ACTA OPHTHALMOLOGICA VOL. 40 1962

From the University Eye Clinic, Rigshospitalet, Copenhagen (Head: Professor H . Ehlers, M . D.)

PLEOPTIC TREATMENT OF REMAINING EYE IN FATHER AND SON")

Exercises Us ing T. 1'.

BY

Eil i f Gregersen

Pleoptic t reatment of t he remaining o r only eye poses cer ta in special problems and indications. It seems justif ied, therefore, t o report cursorily two cases a n d their management.

A f a the r and son had been submitted to enucleation of their good eye because of perforat ing injuries. Both have amblyopia of t he remaining eye. in the father 's case because of anisometropia and in the son's case because of strabismus.

F A T H E R S C A S E H I S T O R Y

The father (case rec. 638/62) had never had strabismus, but from childhood he had had severe amblyopia in the right eye. The left eye had been moderately myopic from youth, but with glasses the vision in this eye had always been normal.

In 1953, when 36 years of age, he sustained a perforating injury to his good, left eye which was enucleated in the local eye department. Allegedly, the vision in the amblyopic, right eye improved somewhat spontaneously during the first two years after the enucleation, but thereafter the vision in the eye had been stationary.

Vision in right eye: 3/60-3/36 + 4.0. Prosthesis in the left orbit. The star test by the visuskop showed the fixation of the right eye to be unsteady foveal. Investigation by the co-ordinator also indicated foveal amblyopia, the patient all the time seeing Haidinger brushes in the centre of the test picture or the test letter.

Slit lamp investigation and ophthalmoscopy of the right eye normal. Outer limits of the visual field and tests of colour sense by Ishihara's plates also normal.

When seen here this year he showed the following findings:

S O N S CASE HISTORY

The son (case rec. 576162) is suffering from strabismic amblyopia in the right eye. His strabismus was stated to have started in infancy. He was first seen by an ophthal-

'>) Received May 24th 1962.

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mologist at the age of 9, when he was furnished with spectacles. At that time, his vision in the left eye was normal, while the right eye was severely amblyopic. In 1961, at the age of 13, he sustained a perforating injury to his good left eye which was enucleated in the local eye department.

On admission here in February 1962, 2 months after the enucleation of the good eye, the findings were: Vision in light eye: 6/60-3/56 + 7.0 sph., not improved with cyl. Anophthalinos on the left (after enucleation).

Fhe star test with the visuskop showed that all the time the boy fixed in a retinal site about 2’ nasal to the fovea. In other words, he has in this site a false fovea or eccentric fixation. When investigated by the co-ordinator accordingly, the boy saw Haidinger brushes situated somewhat nasal to the test picture or the test letter which he perceived only with his false fovea.

Slit-lam]) study, ophthalmoscopy, and outer limits of the visual field showed normal conditions. The boy had an incomplete red-green colour blindness. Adaptation curves showed that his vision in the dark was on the border of normal.

T R E A T M E N T A N D COURSE Father:

As already mentioned, the father lost his good lef t eye 9 years ago, a t the age of 36 His right eye h a d from childhood been severely amblyopic because of anisometropia.

During the past 9 years, since the loss of t h e good eye, the , t r ia l a n d error<< of everyday life had acted as a kind of pleoptic treatment of the patient’s onIy, amblyopic eye. H e also reported that the vision i n this eye had become somewhat better during the first two years of his one-eyed life, but that af ter that time the vision had been stationary.

In this patient’s present situation (9 years’ one-eyed existence, unsteady foveal fixation, and age 44 years) special pleoptic treatment will probably not per- manently improve the vision beyond the acuity of 3160-3136 to which the >,trial a n d errora of everyday life h a d trained the eye in the course of the past 9 years. In t h e father’s case, therefore, we found n o indication for ple- optic therapy.

Son: Oq admission the son had, as a l ready mentioned, eccentric fixation with a

visual acuity of 6160-3/36 + 7.0 sph. i n his remaining eye. Owing to the extra- foveal fixation, pleoptic treatment was absolutely indicated i n his case.

T h e pr imary object of this treatment was to establish normal foveal fixation and to abolish the false fovea. T o this end the boy was treated with euthyskop and co-ordinator by the method of Cuppers. The euthyskop therapy was some- what disturbed by his one-eyed situation which made i t difficult for him to keep the eye still dur ing the treatment which, nevertheless, ,was carried through successfully.

