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Dedication
The gods split these creatures into two parts, creating male and female
humans. The belief is that each one of us, on a deeply subconscious level,knows that something is missing within ourselves, and we seek wholeness.
Rephrased from Plato, The Symposium
For Dale
My missing half
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Fig 1-2The letters used in one of the letter-matching tests. The examiner shows the
child a letter on a flip card on the left. The child holds the card on the right and
matches the same letter by pointing.
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Fig 2-1On the left is a cutaway view of an eye and on the right is a camera.
Lines connect similar components.
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6/''&$ ,0 62$ /0'/3$ ,D 62$ $#$ k 62$ %")0-$k K2/(2 /' 3$'(+/-$3 -$),K= A2$ 0%0#k 62$ F4+6 62463$6$+./0$' ,&+ $#$ (,),+ `-)&$? -+,K0? $6(=c /' 4 3,&:20&6 '24F$3 '6+&(6&+$ -$6K$$0 62$
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./33)$ ,D 62$ $#$? -$D,+$ 62$# D4)) ,0 62$ +$6/04= W0 )4# 6$+.' 62/' /' +$D$++$3 6, 4' -"$%#0E')"1=
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$X&4))# '24+F 403 ()$4+= W0 62$ $#$? 62$ :$&8/$/' 62$ ,0)# F4+6 ,D 62$ %")0-$6246 /' (4F4-)$ ,DF$+($/G/0: 40 /.4:$ 6246 /' '24+F$+ 6240 NOfNOO=
Fig 2-2A) The light rays coming from the sailboat fall on the fovea. The image of
the sailboat will appear sharp. B) The tree is not straight ahead of the eye, so it will
be seen with peripheral vision. The light rays coming from the tree fall on the
peripheral retinainstead of the fovea. It will not be seen a clearly as the sailboat in
Fig 2-2A.
/58 /7
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"*:0%#)* ;%2&5,0-
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Fig 2-4This shows the emmetropicor neutral eye. A) In the relaxed state it is in
sharp focus for distant objects. The sailboat would be seen clearly B) The image
of a near object would impinge on the retina of a neutral eye before it comes
into focus if the ciliary muscleis relaxed. The point at which the image would be
focused lies somewhere behind the retina. C) If the focusing muscle contracts and
makes the shape of the lens more convex, the image of a near object will be
sharply focused on the retina resulting in a clear picture.
"*:0%#)* ;%2&5,0-
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Kushner Eye Muscle Problems/Chapter 2/page-28
Fig 2-5.A) Distant objects would not be in sharp focus on the retina in a hyperopic
eye if the ciliary muscle is relaxed. They would be in focus behind the retina. B) If
the focusing muscle contracts and makes the shape of the lens more convex
(accommodation), the image of distant objects will be sharply focused on the retinaresulting in a clear picture. C) If the eye does not have the ability to accommodate
sufficiently to correct for hyperopia, either because of a large amount of hyperopia
or older age, a convex lens in front of the eye will serve the same purpose as
accommodationand bring the image in sharp focus on the retina. D) The image of
near objects would be even more out of focus on the retina of a hyperopiceye
when the ciliary muscle is relaxed. The point at which they would come into focus
lies even further behind the retina than for distant objects. E) Accommodatingeven
more than is needed for distance viewing will place the images of the near objects
in sharp focus on the retina of a hyperopiceye. F) If the eye does not have the
ability to accommodatesufficiently to correct for hyperopia,or cannot perform the
additional accommodationneeded for near viewing, either because of a large
amount of hyperopiaor older age (presbyopia), an even stronger convex lens infront of the eye is needed to bring a near image in sharp focus on the retina. Thus
if a person needs a different spectacle lens for distance and near viewing, a
bifocal is needed.
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'&+D4($ ,D 62$ $#$c 6, +$)4R ,+ (,06+4(6= "4(2 $#$ 24' '/R ,D 62$'$ .&'()$'= `'$$ ^/:&+$ _\Nc=
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Fig 3-2The location of the six extraocular muscles of a right eye. The medial
rectus rotates the eye inward toward the nose. The lateral rectus rotates the eye
outward toward the ear. The superior rectus and the inferior oblique muscles
rotate the eye upward. The inferior rectus and the superior oblique muscles rotate
the eye downward. These muscles are on the surface of the eye under the white
layer of conjunctiva. The 4 rectus muscles are approximately 4 to 8 millimeters
back from where the white meets the colored part of the eye; the 2 oblique
muscles lie farther back.
