Documenta Ophthalmologica 34 : 301-.315, 1973

STRABISMUS

CARE: PAST, PRESENT

AND FUTURE

by MARSHALL M. PARKS, M.D.

( Washington, D.C.)

ABSTRACT The history of ophthalmology* begins with the development of the culture which started during the Bronze age in the rich alluvial valleys of the rivers Euphrates-Tigris, and Nile, the Indus, and the Yellow River. Recovered documents of the Sumerians of Mesopotamia reveal that medicine was practiced as far back as 3000 B. C. The Sumerians were replaced by the Semitic dynasty of Babylon around 2000 B. C. and we possess records of their anatomical nomenclature and documentation that ophthalmology was practised by craftsmen. A most significant document is the legal code of Hammurabi, sixth King of the first dynasty of Babylon, dated by radio-carbon methods to 1800 B. C., that summarizes the old :Sumerian laws dating back to 3000 B. C. that regulate the practice of ophthalmic surgery. A well to do free man having a successful eye operation could be charged 10 shekels of silver. This represented approximately the total annual wage of a mechanic of that era. The fee for the same on a poor man was 5 shekels and on a slave 2 shekels. In that era the fee allowed the ophthalmic surgeon was sizeable

Delivered as the first annual Clement J. Smith Lecture at the Smith Kettlewell Eye Research Foundation and Department of Visual Sciences, University of the Pacific. * Vol. II, 1961 edition of DUKE ELDERp. 3 tO 35 contains a concise well referenced historical treatise on the early history of ophthalmology. From this source such a large portion of this paper dealing with the history through the fifteenth century was obtained that it is impossible to reference each item. 301

but even greater was the penalty of an unsuccessful operation. An operation resulting in the loss of a free man's eye called for the penalty of amputating the ophthalmic surgeon's hand; the same surgical failure in a slave demanded the ophthalmic surgeon replace the free man's slave. DUKE-ELDERcomments, 'It is interesting and in a sense disappointing that the first extant reference to ophthalmology in the World's literature should be a code of fees and penalties' (DUKE-ELDER, 1961). Medicine in the Nile valley was more mystic since it was controlled by priests rather than craftsmen. According to records the first identified Egyptian physician is Imhotep who lived at approximately 3000 B. C. and also was distinguished as the architect of Egypt's first pyramid, the step pyramid at Sakkarah (CASSON, 1965). In subsequent centuries he underwent deification to become the Egyptian god of medicine. The first ophthalmologist recorded in history is lry who is identified in the large limestone slab discovered at the tomb near the great pyramid of Cheops which indicates he lived in 2400 B. C. during the sixth Egyptian dynasty in which he was the Royal Oculist. In a very lengthy papyrus dating back to 1500 B. C. an ophthalmologist records his sophisticated knowledge of anatomy and describes many ophthalmological disorders, but strabismus is not mentioned, and the only reference to surgery is epilation for trichiasis. In the fourth book of Homer's Odyssey, of approximately 750 to 700 B. C., Egypt is described as a country swarming with physicians and specialization is wide-spread since, according to his poem some treat diseases of the chest, other diseases of the head, and so forth. The first known Chinese medicine developed with the civilization that flourished along the Yellow river in approximately 1000 B. C. during the Chou Empire. Little is known about the Hindu culture and its early medicine in general, and ophthalmology in particular, that developed in the Indus valley. However, early Hindu medicine was mostly folk-lore suggesting knowledge was infused into the people by God bringing it down to earth. The great advance in medicine begins with Greek culture that first developed between 1600 and 1200 B. C. centered at the city of Mycenae as an outgrowth of the still older Minoan brilliant civilization of Crete which dominated the Aegean from about 1600 to 1400 B. C. (~OWRA, 1969). Inscribed on clay tablets in a script only recently deciphered is a listing of more than one hundred Mycenaen occupations of which 'doctor' is one. But one of the principal Mycenaen businesses was war and piracy. On one long drawn-out expedition they laid siege to the city of Troy in the war which legend said was fought for a stolen princess, Helen, that lasted ten years. And then, less than a century later, this vigorous, splendid civilization came to a terrible end. It was obliterated 302

