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Griffin Binocular Anomalies

Griffin habla sobre las anomalías encontradas en la visión binocular desde la ambliopia hasta el estrabismo; acompañado de las pruebas hasta los posibles tratamientos.

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0% found this document useful (0 votes)

958 views599 pages

Griffin Binocular Anomalies

Griffin habla sobre las anomalías encontradas en la visión binocular desde la ambliopia hasta el estrabismo; acompañado de las pruebas hasta los posibles tratamientos.

Uploaded by

Balder Gama

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

Foreword | xiii
Preface I xv

Part OneDiagnosis
1 Normal Binocular Vision I 3
Valu of Normal Binocular Vision |
Anatomy of the Extraocular Muscles
Neurology of Eye Movements | 6
Sensory Aspects of Binocular Vision 10

Visual Skills Efficiency I 19

Heterophoria Case Analysis I 69

Tonic Convergence and Accommodative-Convergence/
Accommodation Ratio | 70 Zone of Clear,
Single Binocular Vision | 72 Morgan's Normative
Analysis 76 Criteria for Lens and Prism
Prescription | 76 Fixation Disparity Analysis | 78
Validity of Diagnostic Criteria | 87
Recommendations for Prism Prescription | 90
Vergence Anomalies 92 Bioengineering Model
| 97

Strabismus Testing I 101

Sensory Adaptations to Strabismus 135

Suppression | 135
Amblyopia | 143
Anomalous Correspondence ) 166

Diagnosis and Prognosis I 189

Establishing a Diagnosis j 189
Prognosis | 190 Modes of Vision
Therapy | 199 Case Examples | 206

Types of Strabismus I 215

8 Other Oculomotor Disorders I 237

Part TwoTreatment
9 Philosophies and Principies of Binocular Vision
Therapy I 263
Philosophies | 263
Principies | 268

10 Therapy for Amblyopia I 279

11 Anomalous Correspondence Therapy I 323

Exotropia and Anomalous Retinal Correspondence | 340

Surgical Results n Cases of Anomalous Retinal
Correspondence | 341
Case Management 342
Case Examples | 343

12 Antisuppression Therapy I 347

Occlusion Antisuppression Therapy | 348 General
Approach to Antisuppression Training 348 Specific
Antisuppression Techniques | 354 Management
Considerations | 363 Case Example 364

13 Vision Therapy for Eso Deviations I 367

Diagnostic Considerations | 368
Vision Therapy Sequence for Comitant Esotropa | 368
Vision Therapy Sequence for Esophoria 373
Specific Training Techniques 373
Case Management and Examples 391

14 Vision Therapy for Exo Deviations I 399

Diagnostic Considerations | 400
Vision Therapy Sequence for Comitant Exotropia | 400
Vision Therapy Sequence for Exophoria 405
Specific Training Techniques 406
Case Management and Examples | 419

15 Management of Noncomitant Deviations, Intractable

16 Therapy for Vision Efficiency I 451

Pa rt Th reeTec h n q u es
17 Vision Training for Eso Deviations I 489
MirrorStereoscope(T13.2,T14.4) | 490
Contents

Dual Polachrome llluminated Trainer Vectograms and Tranaglyphs

for DivergenceTraining at Near (T13.8) | 491
Aperture-RuleTrainer, Double Aperture (T13.13) \ 492
Orthopic Fusin (T13.15) \ 494
Remy Separator (T13.14) | 496
Pencil Push-Aways with Base-ln Prism (T14.13,
Pencil Push-Ups and Push-Aways) | 497
Brock String and Beads with Base-ln Prism (T13.6) | 498
BrewsterStereoscope(T13.3,T13.4) | 499
Peripheral Fusin Rings (T13.7) | 500
Televisin Trainers and Base-ln Prisms (T12.8) j 502
18 Vision Training for Exo Deviations I 505
Voluntary Convergence (T14.1) | 506
Pencil Push-Ups and Push-Aways (T14.13, T11.13, T14.1) | 507
Brock String and Beads (T14.5, T13.6) | 509
Three-DotCard(T14.6) | 511
Aperture-Rule Trainer, Single Aperture (TI 4.12) | 512
Vectograms and Tranaglyphs: ConvergenceTraining at Near
(T14.9) | 514 Vectograms and Tranaglyphs:
Convergence Walk-Aways
(T14.10) 517 Vectograms and Tranaglyphs:
Projected Base-Out Slides
(T14.11) I 518
Chiastopic FusinColored Circles (T14.14) | 519 Chiastopic
FusinEccentric Circles (T14.14) | 521 Vergence Rock
Televisin Trainer and Prisms (T14.16) | 522 Vergence RockBar
Reader and Prisms (T14.17) \ 523
Vergence RockFraming and Prisms (TI 4.18) 525
19 Vision Training for Saccades, Pursuits,
and Accommodation I 527
Electronic Fixation Instruments for Saccades (TI 6.12) | 527
Continuous Motion for Saccades (TI 6.6) | 528
Ann Arbor (Michigan) Tracking (T10.7) | 529
Sequential Fixator (T16.10) | 529
Standing Rotator for Pursuits (T16.13) | 531
Marsden Ball (T16.14) | 531
FlashlightChase(T16.17) 532
Hart Chart Near-Far Rock (T16.22) | 533
Plus-and Minus-Lens Rock (T16.23) I 537
OtherTrainingTechniques | 538
20 Sequencing of Techniques and Practice
Management I 539
Suggested Sequencing of Tra'm'mgTechniques for Amblyopia | 540
Suggested Sequencing of Training Techniques for Eso
Deviations | 540 Suggested Sequencing of
Tra'm'mgTechniques for Exo
Deviations | 541
Vision Training for Visual Skills Efficiency | 543
Practice Management in Vision Therapy | 543
Comments I 546
Contents XI

Appendixes | 547
A. Special Commentary: Vision, Learning, and DyslexiaA Joint
Organizational Policy Statement of the American Academy of
Optometry and the American Optometric Association | 549
B. Developmental History | 551
C. Strabismus Examination Record | 554
D. Stereoacuity Calculations | 556
E. Conversin of Prism Diopters and Degrees | 557
F. Visual Acuity and Visual Efficiency | 557
G. Visual Skills Efficiency Evaluation (Testing Outline) 558 H.
Visual Skills Efficiency Pass-Fail Gritera (Summary from
Previous Chapters) | 559
I. Visual Symptoms Survey 561
J. Suppliers and Equipment 562

Self-Assessment Test | 567

Questions | 567
Answers | 579

Glossary | 589

Index I 593
Foreword

By popular demand, and need, comes this new, ing normal binocular visin, such as stereopsis and
updated, and expanded fourth edition of Drs. Grif- an ncreased field-of-view. Furthermore, an entire
fin and Grisham's now classic Binocular Anomalies: section is now devoted to the objective recording
Diagnosis and Vision Therapy. In the intervenng and evaluation of reading eye movements using the
period since publication of the previous edition Visagraph system. This seems most appropriate as the
(1995), the important and challenging rea of reading demands imposed by society continu to
abnormal binocular visin has continued to flour- ncrease, in both adults and children. Finally, the
ish, and even expand, n optometry, with spill-over addition of a self-assessment test should serve to test
into other disciplines. For example, visin therapy is one's newly acquired knowledge with practica! clini-
beginning to be ntroduced into selected grade cal examples, including full answers, for immediate
school systems using a team approach, including feedback and reinforcement.
consultant optometrist, teacher, therapist, and par- In addition to these new components, the tradi-
ent, with formal legislative support. Furthermore, tional reas of optometric visin therapy are pre-
visin therapy's unique contribution to patients with sented n detall with abundant graphics and case
acquired brain injury n which vergence, accommo- examples, both with respect to diagnosis and thera-
dative, reading, and visual-spatial dysfunctions peutic aspects. To the best of my knowledge, this s
abound has only recently been appreciated by the most complete and encyclopedic treatise on
many, including the traditional medically based visin therapy ever produced, incorporating an
rehabilitation team consisting primarily of physia- appropriate blending of clinical knowledge and
trists and occupational therapists. training protocol with substantial theoretical bases
The updated and new topics included in this latest to satisfy one's ntellectual cravings.
edition are consistent with these deas. For example, Henee, once again, Drs. Griffin and Grisham
the presence of ocular disease may have pronounced share selflessiy their years of clinical experience and
adverse effects on the binocular state (e.g., central devotion to optometric visin therapy. The result is
scotomas n macular degeneration and peripheral an outstanding book that should guide students and
scotomas in retinitis pigmentosa). These will reduce practitioners alike in their quest for a greater under-
disparity drive to the vergence system, resulting n standing of binocular anomalies and their more
fusional problems and, furthermore, produce reading effective and efficacious treatment.
mpairment due to scanning limitations. In addition,
recent research advances n basic aspects of binocu- Kenneth J. Ciuffreda, O.D., Ph.D.
lar visin clearly demnstrate the subtle but impor- DistinguishedTeaching Professor and Chairman
tant adverse effects on dynamic motor control (e.g., Department of Vision Sciences
grasping rapidly for a small or moving object) when State College of Optometry
binocular function is compromised. This s n addi- State University of New York
tion to the more traditional y cited advantages of hav- New York

XIII
Preface

This fourth edition of Binocular Anomalies: Diagno- addition s by popular request of students and prac-
sis andVision Therapy follows the format and philos- titioners. All questions follow the exact chapter-by-
ophy of the third edition. When the exact diagnosis chapter sequence of topics presented n the text.
of a binocular anomaly is known, exact visin ther- Particularly updated topics include diseases
apy can be prescribed. Part One covers diagnosis, affecting binocular visin, binocular anomalies
and Part Two is on treatment We have updated and reading dysfunction, advantages of good bin-
many of the topics, because there have been impor- ocular visin, and pharmacologic treatment. Addi-
tant advances in diagnostic procedures and training tional case examples are included to Ilstrate the
techniques. Deleting some of the od material has mplementation of visin therapy and to help the
been necessary to allow room for discussion of new clinician connect theoretical principies with spe-
methods for diagnosis and treatment. cific visin therapies.
We take the accepted view that visin therapy A CD-ROM is included n which popular train-
encompasses all modes of treatment of binocular ing techniques are discussed; these techniques can
visin problems. Besides visin training, we be downloaded and modified according to the
include the use of lenses and prisms, occlusion, wishes of each practitioner.
pharmaceutical treatment, motivational methods, We have attempted to be semantically consis-
and extraocular muscle surgery when necessary. tent with terminology so that the reader can sean
Vision therapy of binocular anomalies is for treat- through various chapters without ambiguity and
ment of strabismus, heterophoria, amblyopia, and always know what specified terms mean. For
dysfunctions affecting educational, vocational, and example, we speak of viewing at far (e.g., 20 ft or
avocational performance. As n the previous edi- 6 m) rather than using distance, which many clini-
tion, each visin training technique (active visin cians use in their customary discourse. (One
therapy) s identified by a "T" number for easy could wonder if distance is referring to far dis-
identificaron and referencing. Diagnostic methods tance, intermedate distance, or near distance.) In
are referred to as procedures so that confusin can addition, we have set eso and exo (and the like)
be avoided between methods of testing (proce- apart as single words when combined with fixa-
dures) and training (techniques). Although these tion disparity and deviation. We have also
techniques are discussed thoroughly in general ncluded older terms n parentheses when a term
terms, we thought t would be helpful to include s ntroduced. For nstance, visuoscopy was once
specific, detailed discussions n a "how-to" format, spelled as visuscopy; we provide the reader with
similar to the teaching method of a preclinical lab- both terms initially and retain the more accepted
oratory for students and practitioners (especially term throughout the book. Our ntention s to
primary-care clinicians) and other professionals enhance the readability of the text.
and therapists wishing to review and learn new We thank the following individuis for their help
techniques. Part Three presents such detailed in making this new edition possible: Karen Ober-
instructions, including illustrations, on the most heim, Judy Higgins, Judy Badstuebner, Ronda Bar-
frequently used vision-training techniques. These ton, L. Ernie Carrillo, Dr. James Saladin, Dr. James
instructions are applicable to clinicians as well as Bailey, Dr. Walter Chase, Kirsten Griffin, R.N., Dr.
to parents and patients for home training. Also William Ridder, Dr. Lawrence Stark, Kim Vu, David
ncluded n Part Three are recommended sequenc- West, Donnajean Matthews, Denise Hess, Doreen
ng of techniques for specific binocular anomalies Keough, Pam Bickel, Lois Keup, and Holly Hoe.
and practice management principies.
A self-assessment test of 100 multiple-choice John R. J. David Grisham Berkeley
questions and explanatory answers s ncluded. This Griffin
Fullerton

xv
chapter 1 / Normal Binocular Vision

Valu of Normal Binocular Vision 3 Retina! Correspondence 11

Anatomy of the Extraocular Muscles 5 Panum's Fusiona! reas 11
Neurology of Eye Movements 6 Singleness Horopter 11
Accommodation 6 Conjgate Gaze Physiologic Dipiopia 12
Movements 6 Saccades 7 Pathologic Dipiopia 13 Types
Vestbulo-Ocular Eye Movements 7 of Sensory Fusin 13
Pursuits 8 Vergences 8 Color Fusin 13
Sensory Aspeis of Binocular Vision 10 Form Fusin 13 Theories of
Monocular Considerations 11 Sensory Fusin 15 Binocularly
Driven Cells and Ocular Dominance
16

Binocular visin pertains to the motor coordina- motor system is to direct the alignment of both
tion of the eyes and the sensory unification of their foveas (foveae) to the object of attention with i n
respective views of the world. This is a unitary pro- the visual field and to maintain them n that
cess but, for the sake of analysis, t can be broken position as long as the individual requires. The
into sensory and motor components. motor system holds the eyes in alignment and
The sensory side starts with light emitted or sustains clear focus, thereby ensuring the main-
reflected from physical objects n the externa! tenance of binocular visin. Frequently, how-
environment that is brought into focus on the ret- ever, the complete remediation of binocular
ina by each eye's optics. This pattern of light visin anomalies requires attention to both sen-
energy s transformed by retinal photoreceptors sory and motor aspects.
into neuroelectrical impulses and is transmitted to
the visual perceptual reas of the cerebral cortex
and certain subcortical reas. The result of com-
VALU OF NORMAL
plex neural processing, which is only partially
BINOCULAR VISION
understood, is the sensation of object attributes
(i.e., form, color, intensity, and position in space) One distinctive perceptual attribute of humans,
that, n turn, culminates n an immediate, vivid among all primates, s a high degree of stereo-
perception of object identity and of the relations scopic binocular visin. Our skills in hunting,
of objects in the external environment. food gathering, and tool making have helped to
The motor positioning and alignment of the direct our evolution. In the competition for food,
eyes completely subserve the primary sensory shelter, and safety, stereopsis is one of several
function of image unification and allow visual attributes that evidently provided mportant
perception to proceed efficiently. The task of the advantages to those who possessed t. In the mod-
4 Chapter1

Monocular Temporal Crescent Monocular Temporal Crescent

FIGURE 1-1Extent of binocular visual field showing monocular temporal crescents. (OD = oculus dexter [right eye]; OS = oculus sin ster [left
eye].) '

ern age, stereoscopic visin contines to provide difference is even greater when uncorrected
individuis with important information about ametropia is present in each eye.
their environment. Stereopsis significantly aids in Binocular visin, in contrast to monocular
making judgments of depth, whether at school, visin, minimizes the effects of ocular disease.
the workplace, or the sports field. It also helps to Binocular summation of ocular images signifi-
stabilize sensory and motor fusin and can be cantly heightens contrast sensitivity, by approxi-
considered a "barometer" of the status of binocu- mately 40%. 3 In practical terms, this is helpful
lar visin. for driving at night and working under low-illu-
Besides stereopsis, there are other benefits that mination conditions. Individuis with certain
derive from normal binocular visin. The most ocular diseases (e.g., optic nerve demyelination
obvious benefit of having two eyes is that, n case in mltiple sclerosis) may demnstrate profound
of injury to one, there is an eye in reserve. This differences in contrast sensitivity between binoc-
might be called the "spare tire" concept. Whereas ular and monocular sight.
the loss of sight in one eye can cause some signifi- There are several vocational and avocational per-
cant problems for an individual, the loss of sight in formance benefits of having good binocularity.
both eyes can be devastating. Sheedy et al.4 described superior task performance
The binocular individual also has the advantage under binocular versus monocular viewing condi-
of a large field of visin (Figure 1-1). The binocular tions (Table 1-1). Differences favoring binocular
field of visin usually is at least 30 degrees larger viewing were notable n such tasks as card filing,
than the monocular field. needle threading and, surprisingly speed of word
Binocular visual acuity normally is better by decoding. No significant difference was noted,
approximately one-half line of letters on a Snellen however, in letter counting on a video display termi-
chart, as compared with either eye alone. 1'2 The nal or in throwing beanbags accurately. Trese inves-
Chapter1 5

TABLE1-1. Superority of Task Performance under Binocular Conditons as Compared with Monocular Conditions

Percentage of Impr oyerpent of

Task Scores under Binocular Conditons Stgnf eaee (Studerrt*s fr-test)

Puttng sticks in holes 30

Needle threading Card 20
fling 9
Placing pegs in grooves 4 Q.01
Reading (word decoding) 4 0.05
Letter counting on vdeo dfsplay 2 NS
terminal Beanbag tossing
-1 ' NS -
NS = not signiflcant.
Source: Adapted from } Sheedy 1L Baitey, M Muri, E Bass. Binocular vs, monocular task performance. Am } Optom Physlol Qpt.
1986;63(10):839-846.

tigators concluded that stereopsis provides a performance advantage for many different Jobs, par-ticularly
those requiring nearpoint eye-hand coordi-nation. Persons in several occupations (e.g., pilots, microsurgeons,
cartographers) are aided by stereopsis in performing their tasks safely and efficiently.
Strabismus affects only a small percentage of the population (1.3-5.4%),5 but other deficiencies of
binocular visin, such as convergence insuffi-ciency and accommodative infacility, are much more
prevalent and may result in bothersome symptoms and inefficient performance. Except for those individuis
who have acquired strabismus and experience persistent double visin, most constant strabismics report few
extraordinary visual symptoms. On the other hand, many nonstrabismics with binocular visin
dysfunctions experience a variety of anomalies that are visual in origin, such as ntermittent blur at far or
near, tired eyes after reading or viewing a computer monitor, "eye-strain" at day's end, the appearance
of jumping or moving print, vision-related headaches, reduced depth perception, and mild photophobia.
Many of these symptomatic individuis experience "binocular efficiency dysfunction" (see Chapter 2).

