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Summary Opinion will be expressed that the most difficult aspect of ophthalmology for the average registrar to understand is the subject of “Ocular Muscle Imbalance”. Part of the reason for this is that in the United Kingdom and Australia, patient care is usually delegated to the Orthoptic Department and valuable clinical experience is hence denied the registrar. An Ocular Motility Clinic was established at Sydney Eye Hospital in July, 1971. All Orthoptic Department assistance was abandoned in an effort to encourage the training registrar to take a more active part in strabismus management. The ease with which this clinic has functioned suggests that Orthoptic Departments are unnecessary. The subject of “Convergence Insufficiency” will then be discussed in some detail. Brief mention will be made about the possible future role of the Australian orthoptist. This subject was more fully discussed in September, 1972, at the meeting held by the New South Wales Branch of the College of Ophthalmologists.

30 patients with blow-out fractures were referred to our clinic because of serious "eye troubles", most frequently diplopia and haematoma of the eye lids (Table 1). The signs of the characteristic oculomotor imbalance are described. In 10 out of 29 patients motility was normalised spontaneously within 2 weeks. 19 patients underwent surgery because one of the following criteria was fulfilled: 1. Diplopia and positive traction-test not resolving within 10 days. 2. Large hermiation into the antrum. We believe, that posttraumatic diplopia is not only a result of the incarceration, but also of a direct laesion of muscles and connective tissue. Surgery was done by orbital approach. After reposition of antral prolaps and the bony fragment we used Lyodura or, when nessessary, silicon implants. In all patients treated in this way ocular motility was improved, but normalisation was achieved only in 8 cases (Fig. 8).

VARIOUS conditions of paralysis of ocular elevation with and without ptosis will be described and cases illustrating the different types according to the muscles paralyzed will be reported. The purpose of this paper is to differentiate real ptosis and pseudoptosis and to bring out the indications for the application and the technic of surgical procedures which may be useful in correcting the hypotropia of the paretic eye, or the hypertropia of the sound, or fellow, eye when the patient prefers to fix with the paretic eye, and, finally, in correcting the ptosis. DEFINITIONS Under the term "paralysis of ocular elevation" may be grouped a number of cases of disturbed ocular motility in which it is difficult or impossible for the patient to look upward because of the paralysis of the superior rectus and/or the inferior oblique muscle. For the sake of simplicity, the word "ptosis" in this paper signifies blepharoptosis.

Ocular myasthenia gravis resembling the specific brain-stem sign of internuclear ophthalmoplegia has not been described in the literature with the exception of the unique case of Walsh. 1 This interesting motility disturbance has recently been observed in three patients. In each case the peripheral neuromuscular disorder closely mimicked a syndrome pathognomonic of a focal lesion involving the medial longitudinal fasciculus. The purpose of this report is to present the unusual ocular motility found in these three cases and to emphasize the importance of an antimyasthenic agent in this differential diagnosis. Report of Cases Case 1. —A 25-year-old Negro woman was seen with asthenopic symptoms of two months' duration. No history of ptosis, diplopia, or fatigability could be elicited. On examination a mild right ptosis was noted. The pupils were normal as were other parameters of ocular function, with the exception of extraocular movements which were of great interest. The patient

Summary A patient is reported with a defect in visual perception similar to that originally described by Balint. Associated disorders of ocular motility and visual motor coordination were also present. There were significant defects in both spatial and temporal reception of visual stimuli resulting in a very restricted effective field. A significant disorder in visual attending to peripheral stimuli resulted in a very defective pattern of visual searching of the environment. It is suggested that this abnormality of visual exploration in conjunction with the temporal and spatial defects play a significant role in the distorted visual perceptions. The defects noted seemed adequate to explain the patient's behavior without the necessity of postulating an “agnosic” defect.

A clinical finding is presented which is of interest in disease states with asymmetric lid positioning. It is suggested that Hering's law applies to the levator palpebrae superioris as well as the extraocular muscles concerned with motion of the globe. Two cases of myasthenia gravis are presented; one case of orbital myositis, and one case of asymmetric lid positioning of undetermined etiology, all of which seem to indicate that the levator palpebrae superioris obeys the same law of equal innervation as previously ascribed only to the extraocular muscles involved in ocular motility.

