Mention the name “Gunter K. von Noorden”, and many optometrists and ophthalmologists of my era will think of his classic textbook, Binocular Vision and Ocular Motility: Theory and Management of Strabismus. Thanks to CyberSight, the entire book is available online. von Noorden is 86 years old now, having resigned from his faculty position as professor of ophthalmology at Baylor College of Medicine in 2009 to accept the title of distinguished emeritus professor of ophthalmology. von Noorden wrote a memoir published in 2007, titled From Berlin To Texas: Forging a Life from the Devastation of War.
I had the opportunity to read it on the flight from NJ to San Diego yesterday, and highly commend the book to you. There are intricacies regarding von Noorden’s upbringing in Nazi Germany that are unique and revelatory, and for that reason alone the book is worth reading. It is noteworthy that von Noorden wouldn’t have collaborated with his principal mentor Hermann Burian on their classic strabismus textbook were it not for the influence that Alfred Bielschowsky had on Burian in the first place. Bielschowsky emigrated to the United States in 1936 to escape mounting discrimination in Germany, and joined the world’s foremost binocular vision clinic at the Dartmouth Eye Institute. Burian joined him shortly thereafter, but was recruited to Iowa after Bielschowsky died and Dartmouth disintegrated. It was in Iowa where Burian and von Noorden began their monumental collaboration.
Among the many items that popped out in reading about von Noorden’s odyssey, two in particular caught my eye:
1) although the former Austrian and naturalized Canadian physician Hans Selye coined the term “stress”, it was one of von Noorden’s teachers, Professor Ferdinand Hoff, who should be credited with influencing Selye on the pervasive nature of stress in health and disease.
2) When Burian was out of town or otherwise unable to conduct what was called in Iowa the “Muscle Clinic”, von Noorden gladly filled in for him. They both loathed the name, and for good reasons. In his research, von Noorden became increasingly intrigued by how the visual system in the human brain adapts itself to abnormal stimulation as occurs in strabismus. There were complex mechanisms in play, and over the years his work extended beyond medicine into neuroanatomy, neurophysiology, psychophysics, electrophysiology, psychology, and even philosophy.
These influences spring to life in many sections of von Noorden’s Binocular Vision textbook, perhaps best summarized when he writes in his introductory chapter:
Certain motor skills of the eyes are learned and improvable, as are all motor skills. The situation may be compared with that of a musician. ‘‘Innate’’ musical talent is necessary, but to be a pianist or violinist the motor skills of fingers and arms must be learned and continually reinforced through practice.
… and perhaps best encapsulated in chapter 9 when he states:
The relative position of the visual axes is determined by the equilibrium or disequilibrium of forces that keep the eyes properly aligned and of forces that disrupt this alignment. Clearly, the fusion mechanism and its anomalies are involved in some manner in producing comitant heterotropias. To understand the etiology of neuromuscular anomalies of the eyes, therefore, one should also gain an insight into other factors that determine the relative position of the visual axes.
First, there are anatomical factors, which consist of orientation, size, and shape of the orbits; size and shape of the globes; volume and viscosity of the retrobulbar tissue; functioning of the eye muscles as determined by their insertion, length, elasticity, and structure; and anatomical arrangement and condition of fasciae, ligaments, and pulleys of the orbit.
Second, there are innervational factors, that is, all the nervous impulses that reach the eyes. These factors include the co-movements of extraocular muscles with intrinsic ocular muscles, psycho-optical reflexes (fixation reflex, fusional impulses), influences of the static apparatus on extraocular muscles and their tonus (endolymph, vestibular system, reflexes from neck muscles), and influences of the several nuclear and supranuclear areas that govern ocular motility.