School of Orthoptics, Moorfields Eye Hospital. Secretary-General, International Orthoptic Association

1. The First Fifty Years

Miss Barbara M. Lee, M.B.E., D.B.O.(T) Principal, School of Orthoptics, Moorfields Eye Hospital. Secretary-General, International Orthoptic Association.

PREAMBLE I will discuss the origins of orthoptics in the United Kingdom and its development as a Profession Supplementary to Medicine with reference to the British Orthoptic Council, the British Orthoptic'b Society and the part played in the formation of the International Orthoptic Association. I will speak about Education, continuing Education, conditions of service and the development of practices 1929-1981. I wiil conclude with ideas we foresee in the future.

It was with the greatest pleasure that I received the most kind and generous invitation of the Japanese Orthoptic Society, and a great honour to be asked to speak about developments in Orthoptics in the United Kingdom.

1934 BRITISHORTHOPTIC COUNCIL (B.O.C.) of which we are aware of orthoptists working 1937 BRITISHORTHOPTIC SOCIETY (B.O.S.) alongside ophthalmologists before then. 1967 INTERNATIONALORTHOPTIC ASSOCIATION (I.O.A.) It is therefore fitting to look back to those early beginnings when in 1929 Mary Maddox It is fortuitous that this invitation coincides began her work at the Royal Westminster in the same year as a celebration at the High Ophthalmic Hospital in London. That Holborn branch of Moorfields Eye Hospital hospital is now the Holborn branch of to mark the 50th Anniversary of the opening Moorfields Eye Hospital where it is my of the first orthoptic clinic in the United privilege to work. Kingdom, which was possibly the first in the The History of the Royal Westminster world there being no other recorded evidence Ophthalmic Hospital is in itself an interesting

70 describe this part of London) within which was the leper hospital-supposedly on the site of the present hospital. Records tell us that in about AD 1225 a small blacksmith shop stood at the North West end of Drury Lane and that this existed until AD 1595. This no doubt was on the hospital's site. The Manor of St. Giles has prospered and declined throughout the ages. It received special favours from Pope Alexander IV which increased its prestige and naturally brought other endowments. The first decli- ne occurred during the reign of Henry VIII with his policy of the dissolution of the monastries coupled with the hospitals contro- lled by the power of the church. A different prosperity followed as the area now rich in game-particularly hare, fox and boar became the hunting ground of the the Holborn branch of Moorfields Eye Hospital nobility. This led to their building hunting lodges and houses in which to entertain guests; and cottages to house their servants and gamekeepers. Queen Elizabeth I, however decreed that this re-strained agriculture and engendered pestilence and as such must stop! There followed periods during which only the poorest inhabited the area-was the place where the great plague first occurred-and by the middle of the 19th Century had become and long one. To set the scene I make the place of shelter for thieves, cut-throats reference to this. and beggars living in indescribable squalor. Before AD 1066 at the time of the Norman Fortunes changed yet again with the build- Invasion this part of London was marshland ing of a new road to connect the old city to with few inhabitants and one small church. the East with the West (New Oxford Street) It was a wet and unhealthy place causing a so that slums were pulled down and it again great deal of sickness particularly leprosy. became fashionable for the upper middle In AD 1117 Queen Matilda, the consort of class to reside in the district and especially King Henry I much concerned by the pestilen- neighbouring Bloomsbury that attracted ce and suffering founded a hospital for 40 poets, painters and men of letters. lepers and their attendants. Thus began the The devastation caused by bombs damage Manor of St. Giles (a name still used to during the Second World War and the post

71 -war building programmes has removed yet A newspaper cutting from •gThe Morning more slum areas so that today the district Chronicle•h of December 7th 1816 bears may have a smaller residential population witness to this and can be seen in the than for hundreds of years but a great incre- Hospital Secretary's office at Hollborn,

ase in business premises has brought increas- naming His Royal Highness the Duke of ed numbers to the district for their work and York KG as Patron, His Grace the Duke of

increasing prosperity of a different kind. Wellington, KG, as President and other

nobles and gentlemen including Guthrie as II the only surgeon.

The first hospital in London specially The hospital was first in Piccadilly; but devoted to diseases of the eye, the forerunner because of cramped conidtions and increased to Moorfield was the London Infirmary for extension of work had three homes before curing diseases of the eye-opened in 1805. coming to Holborn where an 8 storey-100

In 1816 an Army surgeon, George James bedded-hospital was built at the cost of a

Guthrie who had served with the Duke of mere •’150,000 and opened for use in 1928. Wellington in the Peninsular War in Portugal succeeded in influencing that great man of the need for an eye hospital in the Western section of the City of London. Until the hospital could be built Guthrie would see patients on three mornings a week at his private home in Berkeley Square.