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/.4:$ ,D 62$ F4+6/(&)4+ ,-V$(6 /' D4))/0: ,0 62$=*,"$/0 $4(2 $#$= A2/' F+,($'' ,((&+'
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/7) G8). 0. 0 /)0,
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(,06+,) /6' 62$ 3/+$(6/,0 ,D /6' 2$43? ,0$ 6, 6&+0 +/:26? ,0$ )$D6? 6K, 6, F&)) /6 &FK4+3? 403
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'/3$ ,D 62$ 2,+'$[' 2$43=
Fig 3-3In this team of horses each horse has three reins running to each side of its
head instead of the usual single rein. Keeping each horse facing exactly the same
direction is difficult, because it is necessary to pull equally on the proper reins at
the same time. Just as the reins turn the horses heads, each eye is controlled by
six extraocular muscles, which pull the eyes to turn them in specific directions. The
very accurate ability of the eyes to team together seems even more remarkable
when one realizes what a complicated mechanism is involved=
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WD K$ 4+$ 6, .4/064/0=8#0*-? 62$ 6K, $#$' .&'6 .,G$ 46 $R4(6)# 62$ '4.$ 6/.$? 'F$$3? 403
3/+$(6/,0= Q8#0*-/' 62$ 6/$ 6246 -/03' 62$ )/0$' ,D G/'/,0 6,:$62$+ 403 2$)F' M$$F 62$ $#$'
F4+4))$)= A2/' /' 4 G$+# (,.F)/(46$3 F+,($''? ', /6 /' 0,6 '&+F+/'/0: 6246 /6 (40 ',.$6/.$' :, 4K+#=
C.B64#
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K+/'6K46(2 (),'$\&Fc= W0 433/6/,0? /D $4(2 $#$ /03/G/3&4))# /' 6, '$$ 62$ ,-V$(6 ()$4+)# /6 .&'6
(240:$ /6' D,(&' D+,. 3/'640($ 6, 0$4+ -# $&&*::*1$)0-E= U$(4)) 62$ (,.F4+/',0 ,D 4 (4.$+4
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62$ +/:26 4.,&06 6, 24G$ -,62 $#$' F,/06/0: 46 62$ ,-V$(6 ,0 K2/(2 K$ 4+$ D,(&'/0:= A2/' /' 404&6,.46/( +$D)$R 6246 ,((&+' K/62,&6 ,&+ 62/0M/0: 4-,&6 /6= W0 0,+.4) /03/G/3&4)'? 62/' +$D)$R /'
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5' K$ ),,M D+,. 4 0$4+ ,-V$(6 6, 4 3/'6406 ,0$? 62$ )/0$' ,D G/'/,0 .&'6 .,G$ 4F4+6= A2/'
0,+.4) F+,($'' /' (4))$3 10,"%E"-&"= `I$$ 4:4/0 ^/:&+$ N\Q ,0 F4:$ NTc= WD :4b$ /' '2/D6$3 D+,.
62$ K+/'6K46(2 (),'$\&F 6, 62$ '4/)-,46 /0 62$ 3/'640($? 62$ )/0$' ,D '/:26 K,&)3 0$$3 6, .,G$
4F4+6 k ,+ 3/G$+:$=
!)//#4''&.B
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D&+62$+ #,& (40 '$$ /0 62$ +/:26 F$+/F2$+#= A2/' /' 404),:,&' 6, 62$ 34#\6,\34# -$0$D/6 ,D 24G/0:
F$+/F2$+4)=8#0*-= W0 433/6/,0? 24G/0: F$+/F2$+4)=8#0*-2$)F' M$$F $#$' K$)) 4)/:0$3 /0
/03/G/3&4)' K/62 #)%$90#:8#4' #$4+' F4''=
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/0 62$ D&6&+$= ^,+ $R4.F)$? #)"%"*4#0#.4/0)# 2$)F' &' K2$0 ,-V$(6' 4+$ K/62/0 4-,&6 _ ,+ Q D$$6
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3/'640($? '2$ K,&)3 24G$ K4/6$3 6,, ),0:i
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K2/6$ ,0 $4(2 '/3$ ,D 62$ (,),+$3 F4+6 ,D 62$ $#$= W0 4 (2/)3 K/624#"81*#)%$90#:8#? 62$ '.4))
D,)3 ,D 'M/0 /0 62$ /0'/3$ (,+0$+ ,D 62$ $#$ (,G$+' .&(2 ,D 62$ K2/6$ ,D 62$ $#$= A2/' 4)6$+' ,&+
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" =Fig 4-1A) A photograph of a baby with pseudostrabismus . Although in this picture
it appears as though his left eye is turning inward, it is in fact perfectly aligned
with his right eye. This normal child is merely looking slightly to his right. His widebridge of the nose covers most of the adjacent white of the left eye, giving the
false appearance of strabismus. One way your doctor can tell that the eyes are
properly aligned is by studying the reflection of a light in the pupils. If the eyes
are pointing in the same direction, the light reflection (in the above photograph it
is created by the camera flash) will be symmetrically positioned in the two eyes as
seen in this photograph. B) A photograph of a baby with a crossed right eye. Note
that the light reflections from the camera are not symmetrically located in the two
eyes. The right eye is turned in.
