY, RAT, MOUSE AND cow

FiKRET MuTLu, M . D . , AND IRVING H . LEOPOLD, M . D . Philadelphia, Pennsylvania

INTRODUCTION AND METHOD

Studies of the structure of trypsin-di-gested retinal vascular system of the cat and the rabbit have been described.''^ The pres­ent report concerns similar analyses of the dog, monkey, rat, mouse and cow retinal vasculature. The anatomy of the retinal \'as-cular system and various characteristics of the vessels of these animals have been de­scribed previously by Michaelson." Visual­ization of the retinal vessels of these animals

* From the Research Department of the Wills Eye Hospital.

was performed with the trypsin digestion and water method.' '* The observations of the flat preparations will be described sepa­rately for each animal.

STRUCTURE OF DOG RETINAL VESSELS

The vessels of the dog retina do not pre­sent an architecture similar in all aspects to those of human, monkey and cat. In the dog retina, there is no central retinal artery. Sev­eral posterior ciliary vessels pierce the sclera around the optic nervehead where they give off retinal branches at the margin of the disc as cilioretinal arteries (Duke-Elder") . The