ANATOMY OF THE EXTRAOCULAR MUSCLES

Three pairs of extraocular muscles control the movements of each eye: a pair of horizontal rec-
tus muscles, a pair of vertical rectus muscles, and a pair of oblique muscles. The rectus muscles, the
superior oblique muscle, and the leva-tor muscle (controlling the upper eyelid) are attached to the
bones at the back of the orbit by a tendinous ring (the annulus of Zinn) that sur-rounds the optic
foramen and part of the superior orbital fissure. The four rectus muscles, optic nerve, ophthalmic
artery, cranial nerve VI, and two branches of cranial nerve III form a muscle cone (Figure 1-2). The
insertions of the rectus muscles are not equidistant from the corneal limbus but form a spiral, known
as the spiral of Tillaux, with the superior rectus inserting farthest away from the limbus (7.7 mm) and
the medial rectus inserting nearest to the limbus (5.5 mm) (Figure 1-3). The more advanced the
nsertion, the greater the mechanical advantage of the muscle (e.g., the medial rectus as
compared with the superior rectus).
As with the rectus muscles, the superior oblique muscle originates from the annulus of Zinn, but
it courses along the superior medial wall of the orbit to the trochlea, a U-shaped fibrocartilage, that
acts as a pulley. Near the trochlea, the muscle tissue becomes a tendn as it passes through the
trochlea and then reflects back normally at an angle of approximately 51 degrees to the medial wall. The
muscle then crosses the globe superiorly, passing under the superior rectus, to insert n the posterior,
superior quad-rant near the vortex veins. The trochlea, there-
Chapter1

Levator Superior SR
Palpebrae^ obligue
Superior
Rectus

A LR = :
?
Oculomotor
Foramen
Inferior
Rectus
Pulley IR
Inferior -12mm
Oblique
- 24mm

FIGURE 1 -2Lateral view of muscles of trie right eye.

fore, becomes the effective mechan cal origin for of rectus pulleys has been implicated as a cause of
the action of the superior oblique (Figure 1-4). noncomitant strabismus.
The inferior oblique is the only extraocular mus-
cle that does not orignate n the orbital apex; t
arises from a small fossa in the anterior, inferior, Accommodation
orbital wall (the maxilla bone). This muscle's Accommodation s one member of the oculomo-
course parallels the reflective portion of the tor triad that also includes pupillary constriction
superior oblique muscle, again forming a 51- and accommodative convergence, all mediated
degree angle as it courses inferiorly and laterally by the third nerve nucleus n the midbrain.
across the globe and over the inferior rectus to Accommodation is a reflex initiated by retinal
insert in the inferior, posterior quadrant. blur; t can, however, be consciously controlled.
Evidence from magnetic resonance imaging stud- The afferent pathway extends from the retina to
ies of the orbit indcate that all rectus muscles pass the visual cortex and projects from rea 19 to the
through pulleys, structures composed of connective pretectum and superior colliculus before enter-
tissue and smooth muscle, that are coupled to the ing the Edinger-Westphal nucleus of the third
orbital wall and located just behind the equator of nerve complex. Projections from the frontal eye
the globe.6"8 In effect, these pulleys ("sleeves") fields (traditionally referred to as Brodmann's
rather than the attachments of these muscles at the rea 8) also enter the third nerve complex that, in
annulus of Zinn in the back of the orbitact as the part, mediates conscious control of accommoda-
origin for the action of the rectus muscles. In most tion. The efferent component of the reflex are
people, the location of these pulleys s remarkably from the third nerve complex synapses n the cil-
consistent and does not shift much with rotation of iary ganglion and again n the ciliary muscle
the globe into the various fields of gaze. Many stra- which, in turn, effectuates the change of lens
bismic individuis have been found to have normal power (Figure 1-5).
pulleys, although some do not. Abnormal location

Conjgate Gaze Movements

NEUROLOGY OF Conjgate eye movements are tndem movements
EYE of the two eyes, known as versions. These are sac-
MOVEMENTS cades, vestbulo-ocular movements, or pursuits.
The neurology of the following systems are dis- These three eye movement systems share a com-
cussed briefly: accommodation, conjgate gaze mon final pathway to the extraocular muscles, but
movements, and vergence.
Chapter1

that carry the eyes from one target to another pre-

determined target.9 The anatomy subserving vol-
51 < untary saccades has been partly established by
monkey studies and clinical observation in
humans. For example, if there s an ntention for
Medial dextroversion (eye movement to the right), stimu-
Wall lation occurs n Brodmann's rea 8 (frontal eye
field) in the frontal lobe of the left hemisphere.
Impulses then travel to the right pontine gaze cen-
ter and are forwarded to the ipsilateral nucleus of
cranial nerve VI. Subsequently, the lateral rectus
muscle of the right eye contracts. Simultaneously,
impulses travel from the ipsilateral pontine gaze
center up through the medial longitudinal fascicu-
lus that decussates to the left third nerve nucleus.
That results in contraction of the medial rectus of
the left eye (Figure 1-6). Because yoked muscles
FIGURE 1-4Relation between the superior oblique muscle and the have equal nnervation (Hering's law),10 the two
superior rectus muscle. (Note: Both the inferior and superior oblique eyes move n tndem. Versions are not restricted
muscles form a 51-degree angle with the medial wall, and both the because of the simultaneous relaxation of the
inferior and superior rectus form a 23-degree angle with the medial
wall. The action fields for clinical purposes are approximately 50 and
antagonistic yoked muscles (Sherrington's law of
25 degrees for the oblique and vertical recti, respectively.) reciproca! nnervation)10 (Figure 1-7).

they are neurologically distinct, with different cen- Vestbulo-Ocular Eye Movements
tral pathways and dynamic properties. The vestbulo-ocular system stabilizes the eyes on
a target during head movements and can be tested
Saccades with the "doll's-head" maneuver. The dynamics of
Saccadic eye movements refer to ballistic-type eye vestibular eye movements are relatively fast, hav-
movements that carry the eye quickly from one ing a latency of only 16 milliseconds as compared
target in space to another (i.e., a change in fixa- with the 75-millisecond latency of the pursuit sys-
tion). There are several types of saccades: (1)the tem.11 As the head turns, vestbulo-ocular reflexes
fast phases of either vestibular or optokinetic nys- are initated by the movement of fluid wthin the
tagmus; (2) spontaneous saccades occurring semicircular cais of the inner ear. For example,
approximately 20 times per minute and used to stimulation of the left vestibular nucleus causes
sean the environment; (3) reflexive (nonvolitional) impulses to travel to the right pontine gaze center.
saccades that occur in response to any new envi- From there, the pathway to the extraocular muscles
ronmental stimulus; and (4) intentional saccades is the same as that described for saccadic eye

A F F E R E N T
Retinal image blur LGN reas 17-19

Lens of eye -< ----------- Ciliaty muscle Ciliary ganglion N III nucleus

E F F E R E N T

FIGURE 1-5Neural pathway for accommodation. (LGN = lateral geniculate nucleus; N III = cranial nerve III [oculomotor nerve].;
8 Chapter 1

Midbnn

Pona

Medidla

LMR RLR

FIGURE 1 -6Neurologic pathways for saccades. a. Side view. Versional eye movements are initiated in rea 8 (supranuclear). A signal from rea 8
in the left hemisphere causes a versional movement of the eyes to the right. Axons travel down the left side of the midbrain and then decussate to
the right side at the level of the pons-midbrain. These axons then innervate the right pontine conjgate gaze center, which in turn innervates the
psilateral abducens (VI) and the contralateral oculomotor (111) nerve. b. Posterior view. (C = conjgate gaze center; IV = trochlear nerve; LMR = left
medial rectus; RLR = right lateral rectus.)

movements. Stimuiation from the left vestibular cally.iz The assumption is that the right and left
nucleus by a left head turn causes compensatory occipital reas are connected to each right and
dextroversion. left pontine gaze center, so that stimulation from
one occipital lobe may stimulate both the left and
Pursuits right pontine gaze centers for left or right pursuit
The pursuit system mediales constant tracking of movements. Because of this double coverage,
a moving target and is the slowest of the three pursuits may sometimes be intact despite an
eye movement systems. Pursuit eye movements extensive lesin in one hemisphere of the brain
are mediated via the occipitomesencephalic that could also cause a homonymous hemianopic
pathway. Impulses travel from the occipital lobes visual field loss (Figure 1-8).
(presumably from Brodmann's rea 19) to the
midbrain and pontine gaze centers and on to the
nuclei of the third, fourth, and sixth cranial Vergences
nerves to innervate the extraocular muscles. Each Vergence refers to disjunctive eye movements, or
occipital lobe is involved in the pursuit of a tar- rotation of the eyes in opposite directions. The
get, in both directions, horizontally or verti- two main types of vergence movements are
Chapter1

Occipital Lobes

Left Right

U J
U
LLR LMR RMR RLR
trolled to some degree, but they usually are
involuntary psycho-optic reflexes.13 Vergence
movements are slow and show a negative expo-
nential waveform (velocity diminishing from fast
to slow). For most visual tasks, both vergence and
saccadic eye movements are used
in combina-tion to place objects on
the foveas.
Little s known about the supranuclear pathways
subserving vergence eye movements, although
convergence n the monkey was produced as early
as 1890 by electrical stimulation of sites in the cor-
14
tex. Vergence eye movements probably are syn-
15
thesized bilaterally n the cerebral cortex (Figure
1-9). Impulses travel from the cortex to the pretec-
tum and rostral mesencephalic reticular formation.
Innervation is integrated from several sites, includ-
ing the cerebellum. In the midbrain, convergence is
mediated by the bilateral nuclei of the oculomotor
nuclear complex (cranial nerve III) that sends effer-
ent signis to both medial rectus muscles. There is
probably no single convergence center, contrary to
what once was believed (the so-called "nucleus of
FIGURE 1-7Hering's law and Sherrington's law evident during levo-
Perlia"). Regarding vergences, it s not certain
version. The right medial rectus (RMR) and the left lateral rectus (LLR)
ivoked muscles) contract, in accord with Hering's law. The left medial whether Hering's law of equal innervation of yoke
rectus (LMR) is the antagonist of the left lateral rectus, and it relaxes,
as does the right lateral rectus (RLR) (antagonist of the right medial
rectus), in accord with Sherrington's law.

accommodative vergence, stimulated by blur,

and fusional vergence, stimulated by retinal
image disparity. Vergences are consciously con-
10 Chapter1

Retinas Blur Disparity

Visual and
Cerebral
Pathways

Midbrain
and
Pons
NYI
Extraocular
Muscles
MR i
LR
Nnr

FIGURE 1-9Simplified illustration of neurology of vergences showing retinal blur stimulating accommodation, which in turn results in ac commo-dative
vergence, and retinal disparity resulting n disjunctive eye movements. Indirect stimuli (e.g., proximity and volition) are not depicted, or s cerebellar
integration. (IO = inferior oblique; IR = inferior rectus; LR = lateral rectus; MR = medial rectus; N III = oculomotor nerve [cranial nerve III]; N IV = trochiear
nerve [cranial nerve IV]; N VI = abducens nerve [cranial nerve VI]; SO = superior oblique; SR = superior rectus.)

muscles s the operative principie. In the real (mainly n the calcarine fissure) located bilaterally
world, vergence stimuli often are presented asym- on the medial aspect of each occipital lobe.
metrically to the eyes, and asymmetric responses Other functions of the primary visual cortex (V1,
have been found by cise inspection.16 Henee, formerly Brodmann's rea 17) include detecting
each eye appears to be responding independently spatial organizaron of the visual scene, bright-
to that eye's view of the target. Therefore, vergence ness, shading, and rudimentary form organiza-
testing can be done using symmetric stimuli (e.g., tion. Specific points of the retina connect with
Risley prism procedure) or an asymmetric stimulus specific points of the visual cortex (e.g., the
(e.g., step prism procedure). homonymous right halves of the two respective
Divergence once was accepted as merely the retinas connect with the right visual cortex). In
relaxation of convergence innervation. However, other words, the primary visual cortex is orga-
divergence usually is an active neurophysiologic nized like a map of the retina. Because the eyes
process, as indicated by electromyographic record- are separated by a distance of approximately 60
ings from the lateral rectus muscles.17 The path- mm in humans, each eye's view of the environ-
ways that subserve divergence remain essentially ment is from a slightly different perspective. The
unknown. sol basis for stereopsis is the horizontal disparity
SENSORY ASPECTS OF BINOCULAR between the two retinal images. A little-under-
VISION stood neural mechanism presumably located
within the visual cortex compares the retinal
The ability to intgrate Information from the two
images from each eye for disparity information.
eyes into one fused image and to extract depth
Further neural processing in this visual pathway
Information depends on the primary visual cortex
(also not fully understood) gives almost all people
Chapter 1 11

with normal binocular visin a vivid sense of corresponding retinal points are sufficiently
three-dimensionality (e.g., volume) n their visual stimulated.
perception of the external world.
Binocular visin seems so natural to most peo- Panum's Fusiona! reas
ple that they are hardly aware that their perception Rather than a point-to-point correspondence
of the world arises from the unification of two sep- between the two eyes, there exists a point-to-area
rate and slightly different images. Most people are relationship subserving binocular fusin. This rela-
surprised f diplopia occurs. What s truly remark- tionship was first described by Panum, a Danish
able, however, s that we usually do see single physiologist, in the middle of the nineteenth cen-
imagesa fact that requires an explanation. tury.18 Panum's rea s "an rea n the retina of one
Fusin of two ocular images requires adequate eye, any point of which, when stimulated simulta-
functioning of each eye and sufficient stimulation neously with a single specific point in the retina of
of corresponding retinal points n the two eyes to the other eye, will give rise to a single fused per-
produce single binocular visin. cept."10 Panum's reas are oval and larger horizontal
ly than vertical ly. Foveal Panum's reas are very
Monocular Considerations small, only a few minutes of are, as compared with
peripheral Panum's reas, which may be several
For normal binocular visin, the best possible
prism diopters n extent. The ncreasing size of these
visual acuity of each eye should be attained,
reas n the periphery may be related to anatomic
whether by means of spectacle lenses, contact
and physiologic differences known to exist between
lenses, surgical ntervention (e.g., to correct for
central and peripheral retina, receptors being
cataract), or other possible treatments (e.g., visin
densely packed at the fovea but widely separated n
therapy for amblyopia). Poor acuity of either or
the peripheral retina. Panum's reas parallel the
both eyes s a deterrent to sensory fusin. This s
increase in size of the retinal receptive fields, but
particularly true when the visin of one eye s
they are functionally part of the visual cortex, where
much poorer than that of the other eye. The dis-
binocular information comes together.
crepancy may be due to such functional reasons
as anisometropic amblyopia and strabismic
Sngleness Horopter
amblyopia, or it may be due to organic causes,
Sensory fusin can also be described in terms of the
such as macular degeneraron, cataract, and optic
location of stimuli n the visual environment. The
nerve atrophy. Any organic disease must be ruled
horopter s defined as the locus of all object points
out or managed correctly before functional test-
that are imaged on corresponding retinal elements
ing s continued and visin training techniques
at a given fixation distance.19 The dentical visual
are begun.
direction (IVD) horopter s a locus of object points
n which images on the two retinas give rise to a
Retinal Correspondence common visual direction. The IVD horopter usually
Retinal correspondence refers to the subjective is represented as a single horizontal line passing
visual direction and the spatial location of objects through the fixation point and having no thickness.
n the binocular visual field. An individual s said The concept of Panum's fusional reas is easily visu-
to have normal retinal correspondence when the al ized by reference to the IVD horopter that is
stimulation of both foveas (and other geometri- enveloped by the haplopic (singleness) horopter.
cally paired retinal points) give rise to a unitary The haplopic horopter s "an empirical horopter
percept. (The correspondence actually occurs n represented as having thickness corresponding to
the cortex, but clinically it is easier to concept- Panum's reas expressed by the anteroposterior lim-
ale retinal points.) The existence of correspond- ts through which a nonfixated test object may be
ing retinal elements with their common subjective displaced and still be seen as single (Figure 1-10).10
visual direction s fundamental to binocular visin. Note that the horopter is thicker in the periphery,
Stimulation of corresponding retinal points results corresponding to the increasing size of Panum's
n haplopia (singleness of visin), whether corre- fusional reas. The significance of the singleness
spondence s normal or anomalous. (Anomalous horopter, which nvolves the IVD horopter and
retinal correspondence s discussed in Chapter Panum's reas, s that any object seen outside the
5.) Conversely, double visin results when non- horopter necessarily falls on diplopia-producing,
12 Chapter 1

diplopia

singleness diplopia singleness

Fixatton
Spot

FIGURE 1 -10Singleness (haplopia) horopter. Diplopia can occur for

an object that is not within the horopter.

noncorresponding points. In other words, the visual

worid outside the singleness horopter should theo-
retically appear as double when retinal stimulation
is sufficient. Fortunately, nature is grand: Physiologic
suppression usually eliminates physiologic diplopia
so that most people can go about living normal
Uves, at least visually. Similarly, nature provides sen-
sory antidiplopic mechanisms for the strabismic
individual in the forms of anomalous retinal corre-
spondence and pathologic suppression (as dis-
cussed in Chapter 5).