F8-7@5)) -4-/$' 4+$ 0,+.4))# &%*##M"6"1=
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$#$' 4+$ 6+&)# 403 '&-'6406/4))# (+,''$3 2$ 4).,'6 0$G$+ ,&6:+,K' 62$ F+,-)$.=
/8A). &2 X-501
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" =
3 K
Fig 4-2Types of strabismus. A) Esotropia(right eye is turned in towards nose). B)
Exotropia(left eye is turned out toward ear). C)
Hypertropia(left eye is turned upward). D) Hypotropia(right eye is turned
downward).
ED).-
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Kushner Eye Muscle Problems/Chapter 4/page-43
" =Figure 4-3A) These two girls are mirror image identical twins. The twin on your left in the
photo has a right eye that is turned in. Her sister, on your right in the photo has a left eye
that is turned in. B) Both girls required glasses which essentially had identical prescriptions.
With their glasses on, their eyes were properly aligned.
;$(4&'$ (,06+,) ,D 62$ $#$ .&'()$' /' '&(2 4 (,.F)/(46$3 64'M? /6 /' (,..,0 D,+ #)%$90#:8#
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#)%$90#:8#,((&+' /0 (,0V&0(6/,0 K/62 ,62$+ 0$&+,),:/( F+,-)$.'? /6 K/)) 64M$ 4 'M/))$3 F2#'/(/40
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Fig 5-2Child with esotropiawith alternating fixation. At times he looks with his
right eye and the left eye crosses (right photo). At other times he looks with his left
eye and the right eye crosses (left photo).
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Fig 5-4Decorating the eye patch and placing a similar patch on a childs favorite toy
animal may help overcome resistance to patching.
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,)3$+ (2/)3+$0 K2, ./:26 -$ '$)D\(,0'(/,&' 4-,&6 K$4+/0: 40 $#$ F46(2 4+,&03 D+/$03'= E0 62$
,62$+ 2403? 62/' 6+$46.$06 3,$' 24G$ ',.$ 3/'43G4064:$'= W6 64M$' ),0:$+ 6, K,+M 6240F46(2/0:? -$(4&'$ '/.F)# -)&++/0: 62$ $#$ .4# '6/)) F$+./6 /6' &'$ 4 D4/+ 4.,&06 ,D 62$ 6/.$=
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3/DD$+$0($ /0 2,K '2$ '$$' K/62 62$ /$@6 "6" K2$0 62$ :)4''$' 4+$ ,0 G$+'&' K2$0 62$# 4+$ ,DD=
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Figure 6-2A) This shows a girl with a crossed left eye. B) If you make her look with
the left eye by occluding her right eye, her left eye straightens. If you peek behind
whatever is occluding her right eye, you will see that it is turned in behind the
occluder.
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Figure 6-4A) Normal eyes looking at a sailboat in the distance, and B) at a near
object. The ciliary muscle(or focusing muscle) is thin and relaxed when looking at a
distant object as shown in A. This muscle is noticeably thickened and contracted
when looking at near objects as seen in B. By means of the ciliary muscle, the eye
accommodatesitself for objects at varying distances, hence the process is known as
accommodation. In addition, when the eyes accommodateand look close up, they
also converge(or turn in a bit) as seen in B so both eyes point toward the close upwristwatch.
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Figure 6-6A) Child with V pattern esotropia. Eyes are more crossed looking downand less crossed looking up. B) Man with an A pattern esotropia. Eyes are properly
aligned looking down and more crossed looking up=
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Fig 7-1This view of a right eye is very similar to what an ophthalmologistwould
see during strabismussurgery. The eyelids are gently held apart by a speculum.
