COGGIN: Some Vagaries of Accommodation.
4429
SOME VAGARIES OF ACCOMMODATION. By D. COGGIN, M.D.
I. A CASE OF APPARENT AH. WHICH GRADUALLY PASSED INTO MYOPIA. April 24, i88o, L. F. G., a boy of nine years, sought advice because of pain in his eyes (more in the left) on reading music when playing on the violin. V. = -4 o. d. and - o. s. A.= IO, and V. = -6-50 o. u. Preferred + I D. cylinder axis horizontal o. s. and + .75 cylinder axis horizontal o. d. and V. =4 or 5-0 O. U. It being desirable not to take the boy from school, his accommodation was not paralyzed -at that time atropine being the available mydriatic -but the cylinder glasses referred to were ordered, and they gave relief. Both parents are am. Over two years later (August 28, I882) he was seen again. Recently, pain on using his eyes. Atropine (0.03 - 4.0) for four days. V. =-- o. v. + .50 D. c. ax. horizontal =-. Sept. 7th, V. = 4. A. = IO and V. =50. Horizontal line in Green's Dial perhaps the clearest; -.50 c. axis vertical corruts. To omit use of his + c. glasses as they tire. Eyes feel better. April 22, I883. Letters indistinct and lids twitch of late. V. = A o. u. After four days of atropine instillations, V. =-. To discontinue. May 8th, V. = 4 o. u. A. = 12 and V.-. 4o0 out lines in dial the blackest, but - .75 s. clears and is preferred to a cylinder. A zinc and boric acid lotion ordered for the relief of a conjunctivitis. June 22d, V. --4-.75 D =4 and dial clear, so gave -.75 glasses to use at will. Jan. I6, i886. For a month some dizziness, and letters waver on reading. V. =-. A = I2 and V. = . -.5 = 4, and prescribed for music and for distance. Is taking tonics and the like.
430
COGGIN: Some Vagaries of Accommodation.,
March 20, I887. Eyes still trouble him. Dyer's exercise, the use of prisms, etc., were all declined, so he was given a lotion containing cocaine and pilocarpine. June 2, I 889. The old story, if he uses his eyes. At present there is less accommodative strain, as the patient is out of o. u. - I.5 = 6. No corneal As. by shadowschool. V. test -my. only. It will be noticed that, unlike the cases of H. passing into M. that were reported before this society by Dr. Risley two years ago, this one first presented symptoms of Ah., which are, however, no longer present. It would seem as if, in this instance, there had been a partial contraction of both ciliary muscles (according to Javal and other observers), which produced a lenticular As. The frequency with which ordinary spasm of the accommodation is encountered-especially among school-children-and the rarity of cases like the one referred to in these notes, are .somewhat remarkable. (Since writing the above, a woman of twenty years sought treatment because of pain in her eyes when doing trying work in a woolen mill. V. 6 0. U. - 75 c. ax. vertical -45 and dial clear. After the use of homatropine V.= o. d. 5 . S. ± .75 o. d. and ±1.25 o. s.=. No As. Here, then, was an example of seeming Am., but which, on paralyzing the accommodation, was found to be H.) II. RECURRENT SPASM OF THE ACCOMMODATION. (H. O. d., MY. O. S.) Sept. 8, I887, G. R. N., aged 14 years, a Phillips Academy student, first came to me because of asthenopic symptoms.
V. -152 O. d. -ff51 O. S. Two years before, -i D. glasses had been prescribed for distance, with which his V. = 5 O. u. A. = I2, and V. = o5 O . it. Nose broad above-almost amounting to epicanthus. H. by shadow-test. No As. Homatropine hydrobromate (i-6o) failing to remove the spasm, atropine sulphate (0.03-8.) was ordered to be used morning and niht. Oct. I Ith, atropine instillation for three days and spasm less. V. = o. d. -15W o. s. To continue its use.
COGGIN: Some Vagaries of Accommodation.
431
Oct. 27th, noon, V. _ o. d. - o. s. Overcomes 8? prisms, base out. To relieve muscular fatigue, advised + .75 glasses to wear when studying evenings. July 2, i888. The + spherical glasses less restful of late. Is again unable to see off. V. = O. U. With -I. O. d. and I.25 O.
S.
V. = -5.
Sept. 8th, eyes have been atropinized for two weeks. V. - o. d. o.s. .5 = 5. s. No pain on studying since he began to wear the + .75 glasses. The refraction of the left eye being clearly myopic it was suggested that the + glass should be removed from the left side of the spectacle frame that he wore when studying. Oct. 6th, reported that he was doing well and that he preferred to study with, rather than without, the + .75 S. in front of his right eye. March 9, I889. Return of spasm, but unaccompanied by pain unless he goes without his somewhat unique monocular when studying. V. X o. d. -f5§ o. s. A. = I2, and V. 650Q o. d. A. = i6, and V. = -o50 s. .-.50= o. d. -i O. S. Ophthalmoscopic image is still H. of the right eye and My. of the left. The spasm of the right eye is less -though the use of the + glass has not prevented its return -as shown by the increased acuteness of vision and also by the weak negative glass that is required to neutralize it. Whether the refraction of the right eye will, like that of the left, eventually become My. is a question that can best be answered later. III. TEMPORARY ANOMALY OF SIGHT OCCURRING DAILY.