Physiologic Diplopia
The doubling of a nonfixated object is known as
physiologic diplopia, because there is nothing
abnormal about this phenomenon. With normal
binocular visin, all objects falling outside the sin-
gleness horopter can be seen as double if sufficient FIGURE 1-11Homonymous ("uncrossed") physiologic diplopia.
(f = fovea.)
attention is paid to the stimulus object. Homony-
mous physiologic diplopia (also called "uncrossed"
diplopia) occurs when objects are beyond the point
of bifixation. Conversely, heteronymous ("crossec/") tor must explain that this is a feature of normal
diplopia occurs when a farther object is bifixated binocular visin that is normally not noticed.
with a nearer object in view (Figures 1 -11 and 1 -12). Some patients are not easily convinced of this
Because of physiologic suppression, these physio- physiologic fact about binocular visin because
logic diplopic images usually are unnoticed under the phenomenon seems counterintuitive. None-
ordinary viewing conditions. theless, physiologic diplopia s easy to demn-
Most patients consider seeing double to be strate to a patient with normal binocular visin
abnormal and seek help from an eye doctor. If the and can be used as a binocular visin screening
examination does not reveal a paretic muscle or a technique: As a patient fixates a pencil at 40 cm,
motor fusin problem and physiologic diplopia for example, the clinician asks the patient to hold
seems the most likely explanation, then the doc- up an ndex finger halfway between the fixation
Chapter1 13

object and the patient's nose. If the patient's Fixation

Spot
attention s drawn to the nonfixated finger, then
the finger usually appears to be double, like two
ghost images. Patients who have active suppres-
sion of one eye due to a binocular visin disorder
often cannot easily see the diplopic image. Physi-
ologic diplopia is an important tool n visin
training, used to help remedate binocular visin
n both strabismic and nonstrabismic cases.

Pathologic Diplopia
Diplopia of a fixated target, or pathologic diplo-
pia, s considered abnormal. It occurs n cases of
strabismus in which there is little or no suppres-
sion. Figure 1-10 shows one eye (left) fixating the
target of regard whe the esotropic (right) eye is
not fixating the target. In the right eye, the image,
rather than falling on the fovea, is nasal relative to
the fovea. This produces homonymous diplopia
("uncrossed"), in which the diplopic image s
seen on the same side as the strabismic eye. In
contrast, n cases of exotropia, pathologic diplo-
pia s heteronymous ("crossed"); that s, the
diplopic image s seen on the opposite side of the
strabismic eye.
Cyclopean projection depicts the manner in
which the visual cortex mediates subjective
directionalization of ocular images. If the cyclo-
pean eye is compared with a clock's face, the
principal visual direction would occur at the
fovea (assuming normal fixation and correspon-
dence). In Figure 1-13, assume that the nasally
stimulated portion of the right eye is at the 7-
o'clock position. The directional projection is,
therefore, at the 7-o'clock position n the cyclo-
pean eye. The difference of "1 hour" would nor- FIGURE 1-12Heteronymous ("crossed") physiologic diplopia. (f =
mally cause noticeable diplopia (assuming one fovea.)
image s not suppressed). When, however, the
difference is only a very small fraction of an
"hour," diplopia may not be obvious, as n fixa- unlike either of the stimulating fields." 10 Color
tion disparity. (Fixation disparity measurement is fusin is independent of the singleness horopter. It
discussed in Chapter 3.) is the lowest level of sensory fusin and s of rela-
tively little importance, except that many visin
testing and training methods use color fusin (e.g.,
Types of Sensory Fusin
Worth dot test and anaglyphic targets).
Sensory fusin may be that of color or form.
Form Fusin
Color Fusin
Binocular fusin of forms occurs within the single-
Color fusin is "a type of sensory fusin wherein ness horopter, whereas diplopia occurs outside the
spectral stimulation which differs for the two eyes horopter. Fused binocular visin is precious, but it
s combined or integrated into a unitary percept is possible only in a relatively small band of visual
14 Chapter1

Fixation Whereas diplopia results from stimulation of non-

Spot corresponding retinal points, superimposition of two
-------------------- >
ocular images (e.g., a bird in a cage) requires stimula-
tion of retinal reas having common visual direc-
tions. Worth20 classified superimposition as "first
degree fusin." The importance of superimposition
testing is in measuring the subjective angle of direc-
tionalization (angle S) and also assessing the degree
of suppression, particularly in strabismic patients.
Worth20 classified fat fusin as "second-degree
fusin." This is true fusin but without stereopsis.
Fat fusin is defined as "sensory fusin in which
the resultant percept is two-dimensional, that is,
occupying a single plae, as may be induced by
viewing a stereogram in a stereoscope in which
the separation of all homologous points is identi-
cal."10 The most important reason to consider fat
fusin is for visin testing and training purposes, as
in phorometry measurements, fixation disparity
testing, and in amblyoscopic assessment and treat-
ment (i.e., major amblyoscope instrumentation).
Worth20 classified stereopsis as third-degree
fusin. Stereopsis may be defined as "binocular
visual perception of three-dimensional space based
on retinal disparity."10
Figure 1-14 illustrates central stereopsis: The
fused, small vertical une is perceived as being
closer than the star. Although there is lateral dis-
FIGURE 1-13Rathologic diplopia in an example of esotropa of the
placement of the vertical line, as seen by each eye,
right eye. The diplopia is homonymous (uncrossed). (f = fovea.)
there will be fusin of the two lines into one verti-
cal line which appears centered (but closer) with
respect to the star. Lateral displacement of such
spaceanalogous to a vein of gold in the side of a
types of stimuli to produce stereoscopic depth is a
granite mountain.
feature of many visin therapy targets, such as vec-
Form fusin is the driving forc behind good
tographs (Vectograms), anaglyphs, and stereo-
binocularity, as it is the blending of form informa-
grams (as in this example).
tion from the two eyes.
When the laterally displaced stimuli are located
Diplopia is the simultaneous perception of two
more than 5 degrees from the center of the fovea,
ocular images of a single object. This sensory phe-
peripheral stereopsis is being evaluated. In Figure
nomenon is important in clinical assessment and
1 -15, the "Y" appears to be closer to the patient and
visin therapy. As discussed previously, physiologic
the "X" farther away in relation to the star. Clinicians
diplopia testing refers to the perception of diplopic
also describe stereopsis as "gross" or "fine." Periph-
images that lie outside the singleness horopter.
eral stereopsis is necessarily classified as being
Physiologic diplopia training is frequently useful in
"gross," whereas central stereopsis is considered
visin therapy to break pathologic suppression and
"fine" if it measures 200 seconds of are or better.
to increase vergence ranges.
Stereoscopically fused images appear to be
Clinicians use many tests involving pathologic
nearer to a bifixated reference point if Panum's
diplopia, particularly as part of strabismus evalua-
reas are stimulated temporally from the center of
tions. In cases of noncomitant strabismus, for exam-
the foveas. Conversely, if Panum's reas are stimu-
ple, pathologic diplopia testing is very important in
lated nasal ly from the center of the foveas, an
determining the severity of underactions and over-
image seems farther from the bifixated reference
actions of extraocular muscles in various positions
point. If we think of the temporal retina as having
of gaze.
Chapter1 15

Une in Temporal Panum's rea Line in

Temporal
Panum's
rea FIGURE 1-16Stereopsis vales for
FIGURE 1-14Stereogram for central stereopsis induced nearer and farther perception. Plus signs indcate nearness, which is
by laterally displaced vertical Unes. The fused vertical une appears also referred to as "crossed dis-parity." Minus signs indcate far
closer than the star because the temporal (to the fovea [f]) Panum's distance, or "uncrossed disparity." The greater the temporal Panum's
rea is stimulated in each eye. rea (larger plus signs) the greater the stereopsis effect, as s true also
for the nasal Panum's rea (minus signs). (f = fovea.)

Generally speaking, the finer the degree of ste-

positive vales for nearness and of the nasal retina reoscopic discrimination, the higher the quality of
as having negative vales, we can more easily binocular visin. Conversely, suppression and
understand the concept of stereopsis related to lat- excessive fixation disparity tend to decrease stereo-
eral displacement. The greater the distance from the acuity; these anomalies often predispose a patient
center of the fovea, the greater the valueither to asthenopic symptoms and reduced visual perfor-
positive or negativefor the perception of objects mance. The main valu of stereopsis is as a clue to
appearing nearer or farther, respectively. This con- depth at cise viewing distances; its valu to the
cept is llustrated in Figure 1-16 by the increasing individual is barely significant at far distances.21 For
sizes of the plus and minus signs toward the periph- instance, a surgeon is more likely to need stereo-
ery of the retina. scopic depth perception than is an airline pilot.
Monocular clues to depth (e.g., size, linear perspec-
tive, texture gradient, and overlap) tend to predom-
nate at far distances. Nevertheless, most passenger
airlines require their pilots to have superior stereop-
Y sis, because safety and prudence demand that every
possible perceptual clue to making accurate depth
judgments be available. This stringent criterion s
probably imposed because stereopsis is the "barom-
eter of binocular visin."

Theories of Sensory Fusin

The salient features accounting for sensory fusin
are retinal correspondence, retinal image disparity
detection, and neural summation of nformation
from the two eyes. A system of correspondence
provides feedback about whether the motor align-
ment of the eyes s in registry. Retinal image dispar-
ity detection is the stimulus to the vergence system
FIGURE 1 -15Example of target for peripheral stereopsis. (f = fovea.; to make correctional vergence eye movements.
Chapter1

fication of the two ocular images did not, in fact,

take place. This theory claimed that retinal rivalry
phenomena provided evidence that the binocular
field was composed of a mosaic of monocularly
perceived patches. Henee, no true fusin occurred;
the input for one eye would inhibit the input from
the other. Retinal rivalry of dissimilar forms, a com-
mon clinical observation, is the primary evidence
supporting the alternation theory, which purports
that the mosaic pattern of the "fused" image is
ever-changing, with certain portions at times
being dominated by the left eye's responses and
at other times by the right eye's responses (Figure
1-17). This theory left unexplained many features
of binocular perception, such as contrast sensitiv-
ity enhancement. Moreover, single-cell electro-
physiologic evidence has conclusively shown this
notion of binocular visin to be essentially incor-
rect. The more modern theory of neural summa-
tion is fundamental to binocular perception.
Studies of reaction time to binocular versus monoc-
ular visin stimulation and cortical electrophysi-
ology indcate that information from both eyes is
available during binocular viewing. 26 Binocular
fusin is characterized by summation of informa-
tion from the two eyes and synchronization of
neural activity from each eye's dominance col-
umns in the striate cortex.
FIGURE 1-17Cyclopean projection showing perception of retinal
rivalry.

Binocularly Driven Cells and

Within certain limits, retinal image disparities are Ocular Dominance
also necessary for stereopsis. Research has indi- Ocular dominance is another important physiologic
cated that certain striate cells in reas V1 and V2 (in feature of binocularly driven cells. Only approxi-
occipital reas 17 and 18) are sensitiva to horizon- mately one-fourth of these cells respond equally to
tal disparity for the perception of stereopsis.22'23 input from the right and left eye; the others respond
Studies of higher mammals have shown that more vigorously to the input from either one eye or
approximately 80% of cells in the striate cortex can the other.24 Ocular dominance of binocular cortical
be binocularly stimulated.24 Neural summation of cells is particularly sensitive to the amount of binocu-
these binocular cells has been demonstrated by sin- lar stimulation during development in infancy. Even
gle-cell neurophysiologic investigations.22 The cor- minor obstacles to sensory fusin can have long-term
responding reas, however, ,must be in proper consequences. Obstacles to sensory fusin, such as
registry for mximum responsiveness. When these anisometropia, aniseikonia, strabismus, and form
fields are out of alignment, they mutually inhibit deprivation (e.g., cataract), can result in a rapid shift
one another.25 These physiologic features are the in striate cell ocular dominance. When most cortical
basis for the perceptual unification of the two ocu- cells are controlled exclusively by one eye during the
lar images and represent some of the advantages of sensitive period, the natural consequences are binoc-
normal binocular visin. As discussed previously, ular anomalies.27 These include suppression, ambly-
contrast sensitivity and visual acuity are enhanced opia, anomalous retinal correspondence, loss of
by binocular neural summation. stereopsis, and deficient fusional vergences. Such
One of the more popular, older theories of bin- binocular anomalies may become permanent unless
ocular visin, the alternation theory, held that uni- timely and appropriate visin therapy takes place.
Chapter1 17

REFERENCES 14. Mukuno K. Electron microscopic studies on the human

extraocular muscles under pathologic conditions. Jpn J
1. Brny E. A theory of binocular visual acuity and an anal- Ophthalmol. 1969;13:35.
ysis of the variability of visual acuity. Acta Ophthalmol. 15. Dale RT. Fundamentis of Ocular Motility and Strabis-
1946-24:63. mus. New York: Grue & Stratton; 1982:105.
2. Horowtz MW. An analysis of the superiority of binocular 16. Enright JT. Slow-velocity asymmetrical convergence: a deci-
over monocular visual acuity. J Exp Psychol. 1949;39:581. sive failure of "Hering's law." Vision Res. 1996;36:3667-
3. Campbell FW, Creen DG. Monocular vs. binocular visual 3684.
acuity. Nature. 1965;200:191-192. 17. Tamler E, Jampolsky A. Is divergence active? An elec-
4. Sheedy JE, Bailey IL, Muri M, Bass E. Binocular vs. monoc tromyographc study. AmJ Ophthalmol. 1967;63:452.
ular task performance. Am J Optom Physiol Opt. 1986;63 18. Panum PL. Physiologische Untersuchungen ber das Sehen
(10):839-846. mitzwei Augen. Kiel: Schwerssche Buchandlung; 1858:52.
5. Michaels DD. Visual Optics and Refraction. St. Louis: 19. von Noorden GK. Binocular Vision and Ocular Motility:
Mosby; 1980:677. Theory and Management of Strabismus, 4th ed. St. Louis:
6. Derner JL, Miller JM, Poukens V, et al. Evidence for fibro- Mosby; 1990:17.
muscular pulleys of the recti extraocular muscles. Invest 20. Worth C. Squint: Its Causes, Pathology, and Treatment.
Ophthalmol Vis Sci. 1 995;36:1125-1136. Philadelphia: Blakiston's; 1921.
7. Clark RA, Miller JM, Demer JL. Location and stability of 21. Schor C, Flom MC. The relative valu of stereopsis as a
rectus muscle pulleys. Invest Ophthalmol Vis Sci. 1997; function of viewing distance. Am J Optom Physiol Opt.
38:227-240. 1969;46:805-809.
8. Clark R, Miller J, Demer J. Three-dimensional location of 22. Hubel DH, Wiesel TN. Stereoscopic visin in macaque
human rectus pulleys by path inflections in secondary monkey: cells sensitive to binocular depth in rea 18 of
gaze positions. Invest Ophthalmol Vis Sci. 2000;41:3787- the macaque monkey cortex. Nature. 1970;225:41.
3797. 23. Poggio GF, Poggio T. The analysis of stereopsis. Annu Rev
9. Glaser JS. Neuro-ophthalmology. Philadelphia: Lippin- Neuroso. 1984;7:379.
cott; 1990:300.
24. Hubel DH, Wiesel TN. Receptive fields, binocular inter-
10. Hofstetter H, Griffin J, Berman M, Everson R. Dictionary action and functional architecture in the cat's visual cor
of Visual Science and Related Clinical Terms, 5th ed. Bos tex. J Physiol (Lond). 1962; 160:106.
ton: Butterworth-Heinemann; 2000:284. 25. Nikara T, Bishop PO, Pettigrew JD. Analysis of retinal cor-
11. Maas EF, HuebnerWP, Seidman SH, Leigh RJ. Behavior of respondence by studying receptive fields of binocular sin
human horizontal vestbulo-ocular reflex in response to gle units in cat striate cortex. Exp Brain Res. 1968;6:353.
high-acceleration stimuli. Brain Res. 1989;499:153-156. 26. O'Shea RP. Chronometric analysis supports fusin rather
12. Bajandas FJ, Kline LB. Neum-Ophthalmology Review than suppression theory of binocular visin. Vision Res.
Manual, 2nd ed. Thorofare, N.J.: Slack Inc.; 1987:51-54. 1987;27:781-791.
13. Hoffman FB, Bielshowsky A. ber die der Wilkur entzo- 27. Weakly DR Jr. The association between nonstrabismic
genen Fusionsbewegungen der Augen. Arch Ges Physiol. anisometropia, amblyopia, and subnormal binocularity.
1900;80:1. Ophthalmology. 2001;108:163-171.
chapter2 / Visual Skills Efficiency