The muscles lie on the outside of the eyeball, just underneath the conjunctiva, which
is a thin membrane covering the eyeball. In this drawing, the conjunctiva is
reflected to the side and held by two forceps in order to expose themedial rectus
muscle. There is an L-shaped surgical instrument (called a muscle hook) under
the muscle. The other extraocular musclescannot be seen in this drawing, because
they are covered by the conjunctivaand are in different locations.
A2$ *4')'$/:*/*E0#)62$0 ),(46$' 62$ .&'()$ 403 F+,($$3' 6, $/62$+ ),,'$0 ,+ 6/:26$0 /6= ^,+
.,'6 #)%$90#:8#'&+:$+#? 62$ '6/6(2$' &'$3 6, '$(&+$ 62$ .&'()$ 3/'',)G$ ,0 62$/+ ,K0 4-,&6 d
K$$M' 4D6$+ '&+:$+# 403 3, 0,6 0$$3 6, -$ +$.,G$3=
F8-7@"#$ .&'()$ '&+:$+# +$X&/+$' +$.,G/0: 62$ $#$ D+,. 62$ $#$ ',(M$6=
B0#-@A2$ $#$ /' 0$G$+ +$.,G$3 D+,. 62$ $#$ ',(M$6? 0,+ K,&)3 /6 $G$0 -$ F,''/-)$ 6,
'4D$)# 3, ',i
F8-7@"#$ .&'()$ '&+:$+# /' F$+D,+.$3 K/62 )4'$+'=
B0#-@ 5)62,&:2 )4'$+' 4+$ &'$3 X&/6$ $R6$0'/G$)# /0 ,62$+ 6#F$' ,D $#$ '&+:$+#? 62$# 4+$
0,6 &'$3 403 K,&)3 -$ ,D 0, -$0$D/6 D,+ #)%$90#:8#'&+:$+#= a4'$+' 4-)46$ `+$.,G$c 6/''&$ 403K$ 3, 0,6 K406 6, +$.,G$ 62$ $#$ .&'()$'=
L&&.)%
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4664(2.$06 /' 62$0 '$F4+46$3? 403 62$ .&'()$ /' +$\4664(2$3 6, 62$ $#$ &'/0: 62$ F+$G/,&')#
F)4($3 '&6&+$'= `'$$ ^/: T\Nc=
Fig 7-2In a recession operation, sutures are placed in the muscle, the muscle is
detached from the eye, and is re-attached to a new location behind the original
one=
A2$ 0$K 4664(2.$06 '/6$ ,D 62$ .&'()$ /' 6#F/(4))# _ 6, PP ./))/.$6$+' -$2/03 62$ ,+/:/04)
4664(2.$06? 62$ $R4(6 3/'640($ -$/0: 3$6$+./0$3 -# 2,K .40# 3$:+$$' 62$ $#$ K4'
./'4)/:0$3= A2$ D&+62$+ 62$ .&'()$ /' Y+$($''$3Z `.,G$3 -4(Mc? 62$ :+$46$+ 62$ (240:$ /0 62$
F,'/6/,0 ,D 62$ $#$=
/
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edge of the remaining muscle is attached to original attachment site, thus placing
the muscle on stretch.
4(0%%
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Fig 7-5A) Esotropia with left eye turned inward. B) Recession of the in-turning
muscle in each eye will correct the strabismus.
WD $#$' 4+$ "G*)%*40&`L$//M"6"1c? '&+:$+# ./:26 /0G,)G$ +$($''/0: 62$ ,&6\6&+0/0: .&'()$ /0
$4(2 `'$$ ^/:&+$ T\dc? ,+ ),,'$0/0: 62$ ,&6\6&+0/0: 403 6/:26$0/0: 62$ /0\6&+0/0: .&'()$ /0 62$'4.$ $#$ `'$$ ^/:&+$ T\Tc=
Fig 7-6A) Exotropia with the left eye turned outward. B) Recession of the out-
turning muscle in each eye will correct the strabismus.
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Fig 7-7A) Exotropia with the left eye turned outward. B) Recession of the out-
turning muscle and resection of the in-turning muscle in the left eye will correct the
strabismus.