by successive invasions of far less civilized Greeks from the North, called Dorians. For four hundred and fifty years, between 1200 and 750 B. C. the Greek world passed through a Dark Age as the tightly organized Mycenaen society was all but totally disintegrated by the Dorian assault. A few remnants of Mycenaen culture remained - one being in Attica clustered around the small town of Athens. Athens held off the Dorians and was able to give refuge to fellow Mycenaens fleeing the invaders. In the crowded city were preserved elements of the splendid past on which a glorious future would some day be built. In the meantime the Dorians settled at Sparta and organized it as a military camp. Both Athens and Sparta flourished and the stage was set for the important roles each would play in the rise and fall in the great Greek influence on early medicine. Athens and Sparta represented opposing philosophies in Greek life - intellectual and political freedom against stern, military dJiscipline. Soon the population of Athens increased and the solution was to colonize the Aegean islands - these colonies came to be called Ionia. Like all expatriates, the Ionians were extremely conscious of the ties with the homeland. They kept the gods and ceremonies and social systems that they had brought with them. Most important of all, these hardy people had a natural drive to establish various sciences. These Ionians ascribed a form of deity to Aesculapius who is described in Homer's Iliad as a fearless physician. But eventually, Aesculapius became the Greek god of medicine to the Greeks like lmhotep to the Egyptians. According to legend Aesculapius was the son of Apollo by Coronis. Later, he was accused by Pluto of depopulating Hades and slain by a thunderbolt from Zeus lest his healing activities would make man immortal and divert the ceaseless stream of mankind from the field of the living to the regions of the dead. The Ionian culture terminated with their defeat by the Persians in the sixth century B. C. The city state of Athens eventually defeated the Persians in 480 B. C. and this ushered in the Golden period of Greece that lasted until 330 B. C. Some of the priests of Aesculapius, who until this era were considered to be direct descendents of God, disclaimed this; left the temple worship of medicine and began to apply objective techniques in their observations and practice of medicine. Medicine now was removed from the control of the priests and no longer relegated to the level of magic and supernaturalism. Hippocrates of Kos, 460 to 375 B. C. has inherited the title of 'Father of Medicine' for under his tutelage medicine first became devoid of ritualism and was established as a science based upon adequate observation. For the first time medicine acknowledged the unknown; diagnosis, prognosis, and therapy were put on a logical footing. Hippocrates described strabismus and differentiated it into comitant and non-comitant. However, Hippocrates was limited by his absence 303

of knowledge of anatomy. Hippocrates was still under the influence of Pythagoras who lived in the century preceding him. Pythagoras, the great mathematician, left his island home of Samos in the Aegean to establish his School of Philosophy at Croton in the Greek colonies of southern Italy. Students of the Pythagorean School formulated a theory of the four humours which seems to be a theory well-rounded with the four elements of the world and the four sacred colors of alchemy. The four elements of the world were fire, air, water, and earth. The four sacred colors were red, yellow, black, and white. The four burnouts of the body that matched the four sacred colors were blood, yellow bile, black bile, and phlegm. According to predominance of either a patient was described as sanguine, choleric, melancholic, or phlegmatic. The diseases observed and described by Hippocrates were discussed in terms of a deficiency or excess in one of the four humours. The brain was described only as a seat of nervous activity. Anatomy was discouraged because the human body was considered sacred demanding a proper burial with the same ritual provided to friend and foe so the dead would find rest and leave the living unmolested. This philosophy remained until Plato, 427 to 347 B. C. introduced the concept of the soul and body being separate entities and gradually as his teaching was perpetuated through his students the sacredness of the human body was lost allowing dissection to become possible. By the time Plato's philosophy was disseminated Greece was in intellectual decadence as a result of Athens defeat by the militant Spartans. The thrust of each of these great and opposing philosophies was destroyed by their prolonged conflict and new Greek leadership came out of Macedonia. Alexander the Great took over the rule of Greek City States upon the death of his father, Philip, in 336 B. C. This youthful leader, imbued with the love of Greek art, poetry, philosophy, and science by his boyhood teacher, Aristotle, conceived a Greek political system that embraced the whole world. He was liberal with his name and among the cities he founded were no fewer than sixteen Alexandrias. Most of them were built from the foundation up. The first and most famous one was the Egyptian city which became not only the center of the Hellenistic world, but also the new center of Greek scientific activity. The medical school was founded in Alexandria in about 300 B. C. This great school flourished for 300 years under the direction of the Ptolemies spawning extraordinary advances in the knowledge of anatomy and pathology. Hundreds of condemned criminals were dissected alive and the movements of their organs observed. But the enormous surge of academic progress died with the death of Cleopatra in 30 B. C., the last of the Ptolemies, since Egypt then became subject to Rome. Rome had nothing to compare with the sophisticated knowledge stored in 304