Of particular interest to this audience was

the reference to a •gSquint Department where

ocular exercises are undertaken for cases of

squint both before and after operation.•h

The interest to orthoptists that we have in

Guthrie is mainly with his son who succeeded

him.

Guthrie Senior was born in London in 1785

of Scottish parents, his grandfather also

being a doctor of repute.

As was the custom in those days he was

apprenticed to a surgeon from the age of 13

years, and three years later (aged 16) posted

to a regiment in North America where he

saw service as Inspector-General of Army

Hospitals in France, Holland, Portugal and

Spain returning home in 1814. Two years

George James Guthrie later he had founded the Royal Westminster

72 Ophthalmic Hospital. made; but it was Guthrie- a fashionable

A colleague at RWOH, Sir Charles Forbes, surgeon who performed a prodigious number also a military gentleman of repute had of tenotomies all without anaesthetic in 10 served in Egypt, the West Indies as well as months April 1880-February 1881 a total of many European countries thus proving bet- 567. ween them that it was just as easy to see the His paper presented to the Governors of world at your Government's expense in the RWOH states that •gIn no instance under my

19th Century as it is today. care has the sight of the eye operated on been

These 2 surgeons had a dispute causing the lost or impaired•h (quote) resignation of Sir Charles. The trouble seems to us now to be childish that of one member of staff altering the treatment of the other during a colleague's absence. Unlike today a dual was fought. The principals being poor marksmen exchanged shots not once but three times without effect-where- 8 cases diverged post-operatively, of which upon the seconds left and would not permit 4 had •gthe opposing rectus divided with the dual to continue. Had shots continued success.•h Post-operative care consisted of a they would no doubt have been liable to a pad and bandage and bathing with cold criminal charge. water.

Guthrie senior wrote a paper on cataract in Javal in France (1839-1907) would dispute

1834 and mentions that Von Graefe of Berlin, these successes referring as he did to the

Germany, had been asked to demonstrate his tenotomy as •gmassacre of the internal new knife when invited to operate at RWOH. rectus.•h He spoke with feeling his own

Guthrie remarked afterwards that •gI was sister being a victim of this form of treatme- satisfied that he knew as much as I did about nt. it, and I was infinitely more gratified to III perceive that he did not know more•h (quote). This therefore was the background to be Guthrie also wrote a book of lectures on •g faced by those studying orthoptics.

Operative Surgery•h (1819). In this there is That of the routine of ordering glasses to no mention of operations for squint.

However, the son Charles William Gardin- er Guthrie (1816-1859) who succeeded his father at RWOH in 1838 wrote a paper (1841) just 100 years ago entitled •gThe Cure of

Squinting.•h

Dieffenbach of Berlin, Germany seems to have been the first to perform a tenotomy for squint. An enthusiatic medical student (A

Mr. Pyper) went to Berlin to study Diffenba- ch's methods and having assisted with several

operations brought back an account of the method used and had a set of instruments Louis Emile Javal (1839-1907)

73 be worn and hoping for the best. The

•g best•h if it occurred pin-pointed whatwe now

know as Accommodative Squint of one sort

or another. Cases in which this magical

solution was not achieved had operation.

After that the eyes were said to be generally

straight and classed as •gcured•h. That

there was defective vision was frequently

ignored.

And then.... a quiet, sensitive and dedicat-

ed ophthalmologist practising in the South

coast seaside resort of Bournemouth in the

1920s came to the fore. He found all this

very disturbing and totally unacceptable.

His name was ERNEST MADDOX and he George Louis Leclerc, Comte de Button (1707-1788) postulated that if the orthopaedic surgeon (Courtesy of the Royal Society.) can give massage and muscle stretching

exercises why was it not possible to do the references to squint in the Ancient World are

same with ocular muscles? And why was it not unknown. We have evidence of a mask

not possible to improve vision by re-educa- used to straighten eyes used in the 7th

tion of the •glazy•h eye when there was no century by the Greek physician Paulus Aegin-

organic reason for this defect? eta of the 19th century invention of the stereo-

This idea had been recommended by scope by Wheatstone and used by Javal; the

Buffon in France (1743). And others in forerunner of the synoptophore-the amblyo-

history had conributed in some way. Early scope invented by Worth, the development of the synoptophore in England-the troposcope in USA, the synoptometer in Germany. And without a doubt Japan has contributed also. Information of this would be most interesting and would enhance considerably the global knowledge of our subject. The inclusion of Japan on the Council of the International Orthoptic Association is most welcome and

Ernest Edmund Maddox (1863-1933) the forerunner of the synoptophone

74 The Worth Black Amblyoscope

She moved from Bournemouth to set up a

practice in London's Wimpole Street where

she treated patients and taught others the

skills learnt from her father.

gives us all the opportunity to share our In 1929 she was invited to join the staff of

knowledge and our experiences. the RWOH and to open what in those days

We have moved a long way from simple was called the •gSquint Department.•h

solutions and our reasoning has become more It is interesting to observe that in the

sophisticated, more critical and more scienti- building of that hospital, opened one year

fic-although much of the earlier notions of before provision had been made in the plans

Javal, Worth and Maddox still have a place to include an orthoptic department. This

within our practises. was a unique departure and one which should

Our reputation has much to do with the be remembered today. selection of patients that will respond to treatment. Through knowledge we are now able to predict with greater certainty the outcome of treatment and have moved far away from the •ghit-or-miss•h and •gtry any- thing•h concept of the 1920s.