DISTURBANCES of eye movements frequently confront the physician with puzzling diagnostic problems. First of all, the examiner must determine whether the abnormal function of eye muscles is the result of mechanical factors or caused by a disorder of innervation. Since purely mechanical impairment of ocular motility depends on local factors, such cases belong exclusively to the domain of ophthalmology and, therefore, are not discussed here. On the other hand neuroarenic disorders of eve movements rarely originate in the eye itself but are due to a lesion (or lesions) in the nervous system; consequently, a detailed neurologic examination becomes mandatory. It . . .

THE ERRORS committed by great men are usually in direct proportion to their greatness. This has happened in the matter to be discussed here. From correct observations they have drawn wrong conclusions. I shall reconstruct this confused chapter in physiologic optics and ocular motility, using, in addition to the experiments of others, those of my own. This work had its origin in some questions about ocular torsion which were put to me by Dr. Joseph I. Pascal at our meeting in Mexico in August 1947. Frankly, I could not answer them satisfactorily, nor did we get much enlightenment when we consulted together the classic works of von Helmholtz, 1 Tscherning, 2 Giraud-Teulon, 3 and Le Conte, 4 the most recent works of Ives Le Grand, 5 and other publications. On parting, I promised Dr. Pascal to get to the bottom of this matter and the results of my investigations are

Ocular motility defects occurring as a result of unilateral stereotactic thermal lesions in the midbrain pretectal areas have been observed in 16 patients. The preponderance of convergence defects leads to the conclusion that convergence function is not focally localized to the midline but is mediated more diffusely from pretectal regions of the midbrain. It appears as if midline structures are not the primary center for convergence. Miotic pupils in 15 patients suggests a diffuse association of accommodation and pupillary reaction which can be symmetrically affected by a unilateral lesion. The observation of skew deviation suggests that vertical gaze is also more diffusely organized in the dorsolateral midbrain. A unilateral stereotactic lesion can cause both bilateral paralysis of vertical gaze as well as skew deviation.

Twenty-one years of study and practice in the field of normal and pathologic ocular motility have led to certain impressions and convictions. These beliefs have taken form, first, as the result of the opinions of those who seem to me to have been the leaders in this special field of investigation, and, second, as the result of my personal study and experience. Certain rather definite conclusions, therefore, seem to be logical, and for the most part have received general acceptance. It is true that some of these conclusions are not accepted by all, but those who dissent have not been able to replace them by theories that will stand the test of minute analysis as well as the ones that I shall set forth as a working premise. As the surgical phases of squint are formulated on some of these generally accepted theories, it is important to state briefly

(1969). The Use of Compensated Lenses in Ocular Motility. American Orthoptic Journal: Vol. 19, No. 1, pp. 104-109.

"In some ways we are so obsessed with the delight and advantage of discovery of new things that we have no proportionate regard for the problems of arrangement and absorption of the things discovered," Sir Josiah Stamp stated in his address as president of the British Association for the Advancement of Science in 1936. 1 The facts and theories which are here presented are long established and should be better known and made a part of one's thinking about disturbances of ocular motility. 1a The anatomy of the parts concerned in ocular movements is well known. Attention is here called only to some anatomic facts which throw light on the widespread erroneous idea that in most cases heterophoria is due to weakness of one or more of the extra-ocular muscles. The strength of a muscle depends on its cross-section. The amount of its shortening depends on its length. The ocular

The recording of potentials from the ocular muscles in man is a new technique which is providing a greater insight into ocular motility and innervation than we have had in the past. While the neurophysiologist considers electromyography a basically simple technique, it is fraught with difficulties in both the recording and the interpretation of the records for others who may not be sophisticated in electrophysiological methods. It is our goal to present the elements of the human electromyography of the extraocular muscles. We hope that this presentation will aid anyone who wishes to take an extraocular electromyogram himself but above all serve as a guide in aiding the reader to interpret and evaluate electromyograms, which are becoming commoner in the ophthalmic literature. Furthermore, this paper will serve as a basis for subsequent publications from this laboratory.

Study of ocular motility and of the relative visual acuity in patients who have been treated for retinal detachment emphasize the need for early treatment, especially when the macula is involved, and for selection of the simplest method of retinopexy that is thought to be adequate. It is important to avoid unnecessary trauma to the motor and suspensory system of the eye. Prismatic correction should be employed without delay in those patients who develop heterotropia after re-attachment of the retina.