Patient History 21 Maladaptive Behaviors Nott Method 43 Monocular

21 Reading Dysfunction 21 Saccadic Eye Estmate Method Retinoscopy
Movements 22 Saccadic Suppression 23 43
Objective Testing 23 Southern California Excess of Accommodation 44
College of Optometry System 24 Heinsen- Facility of Accommodation 45
Schrock System 24 Ophthalmography Ill-Sustained Accommodation 48
(Visagraph) 25 Sequential Fixation Tests Summary of Accommodation Testing 49
27 Subjective Testing 27 P|erce Test 28 Vergences 49
King-Devick Test 30 Developmental Eye Absolute Convergence 49 Testing
Movement Test 31 Maples Oculomotor Techniques 49 Functions and
Test 33 Standard Scoring System 34 Norms for Absolute Convergence
Summary of Saccade Testing 35 Pursuit 50 Developmental Considerations
Eye Movements 35 Characteristics 35 51
Testing of Pursuit Skills 36 Direct Relative Convergence Testing and
Observation 36 Heinsen-Schrock Scale Norms 52 Fusional Vergences at
36 Afterimages 37 Signs and Symptoms Far 52 Fusional Vergences at
37 Summary and Recommended Tests 38 Near 53
Fixation 38 Southern California College Vergence Facility 54
of Optometry Reflex Fusin 54
4+ System 38 Vergence Stamina 57
Summary of Fixation Testing 39 Summary of Vergence Testing 57
Vestbulo-Ocular Reflexes 39 Sensory Fusin 57
Accommodation 40 Insufficiency of Simultaneos Perception 58
Accommodation 40 Absolute Superimposition 58
Accommodation 41 Relative Fat Fusin 58
Accommodation 42 Lag of Stereopsis 59 Vectographic
Accommodation 43 Methods 59 Linear Displacement
Methods 59 Percentage of
Stereopss 63 Screenng for
Binocular Problems with
Stereopsis 63 Norms for
Stereoacuity 64
Summary of Sensory FusionTesting 65
Recommendations on the Basis of
Test Results 65
20 Chapter 2

For any patient being treated for binocular anoma- As with other neuromuscular abilities, the health
lies, the ultmate goal is the achievement of clear, and vigor of specific visual-motor skills required
single, comfortable, and effcient binocular visin'. for everyday tasks vares considerabiy among indi-
Visual ski lis efficiency (VSE) s the term applied to viduis. Normative data collection has indicated
the ways n which various ocular systems oprate that most oculomotor and binocular visin skills
over time and under various viewing conditions. are distributed in a population along a normal
Clinical evaluation of visin efficiency necessitates bell-shaped curve. Some people are well suited
the assessment of sufficiency (amplitude), facility for intensive visual activity such as p rolonged
\WQ\\\tj\ acawaq, wb stamm oi each ocular pev\ods o readmg or computer work, whereas
function. others ave not Occupatiom and veaea \\ona\
Practitioners in the nineteenth century were activities vary tremendously in their requirements
concerned almost exclusively with clearness of for efficient visual skills. The visual work require-
eyesight and with lenses that would optimally ments of an attorney and computer programmer
reduce or elimnate blurred visin. Clearness and are much more intensive than those of the average
singleness of binocular visin became the issue farmer and sales clerk. Full-time computer opera-
with the advent of orthoptics. Effective therapeutic tors have come to expect some eyestrain and dis-
regimens for strabismus were introduced by Javal1 comfort as part of their job. Several studies have
and were expanded later by others. shown that the prevalence of visual symptoms
Astute clinicians in the first half of the twenti- increases with increased visual demands. Sensitiv-
eth century became aware of the relationship ity to visual and other forms of stress also differs
between accommodation and vergence. Knowl- among individuis, so a psychological dimensin
edge of the zone of clear, single, comfortable influences the manifestation of symptoms as well.
binocular visin was gained through various Henee, at least three factors interact to define a
models of visin, such as the graphical analysis visin efficiency dysfunction: (1) a patient's physi-
approach, and through an understanding of fixa- ologic level of visual skills, (2) specific visual
tion disparity (see Chapter 3). requirements (how visin is used), and (3) sensitiv-
In the latter half of the twentieth century, more ity to visual stress. The clinician must eval ate
and more emphasis was placed on efficiency of these factors when obtaining a patient's case his-
visin, implying that effcient visual skills are tory and performing the examination.
related to good scholastic abilities (school) and The oculomotor and binocular visual skills that
occupational production (work) and to achieve- have been widely implicated in dysfunction are
ment in sports and hobbies (play). As a result, (1) deficient pursuit tracking; (2) deficient saccadic
lenses or functional training techniques frequently tracking, particularly in reading; (3) overstressed
are applied in clinical practice to help patients or deficient accommodative skills; (4) excessive
attain efficient binocular visin in these activities. heterophoria (esophoria, exophoria, and hyper-
(Surgery is not a mode of therapy commonly asso- phoria); (5) deficient or overstressed vergence
ciated with visin efficiency therapy.) skills; and (6) deficient sensory integration and ste-
Fundamental to having good VSE is the opti- reopsis. The relationships among accommodation,
mum correction of any significant refractive error. vergence, and sensory fusin skills have been a
Clinicians have found that correcting even small focus of optometric research and practice since
errors of refraction can result in large changes in the 1930s and encompass classic heterophoria
visual comfort, stamina, and performance. If a case analysis and fixation disparity analysis (cov-
patient presents with a significant refractive error, ered in Chapter 3). These historie approaches are
a visin efficiency evaluation ideally should be part and parcel of visin efficiency analysis, but
performed with the new lens correction in place, testing and evaluation of oculomotor and binocu-
if necessary using a trial frame spectacle correc- lar visual skills have evolved to include efficiency
tion. Normative data presented in this chapter considerations of how a patient's specific skills
assume that refractive error has been corrected. respond over time and relative to specific tasks or
Dysfunctions of visual skills also result from a conditions. In a society of increasing educational,
mismatch between a patient's oculomotor and occupational, and recreational demands on
binocular physiology and the environmental visin, the testing and evaluation of VSE has taken
demands placed on the individuaos visual system.
center stage.
Chapter 2 21

PATIENT HISTORY one's place; (4) laborious or slow reading; and (5) the
need to use a finger or ruler as a place keeper. (See
The most mportant and revealing component of Appendix I, Visual Symptoms Survey.)
the history is the chief symptom. Intense eye pain
and prolonged double visin are not symptoms
commonly associated with visin efficiency dys-
MALADAPTIVE BEHAVIORS
functions and usually indcate more severe and
acuite disorders. Vision efficiency dysfunctions, Preschool and elementary school children rarely
particularly in adults, often are associated with report visual symptoms, even in cases of frank
symptoms related to visually demanding activities visual dysfunction. On careful examination, some
at near distances, such as reading, writing, sewing, are found to have significant dysfunctions by stan-
and computer use. The symptoms usually increase dardized clinical criteria but, when asked, they
in ntensity with ncreased time devoted to the task seldom admit to any visin problem. As observed
and abate with sleep or rest. n cases of early-onset myopia, n which reports of
Asthenopia applies to symptoms of ocular blurred visin are also rare, young children do not
fatigue or discomfort. The common symptoms of have a standard for comparison. They believe that
tired eye with sustained visual activity should be what they are experiencing visually, for better or
distinguished from reports of general fatigue. Tired worse, is normal and expected. Children also rap-
eyes do occur as part of chronic fatigue, systemic idly modify their behavior when they do encounter
diseases (e.g., hypothyroidism and other endocrine difficulties. With careful questioning of a child,
mbalances), allergy attacks, and general stress parents, and teacher, the clinician often finds that
reactions. Clinicians are often challenged to make the child compensates or maladapts by demon-
the distinction between ocular fatigue and general strating avoidance behavior, a short attention span,
fatigue, because each can contribute to manifesta- and distractibility, and develops a dislike for the
tions of the other. A carefully obtained, detailed activity causing discomfort. To compnsate for a
patient history may be necessary but sometimes binocular visin problem, a child might hold read-
still is nsufficient. ing material very cise to enlarge the print, shut or
Headaches can be causes of or exacerbated by cover an eye with a hand, or lay his or her head on
dysfunctions of accommodation or vergence or the upper arm to disrupt binocular fusin. Some
both. However, headaches are attributable to children learn to hold the head up and turned to
many different medical and psychological etiolo- one side so that the nose can act as an effective
gies, and so differential diagnosis is necessary. occluder. Using one's hand to shade the eyes from
Ocular headaches usually are described as a dull overhead lights provides some relief when over-
to modrate ache at the brow line, around the sensitivity is present (e.g., from a mild nflamma-
eyes, or emanating from the orbits. Other locations tion of the eyes). Rather than conducting a
may be mplicated, particularly the back of the problem-based examination of a child, the clini-
head and neck, which are also associated with cian must take a proactive approach to history tak -
general stress. Vision efficiency dysfunctions have ing for behavioral maladaptations and then
also been known to initiate a m igraine headache undertake a thorough examination, including mea-
in sensitive individuis. sures of visin efficiency.
Reports of intermittent blur, doubling, or "wob-
bling" of print are also common and are highly asso-
ciated with disorders of accommodation and
READING DYSFUNCTION
vergence. Except for symptoms associated with track-
ing dysfunctions, pinpointing specific conditions Do visual skill deficiencies adversely affect reading
associated with specific symptoms is difficult. The performance? Does visin therapy for visual skill
symptoms associated with accommodative and ver- dysfunctions result n mproved comfort, reading
gence dysfunctions often overlap. Saccadic tracking efficiency, and reading performance on standard-
dysfunctions, however, often result n definitive signs ized tests? These are mportant and somewhat con-
and symptoms. In such cases, patients report (1) skip- troversial questions. The American Academy of
ping over words, parts of words, or sentences; Ophthalmology and the American Academy of
(2) inadvertent rereading of a line of print; (3) losing Pediatrics drafted a position statement denying any
22 Chapter 2

relationship between visual conditions (save uncor- hyperopes must use accommodative effort to bring
rected refractiva error) and reading disabilities. The a distant mage into clear focus on the retina, thus
mplication is that visin therapy s ineffective and requiring additional and often excessive accom-
a waste of remedial time.2 This statement s ambig- modation to clear print at the preferred reading
uous in that the term "reading disability" can be distance. These facts suggest that the amount of
interpreted to mean dyslexia, a neurologically accommodative effort is associated with reading
based disorder in word decoding, or t can be inter- performancea relationship that has been con-
preted to mean any significant reading problem firmed by other studies.
from other causes. The American Optometric Asso- As part of the meta-analysis, Simons and
ciation, n collaboration with other optometric Gassler5 found several other conditions associating
organizations, have issued their own position state- disorders of fusin with poor reading: Among poor
ment arguing that several visual conditions aside readers, there was a high prevalence of (1) ani-
from refractive error are associated with poor read- sometropia, in which different refractive errors in
ing performance and not necessarily dyslexia.3 (See the two eyes presented an obstacle to binocular
Appendix A for text of statement.) Furthermore, integration of the images; (2) aniseikonia, in which
visin therapy s a recognized and effective thera- different image sizes in the two eyes posed as an
peutic intervention for improving or curing visin obstacle to fusin; (3) excessive exophoria and
efficiency dysfunctions. In cases n which such hyperphoria, eye teaming conditions that stress
therapy s applied, improved reading performance fusin skills; and (4) fusional vergence deficiency
often occurs. However, visin therapy techniques or restricted vergence skills. The common feature
for visual skill deficiencies are not intended to cure among these conditions is emphasis on an individ-
dyseidetic or dysphonetic types of dyslexia.4 Both ual's sensory fusin capacity and vergence system,
visin specialists and the public at large need which keeps the eyes in alignment for nearpoint
authoritative information on these issues, due to the tasks. Asthenopia and quick visual fatigue usually
obvious important mplications for school visin are the consequences. This association with poor
screening and because of the serious social con- reading skills implies that the symptoms or mal-
cern regarding improving students' reading perfor- adaptive behaviors are severe enough to influence
mance across the nation. reading progress, although a direct causal relation-
Many studies have sought an association between ship has not been established.
visual conditions and reading performance. As one Grisham et al.6 have found a significant, although
might expect, these studies vary considerably in weak, correlation between reading test scores and
their subject groups, tests of reading and visin, the number of visual symptoms that college stu-
and quality of research design and analysis. One dents reported. Generally, the more symptomatic
statistical approach used to evalate a large num- the students were, the poorer was the reading per-
ber of studies with varying design features s called formance, and vice versa.
meta-analysis. Simons and Gassler5 used this tech- Assessment of VSE should include both sensory
nique in evaluating the results of 32 controlled and motor functions of the eye. We recommend test-
studies that used valid tests for visin conditions ing of five eye movement and fixation systems:
and reading performance. Good reading perfor- (1) saccades, (2) pursuits, (3) position maintenance,
mance was found to be associated with uncor- (4> vestbulo-ocular reflexes (VOR), and (5) vergences
rected myopia. The tested students, as a group, (aside from accommodation). Sensory fusin and
read better than did emmetropic students requiring stereopsis are the final goals of accurate and efficient
no spectacle correction. In uncorrected myopia, binocular alignment of the eyes; henee, they should
the farpoint of accommodation (the punctum be ncluded n a comprehensive evaluation.
remotum) resides at a near distance, so less accom-
modative effort is required for reading. Distant
visin s mpaired, but the eyes are optically in
focus at some near distance f the amount of near-
SACCADIC EYE MOVEMENTS
sightedness is approximately equal in each eye Saccadic eye movements are abrupt shifts in fixa-
and is not severe. In contrast, poor reading was tion and are classified as fast, as compared with
found to be strongly associated with uncorrected pursuit and vergence eye movements.7 A good
hyperopia (i.e., farsightedness). In these cases, clinical average velocity is approximately 300
Chapter 2 23

degrees per second, which s approximately 10 What are the symptoms of either organic soft-
times greater than the velocity of pursuit and ver- sign or functional saccadic dysfunctioning? Several
gence movements (approximately 30 degrees per performance problems may be evident f saccadic
second).8 Saccadic eye movements are mainly eye movements are poor, even though the patient
voluntary, the other eye movements being mainly s otherwise considered neurologically normal.
involuntary. The duration and velocity of a sac- Inefficiency in reading is a major problem and s
cade are proportional to the magnitude of the eye frequently reported n such cases. Words may be
movement. For example, a 40-degree sweep omitted, lines may be skipped, or loss of place may
would have a greater velocity and a longer dura- occur often during reading. "Finger reading" may
tion than would a 5-degree sweep. The velocity of indcate the need for hand support due to poor eye
a saccade changes during its course, being faster movements. Head movement when reading is
at the beginning and slower toward the end of the another common sign of poor saccades. The
sweep. Although this may be shown in the labora- patient may present with a history of "having trou-
tory, its observation clinically s difficult, even ble hitting the ball" or "doing poorly in many ath-
with recording instruments such as the Visagraph letic events." Job performance may be affected
isee Appendix J). adversely if eye-hand coordinaron is exceptionally
poor due to saccadic eye movement problems.