Nevertheless the inspiration to evolve a specialist field of study came from Ernest

Maddox who had the foresight to teach his daughter-Mary MADDOX these skills. Keith Lyle and Sylvia Jackson Thus she became the first orthoptist. (I.O.A. in London, 1967)

75 The first report of her work to be included who feel that they can succeed where Javal in the hospital records written in 1931 refers with all his intellect had so gloriously failed•h to the completion of two years work. The It was tragic that this eminent strabologist following year the appointments of Charles should be killed in a motor accident in 1941

Leonard Gimblett as advisory surgeon (him- only 2 years after he had re-written the 7th self a strabologist) and Sylvia Jackson (the Edition of Worth's •gSquint-its causes and co-author with Keith Lyle of the original Lyle 1980 CONDITIONS OF NEW PATIENTS and Jackson •gPractical Orthoptics•h as a second orthoptist were made and a full-time service provided for patients.

Of interest to us in 1931 of these first reports is the age scale of the patients seen.

How different is this in 1981.

1931 AGE RANGE OF PATIENTS (MANIFEST SQUINT) treatment.•h The 9th Edition of this classic

revised by T.K. Lyle and Bridgeman is still

regarded as a major textbook in the United

Kingdom for those studying binocular vision.

Were he alive today I feel he would now

approve of the advances in orthoptic work

which were quite considerably altered as a

result of his works. 1980 AGE RANGE OF NEW PATIENTS

With referrals so late, with inadequate

knowledge about the development of binocu-

lar function, but with great enthusiasm for

treatment the results were disappointing.

No wonder that Chavasse spoke of the •g

young ladies of School Certificate standard

1931 CONDITIONS OF NEW PATIENTS

Bernard Chavasse (1889-1941)

The opening of orthoptic departments up and down the United Kingdom was not slow in following the Royal Westminster Ophthal-

76 mic Hospital. The news spread rapidly and examinations, is concerned with advanced within a very few years not only were many education for orthoptists as teachers and clinics opened but the beginning of training clinical teachers evolving these training programmes to teach the skills to those programmes also, takes care to see that wishing to become orthoptists. Birmingha- continuing education programmes for orthop- m (1930) Eye Hospital and Children Hospital tists are provided, issues certificates of profi- Reading (1931), Great Ormond Street Hospi- ciency, selects and appoints examiners both tal for Sick Children (1932), Durham in the ophthalmologists and orthoptic teachers for North (1933) and the Central Eye Hospital- all examinations. which until 1948 housed the department now To some extent the overall control of the at Moorfields City Road. Council has been diminished in recent years Twenty-two orthoptists began work in since orthoptists-in line with all the other those pioneering days having been taught major paramedical professions-have become informally by the surgeons for whom they State Registered. This body created by Act worked. of Parliament is the Council for Professions But by 1934 it became evident that a Supplementary to Medicine. Each profes- national progamme of education and exami- sion has its own Board within CPSM and it is nation was necessary. Thus the British obligatory for every practising member to be Orthoptic Council came about. Four ophth- state registered in order to work. Thus almolgists, two from the Royal Westminter, orthoptists are protected and only those with one from Birmingham Children's Hospital the recognized qualification are permitted to and one from the Central Eye Hospital work. The Orthoptists Board of CPSM decided to form an Education Committee- controls training and takes advice from the which still exists although its membership is British Orthoptic Council on all issues dealing now greatly altered. From four ophtal- with education. It also on a regular basis mologists to a committee of orthoptists inspects all twelve of the training schools in teachers and ophthalmologists, together, it the United Kingdom in order that all are up now for the past three years has a Chairman to the standard required; and must agree all who is an orthoptist; and it runs specialised policies of change-be it a raise in the entry sub-committees to regulate examinations to standards of education for students, the look at future education requirements includ- change from Diploma to Degree status and ing possible establishment of degree status all matters educational. for orthoptists.