STRABISMUS is a disturbance of ocular motility due to a number of separate and unrelated pathologic processes. The thesis I wish to develop is that, although at the present time we do not know what all these processes are, we may obtain a better understanding of strabismus by analyzing where and how each process affects ocular motility. The neuromusclar mechanism which controls eye movements may be compared to that which moves the limbs. The pathways of each mechanism may be divided into two easily identifiable portions: (1) a supranuclear portion, or upper motor neuron, and (2) a nuclear and infranuclear portion, or lower motor neuron. It makes no difference whether the pathways we are considering are transmitting impulses for what, philosophically, we may choose to call "willed," or voluntary, movements, or whether they transmit reflex, or involuntary, activity, each pathway is divisible into these two main portions, and affections of

A photoelectric oculographic system for measuring the dynamics of eye movements in response to accommodative stimuli has proven itself to have practical advantages in the evaluation of the accommodation-convergence relationship. Investigation of the change in accommodative convergence to accommodation ratio (AC/A) in several emmetropic and hyperopic subjects in response to echothiophate (Phospholine) iodide has confirmed the usefulness of an objective measurement method in judging the lessened accommodation requirement. The application of this and similar devices to studies in the wide spectrum of motor anomalies, holds promise of adding significant objectivity and knowledge to the expanding field of ocular motility.

It has been suggested that retinal hemorrhages at birth may be the cause of organic amblyopia and strabismus later in life. Of 1,000 newborns examined within the first 24 hours of life, we found 245 cases with retinal hemorrhages; the macula was involved in 18 patients. Five children who had macular hemorrhages at birth were available for reexamination; visual acuity and ocular motility were normal. On the basis of this study we conclude that macular hemorrhages at birth do not play a significant role in the cause of amblyopia or strabismus.

Superior oblique myokymia is an unusual disorder of ocular motility characterized by rapid, small amplitude, rotary oscillations limited to one eye. Symptoms of monocular oscillopsia and torsional diplopia are experienced by the patient. Although symptomatically obtrusive, the syndrome is benign in our experience. While the cause remains obscure, we have found carbamazepine (Tegretol) to be effective in treating this condition.

Improving ocular motility has become a widely discussed technique of assisting children who have learning disabilities. It has been assumed that learning difficulties in some cases were due to lack of binocular coordination. This paper demonstrates that learning is done in the brain and not in the eyes and that while the Electronystagmograph does demonstrate incoordinate eye movements in children who have difficulty in reading, the experiments performed demonstrate that it is the degree of comprehension that produces the type of ocular movement and not ocular motility that determines the degree of comprehension.

A patient who underwent a cosmetic blepharoplasty suffered a retrobulbar hemorrhage with no light perception deception detected when the dressing was removed two hours postoperatively. Opening the incision site led to the complete return of visual acuity and ocular motility and relief of the proptosis. The rebleeding of cauterized blood vessels may have caused the retrobulbar hemorrhage and seems to be a potential problem in all cosmetic blepharoplasties. Eliminating the use of postoperative bandages may prevent blindness after cosmetic blepharoplasty since it allows early detection of a retrobulbar hemmorrhage. This allows the nurse to check the patient for loss of vision and proptosis at ten-minute intervals for the first two hours after surgery so immediate treatment can be implemented if retrobulbar hemorrhage and central retinal artery occlusion occur.

In diagnosing and treating small malignant lesions of the eyelids, physicians should be alert for possible extension of the cancer into the orbit, endangering not only the patient's sight but his life as well. Important signs and symptoms include bone thickening, disturbances of ocular motility, intermittent epiphora, and positive results of radiologic studies. From histopathologic study of the resected carcinomatous tissues, it is apparent that the creeping, cicatrizing, ulcerated, and invasive patterns of basal cell carcinoma predominate in this group of eyelid tumors, all of which are aggressive lesions; however, the histologic type is quite variable and no definite trends can be established.

Leigh's encephalomyelopathy is a metabolic disorder of infancy and childhood with a probably recessive mode of inheritance. Its course is remittent. Outstanding features are early and prominent neuro-ophthalmologic signs and psychomotor retardation. The former, with the remittent course, are highly suggestive of this disorder, while manifestations of the latter are nonspecific. Biochemical studies revealed diverse abnormalities. At necropsy, white and gray matter in many regions may be found affected, but there is predilection for symmetrical involvement of tegmental portions of the brain stem (abnormalities of ocular motility), optic nerves and tracts (visual deficits), and basal ganglia. Microscopically, there is myelin loss, necrosis, and capillary proliferation.