the vast Hellenistic school, museum, and libraries in Alexandria. ][--Iowevel, Rome did respect the Greek physicians, even conferring citizenship upon them in the Imperial City. But unfortunately, the Roman decree that dissection of the human body was not premitted removed the primary factor that allowed the advance of medical knowledge to continue. Still worse was the total destruction of the 750,000 documents purported to be in the Alexandria medical school libraries when Roman authority asserted itself. In 48 B. C. Cleopratra presented Julius Cesear a gift of 40,000 books from the school but the Romans destroyed them by setting fire to the Egyptian ships while still in the harbor. The medical school continued at Alexandria but two fires in 272 and 295 A. D. took their toll of manuscripts. Alexandria was captured in 641 by the Mohammedans who kept the baths of the city warm for six months burning the treasurers of knowledge accumulated in this center over a period of 900 years. We are entirely dependent upon Roman and Arabic writers to convey to us the concepts contained in the destroyed original manuscripts of the Hellenistic medical library in Alexandria. A Roman writer named Celsus, 25 B. C. to 50 A. D. provides the oldest source in his book entitled 'De Medicina'. A most interesting and prolific writer was Galen, 130 to 200 A. D., who wrote a complete treatise on medicine including ophthalmology. Unfortunately, Galen's original ophthalmological writings were lost but through the Arabic translation of this work, which in turn was retranslated back into Latin by the Dominican monk Constantinus Africanus (1018-1085), a scholar of the first medical school in Europe located in Salerno, Italy, a third hand source of this work is available. Galen was the physician for Emperors Marcus Aurelius and Commodus. Galen's writings are criticized because of a glaring propensity to speculate answers to matters about which he had no information. Unlike Hippocrates who openly admitted the unknown in medicine, Galen admitted no~Lhingwas unknown and for every problem he supplied an answer. Also, medicine and the supernatural were rejoined through his theocratic writing style which probably is the reason for his book's wide acceptance as medical dogma, for the next 1000 years finding appeal to both Islam and Christendom. Concerning the subject of strabismus one finds only related material such as descriptions of the tendonous spread of the ocular muscles and of the corneoscleral junction. His lack of human dissection is manifest by the description of seven extraocular muscles including the six normally found in humans plus the retractor bulbi found in lower vertebrates. With the decadence of Rome and the upsurge of Christendom further advance in medical knowledge was interrupted for centuries. For the Christian the human body was unimportant and unworthy of one's devotion. Disease 305