In the beginning the schools of orthoptics

This Council decides the syllabus upon were an •gaccident of history•h springing up in which all students training is based, arranges places where an ophthalmologist had a parti- and monitors very carefully the format of all cular interest in study of strabismus. These

77 dedicated persons, who took the respo- The Society has much to offer its members nsibility for training orthoptists were all and is always awake to new developments, members of the British Orthoptic Council. and new ideas whether in practice or in In this way conformity of practice and edu- organisation. It publishes the British Ortho- cation was achieved from an early date in the ptic Journal and a glossary of terms appro- development of the profession. A link ved by the British Orthoptic Council for which is still maintained today. general use. It provides clinical meetings at For the most part the location of the national and regional level. It provides an Schools has remained-the geographical spr- annual three day residential scientific confe- ead being adequate. A few have ceased to rence. It provides in-service training on a operate and others have joined together regional basis which gives local orthoptists thereby strengthening their influence. the opportunity to keep up to date with new By 1937 the original 22 orthoptists were developments and to be able to discuss these joined by another 49 all of whom after a with colleagues. The question of the conti- period of training had been properly examin- nuing education of practitioners throughout ed by the Council's examiners and found to their career is a major concern of both the have sufficient knowledge and practical Council and the Society who make constant ability to carry out the work. Initially this plans to increase these opportunities. period of training was one year but gradually Whilst membership of the Society is a this was increased by stages in order to keep voluntary matter, continuing education is pace with the amount of knowledge and the becoming wide spread and with degree edu- depth that is required. It now stands at 3 cation will be obligatory. years and is an integrated theoretical and Since Great Britain operates a national practical course of studies. health service, all levels of pay, grades for It was in 1937 that this band of 70 who had promotion, hours of work etc, are laid down qualified, felt the need for an association of by the Government of the day, on a national orthoptists to take care of their interests and level. The Society is recognised by the needs. Thus the British Orthoptic Society Government as the body with whom it negiot- was formed. es. As a consequence of this the Society elects representatives to sit on the committees of the Department of Health to deal with these matters. With the expansion of orthoptics it has become necessary to divide the Society into regional zones so that the individual where- ever she is working may express her views whether scientific or administrative at local and national levels. REGIONAL BRANCH COMMITTEES (4) Local committees are therefore represen- Then as now the Society is an association ted on the Central Executive Committee of solely of qualified orthoptists that looks into the Society by two orthoptists from each of the affairs of those who practise. Students the four regional zones. Additionally the are associate members. Central Executive consists of a nationally

78 elected Chairman, Honorary Secretary and Council of Management representing 14 Honorary Treasurer. A maximum term of countries. The newest member is Japan office is imposed on the Chairman of 6 years whom the IOA welcomes most sincerely. but elections are required every 3 years. IV Whilst all these organizational changes were taking place so also were changes in the practice of orthoptics as the practitioners increased their knowledge and reviewed their result. The standard of education was much enhanced by the development of advanced courses achieving higher education by

ARCHIVIST examination for clinical instructors and for LIAISON OFFICER WITH B.O.C. ON EDUCATION Teachers who undertook a further two years

Twenty years after its formation (1967) of study. The most dramatic changes in practise during my period as Chairman of the British date from after the war. Before 1939 the Orthoptic Society the Executive conceived concept of the 1920s formed the basis of all the idea of proposing the formation of an international association of orthoptists. We practise and remained at a relative standstill felt that the profession had arrived at a stage International Orthoptic Association in its development which called for international cooperation and exchange of ideas . Council of Management As a means of sponsoring this venture the 1968 Society staged a first international congress Orthoptic Association of Australia of orthoptists in London with the express Associacao Brasileira de Ortoptica wish of proposing to those present, the for- Canadian Orthoptic Society mation of an International Orthoptic Associ- Association des Orthoptistes Francaises ation. British Orthoptic Society It was in this way that the IOA came to be Nederlandse Vereniging van Orthoptisten formed. Eight of the countries present at Association des Orthoptistes Suisse that 1967 meeting were the original signatu- ries and now there is a membership of International Orthoptic Association something like thousand orthontists with a Council of Management

International Orthoptic Association 1969 Aims American Association of Certified Orthoptists 1. To give a service to the patient by encouraging 1973 high standards of training and practice in orthoptics. Berufsverband der Orthoptistinnen Deutschlands 2. To foster the science of orthoptics and to encourage Associazione Italiana Ortottiste the maintenance of an internationally accepted 1977 terminology. 3. To provide information and assistance to national South African Orthoptic Society authorities and individuals to initiate and develop orthoptic services throughout the world. 1978 4. To organize at regular intervals international congresses on orthoptics. Berufsverband der Orthoptistinnen Osterreich

79 merely reduced deviation was disregarded.

