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of the bad eye is 6/9, a film of soap is applied to the glasses instead of the paper, a stage of
progress which gives great joy to the small patient and to the parents. The good eye is not
uncovered until the sight of the bad eye is equal in every respect to that of the good one.
Treatment to teach eyes to act together is carried out by exercises with the amblyoscope,
an instrument with two bent tubes, each holding a picture of a different kind. The patient
sees one object with each eye. One object may be a bird, the other a cage. By shifting the
tubes to and fro, the images coincide, and, if the patient can "get the bird in the cage," he is
said to have binocular vision at that point. Other images are put on, increasing in difficulty,
and, by moving the tubes, the muscles of the eyes controlling convergence and divergence are
exercised, and the eyes gradually learn in this way to focus on the same object simultaneously,
and the eyes become straight.
The average length of time taken to restore sight in children is as follows:—to vision 6/60,
13 months; 6/36, 12 months; 6/24, 9 months; 6/18, 7 months. In children with less than
6/60 and with loss of central vision, the average time taken during the five years preceding 1932
was 18 months, but in the earliest cases the average time was 21 months. It can be said with
certainty that if the treatment is carried out well, it is always attended with success. Failures
are comparatively few, and have been due in most cases to the opposition or carelessness of
the parents. A few children come without the parents, being brought by brothers, sisters, friends,
or coming with other children from the same school, and it is among these that failures chiefly
occur. Some failures also occur in children who are of a very low order of intelligence, or who
develop late. The fact that the average time taken in the earliest years of the clinic was greater
than that in the later ones shows that experience in the treatment is of primary importance.
The cases of 1932 and this year show an even greater improvement, but, as they are unfinished,
it has been thought unwise to include them.
When squint is associated with extremely deficient vision in the bad eye, it is sometimes
found advisable to interrupt the treatment for six months, when the child will return older
and wiser, and keener on getting cured. When the child is considered to be cured, with no squint
either with or without the glasses, he is discharged for six months. On returning, the vision of
each eye is taken, fresh refraction ordered if necessary, and, if the vision has deteriorated, as it
occasionally does, the treatment is repeated. The further treatment usually occupies only a
few weeks or a month. If all is satisfactory, the child is discharged for a year, and if at the
end of that time the squint is still absent, he gets a permanent discharge.
Cases of alternating squint are in a minority. They usually have a very large squint and
a very slight error of refraction, and occur very early in life. They are extraordinarily difficult
to cure. They do not lose the vision of either eye, because the eyes alternately take on the
work of looking. Exercises have to be begun at once, and it may be years before the child is able
to get binocular vision at any point. The brain seems to be unable to attend to more than one
image at a time, so that when looking through the amblyoscope, first one image disappears,
then the other. Even when binocular vision is established, and a tremendous range of convergence
is obtained, the squint may be as marked as ever. My greatest failure is a girl of 13 who has
attended regularly since she was five years old. She can do all the exercises better than anyone
else, but the squint is still a large one. These cases have to be operated upon when the patient
is older, and after a prolonged course of these exercises the operation is nearly always successful.
If, however, the operation is done before squint-training, the result is usually a failure.
When the clinic was first started, I found the greatest difficulty in persuading the parents
to pursue the treatment. They disliked the patch; they could not understand that an eye,
apparently normal, was unable to see. They said: "When the glasses are off he can see quite
well," which, of course, was true, because he was then using the good eye. They were unwilling
to take the trouble of looking after a child who was, in the first month or two, nearly blind.
In the first two years of the clinic, those cases which were failures were the result of the parents'
unwillingness. Gradually, however, as the clinic became known, the people in the neighbourhood
realised the value of the work, and whereas, in those years, one had to spend half an hour explaining
to the mother the danger and loss to the child, nowadays one has merely to indicate the treatment
to her, and to concentrate on gaining the co-operation, interest and consent of the child. This
is just as important as that of the mother. His interest, ambition, pride, vanity, and even
greed are all called upon, and he is promised a prize if, and when, he is able to have the patch
off on gaining good vision. One little boy, coming from a terrible home with a witless mother
and obstinate father, was so impressed by the necessity of wearing his patch that he actually
fought with his father for the right to wear it.
Some ophthalmic surgeons are content to see the children once in two or three months.
I find that this is quite useless. One must have them up once a week at least in order to see
that the eye is kept covered, that the child does not "peep" out of the covered eye, and to gain
his interest and confidence. If this is not done, when the time comes for training, he is frightened
or uninterested, and will romance as to what he sees; and, as one is entirely at the mercy of the
child in this respect, one has to teach him to speak the truth, which he usually does if he has no
fear of the doctor and nurse. The weekly encouragement, the word of commendation or of
censure must not be foregone. Moreover, children have to be taught to close the mouth, and to
learn to breathe through the nose. As stated above, the vast majority of these patients ate