Saccadic Suppression
Javal may have been among the first to note that Objective Testing
visin turns off as a saccadic eye movement is Clinicians should evalate saccadic eye move-
occurring. This makes sense; otherwise, the world ments using both gross and fine tasks. Fine sac-
would appear to be a swimming, blurry mess as we cades are those nvolved in reading (approximately
sean our environment. This perceptual inhibition, 7 degrees or less). Larger saccades than these are
which has been called saccadic "blindness," is considered gross. A patient's saccadic eye move-
more aptly named saccadic suppression. According ment skills can be evaluated either on an objective
to Solomons,9 each saccadic eye movement is pre- or a subjective basis.
ceded by a latent period of approximately 120-180 Any target, such as small letters on two pencils,
milliseconds before the eye movement actually can be used to test for gross saccadic ability. The
begins, and saccadic suppression begins to occur patient s asked to look voluntarily from one target
approximately 40 milliseconds before the move- to the other. This usually is done n right- and left-
ment commences. The inhibition ncreases until gaze orientations, but vertical as well as oblique
visual perception is almost zero during the first part orientations can be tested. If one of the patient's
of the movement. Probably not until after the sac- eyes is occluded, testing s for saccadic ductions. If
cadic movement has ended does the saccadic sup- both eyes are open, testing s for saccadic versions.
pression completely cease. It should be noted that even behind an occluder,
The first differential diagnostic issue for consider- the covered eye moves conjugately with the uncov-
ation s whether a pathologic etiology s present ered, fixating eye. A difference may be noted, how-
when deficient saccadic eye movements are found. ever, in the performance of one eye as compared
If voluntary versions are severely restricted, the cli- with the other during duction testing. This possibil-
nician should suspect neurologic problems affect- ity s an important consideration n therapy, as the
ing the saccadic pathway, such as myasthenia, patient should, f possible, have equal saccadic
vascular disease, or tumors that may affect supranu- skills in both eyes.
clear control. Other signs of neurologic dysfunc- Gross saccades are used in general environmen-
tioning would likely be evident n such cases. tal scanning to direct fixation to a point of interest.
Many times, however, only subclinical "soft" signs They can be initiated by reflex stimuli or by voli-
are present, with the patient appearing to be nor- tion, so both stimulus modes are employed n
mal n all other respects. Many patients have func- screening. Because reading requires finer control of
tional saccadic problems, such as those from poor saccades than s sampled by such screening tests,
attention, hyperkinesis, or poor visual acuity due to these procedures are more appropriate for evaluat-
uncorrected refractive errors, and possibly because ing saccadic skill n general scanning and in sports
saccadic skills were never learned adequately. performance. The patient is asked to stand free of
24 Chapter 2

support in front of the clinician and is instructed to horizontal saccadic eye movements is as follows:
particpate in a penlight game: "Look only at the A target with a letter printed on it that is approxi-
light that is on, not at the light that is off." The clini- mately equivalent to 20/80 (6/24) acuity demand s
cian then holds two penlights approximately 10 cm placed to the patient's right side. A similar target is
apart at a distance of 40 cm from the patient. placed to the patient's left. The targets are sepa-
Directing the beams away from the patient's eyes, rated by approximately 20 cm and are held at a
the doctor alternately flashes the lights in a random distance of 40 cm from the patient. (In the past, 25-
pattern to elicit "reflex" saccades. The patient wins cm separation was recommended, but separation
the game if he or she does not make a mistake and greater than 20 cm is not always feasible without
look at the "off" light through 10 randomized the need for some head movement.) The patient is
cycles. Most children, age 6 and older, who follow asked to move his or her eyes alternately to each
a normal developmental pattern can complete this target approximately 10 times. The clinician
task with three or fewer errors, show good saccadic should look for naccuracies (i.e., either under-
accuracy, and exhibit minimal head and body shooting or overshooting). Scoring the results of
movement. Children having attentional difficulties observation is on a 4+ basis, as follows: 4+ f
often cannot play this game successfully. Children movements are accurate, 3+ if there is some
in whom oculomotor coordination development is undershooting, 2+ if there is gross undershooting
mmature and adults having neurologic conditions or any overshooting, and 1+ if there is either
show saccadic undershoots or overshoots and inability to perform the task or an increased
excessive head and body movements. latency. A score of 2+ or less is considered failing,
"Voluntary" (volitional) saccades are sampled in a as would be any uncontrolled head movement.
similar way. Still standing, the patient is instructed to Hoffman and Rouse10 considered a failure on
look back and forth from one light to the other 10 this basis to indcate a need for referral for visin
times and as quickly as possible; both lights are now therapy for saccadic dysfunctioning. Whether or
on. The clinician counts aloud as the patient per- not referral s actually made, failure of the SCCO
forms the task. Observations indicating immature or test, which demonstrates poor saccadic skills,
defective voluntary control of saccadic fixation should alert the practitioner at least to consider the
include (1) inaccuracy of saccades (undershoots and possibility of advising visin therapy. In other
overshoots); (2) mltiple intervening saccades; words, clinical judgment is required; referrals for
(3) slow alternation (longer than 2 seconds per visin therapy are not automatic merely on the
cycle); (4) lack of rhythm in the alternating pattern of basis of a single poor test result.
fixation; (5) motor overflow, indicated by facial Two alphabet pencils may be used in the man-
movements, particularly jaw and eye brow move- ner described earlier (Figure 2-1). However, the
ments; and (6) excessive head and body movements young child cannot be expected to proceed all the
(greater than a few degrees). This screening test is way through the alphabet; rather, the patient
quite good at identifying those school-aged children should be allowed to read the "A" on each pencil.
who have immature oculomotor skills and who have For an adult, one pencil can be turned to expose
not made the developmental shift from making pre- the Z, Y, X . . . sequence. A task of A-Z, B-Y, C-X,
dominantly head movements to eye movements. and so on, is demanding and checks for false
Immature gross saccadic tracking is a prodromal sign reporting as the patient looks from one alphabet
of tracking difficulties in reading and writing. How- pencil to the other. This is because verbalizing the
ever, just because a child shows good gross saccadic alphabet in reverse sequence without seeing the
maturity does not necessarily mean that tracking for letters is difficult (see Figure 2-1).
reading material is also adequate to the task. Further-
more, we have seen deficient gross saccadic tracking Heinsen-Schrock System
even as reading eye movements appear to be nor- A 10-point scale is another system created by Dr.
mal, although this finding is infrequent. Arthur Heinsen and Dr. Ralph Schrock (A. Hein-
sen, R. Schrock, personal communication, 1981).
Southern California College of It can be performed with alphabet pencils (previ-
Optometry System ously described). For example, the patient can
A quick and simple routine used at the Southern receive 3 points if there is no head movement, 2
California College of Optometry (SCCO) for testing points if saccades are accurate, 2 points if sac-
Chapter 2 25

TABLE 2-1. Hensen-Schrock System for Testng and

Rating Saccadic Eye Movements

N0 head movement (3)

Head movement, but can nbibit (2)
cades are automated (that is, occurring normally
Sfight head movement persists {1)
and simultaneously with relatively simple cogni-
tive demands), 2 points if eye movements are sta-
I ' -
All accuracles (2)
ble for 20 seconds, and 1 point f there is adequate
Sligtrt inaeeuraees f 1)
stamina when the test s continued for 1 minute.
C
Ttius, 10 possible points can be accrued using this
Automated sacc&des (2)
procedure (Table 2-1).
Reduced automatlon (1)
With regard to automated saccades, the clini-
cian should ask a simple question that is appropri- D
Stable saccades for 20 secs (2)
ate to the patient's cognitive abilities under such
Stable saccades for 10 secs (1)
circumstances. For example, a 5-year-old patient
E
might be asked his or her ame as the patient looks
Adequate stamjna (1)
from one target to the other. A 7-year-old patient
could be expected to count from 1 to 10 while Source: A, Heinsen, R, Schrock, personal communication, 1981.
maintaining accurate saccades. A 9-year-old
patient should be able to count backward from 10
to 1. An 11-year-old patient should be able to
count backward from 100 on down. A 13-year-old believe is meant by automated. Unless a reader
patient can normally be expected to count back- can automatically make accurate saccades, he or
ward from 100 by ntervals of 3. This is what we she is unlikely to visualize and concntrate on the
contents of the reading material. Frequently, during
testing of patients who have saccadic eye move-
ment problems, a cognitive demand will cause
patients to look n the wrong direction of the test
target and fail to make an accurate saccade. In
other words, the cognitive demand can make the
saccadic movements poor (and poor saccades
even poorer) unless automation is achieved. It s
conversely presumed that poor saccadic eye
movements have an adverse effect on reading
(cognitive) skills.

Ophthalmography (Visagraph)
A traditionally used clinical ophthalmographic test
for recording reading saccades was the Eye-Trac.
However, this instrument s no longer manufac-
tured. In ts stead, the Visagraph (Figure 2-2) has
become the standard ophthalmolophic testing
nstrument. An ideal target s a five-dot card (Figure
2-3), designed by Walton and tested by Griffin et
al.,11 who analyzed the eye movements of 25 sub-
jects during reading and fixation tasks using a pho-
tographic recording nstrument. The previously
selected subjects included 12 adequate readers
and 13 inadequate ones. Griffin etal.11 concluded,
"
A normal saccadic pattern in five-dot testing is
shown on the Eye-Trac recording strip in Figure 2-4a.
Note that five fixations were made for each row of
dots, and they were spaced fairly equally, but a very
slight undershooting occurred on the return sweeps
(gross saccades to the left). Figure 2-4b shows many
inaccuracies and regressions on this test. This type
of analysis is also possible with the Visagraph.
The Visagraph is comparable to the Eye-Trac.
The principal difference between these two systems
is that the patient being assessed by the Visagraph
wears special spectacles containing photosensitive
cells. The presumed advantage of the Visagraph is
that head movements will not interfere with
recordings of eye movements, in contrast to the
Eye-Trac.
The Visagraph II is an infrared eye movement-
recording system used in conjunction with a per-
sonal computer for analysis of the eye movement
record. Taylor Associates (see Appendix J) designed
this instrument for clinicians and educators to eval-
ate an individual's eye movement characteristics
during the act of reading standardized selections of
print and for analysis of saccadic control indepen-
dent of information processing. For the purpose of
oculomotor evaluation, patients are asked to stare
at a dot target for 10 seconds and then alternately
to fixate two separated points for 10 cycles. The
record then is evaluated for stability of fixation and
saccadic accuracy (i.e., the number of fixations
actually made during the test). No normative data
are currently available, but gross disorders of fixa-
tion (e.g., nystagmus, saccadic intrusions, and
lapses of visual attention) can be identified by the
computer analysis of the fixation record or by
direct inspection of the original graph.
For evaluating sequential saccades (as used n
reading) independent of information processing, sev-
era! lines of targets can be presented on a test card
(see Figures 2-3 and 2-5). The patient (or student) is
instructed as follows: "Look at each and every target
as rapidly as possible as if you were reading a book.
Don't say anything, however, even to yourself. Don't
miss any number and move from one to the next as
quickly as you can." After the test is given, the com-
puter eye movement profile and the original graph
can be inspected relative to several detailed oculo-
Chapter 2 27

FIGURE 2-3Five-dot card designed to

test fine saccades as n the act of readi'ng.

motor ndices of performance: excessive number of cadic ability must be performed quickly, as there is
fixations, number of regressions, prolonged average no permanent printout for later analysis. Judgments
duration of fixation, rate in targets per minute, sac- are strictly qualitative and lack precisin. Notwith-
cades in return sweeps, and cross-correlation of the standing these drawbacks, experience goes a long
two eyes, a possible measure of vergence accuracy way in making this procedure useful n the event
(Figure 2-6). Although normative data have not been that either the Eye-Trac or Visagraph is not available
published to date, Taylor Associates offer clinical at the time of testing. Sequential fixation tests are
guidelines for evaluating oculomotor performance of colloquially called a "poor person's ophthalmo-
children and adults (see Figure 2-4) for graphic exam- graph." The practitioner can increase clinical acu-
ples of good and poor sequential saccadic perfor- men with this simple testing procedure by
mance on the five-dot card. comparing results with those obtained by ophthal-
mographic recording instruments.
Sequential Fixation Tests Whether the Eye-Trac or Visagraph is used, the
Another reading saccade test that is objective but patient should also be tested while reading sen-
much less sensitive than the Eye-Trac and Visagraph tences and paragraphs. Figure 2-8 shows relatively
is the use of printed cards, such as the five-dot test, poor and good reading saccades; the patient was a
for which the clinician directly observes a patienfs more efficient reader after saccadic visin training.
eye movements to evalate dot-to-dot saccades. Testing with cognitive (paragraph) and noncogni-
These sequential fixation tests come in a variety of tive (five-dot) visual stimuli can suggest a differen-
forms. The dots (or other symbols such as asterisks, tial diagnosis between purely saccadic problems
stars, numbers, letters, and words) may be printed and cognitive problems (e.g., dyslexia, poor com-
on a clear actate sheet so that the clinician can prehension, or unfamiliarity with certain words).
look directly at the patienfs eyes through the
printed sheet to observe inaccuracies and head
movements (Figure 2-7a). Another variation is an Subjective Testing
opaque card on which the symbols are printed and Saccades may also be evaluated indirectly by sub-
in which a center hole allows the clinician to jective means rather than directly by objective
observe the patienfs eye movements (see Figure 2- observations. The following tests are examples of
7b). Obviously, in such a test, assessment of sac- subjective methods.
Chapter 2

FIGURE 2-4Saccadic eye movements on the five-dot test. a. Good

saccades. b. Poor saccades.

Pierce Test for saccadic eye movements. It consists of three

The Pierce saccade test,12 designed sub-tests, each of which is a series of two laterally
by Dr. John R. Pierce, was the first displaced numbers.The patient is asked to hold the
of its kind to evalate a patient's demonstration card at his or her habitual reading
gross saccadic eye movements distance and to read each number aloud, from
according to age expectancies and was the first side
normed subjective test

2 1 S 4 ^
M * . . _/ * * * * ^ J

JL <J

"JL** t t

f >^>* o^ >/ %) >?

^
fc^*# *******
7
*<M** ******
*
*H/*
1
****ftJL******
^ 1
*^*-*.*^
^
FIGURE 2-5The numbers test used
4 1 ^ 2 1 4 ^ with the Visagraph. The purpose s to
nr JL ******^<*****M** assess binocular and tracking accu-
JLTr/ racy. (Courtesy ofTaylor Associates.)

JL * ^w ** t ^m JL JL "
Chapter 2 29

Numbers Profile Visagraph versin 4.1

Left Right 164 164 36 38

Fixations/100 numbers
Regressions/100 numbers

Av. Duration of Rxation (sec) 0.28 0.28

Rate (numbers/min) 130

Directional Attack 23% Countable unes in text 7

Rate adj. for Rereading (numbers/min) 281 Lines found
Saccades in Return Sweeps 10
Anomalies (Fix/Regr/Both) 1/1/0
Cross Correction 0.990
ame: Test Numbers Recorded: 1 1/29/99 09:39
FIGURE 2-6Example of computer- Class: Sex: M Grade: 1 Text: t-0-0.txt
izad results of the numbers test.
School: Title: Numbers
Comment:

to side. Holding the card too cise invaldales the Once the demonstration is completed, the first
test, as very large saccades would be demanded; of three subtests is begun. This s a timed test,
therefore, the patient should hold the card at a dis- and a corrected score, using the following for-
tance of approximately 40 cm. A demonstration s mula for each subtest, takes into account the
given initially so that the patient can start with the errors:
number at the upper left crner of the page and fol-
Corrected time score = 30 / 30
low the arrow to the number on the upper right cr-
- errors x time in seconds
ner, then follow the arrow for the return sweep to the
number on the left-hand side of the page, and so The total of the three corrected scores s deter-
forth. The room should be well lluminated for test- mined and compared with the norms to judge the
ing purposes. patient's chronologic age equivalence (Table 2-2).

FIGURE 2-7Sequential fixation test

using (a) clear sheet with printed symbols
or (b) an opaque card with a viewing
30 Chapter 2

FIGURE 2-8Eye-Trac recordings (a) before and (b) after visin therapy showing improved performance for reading a paragraph.