Equally the teaching of convergence for these

patients was totally ignored creating problems later in life. Convergence exercises

were reserved for those patients with an EXO

deviation. Enthusiastic bouts of adduction until 1947 when the training of orthoptists exercises to some extent gave rise to over picked up once more, the Schools re-opened convergence and accommodation problems. and the ophthalmologists returned from the The insistence of recognisable diplopia armed services. undoubtedly has a place in modern orthoptics

but is no longer considered essential for all as

a pre-operative measure.

Operative procedures most frequently used

were recession, resection, myectomy without

cauterisation and tenotomy (usually guard-

ed). Over liberal surgery with resulting

consecutive squint was not unknown.

Patients were double padded for as long as

A backward look at a typical day in the a week which must have been distressing and work of an average British orthoptists in the led to children straining to peep under the

1930s can be seen by referring to the case pads thus worsening matters. notes of that time. Less exact and often The Gold Bar operation of Alabaster inadequate diagnostic procedures coupled (Birmingham) was developed in which a thin with quantities (sometimes as many as 200 gold wire was inserted under the medial visits) of half hourly thrice weekly treatment rectus and left in place for 5 days or so. sessions. These treatments were given to At the end of this period it was removed. eradicate Abnormal Retinal Correspondence, A •ggood•h result would be marked divergen- to establish Fusion, to teach control of devia ce which should very slowly reduce. To aid tion by methods now considered dubious and this, abduction exercises were given until perhaps damaging. Damaging also, due to BSV was achieved or the patient re-converg- lack of knowledge, the use of occlusion for ed as was of en the case. Was this the fore- amblyopia in the older child with lack of runner of adjustable sutures or should the improvement or worse-the development of claim to fame for this procedure go to. intractible diplopia for which there is no The pendulum swings and whilst one has paliative. Occlusion was frequently total- learnt by the mistake notions of the pioneers a black patch worn night and day for months we should not ridicule their work our know- on end; anti suppression treatment and ledge and our research to some extent is attempts to eradicate ARC were given on the based on their successes and failings. But synoptophore; accommodative squints of all for them where would we be now? Neverthe- types were taught the exercise of •gclear and less this has helped us to give a better service misty•h to relax accommodation in which the and we are still learning and must ever insufficient use of the Cover Test to different- remain so. iate between the achievement of BSV or Let us now reflect for a moment on a

80 typical day for an average orthoptist 50 years tant contributing factor. later in the 1980s. Through the years different approaches to With great exactness she will investigate orthoptic exercises have come and gone and the history of the case and will heed the today we find these practised by some and points made with care. With meticious care not at all by others. But whatever the she will select diagnostic procedures for each approach, the concept of being a diagno- patient selecting those tests that are relevant stician comes first and formost. proving that she is not a mere technician but Our approach at Holborn is the cautious is a worker able to interpret her findings. selection of cases whom we will treat-an She has the advantage of much sophisticated approach largely representative of orthoptic equipment to aid her-a particular break- practices in the country as a whole. through in approach is possibly the visuscope, 1. Amblyopes are given occlusion of the the envy of the early workers in the selection fixing eye which may be total, but partial of patients thought able to respond to occlu- occlusion is becoming more common. sion providing easier methods in the diagno- Short periods of total occlusion have sis of eccentric fixation and microstrabismus. proved very beneficial. The recent She has the advantage of devices for studies of Von Noorden and others, assessments in free space to show exact based on the work of Hubel and Weisel circumstances of the state of binocular func- with the emphasis of the dangers of long- tion and deviation under differing circumsta- term full-time occlusion especially of nces of distance and gaze position. infants has led to the adoption of quite The whole battery of instruments have short period of occlusion being the treat- their uses and their place, but nothing surpas- ment of choice with favourable results. ses the usefulness of the Cover Test when The so-called inverse occlusion of the used by the expert, in the detection of minute affected eye is rarely used. deviation as well as marked ones and by meticulous interpretation-not only in its own right but when used in conjunction with other instruments and devices. Thus greater and important emphasis is place on diagnostic techniques and the finer points of diagnosis arrived at not forgetting the prognosis. This combination enables more exact predictions of the outcome of management from the outset. The philoso- phy of trying things out without knowledge Cambridge Stimulator and forethought has disappeared. The stages of treatment are established before it Penalization or treatment with the commences which is enhanced by the team- Cambridge Stimulator may be used if work which now exists between ophthalmolo- conventional occlusion is unsatisfactory. gist, orthoptist, patient and if a child the We limit the Cambridge Stimulator in parents. The involvement of parents and this way but undoubtedly it has a place in child encourages motivation and is an impor- the treatment of selected cases for which