was considered a manifestation of the wrath of God and the diseased was expected to appeal to Heaven rather than to a physician. Rome fell in 455 so the Teutonic barbarians and the dark ages settled over Western Europe. The Eastern Byzantine empire continued for a time longer along with the Hellenistic medical school in Alexandria. Two Byzantine medical writers, Aetius of Amida, 502 to 575, and Paulus of Aegina, 625 to 690, document the level of knowledge in the Alexandria medical school just prior to its final destruction by the Mohammadans. Mohammad died in 632 and within seven years his fanatical followers had succeeded in putting together an empire stretching from India through the Middle East, across North Africa, and up into Spain. After the initial wave of destruction the Caliph successors of the prophet seriously attempted to reassemble and utilize the classical Greek knowledge in mathematics, astronomy, and medicine. Baghdad, Damascus, and Basra, in Asia; Cairo, Tunis, and Fez in Africa; and Cordoba, Toledo, Seville, and Granada in Spain became great centers for Arabic scholastics. Cordoba became the most enlightened and prosperous of all the Arabic cities and during the eleventh and twelfth centuries the streets were paved and illuminated while those of Paris and London were still muddy and dark 700 years later. Cordoba had seventy libraries and compulsory education for children but despite this enormous enlightenment the Arabic culture contributed little in the way of original development in the overall field of medicine, however, there were a few noteworthy contributions made in the field of ophthalmology. Historians agree the most significant Arabic contribution was collecting and preserving the great classical Greek knowledge that it originally attempted to destroy so thoroughly. By the mid thirteenth century the Arabic empire was destroyed in the West by the Christian nations and in the East by the Ottoman Empire. Ophthalmologically the Arabic epoch gave us the aspiration operation for cataract, as described by Ammar. Alhazen, 965 to 1038, reshaped the field of geometric and physiologic optics; first described both the dioptrics of the eye and the law of reflection; i.e., the angle of incidence equals the angle of reflection, lbn Rushe proved the retina to be the visual receptor instead of the lens which formerly had been attributed as the center of sight. One cannot depart from the Arabic era without commenting about Avicenna, 980 to 1038, whose writings ranked with Galen for authoritativeness at the time the Renaissance in Europe took up from where the Arabic influence left off. The two portals of entry of intellectual knowledge into Europe at the beginning of the Renaissance were through Salerno, Italy and Toledo, Spain, the latter falling in 1085 from the Moorish Caliphate into Christian hands. Chris306

tian kingdoms soon established libraries in Toledo and scholars flocked from all over Europe to study Moslem literature. For two centuries a major task of the scholars was to translate Arabic texts into Latin, accomplished principally by Spanish Jews previously expelled from Moslem centers of learning. In Salerno Constantinus Africanus, the Carthaginian monk, first used the word 'cataract'. Other writers wrote on ophthalmology including Peter the Spaniard 1210 to 1276, a Portuguese physician who became Pope John XXI. At the beginning of the fourteenth century, Roger Bacon the Franciscan friar at Oxford, and John Peekham, an Archbishop of Canterbury, wrote on the anatomy of the eye and optics, but it was principally a restatement of the old tenents of the Hellenistic school transmitted through Arabic and Latin sources. Leonardo Da Vinci 1452 to 1519 the Florentine artist, scientist, and engineer, made beautiful anatomical drawings in perspective for the first time but they remained largely unknown because of an inability to reproduce them. In 1467 at Strasbourgh, medical writings were first printed and this revoluntionized ~the dissemination of information among universities. Andrea Vesalius, 1514 to 1564, a native of Brussels, also a professor of medicine at the University of Padua, reproduced DaVinci's perspective anatomical drawings by using wood-cuts, providing a significant step forward in teaching techniques. The Sixteenth century seemed to be the beginning of a movement ro understand and treat strabismus.* Ambroise Pare, 1509 to 1590 advised wearing a mask before the eyes to straighten them (DUKE-ELDER, 1949). The mask covered the inner canthi of esotropes and presumably covered the outer canthi of exotropes. Paulus of Aegina in the seventh century had advised the same treatment but it was not known whether Pare was aware of this. Pare attributed strabismus to the malposition of the infant in the cradle or possibly to imitation of the nurse by the child. But an intriguing concept that received wide acceptance for more than a century was presented by de la Hire, 1640 to 1718, who explained strabismus as a result of the most sensitive portion of the retina being eccentrically displaced to an abnormal position, shifting the visual axis accordingly. As late as 1826 Johannes Muller elaborated the ideas of de la Hire, attributing strabismus to this reason. Interest in explaining the nature of single binocular vision first began to appear during this time and it was for such a genius as Isaac Newton, 1642 to 1727 to clearly enunciate the thesis that a partial decussation of optic nerves