Note the approximate 3-to-1 mprovement in sac- that subtests II and III were too difficult for many 6-
cadic efficiency between ages 6 and 13, whereas year-old children, and so only subtest I is recom-
beyond age 13, improvement is minimal. mended; it was found to have norms of 30.98 seconds
with 1.32 errors for 6-year-old children. The King-
King-Devick Test
The King-Devick test, a derivation of the Pierce
test, was devised with fine saccades in mind. It
contains five numbers per line, and the numbers
are randomly spaced, supposedly simulating sac-
cades that occur in the act of reading. Scores are
TABLE 2-2. Sample of Normative Vales for the
Pierce Saccade Test

Cheonofcgic Age
I
evaluated in terms of errors and time; they then are Corrected Time Scores Expected
compared with normed scores according to chro- (secs)
nologic age, in a manner similar to that used in the
Pierce saccade test. The authors of the King-Devick 6 150 125 100
test concluded that poor saccadic ability contrib- 7 82
utes to poor reading ability.13 8 70
Samples of approximate norms determined by 9 65
Cohn and Lieberman14 (in a study in cooperation 10 59
with a New York Optometric Association team) are 55
given in Table 2-3. Subjects were 1,202 students n 12
regular public schools. Cohn and Lieberman14 found 13
Chapter 2 31

Pierce test. A possible problem with the Pierce and

TABLE 2-3. Samples ofNorms for the King-Devick tests, however, s that some individuis
King-Devick Test are basically slow n naming digits, independent of
their saccadic skills. Besides poor saccades, perfor-
mance can also be limited by poor attention skills,
Time in Number of deficient binocular visin, and uncorrected refractive
Seconds (total Errors (total of 3 error n children 6 years of age and older.
Age (yrs) of 3 subtests) subtests)
6 119 17
Developmental Eye Movement Test
7 101 12
The Developmental Eye Movement (DEM) Test by
8 77 3
Richman and Garzia further refines the indirect
9 79 3
approach to assessment of saccadic eye move-
10 68 2
ments.15 As n the King-Devick test, the DEM test is
11 57 1
designed to evalate both accuracy and speed of
12 54 1
fine saccades, as n the act of reading. The principal
13 52 1
difference between these two tests is that a subtest
14 50 0
of number naming in a vertical array s ncluded n
Source: A Cohn, S Lieberman. Report, In Manual of the the DEM test, presumably to determine a patient's
NYSOA-KD Saccade Test. Mishawka, Ind.: Bernell Corp.; 1993.
rapid automatized naming (RAN) ability (Figure 2-
10). As to the vertical columns, the DEM test
manual states: "This becomes a test more heavily
Devick test includes a demonstration card (Figure dominated by the individuaos visual-verbal auto-
2-9a) and three test cards (see Figure 2-9b through 2- matic calling skills (automaticity)" (see Appendix J
9d). Each test card displays eight rows of five num- for DEM source information). As in the King-Devick
bers, for a total of 40 numbers per card. The numbers test, a horizontal array of numbers s provided,
are sized to approximate 20/100 (6/30) reduced exceptthe horizontal dimensin is slightly reduced
Snellen acuity at a viewing distance of 40 cm. Testing (to simlate usual reading demands) and the quan-
is performed n a manner similar to that used for the tity of numbers s increased to 80 digits in the DEM

FIGURE 2-9King-Devick test show-

ing demonstration card and the three
subtests. a. Demonstration card. b.
Subtest with lines. c. Subtest without
lines. d. Stimuli more crowded.
32 Chapter 2

3 4 3 75 9 8
7 5 2 5 74 6
5 2 1 4 7 6 3
9 1 7 9 3 9 2
8 7 4 5 2 1 7
2 5 5 3 7 4 8
5 3 7 4 6 5 2
7 7 9 2 3 6 4
4 4 6 3 2 9 1
6 g 7 4 65 2
1 7 5 37 4 8
4 4 4 52 17
7 6 7 93 9 2
6 5 1 4 7 6 3
3 2 2 57 46
7 9 3 75 9 8
9 2 b

3 3
9 6
2 4
a

FIGURE 2-10Developmental Eye MovementTest showing (a) vertical array of numbers and (b) horizontal array of numbers. Similar to the Pierce test,
the Developmental Eye MovementTest uses a formula to determine "adjusted" time: Adjusted time = test time x 80/(80 - O + A), where test time =
actual time for number calling on the horizontal array; O = omission errors; and A = addition errors (numbers either being repeated or added).

test. This added demand is designed to assess abil- 1. Both the vertical time and the adjusted hori
ity for sustained performance (stamina). zontal time are normal. This is considered
Visual stamina and attention in performing sac- normal performance.
cadic tests have been found to be important factors 2. The vertical time is normal but the adjusted
in distinguishing those students who fail the DEM horizontal time is abnormally increased.
test and those who pass.16 More errors were made This indicates "oculomotor dysfunction"
in the second half of the horizontal test by the fail- and, presumably, poor horizontal fine sac-
ing students. cadic eye movements.
Similar to the Pierce test, the DEM test uses a 3. Both the vertical time and the adjusted hori
formula to determine "adjusted" time: zontal time are abnormally increased but are
approximately the same. This indicates a
Adjusted time = test time x 80 / (80 - O + A) problem in automated number calling rather
than a saccadic deficiency (i.e., RAN problem).
where test time is the actual time for number call- 4. Both the vertical and horizontal times are
ing on the horizontal array, O represents omission abnormal, but the horizontal is much worse.
errors, and A indicates addition errors (numbers This indicates both a RAN problem and a
being either repeated or added). saccadic eye movement deficiency.
The essence of the DEM test is to compare the In evaluating symbol tracking using the DEM
test results of vertical time with horizontal time. test, both the speed of tracking (the ratio ndex)
Four outcomes are possible: and accuracy (the number of additions and omis-
Chapter 2 33

TEST A TEST B T E ST C
3 4 6 7 3 7 5 8
7 5 3 9 2 5 7 4 6
5 2 2 3 1 4 7 6
9 1 9 9 7 9 3 9 O
2

8 7 1 2 4 5 1 7
2 5 7 1 5 3 O7 4 8
5 3 4 4 7 4 6**^ S 2
7 7 6 7 9 2 3 6 4
4 4 5 6 6 3 2 0 1
6 8 2 3 -* 4 6 5 2
1 7 5 2 5 3 7 4 8
4 4 3 5 4 5 2 1 7
7 6 7 7 7 9 3 9 2
6 5 4 4 1 4 7 6 3

3 2 8
4
6 2
3
G7 7 4 6
7 9 3 5 9 8
9 2 5 7 TIMI sec
3 3 2 5 J_ _s <y o errors
9 5 1 9 errors
_a / t errors
-L.
FIGURE 2-11 Example of resuits errors
TIME 80
2 4 7 8 ADJ
from a 1 0-year-old patient who passed = TIMEx
(80-o + a)
the vertical subtest of the Develop-
mental Eye Movement Test (36% or
J ADJ T1ME= / sec ,*;
higher s passing) but failed as to errors
(5%), horizontal time (10%), and ratio
21 sec
TOTALTIME: 4/ sec
(/<TOTAL ERRORS (s + o + a
+ 1)
HORIZONTAL ADJ TIME / *O S-.es \
=_z_/>#;
(5%). This suggests poor saccadic eye ADJ TIME '^ s e c ^ O <) VERTICAL ADJ TIME =** T^(***)
movements but reasonably good auto- ERRORS: /
maticity. ' RATIO = -

sions) must be considered. Normative data are sion errors within a line of numbers also suggest
provided for subjects of ages 6-13 years. Chil- inaccuracy, but verbal errors can also explain addi-
dren should have a good knowledge of numbers tions, transpositions, and substitutions (e.g., mis-
1-9, which most do by age 6 years. However, calling a 9 for a 6). The clinician must use
attention ski lis and ability to deal with detail judgment when evaluating saccadic accuracy
seem to be lacking in many 6-year-old children. rather than relying entirely on the total error norms
Therefore, we recommend that such subjects be listed in the test manual. (Figure 2-11 shows an
asked to complete only half the vertical and hori- example of DEM test resuits for a patient, with per-
zontal tests and that the examiner then double centile ranks for vertical and horizontal tests, ratio,
the times and errors before applying the norma- and errors.)
tive analysis. Furthermore, the DEM test s too
difficult for most kindergartners. 17 Nonetheless, Maples Oculomotor Test
the DEM test, specifically the ratio ndex, can be Dr. W. C. Maples19 has produced, n our opinin,
used reliably with Spanish- as well as English- the best standardized and normed set of oculomo-
speaking students.18 tor tests based on the clinician's gross observa-
Accuracy can be evaluated by noting the pattern tions. The testing protocol and scoring are too
of errors a child makes. Whole lines skipped or elabrate to be presented here, but the test s avail-
added usually reveal saccadic inaccuracy. Omis- able from the Optometric Extensin Program Foun-
34 Chapter 2

TABLE 2-4. Ordinal Ranking Method of Visual Skills TABLE 2-6. Modification of the Heinsen-Schrock
System for Testing and Rating Saccadic Eye
Movements for a 5-Point Mximum Score
Rank Description

5432 Very strong (much above average)

1 Strong (above average) No head movement (1.5) Head
Note: A ranking of Adequate (average) movement, but can inhibit (1.0) Slight
toss than 3 s Weak (below average) head movement persists (0,5) Obvious
considered faiture as persistent head movement (0.0)
referral cri-terton for Very weak (much below average)
visin therapy. I
AII saccades accurate (1.0)
Some slight naccuracies (0.5)
Several gross naccuracies (0.0)
dation. Maples' system comes with an nstructional C
videotape that contains many fine examples of Automated saccades (1.0)
children displaying dysfunctional, but not patho- Reduced automation (0.5)
logic, oculomotor behavior. The saccadic test No automation (0.0)
involves rating of gross reflex saccades across trie D
midline n response to the tester's commands. Stable saccades for 20 secs or more (1.0)
Observations are made of basic ability to perform Stable saccades for 10 secs (0.5)
the test, accuracy of saccades, and rating of collat- Stable for lessthan 10 secs (0.0)
eral head and body movements. The same is done i
for pursuit rotations. The patient's eight scores are Stamina for 1 min (0.5)
compared with normative data for boys and girls Stamina for less than 1 min (0.0)
between the ages of 5 and 14+ years; the norms
indcate that girls mature faster than boys in these
visual skills. According to Dr. Maples, the oculo-
Standard Scoring System
motor norms for 14-year-olds are adultlike. Inter-
The aforementioned tests vary in ther scoring of
rater and test-retest reliability seem acceptable.
saccadic efficency, but a standard scoring system
Interestingly, oculomotor behavior on this test, par-
is desirable. Crffin20 reported a system for sac-
ticularly head and body movement, was found to
cades based on a 5-point scale, in common with
discrimnate between good and poor readers.
a 5-point scale for several other visual skills. In
such a scheme, each visual skill function can be
TABLE 2-5. Ranking of Saccadic Performance on
ordinally ranked from 5 (best) to 1 (worst), with
the Pierce, King-Devick, and Developmental Eye semantic differential descriptions (Table 2-4). An
adaptaton of the Pierce, King-Devick, and DEM
Movement Tests tests is shown n Table 2-5. Such a ranking system
is convenent when comparing strengths and
Rank Description Results weaknesses among various visual skills. It allows
for better understanding and commnication to
5 Very strong Two or more years above patients and interested third parties (e.g., the
patient's health nsurance company). A 5-point
average
4
mximum ranking system, which is a modifica-
Strong One year above average
3 Adequate Average performance for
tion of the Heinsen-Schrock scale, s shown n
Table 2-6. This is but one of many possible ways
age
2 Weak One year below average that a practitioner can convert other scoring sys-
1 Very weak Two or more years below tems for saccades into a 5-point scale for ordinal
average ranking.
A simplified and quick sequence of saccade
tests for the primary eye care practitioner is as fol-
Chapter 2 35

lows: (1) SCCO 4+ system, (2) sequential fixation viewing conditions), whereas binocular viewing
testing, and (3) DEM test. conditions allow for testing of pursuit versions.
(Versions, as with ductions, may be saccades, pur-
suits, or nonoptic eye movements.) Regardless of
Summary of Saccade Testing
the fact that an eye may be occluded, the covered
The clinician should attempt objective testing of
eye moves conjugately with the fixating eye under
saccadic eye movements even when electro-oph-
most normal circumstances.
thalmography (Visagraph) is not available. This can
Defective pursuit eye movements, seen n many
be accomplished, for example, with the SCCO 4+
elementary school children, may be attributable to
system, the Heinsen-Schrock system, and sequential
lack of development (immaturity), lack of experi-
fixation tests. When subjective and indirect assess-
ence (untrained), or lack of attention. In many cases,
ment s performed, the DEM test accounts for defi-
pursuit exercises seem appropriate and effective n
ciencies in RAN skill, which must be distinguished
remediating this oculomotor dysfunction. Inatten-
from poor saccadic skills. Unless the RAN s known,
tive children may benefit also from visin therapy,
the practitioner s unable to ascertain whether poor
but usually other techniques are necessary. In
horizontal saccades are due to RAN problems or
adults, however, the absence of smooth pursuit
are due to actual saccadic deficiencies. It s desir-
tracking s predominantly an indication of neurologic
able to convert scores into a ranking system so that
dysfunction. Deficiencies n pursuits, for example,
there s a common denominator for each visual skill
have been found in patients experiencing schizo-
function. We propose a 5-point ordinal ranking sys-
phrenia,24'25 cerebellar degeneraron,26 Parkinson's
tem that s easy to understand and convenient for
disease, and many other neurologic degenerative
patient communication purposes.
conditions. Interestingly, Thaker et al.24 reported
Most of the testing procedures described in this
poorer predictive pursuits n schizophrenic subjects
section are appropriate for patients 7 years and older.
than in normal control subjects, even when effects
Some children between the ages of 5 and 6 are able
of antipsychotic medications were taken into
to respond to some of these tests, but n patients
account.
younger than 5 years, the clinician must rely on gross
There may be neurologic "soft signs" in the case
and objective methods, such as the SCCO 4+ system.
of jerky pursuits. Problems may be so subtle that
no lesin can be found (by radiology or other
means) along the occipitomesencephalic pathway.
PURSUIT EYE MOVEMENTS In some cases, functional training techniques may
A pursuit eye movement s defined as a "move- help. In many others, however, not much can be
ment of an eye fixating a moving object."21 done to improve pursuits when a neurologic
organic etiology exists. Nevertheless, differential
diagnostic testing should be considered. For exam-
Characteristics ple, assume a patient has normal voluntary sac-
According to Michaels,22 pursuits are unlike saccades but pursuit movements that are significantly
cades n that visin is present (without suppression, restricted and jerky: A supranuclear lesin affect-
as n saccades) throughout the eyes' excursions. The ng the occipitomesencephalic pathway would be
speed of pursuits s limited to approximately 30 suspected. In contrast, if saccades are inaccurate
degrees per second. They may be considerably and restricted but pursuits are normal, a fron-
slower but not much faster. If the target velocity is tomesencephalic pathway lesin s suspected.
too high, the pursuits break down into a jerky It s always wise to check both pursuits and sac-
motion. The attempt to keep tracking requires the cades on a routine basis, not only to determine
faster saccadic responses to come into play in order gross organic defects but to detect subtle problems
for the patient to regain fixation of the target. In that can handicap individuis because of resulting
infants, pursuit eye movements start to manifest at inefficiencies of visin. Additionally, drugs, fatigue,
approximately 6 weeks of age and increase n tn- emotional stress, and test anxiety may adversely
dem with the development of sustained visual atten- affect pursuit performance. For example, we have
tion to moving targets.23 examined many children with reading difficulties n
Pursuits are a form of duction eye movements whom we found a "midline hesitation" during con-
when only one eye s being tested (monocular frontation pursuit testing using a penlight, although
36 Chapter 2

Up gaze
TABLE 2-7. Heinsen-Schrock System for Testing
and Rating Pursuit Eye Movements, Modified for
5-Point Scale

Ten-Pont Five-Point
Patient's Patient's Scale Scale
Right _ _ Left
gaze gaze
Smooth, always on target 3 1.5
Smooth, sometimos off target 2 1.0
Jerky, generafly on target 1 0.5
Jerky, generally off target O 0.0
B
Down gaze Free of head movement 3 1.5
Head movement, but can 2 1.0
inhibit
FIGURE 2-12British flag pattern from clinician's view (lines indicat-
Slight head movement persiste 1 0.5
ng movements of penlight) for testing pursuits with the Southern Cali-
fornia College of Optometry 4+ test. Obvious persistent head O 0.0
movement C
Automated pursuits 3
Reduced automation 2 1.5
no irregularity in pursuit function was found using 1.0
laboratory electronic tests. On follow-up clinical Much reduced automation 1
No aytomation O 0.5
testing, our initial findings were repeatable. This 0.0
mystery was solved when we discovered that if we D
moved to the patient's side, the "hesitation" also Adequate stamina for 1 mn 1
Stamina for less than 1 mln
0.5
moved toward that side. The children evidently 0.0
were making eye contact with the examiner, possi-
bly because of being apprehensive in the clinical
testing environment. This example points out the smooth and fixation is always accurate, 3+ if
importance of distinguishing between true pursuit there is one fixation loss, 2+ f there are two fixation
dysfunction and poor tracking induced by inatten- losses, and 1 + if there are more than two fixation
tion, lack of cooperation, or test anxiety. losses. The patient is considered to have pursuit
problems if the score s 2+ or less. If there is any
obvious head movement during testing after the
Testing of Pursuit Skills patient has been instructed notto move the head,
Several objective and subjective testing procedures performance is considered to be inadequate. The
are discussed as examples. The tests are basically right eye, the left eye, and then both eyes should
the same, in that they al I allow for monitoring the routinely be tested for pursuits by eye care
accuracy of pursuit eye movements. practitioners, whether by this or another method.
However, the SCCO method lends itself to testing of
Direct Observation patients of all ages, ncluding infants and young
A quick and convenient testing and rating system for children.
pursuits on a 4+ scale is used at SCCO.10 A fixation
target approximately the size of a 20/80 (6/24) letter Heinsen-Schrock Scale
is moved n front of a patient at a distance of approx- Heinsen and Schrock(A. Heinsen, R. Schrock, per-
imately 40 cm to extents of nearly 20 cm from pri- sonal communication, 1981) introduced a rating
mary gaze. The target is moved left-right-left (one system (the H-S Scale) for pursuits that is similar to
cycle), up-down-up (one cycle), and in two diagonal that for evaluating saccades (discussed previously).
orientations (one cycle each), as in the lines of a Brit- This 10-point scale is shown in Table 2-7. Our 5-
ish flag, with the patient being instructed to track the point ordinal ranking system also is shown, to
target (Figure 2-12). A 4+ is given if pursuits are allow comparison of the very strong to very weak
Chapter 2 37

categories for pursuit skills with rankings of func-

tions for other visual skills, as discussed previously
for saccades. The advantage of the Heinsen-
Schrock system over the SCCO 4+ system is that
automation and stamina are taken into account
along with head movements, smoothness, and
accuracy. Either a Marsden bal I or a motorized
instrument such as the Bernell RotatorTrainer (Ber-
nell Corporation; see Appendix J) (Figure 2-13) is
ideal for this type of testing, although a hand-
held penlight that is moved smoothly and evenly
will suffice. Whatever target s used, smoothness,
accuracy, head movement, automation, and stam-
ina are to be evaluated. Using the same cognitive
demands as in saccadic testing (discussed previ-
ously) and continuing the pursuits for 1 minute will
allow for judgment of automation and stamina,
respectively.