81 it is a most valued piece of equipment. week and long and expensive journeys to 2. Diolopia appreciation as a pre-requisite the clinic. for all cases about to have operation is 5. Operative techniques and procedures no longer so wide-spread. It is impor- have improved through the years as have tant to select those patients in whom the the results. Whilst recession/resection total elimination of suppression is exped- is often the operation of choice for ient. For example we are particularly concomitant squint, other procedures are aware of the danger of achieving diplo- used particularly when vertical deviation pia pre-operatively for Intermittent Dive- is in need of correction. There is now rgence Excess. With the in-built reflex the realization that the vertical compo- action of exerting convergence to over- nent if left uncorrected can influence the come this there can be problems of end result-which has led to more careful consecutive esotropia post-operatively. planning of surgery for patients. The 3. Accommodative squint may be treated bilateral weakening of Inferior obliques by exercises, by operation, by increasing even in cases in which only one appeared or decreasing the power of hypermetro- to be affected is common practice. To pic correction, by bifocals, by the use of a large extent recession has replaced miotics or by combinations of these myectomy as being more reliable. Re- expedients. alignment of the inferior recti to over- In our experience it is of little value to come torsional diplopia associated with give miotic therapy unless it can be traumatic superior oblique palsy has combined with orthoptic exercises-some proved successful particularly for cases binocular function is therefore a pre- in which the complaint is of crossed requisite. Further we have found the images without vertical or even horizon- long-term effect of this treatment is tal separation of images. The orthoptic disappointing and only provides a period assessment is of vital importance in of remission be it 6 months, a year or establishing the pattern of diplopia, even longer. Long-term observation is which can pass undetected. all important. When re-convergence Adjustable sutures have a place in the occurs, all else taken into consideration battery of operations which are being operation may be advised. used but few surgeons are using the Bifocals are almost never advised for Faden procedure of Cuppers although it children. is undergoing a considerable vogue on 4. Heterophoria treatment is profoundly the continent of Europe. Whilst this successful. The methods have altered operation does not alter the deviation in little but the pattern of treatment is the primary position nevertheless the different-the major part being under- British surgeon favours recession/resec- taken at home with the patient attending tion procedures for nystagmus placing every 3-4 weeks for assessment of progr- the Null point straight ahead. ess and instruction as to the next stage. 6. Abnormal Retinal Correspondence is This pattern differs in different parts of almost never treated orthoptically and the country-the underlying reason being only in very carefully selected cases is to avoid disrupting education, working operation advised. Our experience has

82 shown that its eradication rarely if ever With the approval of the Faculty of is replaced by true binocular function. Ophthalmologists of the Royal College of It is a form of binocular function even if Surgeons orthptists now are employed in anomalous and as such is an asset to the Visual Assessment Units. The first of these patient and in our view it is a dis-service schemes using orthoptists was in the Oxford to the patient to take this away and fail area. Afully equipped orthoptic van driven by to replace it with something better. orthoptists, visit on a regular and systematic Operation is equally disappointing and is basis all the villages and outlying areas not embarked upon unless the cosmetic within the control of the Oxford Area Health appearance is poor-which is by no means always the case.

What then does the future hold for the profession and for the individual? The role of orthoptist is already expanding with favourable results. In our view this expansion should proceed slowly but steadily.

Expansion will require deeper knowledge than is at present taught and this we feel can Authority. The orthoptists test vison and be brought about by degree education for ocular muscle imbalance of all children orthptists which is now our goal in Great whose parents wish for the service without Britain in the foreseeable future. referral from a doctor. The testing ages In a country where there is no specialist considered critical are 9 months, 21/2 years, occupation for the •gOphthalmic Assistant•h and 3 years. Children who show any defect as is the case in many countries-we feel it is whatsoever are then referred direct to the the orthoptist who can and should fill this Eye Hospital in Oxford for ophthalmologist role. opinion and appropriate treatment. Apart from the practise of more and more The effect of this Scheme during years of of them alredy working in Glaucoma Units, its operation has been a dramatic drop in the Testing Visual Fields, tonography and so on number of children requiring operation for orthoptists have now entered the field of squint as well as a drop in the number atten- preventative medicine.

83 ding hospital found to have pseudo-squint. etical and practical learning has to be Quite apart from the benfit to the children maintained but the pattern of this will alter.

concerned and the relief of their parents this It is envisaged that two or three univeristies

is cost effective, particularly in a country will provide theoretical training and that

operating a National Health Service, and students will be seconded at appropriate

very rewarding. It is a tremendous achieve- times to orthoptic •gclinics of excellence•h for

ment of the profeesion that orthptists are bloks of clinical teaching with final exami-

now regarded as competent of being the first nation after 3 years followed by a pre-registr-

line of defence in the control of ocular ation year carried out in 80-100 specially

dysfunction. Whilst it may seem a relative- selected clinics before the degree can be

ly simple procedure to screen in this way it awarded.