* Vol. IV, 1949 edition of DUKE ELDER contains an excellent section on the early history of strabismus, particularly pages 3808 to 38 t 2. Much of the remaining historical portion of this manuscript is taken from this text. 307

must occur in the chiasm in order to supply single subjective impressions to the binocular visual act. Newton, not an anatomist, merely reasoned that the optic nerve fibers from the nasal retinas must decussate for the accomplishment of single binocular vision. His speculation was taken up by one of the greatest charlatans of all time - a half quack, and half surgeon, and certainly a bombastic showman and rapacious financier - by the name of Chevalier John Taylor 1703 to 1772. 6EORGE COATS (1933) writes: 'In the eighteenth century ophthalmology had not yet vindicated, in England, its position as a separate branch of practice. It was the province of a set of ambulant practitioners who toured the country accompanied by all the apparatus of shameless advertisement, including monkeys, we are told, couching cataracts, and selling infallible salves and eye washes. This taint of quackery appears to have deterred respectable surgeons from meddling much with the subject; their operative experience was probably small, and the procedure of couching, attended frequently with brilliant immediate, but disastrous after results, was likely to be performed with fewer scruples by intinerant oculists, here today and gone tomorrow, than by settled practitioners who had to abide the consequences of their handiwork. Among these travelling quacks the name of the Chevalier Taylor stands preeminent for unblushing effrontery, blatant self-laudation, and all the methods of the charlatan, but also for mental endownments far above the average of his time, and for a real acquaintance with the contemporary state of ophthahnic knowledge. His fame extended to every country in Europe; his boast of having conversed with kings and princes is no idle one; he had an acquaintance, not always felicitous, with some of the best-known men, medical and lay, of his time; counting translations and minor works he was the author of nearly fifty books.' COATS continues, 'Chevalier's entry into the towns which he honored with his sojourn was scarcely that of a thief in the night. His arrival was accompanied and presumably preceded by showers of leaflets, placards, and advertisements in the public press. In what he called a 'crisis of grandeur' he traveled with no less than eight coaches, ten livery servants, beside gentlemen and companions in his pay. His coaches were painted over with eyes. The spectators who flocked by tens and hundreds to see him were gratified by the sight of his valuables, his magnificent array of instruments glittering with gold, his portfolios of public and private testimonials. In the morning he treated patients, in the afternoon he performed operations and gave demonstrations; and on Sundays and other days he delivered special lectures, such as he had given before all the crowned heads and learned societies of Europe, in praise of the eyes, its beauties, the art of reestablishing and preserving vision. To his lectures 308

and also to his demonstrations and operations the nobility, gentlemen, ladies and most especially the faculty were invited.' In his theoretical views on squint Taylor was certainly in advance of his time; indeed, some of his doctrines have an astonishingly modern sound. He claimed squint was nothing but a misdirection of the axis of the eyes on looking at objects. He disagreed with his predecessors - with St. Yves, who held that the condition was the result of a too great convexity on one or other side of the center of the cornea; with Ferrein who hypothecated an oblique position of the lens and with Porterfield who combined these two explanations. All these as well as de la Hire's view that the most sensitive part of the retina is situated somewhere not on the normal optic axis, according to Taylor lacked confirmation. His concept of single binocular vision being responsible for diplopia in strabismus was evolved from Newton's speculation of the decussation in the chiasm of the optic nerve fibers from the nasal retinas. His concept of suppression occurring in young people with squint, eliminating diplopia is remarkable for his time. It is unfortunate that the first attempt at squint surgery was performed by a person of such questionable character. Taylor's operation consisted of taking up the fold of the conjunctiva toward the inferior part of the globe by means of a needle threaded with silk, cut it off with scissors, clasp a plaster on the sound eye, and the squinting eye would come straight. His explanation for the squinting eye coming straight by this procedure was that the squint was due to a loss of equilibrium of the muscles and in order to reestablish it, the over-powerful muscle must be weakened by dividing one of its nervous filaments of supply. This seemed to be an alteration from his initial story that the suture served to fix the globe while he divided the muscle. Apparently, he had originally conceived the idea that dividing the muscle could cure the misalignment but became convinced the operation was impractical. Therefore, in order to not lose his dishonest emolument - he devised the fraudulent procedure described. Taylor knew well also that on covering the sound eye the squinting eye came straight. This observation is said to ~havebeen made frst in 1722 by St. Yves but apparently it was not generally known and Taylor's unscrupulous cleverness is shown by the manner in which he exploited it for the destruction of the public. The patient was instructed to keep the sound eye covered for five days before uncovering it and Taylor had always moved on to the next town by the fourth day. However, be that as it may, the proposal to divide a muscle for squint slumbered for nearly a century. William Gibson of Baltimore, first professor of surgery at the University of Maryland and later at the University of Pennsylvania unsuccessfully experimented with this operation in 1818 but abandoned it (}IUBBELL, 1908). In 1838 309