Feb. I2, I884, Miss S., aged 43, a private school teacher, presented symptoms of Pr. V. 4 o. u. No H. A. = 3, and V. = -5. + .75 D. = 2, and this number of glasses was ordered and afforded relief. Sept. I8, I888. For over two months, on closing her school at one o'clock, she had every day been unable to recognize people across the street, although she could see as well as ever before beginning her daily school work. OPH. -14
432
COGGIN: Some Vqgaries of Accommnodation.
She was in health, and was not feeling tired. V. = 5' o. u. No glasses help. Perforated disc = 6. No opacity in lenses. A zinc lotion ordered, there being a conjunctivitis. Oct. 4th, continues to see well only in the morning. Vertical lines in dial the brig-htest. No c. or s. glass improves vision. Of late, when tired, has seen double Dec. 3d, noon, V. with either eye covered or with both together, as in incipient cataract. Sees spectrum colors nights, occasionally. T. and field of vision normal. Dec. 4th, morning, V. A5 - after a night's rest. Jan. 5, I889. V. =15 May 29th, V. >. Gave 4 I.5 glasses for evening use -her old ones (+ .75) being insufficient for newspaper type. June 26th. When last seen, Miss S. had V. of 5- in the morning, and only of X about four hours later -no glass improving it. At five metres from Snellen's test-type she saw a second row of letters below, but in contact with, the true one, singly or with both eyes. A. = 4, being greater, apparently, than at any time when it was observed during five years. Though no ischoemia of the retinal vessels was detected, it is possible that prolonged use of the eyes may have occasioned what has been called anaesthesia of the retina. Still, it is to be noticed that, after correcting the Pr., the sight for near was not affected, nor was that for distance, on using the perforated disc. As before stated, the patient is in health and has not presented any symptoms of mental perversion. The double vision was not wholly unlike that seen in scotoma scintillans, but this lasted longer, and it was not followed by headache. Believing the trouble to be accommodative (due to exhaustion of the ciliary muscles), no special treatment was prescribed, and as the daily disturbance in sight is diminishing it is reasonable to expect that it will ultimnately pass away. (In fact, on the 6th instant, when Miss S. had enjoyed a week's rest, her sight, at noon, was i with both eyes.)
4429
SOME VAGARIES OF ACCOMMODATION. By D. COGGIN, M.D.
I. A CASE OF APPARENT AH. WHICH GRADUALLY PASSED INTO MYOPIA. April 24, i88o, L. F. G., a boy of nine years, sought advice because of pain in his eyes (more in the left) on reading music when playing on the violin. V. = -4 o. d. and - o. s. A.= IO, and V. = -6-50 o. u. Preferred + I D. cylinder axis horizontal o. s. and + .75 cylinder axis horizontal o. d. and V. =4 or 5-0 O. U. It being desirable not to take the boy from school, his accommodation was not paralyzed -at that time atropine being the available mydriatic -but the cylinder glasses referred to were ordered, and they gave relief. Both parents are am. Over two years later (August 28, I882) he was seen again. Recently, pain on using his eyes. Atropine (0.03 - 4.0) for four days. V. =-- o. v. + .50 D. c. ax. horizontal =-. Sept. 7th, V. = 4. A. = IO and V. =50. Horizontal line in Green's Dial perhaps the clearest; -.50 c. axis vertical corruts. To omit use of his + c. glasses as they tire. Eyes feel better. April 22, I883. Letters indistinct and lids twitch of late. V. = A o. u. After four days of atropine instillations, V. =-. To discontinue. May 8th, V. = 4 o. u. A. = 12 and V.-. 4o0 out lines in dial the blackest, but - .75 s. clears and is preferred to a cylinder. A zinc and boric acid lotion ordered for the relief of a conjunctivitis. June 22d, V. --4-.75 D =4 and dial clear, so gave -.75 glasses to use at will. Jan. I6, i886. For a month some dizziness, and letters waver on reading. V. =-. A = I2 and V. = . -.5 = 4, and prescribed for music and for distance. Is taking tonics and the like.