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y I

I I I

Fig. 1. Television set-up for the

treatment of eccentric fixation.

fixation (false fovea)

(c) .dazzling light* for false fovea (d) television set b a

In order further to stimulate the boy’s foveal visual functions and simultane- ously to abolish or weaken his false fovea, we resorted to television in a some- what special set-up (cf. Fig. 1).

By the .television treatmentr the fovea proper (a) is stimulated by the alter- nating and intermittent light from the television (d), while the extrafoveal site of fixation (b) is dazzled by a strong and constant light (c). The angle (v) is 2’, corresponding to the distance between the boy’s fovea and the site of extrafoveal fixation. The boy is intelligent and cooperative, and he understood that he was allowed to see the television only when he looked at the light (c) at the same time.

At the orthoptic clinic (orthoptist: E. Rindziunski) he had about one hour’s daily treatment with the euthyskop and co-ordinator and in addition a couple of hour’s daily training with television in the set-up described above.

The boy’s eye was kept in constant atropine mydriasis during the first weeks, and we took away his spectacles (+ 6.5 sph.) as soon as he was not in pleoptic training. His hypermetropia of + 7.0 and the atropine mydriasis without spectacles acted as a kind of occlusion and thus prevented him from using and maintaining his false fovea, when he was not in pleoptic treatment.

After a few weeks’ treatment the eccentric fixation had been abolished and foveal or unsteady foveal fixation was achieved. At this juncture, the boy was talking spontaneously of ,my old, skew direction of gazecc and ,my new direction of gazea.

After foveal fixation was established, the pleoptic treatment with euthyskop, co-ordinator, and television was continued. In addition, the boy was trained by a kind of Bangerter localizator and corrector exercises, partly by pointing exercises using Hess’ screen and partly by tracing letters in a copy book.

387 Acta Ophthalmol. 40, IV 27

Moreover, he had daily reading exercises, as his amblyopia included quite a considerable element of dyslexia. It may be mentioned, for instance, that unaccustonied types of figures and letters caused him considerably more trouble than other. smaller, but known types of letters and figures. I t was characteristic, moreover, that on the television his perception of animated cartoons was rela- tively pool, although the figures stood out sharp.

His visud achievements depended also to a marked extent upon the spacing of the letters and figures, the visual acuity being at a maximum when he was presented with a single figure or letter isolated in the centre of a chart (Ehlers’ wvisual capacity<< or the so-called >>angular<< acuity, or Stuart and Burian’s >>single Ea acuity. His ability to perceive correctly a whole line of figures or letters in a Snellen chart (Ehlers’ ,psychic capacitya or the so-called x o r - tical<< or >>inorphoscopic<< acuity or Stuart and Burian’s >>hellen<< acuity) was thus decidedly poorer than his ability to perceive an isolated figure or letter. In other words, he had a poor .function of separation<<.

After 6 weeks’ treatment the boy was discharged with considerable visual improvement. Ordinary Snellen acuity or >>corticala acuity (= ,psychic capa- city.) was increased to 6/24-6/18 + 6.5 sph., and the >>single Ec< acuity or >>angular<< acuity (= >>visual capacity.) had increased even up to < 6/12. With his distance glasses he could now read an ordinary text, when it was composed of relatively simple words and phrases. However, his reading was rather slow, as it was somewhat compromised by the element of dyslexia.

The boy was told to continue his daily reading exercises after discharge, and we have been in touch with his school asking for such special instruction. During the next few years, continued reading exercises and the ,trial and errora of everyday life will presumably train his vision further and make his visual acuity even somewhat better than on discharge from the Eye Clinic.

S U M M A R Y

Some problems regarding pleoptic treatment of the remaining eye in two patients (father and son) are discussed. As an aid in the treatment of eccentric fixation, we used, among other things, television in a rather special set-up.

REFERENCES

Bangerter, A : Amblyopiebehandlung. Bibliotheca Ophthalmologica 1953, fasc. 37 Ciippers, C.: Klin. Monatsbl. Augenh. 1956, 128: 236. - Klin. Monatsbl. Augenh. 1956, 129: 579. Ehlers, H.: Acta ophth. 1936, 14: 56. - A . M . A. i\rch. Ophth. 1953, 49: 431 Stuart, J. A . R. H . M . Burian: Am. J. Ophth. 1962, 53: 471.

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