Strohmeyer in Hanover performed the procedure on a cadaver but in 1839 Johann Friederick Dieffenbach of Berlin performed successfully a myotomy on a living subject (DUrCE-ZLDER, 1949). The inspiration for this procedure was the tenotomy of the Achilles tendon for relief of club foot which was first performed by Dulpech in Europe in 1816. Soon after Dieffenbach published his operation for strabismus surgeons in Europe and America caught the enthusiasm and published their results and techniques for this procedure. John Dix of Boston was the first in the United States to perform Dieffenbach's operation and in 1841 both he and Alfred Post of New York individually published a small book on this subject (HUBBZLL, 1908). Dix's book was entitled 'A Treatise on Strabismus, or Squinting, and the New Mode of Treatment'. Post's text was entitled 'Observation and the Cure of Strabismus', with an appendix on a 'New Operation for the Cure of Stammering'. Guerin of Paris in 1842 and Bolton of New York in 1843 also published treatises on the myotomy but eventually the extensive disturbance of the local tissues, gross over-effect, and frequent cellulitis which followed resulted in abandonment of the procedure. Von Graefe changed the operation to a partial tenotomy in 1861 and simultaneously devised the advancement operation to correct the over-effects produced by the earlier surgeons who had performed the tenotomy (OU~E-ELDER, 1949). Hence, the recession and resection procedures were born and other than refinements in technique and instrumentation nothing revolutionary has been added. Amblyopia was first treated by George L. de Buffon in 1743 who covered the sound eye and furthermore suggested the use of glasses for the weaker eye. And so it remains that anablyopia therapy has changed practically nil since de Buffon's suggestion in 1743. Orthoptic programs begun in the 1930's and pleoptic techniques begun in the 1950's have not displaced the dependence upon the fundamental occlusion treatment outlined by de Buffon. The cause of strabismus continued to intrigue the nineteenth century ophthalmologists. Dieffenbach's emphasis he promulgated in 1840 concerning the etiology of strabismus due to a vague disturbance of the extraocular muscles was in part refined first by Bohme in 1845 and later by von Graefe in 1854 who both suggested that accommodation caused the medial recti to over-contract. However, MacKenzie in 1854 introduced another vague concept claiming the cause of squint was not to be found within the muscle of the eyes, nor the retinas, but in the brain and nerves that control the eye muscle contractions. Hence, four avenues lead from the etiology circle of strabismus shortly after the middle of the nineteenth century. The student could accept a mechanica l disturbance within the extraocular muscles as the cause, the abnormal retinal 310

projection thesis, the theory that the medial recti contract secondary to accommodation, or the vague concept that the innervational dispatch to the ocular muscles was disturbed. Collectively, all four etiologies have been proven to have merit in the multiple etiologies of strabismus, but a century ago it was vogue to choose that concept that either appealed most, or that one was taught, rather than consider all. Donders of Utrecht in 1863 moved the accommodational theory well along by his total presentation of the mechanism of accommodative esotropia including its treatment with plus lenses. Soon, this component of strabismus became recognized by all and spectacles were established as a routine in the therapy of hypermetropic esotropes. But accommodative esotropia became wedded to hypermetropia in the minds of successive generations of clinicians and even though Alexander Duane in 1896 differentiated his various categories of comitant squint based on different quantities of deviation at distance and near; i.e., convergence excess, convergence insuff• divergence excess, and divergence insufficiency - the abnormal relationship between accommodation and accommodative convergence was not appreciated as the patho-physiologic explanation for these distance and near measurements. Control of Duane's convergence excess with additional plus lens power for near became accepted by a few in the 1930's but the natural evolvement of prescribing bifocals for this condition was as strictly American as Ben Franklin's invention of the bifocal in 1784. Surprisingly, this therapy was regarded with disdain by the British and other European oculists until the mid 1950"s who claimed esotropia at near was properly managed surgically and expressed fear that bifocal wearing children would become premature presbyopes. Moreover, not until 1952, eighty nine years after Donders so clearly identified hypermetropia as the cause of accommodative esotropia, was the high AC/A also described as an etiologic factor ranking equally in importance alongside hypermetropia in producing this disorder. In the 1940's various American ophthalmologists had unsuccessfully experimented with the use of conventional miotics available for glaucoma therapy, such as pilocarpine and eserine, to treat accommodative esotropia. But children experienced annoying visual and discomfort symptoms produced by accommodative spasm which caused the failure of this attempt. In the early 1950's long-acting anticholinesterace drugs became commercially available and with proper dose titration the ciliary muscle spasm was avoided but the transmission of acetycholine at the myoneural junction of the ciliary muscle fibers was sufficiently potentiated to alter the AC/A favorably, offering a revolutionary therapeutic approach to accommodative esotropia. An imposing figure in the nineteenth century was Javel who between 1868 311