Afterimages
Afterimages can be used in conjunction with a
moving target to provide visual feedback for the
patient and to determine whether tracking s accu-
rate. This technique is useful n both testing and
training. An afterimage may be used for a single
eye for monocular testing, or both eyes may be
stimulated simultaneously for binocular pursuit
testing. The same type of afterimage generator used FIGURE 2-13Bernell Rotator Trainer with elephant on the disk.
for testing anomalous correspondence can be used (Courtesy of Bernell Corp.)
for these purposes (see Chapter 5).

approaching ball. Therefore, statements relating to

Signs and Symptoms pursuit skills and athletic skills should be made
Patients who have poor ocular pursuit skills may with caution and with other factors (e.g., athletic
also have histories of various nefficiencies. Poor prowess) kept n rnind.
readers may have poor pursuits, although the Supranuclear lesions restrict pursuit excursions,
cause-and-effect relationship s not as great as with but nuclear or infranuclear lesions affecting the
saccadic dysfunction and poor reading. Reading extraocular muscles also can be expected to pro-
road signs from a moving vehicle would present duce many signs and symptoms. Pursuits would
problems in a case of poor pursuit skills. Patieptsr" likely be inaccurate and jerky in the diagnostic
with poor pursuit eye movements also tend to have action field of the affected muscle (see Chapter 4
significant problems participating n sports. It s regarding noncomitancy). However, these "hard"
conceivable, for example, that tracking a tennis signs of neurologic impairment are relatively easy
ball accurately would be much more difficult f to detect, explain, and understand, in contrast to
head movements were necessary, because the "soft" signs that might be supranuclear. In either
gross neck muscles are not as efficient as the case, the patient with pursuit problems due to neu-
finely tuned extraocular muscles. However, we rologic disease may have symptoms of vrtigo,
saw a patient who had Duane retraction syndrome nausea, asthenopia, or inefficient visin for mov-
involving both eyes, which severely restricted ocu- ing objects, among other difficulties.
lar activity. This patient reported being able to play Because pursuits are mainly involuntary and
tennis "fairly well," despite the fact that head turn- many of the neurologic soft signs are likely incur-
ing was necessary for the patient to see the able, one must ask how functional training tech-
38 Chapter 2

iques might help patients with pursuit problems. are believed to be useful for the purpose of correct-
As mentioned previously, the testing procedures ing fixational errors, to keep the fixated target pre-
for pursuits encompass some voluntary aspects cisely on the fovea, and possibly preventing retinal
(e.g., head movement, automation, and stamina). adaptation (fatigue).
These aspects can be improved and made more Position maintenanc can be assessed by asking
reflexive, starting from volition and progressing to the patient to fixate (monocularly) on a target.
automation. In many cases, accuracy and smooth- There should be no noticeable drifting or eye
ness are improved as a result of functional training movement from the target of regard. If the patient
techniques. In patients in whom the pursuit prob- cannot maintain steady fixation, he or she should
lem is of functional etiology (e.g., due to inatten- be instructed to hold a thumb at 40 cm to deter-
tion), the prognosis for mprovement is favorable. mine whether the proprioceptive input from the
"hand support" is helpful in maintaining steady
Summary and eye positioning. The problem may persist (e.g., due
to congenital nystagmus). If the problem is psycho-
Recommended Tests
logical (e.g., lack of attention) or from other known
Clinical assessment is important for identifying causes (e.g., fatigue or drug effects), improvement
neurologic problems and dysfunctional visual of position maintenanc often is possible through
tracking (particularly relevant to sports perfor- appropriate environmental changes and the efforts
mance). The SCCO 4+ test is recommended for use of functional training techniques.
by primary eye care practitioners in routine cases. The vast majority of patients show steady fixa-
Pursuit tests should usually include monocular tion ability with each eye. Unsteady fixation of
(duction) as well as binocular (versin) testing. one eye can be seen in some cases of amblyopia
Functional and organic causes should be differen- or decreased monocular visual acuity from other
tiated. Some patients may require "diagnostic ther- causes. Saccadic intrusions are unconscious,
apy" to determine whether the identified problem rapid, bidirectional flicks of fixation off a target
abates as a result of visin training. Practitioners and back on. These intrusions may be a present-
choose their favorites from among the available ing sign of a neurologic disorder. They look like
testing procedures. For example, a recently intro- square-wave, to-and-fro "darting" movements of
duced test for pursuits, devised by Dr. W. C. the eyes on attempted fixation. Small saccadic
Maples, is becoming popular (see the section Sum- intrusions, from 1 to 5 degrees, can be seen in the
mary of Saccade Testing). elderly; in patients with dyslexia, strabismus, or
schizophrenia; and in patients who are extremely
fatigued. However, larger saccadic intrusions, 5
FIXATION to 20 degrees, can be associated with degenera-
Fixation (known also as position maintenanc) tive conditions such as mltiple sclerosis.
involves all four eye movement systemssaccades,
pursuits, nonoptic (e.g., VOR) system, and ver-
gences. Fixation evaluation usually is accomplished Southern California College of
toward the beg'mning of an eye examination (e.g., Optometry 4+ System
during the unilateral test). Assessment s made as the The SCCO 4+ system is a quick and easy test for posi-
patient fixates on a target in primary gaze. tion maintenanc.10 The patient is instructed to fixate
Figure 2-14 shows Eye-Trac recordings of good a target approximately the size of a 20/80 (6/24) letter
versus poor position maintenanc. Reading diffi- E at a distance of 40 cm. The left eye is occluded for
culties and various symptoms may occur with poor testing of the right eye; afterward, the left eye is tested
position maintenanc. and, then, binocular testing is undertaken. Testing
True position maintenanc is actually a misno- time is at least 10 seconds per eye. The quality of
mer, in that very small movements are occurring all steadiness is assessed as follows: 4+ if steady for at
the time during so-called steady fixation: The eyes least 10 seconds, 3+ if steady for at least 5 seconds,
are not motionless during fixation. Ocular micro- 2+ if steady fewer than 5 seconds or if hand support
movements consist of rapid flicks and slow drifts of is needed, and 1 + if fixation is unsteady almost con-
a vev\ sma\\ ampVvtude that are not observable tinuously. A 2+ or 1+ is considered failing as criteria
without special equipment.TViese sma\\ movements ior poss\b\e refeua\. NAodtf\cat\on oi the SCCO 4+
Chapter 2 39

FIGURE 2-14Fixation testing results

from Eye-Trac recordings. a. Good,
steady position maintenance. b. Fair
position maintenance. c. Poor position
maintenance.

system allows for a 5-pont ordinal ranking system Vestbulo-Ocular Reflexes

which is compatible with our recommended scale The eyes maintain gaze on a target with rotation of
used in common for other visual ski lis (Table 2-8). the head through the neurologic control of VOR.
Head position and acceleration are sensed by the
Summary of Fixation Testing semicircular cais and otolith apparatus and are
An ophthalmographic instrument such as the Visa- communicated to the oculomotor centers n the
graph is desirable for assessment of position main- midbrain. The effect of this process s that a head
tenance. When this s not practical, as n very movement in any direction s accompanied by an
young children, a quick objective test, such as the equal and opposite eye movement, thus stabilizing
5-point system for direct observation, s recom- the eyes relative to a target. Vestbulo-ocular, neck,
mended. Therapy to improve position maintenance and body reflexes combine with optokinetic
is discussed n Chapter 16. reflexes to stabilize the retinal image as an individ-
Chapter 2

TABLE 2-8. System for Ranking Position Maintenance ACCOMMODATION

Functional disorders of accommodation can be sep-
arated into four types of problems: (1) insufficiency,
, Rank Description Results (2) excess, (3) infacility, and (4) ill-sustained accom-
modation (poor stamina). Patients can present with
5 Very strong Steady fixation for more
an accommodative dysfunction thatfalls into any one
than 10 secs or all of these categories, as the categories are not
4 Strong Steady fixation for at least mutually exclusive. In fact, many patients who can
10 secs be described as having an accommodative insuffi-
3 Adequate Steady fixation for at least ciency also show signs of infacility and poor stamina.
5 secs Two additional categories of accommodative dys-
2 Weak Steady fixation for less function are (5) unequal accommodation and (6)
than 5 secs or hand sup- paresis or paralysis of accommodation. The etiology
port needed of these last two disorders is not functional. In cases
1 Very weak Unsteady fixation almost of accommodative insufficiency stemming from neu-
continuously
rologic disease or trauma, patients are best served by
a prescription for reading glasses rather than visin
27
training. The first four categories do not imply an
ual moves through the environment. Developmen- organic etiology, as they often arise from functional
tal disorders of VOR tracking are relatively rare; causes (e.g., deficient physiology, overwork, or inat-
most deficiencies are acquired by trauma or neuro- tention). Besides describing the characteristics of an
logic disease. accommodative dysfunction, the clinician must
A complete assessment of VSE should include a determine, insofar as possible, the specific etiology
screening of VOR tracking. The patient is directed and must seriously consider the many nonfunctional
to hold gaze on a discreet fixation target at far or factors (Table 2-9) before the condition is assumed to
near, while either he or she moves or the clinician be functional in origin. A review of accommodative
gently moves the patient's head up and down for conditions and appropriate testing follows.
several cycles at the rate of 1 cycle per second.
This procedure then is repeated moving the
Insufficiency of Accommodation
patient's head from side to sidethe so-called
"doll's-head" maneuver. Smooth tracking is the Insuffidency of accommodaton is defined as "insuf-
rule. The presence of either saccadic intrusions ficient amplitude of accommodation to afford clear
("catch-up" saccades) or nystagmus indicates a imagery of a stimulus object at a specified dis -
failure in VOR tracking and should be further tance, usually the normal or desired reading dis -
21
assessed. In children, intervening saccades may tance." This-, is sometimes a problem in
indcate simply lapses of attention to the task, prepresbyopic patients and very often is problematic
which should be taken into consideration. in presbyopic patients but is not too frequent in
Further assessment can include challenging younger patients. However, pathologic conditions
VOR t rac k ing t hroug h head s h ak ing t hat is affecting the third cranial nerve, the ciliary muscle, or
greater than 1 cycle per second. Immediately the crystalline lens itself can result in paresis or paral-
after 10 to 15 seconds of head shaking by the ysis of accommodation for all age groups. The use of
patient in the vertical or horizontal pla e, the sympathomimetic (adrenergic) or parasympatholytic
practitioner should look for nystagmus using a (anticholinergic) drugs also result in symptom -
magnifier or ophthalmoscope. Another technique producing lowered amplitudes of accommodation.
is to measure binocular visual acuity before and Although isolated accommodative insufficiency in
during head shaking, both horizontal and verti - young patients is relatively rare, we saw three young
cal. Snellen visual acuity should not decrease men with isolated accommodative insufficiency
more than one line (e.g., 20/20 to 20/25) during within a 1-month period. All had a history of tropical
head shaking if there is good VOR tracking. illnesses of some kind. All had to wear bifocals to
Patients having signs or symptoms of a VOR dis- read clearly, and we happened to see them after they
order should be referred for further neurologic had been to other practitioners who insisted they did
testing. not need to wear bifocals because of their youth. The
Chapter 2 41

TABLE2-9. Possible Causes ofa Reduction of Accommodation

Functional etiology
Binocular: deficient accommodation due to biolgica! variation in th populaton, excessive nearpoint work, low Illu-
mination, low oxygen level, ocular and general fatigue or stress, vergence problems,
Monocular: strong sighting-eye domtnance resulting in poor accommodation n the nondominant eye
Refractive etiology
Binocular: manifest and latent hyperopia, myopes who do not wear spectacles at near, pseudomyopra, premature
and normal presbyopia
Monocular: uncorrected anisometropia, poor refractive correction, unequal lens sclerosis
Ocular disease
Binocular: internal ophthalmoplegia, bilateral organic amblyopia, premature cataracts, bilateral glaucoma, iridocy-
clitis, ciliary body aplasia, partial subluxation of lens
Monocular: same as for binocular condition, but affecting one eye more than the other, anterior choroidal metstasis,
trauma, rupture of zonular f ibers
Systemic diseases or conditions affecting binocular accommodation
Hormonal or metabolic: pregnancy, menstruation, lactation, menopause, diabetes, thyroid conditions, anemia, vas-
cular hypertension, myotonic dystrophy
Neurologic: myastheia gravis, mltiple sclerosis, pineal tumor, whiplash injury, trauma to the head and neck, cerebral
concussion, mesencephalic disease, including vascular lesions
Infectous: influenza, intestinal toxemia, tuberculosis, whooping cough, measles, syphilis, tonsillar and dental infec-tions,
encephalitis, viral hepatitis, polio, amebic dysentery, malaria, herpes zoster, many acute infections
Drugs, medications, and toxic conditions affecting binocular accommodations
Residual effects of cycloplegic drops, alcohol neuropathy, marijuana, heavy metal poisoning, carbn monoxide,
botulism, antihistamines, central nervous system stimulants, large doses of tranquilizing drugs (phenothiazine
derivatives), parkinsonism drugs, many other systemic medications
Emotional, usually binocular: stress reactions, malingering, hysteria

accommodative amplitude in each of the three for the dimimshed accommodation was suggested
patients was practically zero, but we doubt if that had by history or could be identified by careful examina-
ever been tested. The resumption of wearing plus- tion. All patients were successfully managed opti-
addition bifocals solved their problems, and no fur- cally with bifocals or reading glasses, although three
ther treatment was necessary. We saw another required the addition of base-in (Bl) prisms because
29
patient, a 21-year-old college student, who had only of exophoria at near. Ciuffreda stated that the main
1 diopter (D) of accommodative amplitude but exhib- symptom of accommodative nsufficiency s general
ited no other physical signs or symptoms. She had asthenopia related to near work.
contracted influenza 3 months previously but main- Convergence nsufficiency s commonly associ-
tained a 4-hour-daily swimming schedule on a swim ated with accommodative i nsufficiency, as is
team. Bifocals were prescribed to relieve her near- accommodative infacility. Other symptoms besides
point visin problems, and a subsequent neurologic nearpoint blur that are frequently reported by these
evaluation revealed a low-grade viral encephalitis. patients include headaches, eyestrain, diplopia, and
30
The most prevalent cause of accommodative reading problems.
nsufficiency is functional (Le., a mismatch between
a patient's physiologic accommodative capability Absolute Accommodation
28
and his or her work requirements). Chrousos et al. The amplitude of accommodation s measured
described 10 detailed cases of healthy young people monocularly using the push-up method for one eye
who reported intermittent blur at near. They demon- and then the other. This is absolute accommoda-
strated amplitudes of accommodation considerably tion. The print size should be equivalent to 20/20
lower than those expected for their respective ages (6/6) at 40 cm, or smaller or larger depending on
(an average reduction of 6 D). No organic etiology the patient's mximum visual acuty. The mximum
Chapter 2

TABLE2-10. Donders'Table ofAmplitude of

TABLE 2-12. Ranking of Relative Accommodation
Accommodation (in which Dioptrc Powers Represent the First
Sustained Blur)

Age (yrs) Amplitude (D)

Rank Description PRA (-} anel NRA (+}
10 14.0

20 10.0 5 Very strong >2.5GD*

30 7.0 Strong 2.25 D
40 4.5 4 Adequate 1.7S-2.00D
50 2.5 Weak Very 1.50D
3 weak <1.50D
NRA2= negative relative accommodaton; PRA positive rela-tive
farpoint visual acuity lenses with most plus power accommodation.
The clfnician shouid beskeptical of an NRA finding exceeding +2.50
(also called CAMP lenses [corrected ametropia D at1a 40-cm testing dlstance. K NRA exceeds +250 O, ttie testing
most plus]) should be worn for testing. If the patient procetlure s wrong. Either the patlent is over-nsnused or there s
does not give reliable responses, the clinician latent hyperopia (Le., corrected ametropia most plus [CAMP1 tenses
not being wom). Theoretfcally, 40 cm s the faipoint (ptica! bflnty)
should move the target from near to far by starting wSth +2.50-D tenses. The pattenfs vbfon showld be blurred when
at the spectacle plae and pushing it away until the +2.5-D power s exeeeded, CAMP tenses, ttierefore, are absolutely
designated line of print is read aloud correctly. necessary for reliable baseline clinical data.
Then testing reverts to the push-up method until
first blur is reported. This technique is the method-
of-adjustment (method-of-limits) research tech- very young children because their clinically mea-
nique, referred to as bracketing'm clinical parlance. sured amplitudes are often lower than would be pre-
Table 2-10 is an abridged table of the amplitude of dicted theoretically. Practitioners should consider
accommodation according to age. 31A formula to this when testing children younger than 6 years.
calclate the minimum expected amplitude of Semantic confusin often arises over the term
accommodation was introduced by Hofstetter. 31 accommodative insufficiency. Some sources (inap-
The minimum amplitude is calculated as propriately, in our opinin) refer to "accommoda-
A = 15 - 0.25(x) tive deficiency" or "insufficiency" when talking
about accommodative nfaciUty. (Accommodative
where x is the patient's age in years. For example, if a infacility is discussed later in this chapter.)
patient is 10 years od, the expected amplitude is 15
- 0.25(10), or 12.5 D. An amplitude of only 8.5 D in Relative Accommodation
the right eye would be very weak, as this is 4 D
Another form of accommodative insufficiency s that
below average. Table 2-11 gives accommodative
of poor positive relative accommodation (PRA) and
ranking. The Hofstetter formula may not hold true for
poor negative relative accommodation (NRA). PRA is
tested with minus-power lenses to first sustained blur
TABLE 2-11. Ranking of Accommodative Amplitude under binocular viewing conditions. NRA is tested
similarly but with plus-power lenses. These functions
are traditionally tested at 40 cm, with the patient
Rank Description Amplitude looking through CAMP lenses for baseline reference.
The patient is instructed to maintain clearness and
5 Very strong 1 .00 D or more above singleness while looking at a designated line of letters
4 Strong 3 average 0,50 D above (20/20 [6/6] equivalent or smaller if visible) as the
Adequate 2 average Average for plus or minus lens stimulus is increased (Table 2-12).
Weak 1 Very age 2.00 D below The rate of stimulus increase s approximately every 3
weak average 4.00 D or more seconds in 0.25-D steps. A momentary blur is
below average allowed. Approximately 5 seconds should be
allowed to determine whether the blur is sustained.
The PRA and NRA are record i ngs representing the
Chapter 2 43