W0 D4(6? K2$0 #)%$90#:8#/' '/:0/D/(406 $0,&:2 6, K4++406 '&+:$+#? /6 /' .,+$ (,..,0 D,+ 6K,
$#$ .&'()$' 6, 0$$3 '&+:$+# 6240 ,0)# ,0$= W6 /' ,D6$0 ,D :+$46 (,0($+0 403 (,0D&'/,0 6,F46/$06' 403 F4+$06' K2$0 62$ '&+:$,0 +$(,..$03' ,F$+46/0: ,0 -,62 $#$'? K2$0 62$
F+,-)$. ,0)# 4FF$4+' 6, -$ /0 ,0$ $#$= I/./)4+)#? /6 .4# '$$. $X&4))# F$+F)$R/0: /D '&+:$+# /'
,0)# +$(,..$03$3 ,0 ,0$ $#$? K2$0 -,62 $#$' 4FF$4+ 6, 24G$ 4 F+,-)$.= W6 .4# '$$.
,-G/,&' 6, #,& 6246 62$ 3$(/'/,0 K2$62$+ 6, ,F$+46$ ,0 ,0$ ,+ -,62 $#$' '2,&)3 -$ .43$ -4'$3
,0 K2/(2 $#$ ,+ $#$' '$$. 6, 3$G/46$ ,0 62$/+ ,K0= W0 +$4)/6#? /6 /' .43$ -4'$3 ,0 4
(,.-/046/,0 ,D D4(6,+' K2/(2 .4# 0,6 /06&/6/G$)# '$$. /.F,+6406 6, #,& 4' 4 F4+$06 ,+ F46/$06=
A2$'$ /0()&3$ K2$62$+ 62$ #)%$90#:8#/' K,+'$ ),,M/0: D4+ 4K4# G$+'&' 0$4+? /D /6 /' K,+'$
),,M/0: 6, 62$ +/:26 G$+'&' 62$ )$D6? 403 K246 `/D 40#c .&'()$' .4# 24G$ 243 F+/,+ '&+:$+#= U$(4))
62$ (,.F4+/',0 ,D ./'4)/:0$3 $#$' 6, ./'4)/:0.$06 ,D 62$ D+,06 K2$$)' ,D 4 (4+ `'$$ 4:4/0 F4:$
]ec= B$ )$4+0$3 2,K 62$ (+,,M$3 (4+ K2$$)' (40 -$ .43$ F4+4))$) -# 4)/:0/0: $/62$+ ,0$ K/62
62$ ,62$+= I/./)4+)#? ./'4)/:0$3 $#$' (40 -$ (,++$(6$3 6, 6$4. 6,:$62$+ 0,+.4))# /D )
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$#$' 4+$ 0,6 F,/06/0: /0 62$ '4.$ 3/+$(6/,0 -&6 4+$ 3/G$+:$06= ;&6? K2$0 '2$ ),,M' 46 #,&? '2$
$/62$+ .&'6 ),,M K/62 2$+ +/:26 $#$? ,+ 2$+ )$D6 $#$= E62$+K/'$? '2$ K,&)3 0,6 -$ ),,M/0: 46 #,&=
WD 2$+ +/:26 $#$ /' 2$+ 3,./0406 $#$ `V&'6 4' #,&+ +/:26 2403 .4# -$ .,+$ (,,+3/046$3 6240 #,&+
)$D6c? K2$0 :/G$0 4 (2,/($? '2$ 4)K4#' (2,,'$' 6, ),,M K/62 62$ +/:26 $#$= I, #,& ,0)# '$$ 62$
)$D6 $#$ ,DD ($06$+= 5)) #,& 0$$3 3, /' .4M$ 2$+ ),,M K/62 2$+ )$D6 $#$ `F$+24F' -# (,G$+/0: 2$+
+/:26 $#$c? 403 F+,-4-)# 62$ +/:26 $#$ K/)) -$ V&'6 4' D4+ ,DD ($06$+ 4' K4' 2$+ )$D6 $#$= `'$$ 4:4/0?^/: d\N ,0 F4:$ ]Sc L,& 0$G$+ '$$ 2$+ )$D6 $#$ 3$G/46$ ,0 /6' ,K0? -$(4&'$ '2$ 3,$'0[6 ),,M
K/62 2$+ )$D6 $#$ K2$0 '2$ 24' 6, (2,,'$ ,0$ $#$ ,+ 62$ ,62$+=