430
COGGIN: Some Vagaries of Accommodation.,
March 20, I887. Eyes still trouble him. Dyer's exercise, the use of prisms, etc., were all declined, so he was given a lotion containing cocaine and pilocarpine. June 2, I 889. The old story, if he uses his eyes. At present there is less accommodative strain, as the patient is out of o. u. - I.5 = 6. No corneal As. by shadowschool. V. test -my. only. It will be noticed that, unlike the cases of H. passing into M. that were reported before this society by Dr. Risley two years ago, this one first presented symptoms of Ah., which are, however, no longer present. It would seem as if, in this instance, there had been a partial contraction of both ciliary muscles (according to Javal and other observers), which produced a lenticular As. The frequency with which ordinary spasm of the accommodation is encountered-especially among school-children-and the rarity of cases like the one referred to in these notes, are .somewhat remarkable. (Since writing the above, a woman of twenty years sought treatment because of pain in her eyes when doing trying work in a woolen mill. V. 6 0. U. - 75 c. ax. vertical -45 and dial clear. After the use of homatropine V.= o. d. 5 . S. ± .75 o. d. and ±1.25 o. s.=. No As. Here, then, was an example of seeming Am., but which, on paralyzing the accommodation, was found to be H.) II. RECURRENT SPASM OF THE ACCOMMODATION. (H. O. d., MY. O. S.) Sept. 8, I887, G. R. N., aged 14 years, a Phillips Academy student, first came to me because of asthenopic symptoms.
V. -152 O. d. -ff51 O. S. Two years before, -i D. glasses had been prescribed for distance, with which his V. = 5 O. u. A. = I2, and V. = o5 O . it. Nose broad above-almost amounting to epicanthus. H. by shadow-test. No As. Homatropine hydrobromate (i-6o) failing to remove the spasm, atropine sulphate (0.03-8.) was ordered to be used morning and niht. Oct. I Ith, atropine instillation for three days and spasm less. V. = o. d. -15W o. s. To continue its use.
COGGIN: Some Vagaries of Accommodation.
431
Oct. 27th, noon, V. _ o. d. - o. s. Overcomes 8? prisms, base out. To relieve muscular fatigue, advised + .75 glasses to wear when studying evenings. July 2, i888. The + spherical glasses less restful of late. Is again unable to see off. V. = O. U. With -I. O. d. and I.25 O.
S.
V. = -5.
Sept. 8th, eyes have been atropinized for two weeks. V. - o. d. o.s. .5 = 5. s. No pain on studying since he began to wear the + .75 glasses. The refraction of the left eye being clearly myopic it was suggested that the + glass should be removed from the left side of the spectacle frame that he wore when studying. Oct. 6th, reported that he was doing well and that he preferred to study with, rather than without, the + .75 S. in front of his right eye. March 9, I889. Return of spasm, but unaccompanied by pain unless he goes without his somewhat unique monocular when studying. V. X o. d. -f5§ o. s. A. = I2, and V. 650Q o. d. A. = i6, and V. = -o50 s. .-.50= o. d. -i O. S. Ophthalmoscopic image is still H. of the right eye and My. of the left. The spasm of the right eye is less -though the use of the + glass has not prevented its return -as shown by the increased acuteness of vision and also by the weak negative glass that is required to neutralize it. Whether the refraction of the right eye will, like that of the left, eventually become My. is a question that can best be answered later. III. TEMPORARY ANOMALY OF SIGHT OCCURRING DAILY.
Feb. I2, I884, Miss S., aged 43, a private school teacher, presented symptoms of Pr. V. 4 o. u. No H. A. = 3, and V. = -5. + .75 D. = 2, and this number of glasses was ordered and afforded relief. Sept. I8, I888. For over two months, on closing her school at one o'clock, she had every day been unable to recognize people across the street, although she could see as well as ever before beginning her daily school work. OPH. -14
432
COGGIN: Some Vqgaries of Accommnodation.
She was in health, and was not feeling tired. V. = 5' o. u. No glasses help. Perforated disc = 6. No opacity in lenses. A zinc lotion ordered, there being a conjunctivitis. Oct. 4th, continues to see well only in the morning. Vertical lines in dial the brig-htest. No c. or s. glass improves vision. Of late, when tired, has seen double Dec. 3d, noon, V. with either eye covered or with both together, as in incipient cataract. Sees spectrum colors nights, occasionally. T. and field of vision normal. Dec. 4th, morning, V. A5 - after a night's rest. Jan. 5, I889. V. =15 May 29th, V. >. Gave 4 I.5 glasses for evening use -her old ones (+ .75) being insufficient for newspaper type. June 26th. When last seen, Miss S. had V. of 5- in the morning, and only of X about four hours later -no glass improving it. At five metres from Snellen's test-type she saw a second row of letters below, but in contact with, the true one, singly or with both eyes. A. = 4, being greater, apparently, than at any time when it was observed during five years. Though no ischoemia of the retinal vessels was detected, it is possible that prolonged use of the eyes may have occasioned what has been called anaesthesia of the retina. Still, it is to be noticed that, after correcting the Pr., the sight for near was not affected, nor was that for distance, on using the perforated disc. As before stated, the patient is in health and has not presented any symptoms of mental perversion. The double vision was not wholly unlike that seen in scotoma scintillans, but this lasted longer, and it was not followed by headache. Believing the trouble to be accommodative (due to exhaustion of the ciliary muscles), no special treatment was prescribed, and as the daily disturbance in sight is diminishing it is reasonable to expect that it will ultimnately pass away. (In fact, on the 6th instant, when Miss S. had enjoyed a week's rest, her sight, at noon, was i with both eyes.)