and 1896 logically argued for the central disturbance in the etiology of strabismus and totally rejected the concept that the extraocular muscles were primarily at fault in causing the strabismus. He introduced a treatment known as orthoptics utilizing the stereoscope invented by Wheatstone in 1835 (LEBENSO~N, 1969). His hope was to reeducate the patient's single binocular vision intending to influence the ocular alignment, eradicating strabismus. Parinaud in 1899 embraced this concept and finally in 1903 Claude Worth put forth his fusion theory of squint (DUKE-ELDER, 1949). Louis Emile Javal, 1839 to 1907, is identified as one of the great people in establishing the discipline of orthoptics. It was his firm conviction that strabismus problems could be overcome by a training program, using the surgical approach as an aid in the treatment. He was the first director of the laboratory of ophthahnology established in the department of physiology at the Sorbonne where he was surrounded by others who joined him in the name of Schiotz, Tscherning, Landolt, and Nordenson. Unfortunately, at the age of sixty two he became completely blind from glaucoma despite surgical attempt to control his disease. The therapy he introduced in the form of orthoptic exercises became a matter of much controversy. The public was originally attracted to this exercise program because of a desire to avoid surgery but disenchantment resulted principally from the inexperienced attempting to correct a deviation that only surgery could alter. Therefore, the exercise therapy fell into disrepute, but was revitalized around 1919 by E. E. Maddox in London. Maddox, and his daughter M. C. Maddox, the first orthoptist (LYLE & JACKSON, 1937) introduced a more scientific and moderate approach. F r o m this small beginning came a large group of specialized technicians well founded in ocular motility, spread from England to many other European countries, the United States, Canada, all of Latin American, and Australia as a bonafide auxiliary of the ophthalmologist in strabismus management. However, a large portion of both ophthalmologists and orthoptists, primarily through lack of knowledge about the limitation of orthoptics misapplied it in the past and continue to misuse it up to the present time. There is no question that orthoptics can train the strabismic patient to overcome suppression and abnormal retinal correspondence. But the important question remains, 'Is this therapy essential for a successful result in the overall strabismus care?' Orthoptics has been unable to convince all ophthalmologists who critically follow their patients for many years that such tedious therapy significantly improves the outcome of strabismus care. Concerning fusional vergence amplitude therapy all agree there is no substitute for its benefit in convergence insufficiency but the value of antisuppression and abnormal retinal correspondence therapy in strabismus is still open to question 312