ED).-
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'&+:/(4))# .,G$3 K/)) -$ -4'$3 ,0 62$ 4.,&06 ,D ./'4)/:0.$06 46 62$ 6/.$ 62$ '&+:$+# /'
F$+D,+.$3= A2$+$D,+$ #,& .4# 24G$ 40 433/6/,04) G/'/6 6, 62$ *4')'$/:*/*E0#),0 4 34# '2,+6)#
F+/,+ 6, 62$ '&+:$+#=
W0 (2/)3+$0? #)%$90#:8#'&+:$+# /' F$+D,+.$3 &'/0: :$0$+4) 40$'62$'/4= L,&+ (2/)3 K/)) -$
(,.F)$6$)# 4')$$F 3&+/0: 62$ ,F$+46/,0? ', 2$ K/)) 0,6 .,G$ 4+,&03 3&+/0: 62$ ,F$+46/,0 403
0,6 D$$) 40# 3/'(,.D,+6= W0 43&)6'? #)%$90#:8#'&+:$+# /' ',.$6/.$' F$+D,+.$3 K/62 :$0$+4)40$'62$'/4 403 ',.$6/.$' K/62 ),(4) 40$'62$'/4 `0&.-/0: .$3/(/0$ 4+,&03 62$ $#$c= A2$
(2,/($ 3$F$03' ,0 62$ 046&+$ ,D 62$ '&+:$+# 6246 0$$3' 6, -$ 3,0$? K2$62$+ /6 /0G,)G$' ,0$ ,+
-,62 $#$' `),(4) 40$'62$'/4 .4# -$ )$'' F+4(6/(4) D,+ ',.$ F46/$06' K2$0 62$ '&+:$+# /' -$/0:
F$+D,+.$3 /0 -,62 $#$'c 403 /03/G/3&4) F+$D$+$0($' ,D 62$ F46/$06 403 *4')'$/:*/*E0#)=
%40# 2,'F/64)' ,+ 4.-&)46,+# '&+:$+# ($06$+' 4)),K 4 F4+$06 6, -$ /0 62$ ,F$+46/0: +,,.
&06/) 4 (2/)3 /' 4')$$F? 403 4:4/0 6, -$ /0 62$ +$(,G$+# +,,. 4+,&03 62$ 6/.$ 4 (2/)3 /' '64+6/0: 6,
K4M$ &F= A2$ )$0:62 ,D 62$ '&+:$+# 3$F$03' ,0 2,K .40# .&'()$' 4+$ -$/0: ,F$+46$3 ,0
`,F$+46/0: ,0 D,&+ .&'()$' 64M$' 4-,&6 D,&+ 6/.$' 4' ),0: 4' ,F$+46/0: ,0 ,0$ .&'()$c=
q&$'6/,0' 4-,&6 62$ 6#F$ ,D 40$'62$'/4 403 )$0:62 ,D '&+:$+# D,+ #,& ,+ #,&+ (2/)3 '2,&)3 -$
4'M$3 ,D #,&+ $#$ 3,(6,+= @$F$03/0: ,0 62$ 046&+$ ,D 62$ '&+:$+#? &%)$#$ .4# -$ F46(2$3/..$3/46$)# 4D6$+ '&+:$+#j 2,K$G$+ 3,(6,+' 3, 0,6 F46(2 -,62 $#$'= *46/$06' 4+$ 4-)$ 6, '$$ 4'
',,0 4' 62$# K4M$ &F= 5D6$+ '&+:$+#? 4 F46/$06 K/)) :, 6, 4 +$(,G$+# +,,. 6, K4M$ &F /D 62$
'&+:$+# K4' F$+D,+.$3 K/62 62$. 4')$$F= A2$ 6/.$ 'F$06 /0 62$ +$(,G$+# +,,. G4+/$' D+,. ,0$
24)D 6, '$G$+4) 2,&+'= E0($ '&DD/(/$06)# 4K4M$? 62$ F46/$06 /' 62$0 -+,&:26 -4(M 6, 2$+ /0/6/4)
+,,.= 9'&4))# 62$ ,F2624).,),:/'6 K/)) K406 6, '$$ 4 F46/$06 K/62/0 '$G$+4) 34#' 4D6$+ '&+:$+#?