The purpose of this paper is to draw attention to the facility of the osteoplastic resection of the temporal orbital wall, commonly called the Kronlein operation, as an operative procedure, and its adaptability as a diagnostic step to obtain exact information of conditions present in the depth of the orbit such as morbid processes in the orbital walls, in the optic nerve and in the soft parts. I take it for granted that this operation is accepted to be the best method of removing circumscribed tumors in the depth of the orbit with the preservation of the eyeball and, in many instances, with the preservation of sight and unimpeded ocular motility. The operation, futhermore, permits the best determination of the extent of many orbital tumors, often their operability, and the securing of a proper specimen for microscopic examination as a preliminary to an orbital exenteration if found necessary, or, in

PROGRESSVIE exophthalmos is often called "malignant" exophthalmos, and it is sometimes referred to as exophthalmic ophthalmoplegia (Brain 12 ), thyrotropic exophthalmos (Mulvany 18 ), and a hyperophthalmopathic type of Graves's disease (Means 16 ). In contrast to the slight exophthalmos of goiter, which may be combined with some staring, the malignant type is characterized by its progressive nature; periorbital and lid edema; diminution or lack of resiliency, elicited by palpating the eyeball; limitation of ocular motility, often causing diplopia, and retraction of the upper lid, resulting in staring. In some cases thyrotoxicosis precedes this exophthalmos, but usually by the time there are signs of progressive exophthalmos the thyroid condition is well controlled or has reached the stage of hypothyroidism; occasionally there is no thyroid history whatsoever. Fortunately, malignant exophthalmos occurs infrequently, for it is a disabling and dangerous disease and a great burden to the patient, as well as to the physician, particularly

Indicating the vastness of the subject and the thoroughness of Duke-Elder's treatment, this large book discusses only the congenital deformities which are apparent at birth. Other congenital diseases whose effects are manifest after birth are to be presented in their logical place in subsequent volumes. After devoting a section to teratology both descriptive and experimental, the author goes on to describe congenital deformities of the eye according to their occurrence in the various ocular substructures. He concludes with chapters on anomalies of ocular motility, deformities of the head and neck, anomalies of the central nervous system, and multiple syndromes. The treatment of the subject matter is thorough and the author does not neglect to deal with a large number of congenital abnormalities of minor nature which have no pathological significance. From the clinical point of view, this is a most valuable feature and one frequently neglected. The illustrative material is

For 66 years I have given much thought to binocular vision. Why I have found it such a fascinating subject for study I do not exactly know. Perhaps it is because it has involved my making so many interesting experiments and conclusive demonstrations with the aid only of drawing materials and a stereoscope.* I have published new concepts and tests of binocular vision, yet none of these concepts has been generally accepted. This is not because they are incorrect, for none has been disproved, but because they differ so greatly from prevailing views that they have not been understood. In the past I have given more attention to the sensory than the motor aspects of binocular vision; now I shall deal chiefly with its motor aspects. We know a great deal about what the motor mechanisms of the brain can do and have named and classified them on this basis

A. von Graefe has had a special interest in the problems of ocular motility. His contributions to this field are briefly reviewed. His musculo-mechanical theory of the etiology of strabismus, his elaboration of the diplopia test, his fundamental work on extraocular muscle palsies, especially of the oblique muscles, are discussed. His many fascinating single observations are pointed out. Some of these have been rediscovered of late years and have played a significant role in modern strabismology. It is furthermore related how von Graefe’s early insistence on a rigid interpretation of the identity theory at first led to confusion of pseudostrabismus through ectopia of the macula, eccentric fixation in deep amblyopia, and anomalous correspondence. It was subsequently modified by sharp observations and a willingness to reject a favorite theory on the basis of these observations. Lastly, it is told how von Graefe reintroduced the tenotomy operation and made it acceptable to the profession by improving the indications and technique of the operation.

A SENSORY block of the upper eyelid can be achieved without loss of extraocular muscle function or distortion of lid tissues with a single, small, properly placed injection. This technique simultaneously blocks the frontal and lacrimal nerves at their point of divergence posteriorly in the orbit. It has been used in a variety of lid procedures, but finds its greatest value in ptosis surgery where retention of ocular motility permits ideal placement of the lid margin. Method Any of the usual anesthetic solutions may be used, preferably without the addition of hyaluronidase since this may permit some penetration of the anesthetic solution through the intermuscular membrane into the deeper orbital tissues. A 4-cm needle, about size 23 or 22, is introduced precisely at the midpoint of the upper lid just below the bony orbital margin. At this location, the needle is some distance lateral to the frontal nerve, reducing the