has to be remembered that the responsibility Once this is achieved we believed that our

is enormous and the work requires tremen- contribution to ophthalmology will be greatly

dous dedication to detail. advanced and that the future for profession

To be best fitted for this expanded role it is will be in competent hands.

in our view essential that first and foremost If we could look into a crystal ball at the

the training will be in orthoptics with all the future within the orthoptic clinic itself we

basic teaching of Anatomy, Physiology, Optic would I think find that our patients will fall

and General Ophthalmology taken to a more disinctly into the already prevalent

greater depth. The knowlege learnt should pattern of 2 main catagories-the infants and

be sufficient for orthoptists to carry out the elderly.

visual assessment programmes as described This tendecy has increased in direct relati-

as well as being included Child Assessment onship with the wider understanding of binoc-

Teams dealing with the whole child, in ular function by better understanding of

Glaucoma and Neurological Units, under- general practioners, specialists, and the

taking Fundus photography and other ophth- general public through publicity, throgh the almological photographic work, in electro- media and increased educational opportuni-

diagnostic departments; and generally in all ties.

spects becoming a highly skilled operator Consequently squint is-and will be-detec-

within the ophthalmic team dealing with out- ted and treated earlier and earlier-and in a patients and in-patients, thus creating evern world where the life expectancy has become closer ties with the ophthalmic team. longer, the problems encountered in old age

To become competent in the finer aspects will increase as the orthoptist becomes invol-

of these special duties within ophthalmology ved in the management of patients with

and in order to undertake research in her own thyroid disease, developing and post-surgical

right-we believe that degree education is brain tumour, cerebral thrombosis and strok-

essential. But never must it be said that es to name only a few.

these exciting practices precedence over the The name of game should change from

orthoptist's chosen activity of dealing with •g treatment•h that conjures up a picture of ocular muscle defects. If job satisfaction is exercises to •gmanagement•h that embraces to be maintained a proper balance of duties all aspects of orthoptics-that the orthoptist must include orthoptics. can sympathise and understand these patients

In traning the very close integration of theor- as well as provide paliatives for them is well

84 known. stages of development that have taken place Between these two groups of patients there in the history of the orthoptic profession in will always be the Convergence Deficiencies the United Kingdom and to indicate the and cases of heterophoria in need of treat- trends that have been prevalent. There is ment-fewer we trust but nevertheless some possibly •glittle new under the sun.•h Ideas that have slipped through the net-be they come and go-but each time a little more is anisometropic amblyopes, those with undete- added as the understanding of binocular cted small angle squint or other neglected function becomes clearer. cases. We are grateful to the early workers as Our hope is that a major breakthrough will well as to the experts with whom it has been be made by the physiologists leading to our privilege to be associated. dramatic changes in the understanding of There is an underlying message from the binocular function with consequent improved very start that we do not forget and trust will therapeutic aids. Over all of this hangs an remain. The support, encouragement and enormous question mark. It is my believe that guidance of ophthalmologists including that there should be a place for orthoptists to eminent body-the Faculty of Ophthalmologi- work more closely with physiologists in this sts of the Royal college of Surgeons-has field as well, conducting the clinical trials. been our mainstay and basis for the develop- The work so far undertaken is encouraging ment in clinical practises, in education and and has already changed our approach parti- learning throughout the past 52 years. cularly in the treatment of amblyopea. In our view this support is fundamental to In this and in all aspects of the orthoptists the success of a profession supplementary to work we look forward and are confident that medicine and is as vital in the future as it was there is a future that may be different but can in the past with the orthoptists role in the be very rewarding. ophthalmic team increased in expertize and CONCLUSION in responsibility. I have tried to capsule into this talk the

CURRICULUM VITAE

Miss Barbara M. LEE MBE DBO(T) Road and High Holborn 1980 Qualified Birmingham and Midland Eye Awarded decoration MBE in recognition of Hospital (DBO) services to orthoptics in the international Served as an officer WRNS (Women's Royal field 1968 Naval Service) undertaking duties as an Committee member British Orthoptic Coun- orthoptist. cil Teacher qualification (DBOT) 1955-1978 Principal School of Orthoptics Coventary and Honorary Secretary British Orthoptic Soci- Warwickshire Hospital ety 1954 Principal School of Orthoptics Moorfields Chairman British Orthoptic Society 1955 Eye Hospital, High Holborn 1954 -1967 Principal School of Orthoptics Moorfields Chairman International Orthoptic Associa- Eye Hospitall combined appointment City tion 1967-1975

85 Secretary General Internatiolal Orthoptic る。1967年ロンドンで第1回Orthopticsの国

Association 1975-onwards 際会議が開催され,IOAが8ヵ国で創設さ Chairman Orthoptists Board of Council for れ,その後14ヵ国に増し,今度新しく日本の Professions Supplementary to Medicine 参加が決定した。 1979-onwards. IV Orthopticsの変遷 <要訳> 1. 弱視