403 62$0 '$G$+4) 6/.$' /0 62$ N .,062' 4D6$+K4+3'? &06/) 62$ $#$' 4+$ D/04))# 2$4)$3= A2$ K2/6$
,D 62$ $#$`'c 6246 243 '&+:$+# K/)) -$ +$3 /..$3/46$)# 4D6$+ '&+:$+#? 403 K/)) :+43&4))# ()$4+ &F
,G$+ 62$ '&-'$X&$06 .,062 403 24)D= U$'6+/(6/,0' ,0 4(6/G/6# 4D6$+ $#$ .&'()$ '&+:$+# 3, G4+#
',.$K246 K/62 /03/G/3&4) *4')'$/:*/*E0#)S#F+$D$+$0($' 403 6$(20/X&$= C,K$G$+? +$'6+/(6/,0'
6$03 6, -$ ./0/.4)= %,'6 (2/)3+$0 4+$ -4(M 46 '(2,,) K/62/0 4 D$K 34#' 4D6$+ '&+:$+# 403 .,'6
43&)6' 4+$ -4(M 6, K,+M `3$F$03/0: ,0 62$ 046&+$ ,D 62$ V,-c K/62/0 4 K$$M= A2/' G4+/$'',.$K246 3$F$03/0: ,0 62$ $R4(6 046&+$ ,D 62$ '&+:$+# -$/0: F$+D,+.$3 403 '2,&)3 -$
3/'(&''$3 K/62 #,&+ *4')'$/:*/*E0#)= ED6$0 62$+$ /' 4 '2,+6 6$+. +$'6+/(6/,0 F)4($3 ,0
'K/../0:? (,064(6 'F,+6'? (,064(6 )$0' K$4+? 403 62$ &'$ ,D $#$ .4M$\&F /..$3/46$)# 4D6$+
#)%$90#:8#'&+:$+#=
45)A05
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$R($))$06 -,,M' 4G4/)4-)$? 3$'/:0$3 D,+ (2/)3+$0 ,D 3/DD$+$06 4:$'? 6, F+$F4+$ 62$. D,+ '&+:$+#=
L,&+ ),(4) +$D$+$0($ )/-+4+/40? *4')'$/:*/*E0#)? 2$+ 0&+'$ ,+ *%)'*4)0#)? '2,&)3 -$ 4-)$ 6, :&/3$
#,& /0 D/03/0: ,0$ 6246 /' :,,3 D,+ #,&+ (2/)3[' 4:$ )$G$)= %40# 2,'F/64)' 403 ,&6F46/$06 '&+:$+#
($06$+' 4)),K #,& 403 #,&+ (2/)3 6, G/'/6 62$ D4(/)/6# /0 43G40($ ,D 62$ '&+:$+# 346$? 64M$ 4 6,&+?
403 K4)M 62+,&:2 62$ '6$F' 6246 K/)) ,((&+ K2$0 #,&+ (2/)3 )46$+ +$6&+0' D,+ 62$ 4(6&4))# '&+:/(4)
F+,($3&+$= A2/' 6#F$ ,D 43G40($ F+$F4+46/,0 /' X&/6$ 2$)FD&) /0 +$3&(/0: F+$\,F$+46/G$ 40R/$6#=12/)3+$0 K2, 4+$ F+$F4+$3 /0 62/' K4# 3,0[6 .4M$ D4)'$ 4''&.F6/,0' 4-,&6 K246 K/)) 24FF$0?
-$(4&'$ 62$# 4(6&4))# M0,K K246 6, $RF$(6= WD #,&+ 2,'F/64) ,+ '&+:$+# ($06$+ 3,$' 4)),K '&(2
F+$\,F$+46/G$ G/'/6'? W $0(,&+4:$ #,& 6, 64M$ 43G4064:$ ,D /6=
I
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ED).-
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ED).-
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62$ &'$ ,D 43V&'64-)$ '&6&+$'= W0 433/6/,0? D,+ ($+64/0 6#F$' ,D $#$ .&'()$ F+,-)$.'? 62$#
4FF$4+ )$'' 2$)FD&) 6240 ,62$+'= L,& ./:26 K/'2 6, 3/'(&'' K/62 #,&+ *4')'$/:*/*E0#)62$ F+,'
403 (,0' ,D 43V&'64-)$ '&6&+$' D,+ #,&+ 'F$(/D/( 6#F$ ,D #)%$90#:8#=
=&-&Hc T=&-D(
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370A-)5 d
G8) FD.#() 45&1(),.
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F+,-)$.? /6 (40 2$)F /3$06/D# /03/G/3&4)' K2, 4+$ .,+$ )/M$)# 6, -$ 46 +/'M= ^,+6&046$)#?