and no matter what one's opinion is of its value, the therapy is tedious. One cannot help being impressed with Javal's remark made in 1896 when he was much wiser than in 1868, that he agreed with yon Graefe who, in the early days of Javal's enthusiasm for vision training, had said that people were not worth so much trouble. In light of such equivocal results the present day ophthalmologist still asks the same question, 'Is the hardship of orthoptically treating the strabismus patient's A R C and suppression worth all the trouble involved?' During the past quarter century, and with increasing tempo during this decade, a subtle but ever-increasing emphasis has been placed on initiating early strabismus therapy, including early surgery. A change in attitude among many ophthalmologists is apparent regarding their willingness to examine and treat strabismic infants and young children in North America and maLny other places. A high degree of interest currently is displayed in the pediatric approaches to ophthalmology. Acceptance of the concept of early strabismus surgery is probably responsible for the decline in doing pre and postoperative orthoptic therapy for the strabismus sensorial adaptations similar to the early detection and occlusion therapy for amblyopia making pleoptics nearly unnecessary. The reward that comes from belaboring the historical development of ophthalmology, with special attention to strabismus management, is to indulge in the luxury of speculating about the future. Early strabismus care probably will be rendered more thoroughly than it presently is - all children receiving treatment within days of onset in acquired strabismus and within months of life in congenital strabismus. Pediatricians and the public will demand this as the sophistication of their knowledge of this disorder increases. The basic treatment of strabismus will continue around the three main pillars of surgery, antiaccommodation therapy, and occlusion. The techniques, tools, and drugs will be improved - but the need for these three therapies, properly coordinated, will remain. Atraumatic surgical techniques that cause no scarring will allow multiple procedures on the muscles with repeat surgical intervention on the previously operated muscles being no more difficult than the initial surgery. Sutures will probably be replaced with adhesives, anesthesia accomplished with safer and less debilitating drugs, and postoperative inflammation suppressed entirely with medication. Antiaccommodation therapy probably will contine to be primarily optical rather than medical, although undoubtedly better drugs will become available than the current ones. The soft contact lens is awaited with great anticipation since it is conceivable that totally safe and comfortable contact lenses may be applied that need not be removed. What a boon this will be to the ophthalmologist who today must contend with the youngster who lets his glasses slip 313

down and persists in looking over the top. Probably bifocals will vanish as miotics will be used with soft contact lenses for the high AC/A patients. Occlusion will be aggressively pursued until at least nine years of age and probably will be almost entirely accomplished with the occluder contact lens. Amblyopia will not vanish like typhoid fever, but it will become the unforgiveable sin to allow it to remain undetected and untreated. Prism therapy will not replace surgery but eventually the superb advances made recently in the thin prisms may be adopted to contact lenses and in certain disorders they could render temporary or permanent benefit. Orthoptic therapy of suppression and ARC will probably become history but fusional vergence therapy will continue. The main-stay of ortboptics will be in the diagnostic rather than therapeutic. A technical assistant to the ophthalmologist will become increasingly important in all fields and the orthoptic benefit in the diagnostic area of ocular-motility problems will not diminish. In fact, the orthoptist's role in educating residents in motility diagnostic methods will increase because attending ophthalmologists neither have the time nor the patience to teach this skill. And presuming the ophthalmic assistant's program becomes wide-spread the orthoptist will teach the orthoptic portion of this program. Therefore, the orthoptist survival is assured if they become educators teaching ophthalmology residents and ophthalmic assistants - plus providing a superior diagnostic service to a community of ophthalmologists, doing fusional -

vergence therapy, and managing amblyopia follow-up care. Finally, I wish to record my recognition of the underlying force that has permitted our clinical advances in the field of strabismus to come so rapidly for without the disciplines of the multiple overlapping basic sciences working, both individually and collectively, but always relentlessly, there would be no new concepts to apply clinically. But the flow of benevolence is by no means one way - from the labors of basic science to the benefit of the patient and clinician, for the justification of the luxury of a basic science structme is the clinical problem posed by the patient to the clinician. So long as our clinicians remain like Hippocrates, admitting to the unknown, or that there possibly is a better method, there will be a dedicated basic science support striving to reduce the enormous quantity of the unknown and forever seeking a better method.

REFERENCES

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Ophthalmology in England prior to the Year 1800, p. 132219, Cambridge, at the University Press (1933). DUKE-ELDER, W. STEWART. Textbook of Ophthal. Vol. IV pgs. 3808 to 4199, C. V. Mosby, St. Louis (1949). - - - - System of Ophthal. Vol. II p. 5, C. V. Mosby, St. Louis (1961). HUBBELL, A. A. The Development of Ophthalmology in America 1800 to 1870, W. T. Keenes & Co., Chicago (1908), LEBENSOn~, J. E. An Anthology of Ophthalmic Classics. Williams & Wilkins, Baltimore (1969). LYLE, T. K. & S. JACKSOn. Practical Orthoptics in the Treatment of Squint, London, H. K. Lewis & Co. (1937).

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