英国Moorfieds Eye Hospitalに世界最初の健眼遮閉を行う。完全遮閉であるが,部 Orthopic Clinicが誕生して今年で50年を迎え分遮閉もよく行う。短期間の完全遮閉は非る。この機会に英国におけるOrthopticsの起源常に有効である。いわゆる逆遮閉はめったとその発展について述べる。1929年から1981年に行われない。遮閉法で効果がないときにの間のORTの教育,活動状態および実務の発ペナリゼーションが行われる。展について述べ,ORTの未来像についても考 2. 複視えてみたい。術前に複視を認知させることよりも現在 I 英国のOrthopticsの歴史は1929年Mary では抑制を完全に除去することができる患

MaddoxがLondonのRoyal Westminster 者を厳選することが大切である。 Ophthalmic Hospital(現在のMoorfields 3. 調節性内斜視 Eye HospitalのHolborn分院)で仕事を開訓練,手術,遠視の矯正度の増減,bifocal, 始したのが最初である。このHospitalの歴史 mioticsの使用またはこれらの組み合せには10世紀初めにさかのぼる。よって治療が行われる。Bifocalは子ども II 1805年Londonで最初の眼疾患のための病には処方しない。

院であるLondon Infirmary (Moorfieldの 4. 斜位前身)が設立され,その後1816年ロンドンシ大部分の患者は家庭で治療を行い,3～4 ティ西部にeye hospitalが建てられ,1928年週毎の通院治療で良い効果が得られてい Holbornに建設された病院にはじめて斜視る。

部門が開かれる。 5. 手術 III 歴史の古い時代の斜視治療については7世手術のテクニックや方法は年々進歩して紀にアイパッチを使用したことが知られていおり,共同性斜視ではrecessionやresecti- る。19世紀には英国,アメリカ,ドイツなど onが行われ,他の方法は特に垂直偏位の矯で斜視や弱視に関する種々の器械が開発され正が必要な場合に用いられる。ている。1920年代にErnest Maddoxは自分 6. ARC の娘のMary Maddoxを指導して世界で初治療にOrthopticsはほとんど行われず, のOrthoptistに育てる。1930年代,英国には選ばれた症例のみに手術を行う。治療とスペシャリストの養成のための機関 V 未来像が続々とつくられる。1930年代にORT 22名 Ophthalmic assistantとしてのOrthoptist であったが,1934年までに教育と試験のの役割は広がってきており,"治療"から"管 national programmeの必要性がいわれ, 理"へとかわらなければならない。現在,英

British Orthoptic Councilが組織される。国ではORTの教育にdegreeを採用するこ 1937年には新たに49名のORTが活動するよとが考えられており,有能なORT養成のた

うになり,ORTのトレーニングは最初1年めにはぜひ必要である。ORTがphysiologist

間であったが後に3年間に改められる。70名と協力することによって治療面に大きな効果余りのORTによってBritish Orthoptic をあげることができる。 Societyが創られ,政府に正式に認められ,現 VI 結論

在では会員相互の理解と研鑚に役立ってい英国のOrthopticsの発展を歴史の上から

86 振り返り,ORTの今後の役割について考察答弁授業料は各校により異なりますが500～2,000ポした。治療,教育,研究の発展の基礎には眼ンド位です。B.O.C. (British Orthoptic Council)と科医の支援,激励,指導はなくてはならないしては一律1,000ポンド位になることを希望していまものであり,ORT自身も深い知識を修得すす。その理由としては授業料の10%がB.O.C.の唯一のるよう努力することが重要である。収入源となっているためです。授業料はNational Health Service(公的機関)に (鎗田佑子訳) よって支払われますが,政府が全額負担するというの質問川崎医科大深井小久子ではなく,各家庭の状況に応じて個人の負担額が決め we, Japanese people didn't know the process られています。 of development of science in the Europian coun- 初任給はfull timeで年収4,000ポンド位ですが,こ tries. れはアシスタントとして働く場合で1人で働く場合に Now, today, we were so much impressed by はもう少し高い。 Miss Lee's lecture and we could understand the 新人の場合は1人で働かない方がよいということで development of orthoptics after the long way. 大体アシスタントとして働いています。 For our future, you had emphasized a coope- 質問国としての就学前集団検診制度について東京医科大原沢佳代子 ration of visual physiologist. 答弁さきほどの講演で示したOxfordのような例 For our degree education, I fell orthoptist は,まだ実験的に始まったばかりで,実際に強制的に must be a visual scientist. 検診をするというようなところまでいたっておりませ I do appreciate your fantastic suggestion for ん。今後そのようにしたいと思っています。 our future. 英国の視能訓練士養成校の授業料および初任給について

-87-