F$+'/'6$06 1*89/" ,0#0*-,D 62/' 6#F$ /' G$+# +4+$=
ED).-
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Fig 10-2Proper positioning of a bifocal for a child with esotropia. The bifocal line
is level with the mid-pupil.
ED).-
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"*:0%#)* ;%2&5,0-
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F&%&:
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370A-)5 MM
/7) 4.8#7&(&+
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4FF)/(46/,0'= W0 62$ '6&3#? 62$ F$+',00$) .404:$+' K$+$ (,0'/'6$06)# )$'' )/M$)# 6, 2/+$ 62$
4FF)/(406 /D '2,K0 ,0$ ,D 62$ 3,(6,+$3 F2,6,:+4F2' 3$F/(6/0: 62$ 4FF)/(406 K/62 ./'4)/:0$3
$#$'= %40# 43&)6' K/62 #)%$90#:8#+$F,+6 6246 K2$0 62$# 4+$ $0:4:$3 /0 (,0G$+'46/,0? F$,F)$
D+$X&$06)# 3, 0,6 M0,K /D 62$# 4+$ 62$ ,0$ -$/0: 'F,M$0 6,j 62$# 3, 0,6 M0,K K2, 62$ 'F$4M$+
/' ),,M/0: 46= A2/' /' F4+6/(&)4+)# F+,-)$.46/( D,+ /03/G/3&4)' K/62 #)%$90#:8#K2, D+$X&$06)#
/06$+4(6 K/62 62$ F&-)/(? '&(2 4' 6$4(2$+' 403 '4)$'F$,F)$=8/G$0 62$ (&++$06 2/:2 '&(($'' +46$ /0 62$ 6+$46.$06 ,D 43&)6 #)%$90#:8#? /6 /' &'&4))#
&00$($''4+# D,+ 43&)6' 6, 24G$ 6, F&6 &F K/62 62$'$ 3/'6+$''/0: '/6&46/,0'=
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XA)#
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46 62$ ./3)/0$= `I$$ ^/:&+$ P_\Nc C/' ,62$+ $#$? K2/(2 .4# .,G$ 0,+.4))#? 4FF$4+' 6, ,G$+'2,,6
62$ $#$ K/62 @&40$ I#03+,.$? 403 (40 62&' 4FF$4+ (+,''$3= B2$0 4 F$+',0 K/62 @&40$
I#03+,.$ ),,M' 6, 62$ ,62$+ '/3$ `6,K4+3 2/' 0,'$c 2/' /0\6&+0/0: .&'()$ 6/:26$0' 4' /6 '2,&)3?
403 2/' ,&6\6&+0/0: .&'()$ 6/:26$0' 4 -/6 `K2$0 /6 '2,&)30[6c 403 2/' $#$ /' F&))$3 -4(MK4+3
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I,.$6/.$' 62$'$ ,FF,'/0: D,+($' ,0 62$ $#$ (40 (4&'$ /6 6, +,646$ &FK4+3 ,+ 3,K0K4+3 ,0466$.F6$3 '/3$ :4b$ 4' /' '$$0 /0 ^/:&+$ P_\N=
" = 3
KFigure 13-2This girl has Duane Syndrome of her right eye. B) When she looks
straight ahead her eyes are properly aligned. A) When she looks to her right, her
right eye does not move past the midline position. Sometimes parents feel this
situation is an abnormal crossing of the left eye, when in fact the problem is that
the right eye cannot rotate to the right. C) When she looks to her left, the righteye is pulled back in the eye socket causing the opening of the eyelids to narrow
and the eye look smaller. D) When looking in the distance she turns her face a bit
to the right because her eyes line up better in that position.
%40# F$,F)$ K/62 @&40$ I#03+,.$ 24G$ F$+D$(6)# 4)/:0$3 $#$' K2$0 62$# ),,M '6+4/:26
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/03/G/3&4) K/)) 6&+0 2/' 2$43 6, ,0$ '/3$ 6, :$6 2/' $#$' 6, )/0$ &F 6, 4)),K D&'/,0= ^,+ 2/.? $#$
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2,K$G$+? 6, (240:$ 62$ 4-0,+.4) F466$+0 ,D 0$+G$ (,00$(6/,0'=
/785&
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!"#$%&'()'"..
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/58 /7
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370A-)5 M[
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