FIGURE 2-15Nott method of dynamic

retinoscopy to measure lag of accom-
modation.

first sustained blurpoints. Failure on the PRA test is a from the patient. This distance s converted into
32
sustained blur for 5 seconds with lens powers weaker diopters to determine the accommodative lag. The
than -1.75 D (relative to CAMP lenses). In other patient fixates reading material at 40 cm (2.50-D
words, passing requires clear and sustained visin accommodative stimulus) while retinoscopy s per-
with -1.50 lenses. Failure on the NRA s similarly a formed through a hole in a card (Figure 2-15). The
sustained blur with lens powers weaker than +1.75 clinician physically moves toward the patient until a
D. Clinicians should bear in mind that relative neutralized reflex is observed, say, at 67 cm (1.50-D
accommodation often is limited by deficient ver- accommodative response). The accommodative lag,
gence ranges. For example, an esophoric patient with according to the Nott method, would be 1.00 D in
a high accommodative convergence-accommoda- this example. This test s done while the patient is
tion ratio and with poor fusional divergence will behind the refractor.
likely have a reduced PRA. With the Nott method, the accommodative stimu-
lus does not change, because the testing distance is
Lag of Accommodation kept constant, and no dioptric changes are made by
Although t does not necessarily imply insufficient the intervention of additional lenses. The nearpoint
amplitude of accommodation, lag of accommoda- rod of the refractor can be used to measure directly
tion can be thought of as a clinical form of accom - the dioptric distance between the fixation distance
modative insufficiency for a particular nearpoint and the retinoscopic neutralization distance (i.e., the
target. Accommodative lag can also be thought of distance representing the accommodative lag).
as accommodative inaccuracy, just as fixation dis-
parity can be considered to be an inaccuracy n Monocular Estmate Method Retinoscopy
vergence. Lag of accommodation can be measured When testing is performed outside the refractor,
in several ways, but two of the most reliable clini- monocular estmate method (MEM) retinoscopy may
cal methods are described here. be more convenient than the Nott method. The MEM
s called "monocular" despite the fact that the patient
Nott Method has both eyes open and testing s conducted under
33
The Nott dynamic retinoscopy method is based on binocular viewing conditions. The MEM of Haynes
the linear difference between the fixation distance is similar to the Nott method except that the retino-
(usually 40 cm) and the distance of the retinoscope scopic distance is kept constant. This s often at the
Chapter 2

FIGURE 2-16Monocular estmate

method retinoscopy (dynamic) to
assess accommodative accuracy (i.e.,
lag or lead of accommodation).

Harmon distance (distance equal to that from the tip suggests the possibility of anomalies of insuffi-
of one's elbow to the middle knuckle of the clenched ciency of accommodation, infacility of accommo-
fist measured on the outside of the arm).21 Distances, dation, and ill-sustained accommodation, any of
however, may vary, as the patient's habitual reading which can be adverse factors in visin efficiency.
distance is recommended. The binocularly viewing Ranking of either Nott or MEM results s shown n
patient s instructed to read appropriate material (for Table 2-13. A rank of 2 or 1 s failing, and referral
his or her age or cognitive level) mounted on the reti- for visin therapy may be recommended.
noscope. A trial lens s quickly interposed in the
spectacle plae of one eye to neutralize the retino- Excess of Accommodation
scopic reflex (Figure 2-16). The lens s removed from
Another inaccuracy s accommodative excess,
the eye within a second, because latency of accom-
sometimes called spasm of accommodaton, hyper-
modation response is short. Tucker and Charman34
accommodation, hypertonic accommodation, or
found a mean reaction (latency) time of 0.28 second
pseudomyopia. Accommodation may be excessive n
for one subject and 0.29 second for another. There-
focusing on a stimulus object and is considered to be
fore, the neutralizing lens must be quickly removed
once it is introduced before an eye. The stimulus to
accommodation might be changed if the lens is TABLE 2- 13. Ranking of Accommodative Lag
before the eye for a longer duration. The possibility of (Insufficiency, or Inaccuracy, of Accommodation)
changing accommodative responses by changing
accommodative stimuli must always be kept in mind
when one is conducting the MEM test. Nott or MEM Retinoscopy
The lens power (addition of plus) necessary to of Accommodation (OD Lag
achieve retinoscopic neutralization is the esti- Rank Description or OS)
5 Very strong +0.25 D
mated accommodative lag of the eye being tested
at the moment. If minus power should be required 4 Strong +0.50 D
for neutralzation, accommodative excess would 3 Adequate +0.75 D
be indicated. 2 Weak +1.00D
Using the Nott or MEM procedure, we believe 1 Very weak +1.25D
an accommodative lag of 1.00 D or greater is MEM = monocular method; OD = oculus dexter;
cause for further investigaron. This concern was stimate
OS = ocultis sinister.
shared by Bieber.35 A high lag of accommodation
Chapter 2 45

an anomaly. Latent hyperopia s another variation of

accommodative spasm (.e., accommodation fails to TABLE 2- 14. Ranking of Accommodative
relax using noncycloplegic ["dry"] refractive tech- Excess Using the Monocular Estmate Method
niques); cycloplegic ("wet") refraction may be indi- of Retinoscopy
cated. Causes of spasm may be overstimulation of the
accommodative system as a result of prolonged near
work, emotional problems, focal infections, or other
unknown etiologies. Numerous symptoms may be Lerts Power
associated with accommodative excess, such as Indicating Lead of
Rank Description Accommodation
asthenopia, blurring of distant visin, headaches, 5 Very strong +0.25 D
diplopia (if excessive accommodative convergence is 4 NA NA
brought into play), and inefficient performance at
nearpoint (e.g., a person may hold reading material Adequate
3 (borderline) 0.00 D -
at an exceptionally cise range).
Maintaining or sustaining accommodation n the Weak
2
1 Very weak -0.50 0.25
D or D
greater
absence of a dioptric stimulus s another form of
accommodative excess. This form is physiologic n NA = not applicable.
that it is not abnormal for accommodation of approx-
imately 1.00 D to be n play n a formless field, as in
"night myopia." There s no specific training tech- plished with the binocular crossed-cylinder test at
nique for night myopia; rather, the affected individual near. However, we do not believe this subjective
must become familiar with the set of circumstances method is as reliable as objective testing with either
in which the anomaly occurs and must make appro- the Nott or MEM method.
priate adjustments to it (e.g., temporarily wearing
minus overcorrective lenses, if necessary, for night-
time driving). Facility of Accommodation
Retinoscopy is necessary for reliable diagnosis of Another aspect of accommodation s facility. An
accommodative excess. Static retinoscopy with the infacility of accommodation, also known as inertia
aid of cycloplegia can determine ametropia (.e., far- of accommodaton, is the inability to change focus
point). At nearpoint, however, dynamic retinoscopy s rapidly. Accommodative infacility can cause dis-
important; cycloplegia must not be used n nearpoint comfort and reduced visin efficiency. For example,
testing. Either Nott or MEM dynamic retinoscopy can such patients typically report slow clearing of
be used to determine whether there is a /ag(i.e., insuf- visin, most often noting blurring when looking
ficiency), but MEM s applicable for lead(\.e., excess) from the "book to the board." The standard testing
of accommodation. If accommodative response leads procedure s to use 2.00-D lenses. The recom-
the accommodative stimulus by 0.25 D or more, we mended optotype s the equivalent of a 20/30 (6/9)
believe accommodative excess exists at that moment Une of Snellen letters at 40 cm while the lens power
of testing. This observation should be verified on is changed from plus to minus, and so on, for 1
repeated testing. lf-0.25 D is consistently required for minute. Lenses may be mounted in devices (Figure
neutralization, the patient is considered to have 2-17) that are similar to a Comparator (Bausch
accommodative excess (Table 2-14). &Lomb, Rochester, NY). Testing is done
Accommodative excess can also occur when monocularly (oculus dexter and oculus sinister) and
excessive accommodative convergence s required then binocu-larly. Suppression can be monitored
to maintain fusin, as in patients with exophoria in with vecto-graphic targets (Figure 2-18). Although
whom positive fusional convergence is insufficient. clinicians may ask the patient to say "clear" with
Such a patient may overaccommodate n order to each stimulus change, a better technique s to
have sufficient accommodative convergence to nstruct the patient to read each letter aloud as
maintain single (but blurred) visin. quickly as possi-ble with the introduction of each
Although objective means for determining accom- lens flip. This allows monitoring of correct or
modative accuracy (with Nott or MEM methods) are ncorrect responses. The number of accurate calis
reliable, especially for young patients, subjective test- is recorded and converted into cycles per minute
ing may also be performed. This can be accom- by dividing that number by 2. For example, f the
number of correct calis for an eye is 8, there are 4
cycles per minute.
46 Chapter 2

FIGURE 2-17Bernell flipper devices for accommodative facility test-

ing. (Courtesy of Bernell Corp.)

The standard flipper lens test is contaminated by a

number of factors of which the clinician must be
aware. Because a patient verbally reports when a tar-
get appears to be olear, the measurement depends to
some unknown extent on the speed or automaticity
of verbal expression. The plus and mi us lenses
noticeably magnify and minify the optotype stimulus,
possibly confounding the perception of blur. Further-
more, time and manual dexterity are involved in
mechanically changingthe lenses. Until better instru-
mentation is developed, the clinician should attempt
to mitgate these factors when possible. For example,
a patient can be instructed to ignore the apparent
change in image size and to respond only when the
optotype is perfectly clear regardless of size. The cli-
nician should handle the lenses and flip the lenses in
a consistent manner for each patient. Currently, nor-
mative data are available for most patients using the
traditional lens flipper testing modality; the variance
in norms from one study to another may be due in
part to some of the factors just cited.
A summary of norms of facility by several investi- FIGURE 2-18Accommodative facility testing: Trial lenses can be
31 mounted n an attachment for the Correct-Eye Scope. a. Monocular
gators is included in Table 2-15. Borish stated that testing; left eye is being tested n this figure, b. Binocular testing. c.
monocular accommodative facility, when tested at View of crossed-polarizing filters worn by the patient. d. Vectographic
the patient's habitual nearpoint distance, should have target (Vectogram 9). Line 4 is seen by the left eye, line 5 by both eyes,
and line 6 by the right eye.
a range of lenses from +1.50 to -2.00 D with clear
visin, with the normal response time being less than
5 seconds.
Chapter 2 47

TABLE 2-15. Partial List o Norms for Accommodatve Fadlity

Study Results Age Group

Burge39 2.00 D; 12 c/min monocular; 10 c/mirt binocular; 7 Children and young

c/min binocular, with supppesston belng monitored adults
37
Grffn et al. 2,00 D; 17 c/min monocular 2.00 D; 17 c/min Young adults
38
Griffin et al. monocular; 13 c/min binocular; 6 e/ min binocular, Young adufts
with suppression being monltored 1,50 D; 20 c/64
36
Lu et al. secs with 26 SO 2,00 D; 10 c/52 secs with 24 SD dulls
40 41
Grisham et al. and Pope et al, Children
SO = standard deviation.

36
Liu et al. suggested that the criterion for passing 18 cycles per minute, as compared with 15 cycles per
be 20 cycles per 90 seconds, allowing each cycle to minute for the subjects having poor visual skills. Bin-
take 4.5 seconds or each flip to last 2.25 seconds. ocular rock without suppression monitoring gave
37
Griffin et al. studied monocular accommodative averages of 17 and 9 cycles per minute for the same
facility n 14 subjects ranging in age from 20 to 35 two groups, respectively. When binocular rock was
years. They found 2.00-D rock to have an average tested using suppression monitoring, there was an
valu of 17 cycles per minute. The average response average of nine cycles per minute for the subjects with
time to clear the minus lens was 2 seconds, whereas good visual skills but only four cycles per minute for
1.4 seconds were needed to clear the plus lens. those having poor visual skills. The authors concluded
38
Griffin et al. determined monocular facility as that binocular accommodative facility testing can be
compared with binocular facility. They wanted to definitive n the assessment of a patient's binocular
elimnate the possibility of guessing and ensure that status.
39
patients were actually seeing clearly rather than Burge used a practical clinical method to study
reporting "clear" with each lens flipping. Instead of binocular facility using suppression monitoring. He
manually changed targets (which were double-digit used a Spriangle Vectogram (see Appendix J) target
numbers), an electrical mechanism introduced ran- with crossed polarizing viewers and 2.00-D lens
dom numbers (of six-point type size at a distance of flippers. The mean valu results were 12 cycles per
40 cm) in synchrony with the lens flipper mechanism. minute monocularly, 10 cycles per minute binocu-
Rock of +2.00 D was conducted for 1 minute to larly without suppression monitoring, and 7 cycles
determine the average number of cycles n a young per minute with suppression monitoring. Burge's
adult population, ages 20-23 years. Monocular facil- valu for monocular facility was lower than those
37 38 39
ity was approximately 17 cycles per minute. Binocu- obtained by Griffin et al. ' However, Burge
lar facility was approximately 13 cycles per minute, included younger subjects among his test group
without monitoring of suppression. To monitor sup- (ranging n age from 6 to 30 years).
40 41
pression, a vectographic pate was arranged so that Grisham and Pope et al. established monocular
the leftward (first) digit was seen only by the left eye accommodative facility norms for elementary
and the right eye saw only the second digit. For exam- school children and validated these norms by objec-
ple, the number 53 that appeared with the new lens tive accommodative testing. They tested second,
change would be presented so that only the number 5 fourth, sixth, and eighth graders using 2.00-D flip-
could be seen by the left eye and the number 3 by the pers at 33 cm. The target was a 20/30 optotype, and
right eye. There were only six cycles per minute as an each child was asked to report when the print
average for this group of subjects when suppression appeared to "clear" with each lens. The norms
was monitored. The nvestigators reviewed the 27 proved to be the same for all children except for the
records of complete visin examinations and selected second graders, whose responses were often inac-
16 subjects who showed evidence of poor visual skills curate, presumably due to lapses of attention. The
and 11 who showed good visual skills. Monocular researchers measured the time the subjects took to
rock for the subjects with good visual skills averaged complete 10 cycles and 20 cycles on the test.
48 Chapter 2

TABLE 2-76. Ranking of Accommodative Facility with tive facility. These criteria do not apply to children
2.00 Diopters younger than 7 years. Professional judgment must
be used when evaluating accommodative facility
in very young children.
Cycles per Minute
Ill-Sustained Accommodation
Rank Description OD or OS Binocular* Testing for ill-sustained accommodation is similar to
5 Very strong 4 >18 >10 that for facility of accommodation. Ill-sustained
Strong 3 14-18 8-10 accommodation relates to stamina, or the power to
Adequate 2 10-13 6-7 endure fatigue.42 It is easily detected in most routine
Weak 6-9 4-5 accommodative facility testing, which is why clini-
1 Very weak <6 <4 cians should carry out facility testing over a period
OO = oculus dexter; OS = oculus sinister. of at least 1 minute. Speed and sufficiency may be
*Suppression montorng with vectographic targets. normal in the beginning but may be maintained
only with effort and will decrease with time. The
time during which stamina diminishes may be short,
often within 1 minute. For example, a patient with
Because no significant difference in cycles per ill-sustained accommodation may begin 2.00-D
minute was found, they recommended using 10 lens rock quickly and sufficiently, but the responses
cycles for testing children age 8 years and older. The may become inadequate after a few flips of the
mean time was 52 seconds, with a standard devia- lenses. If the clinician tests for only one or two
tion of 24 seconds. A unique feature of this study cycles, the patient's lack of accommodative stamina
was the objective verification of the clinical proce- may not be discovered.
dure. The properties of accommodative facility Ill-sustained accommodation can affect perfor-
(latency, velocity, and completion time) were objec- mance and result in various visual symptoms. Indi-
tively measured using a dynamic optometer in ran- viduis vary widely in their ability to meet and
domly selected subjects. The rank correlation sustain accommodative demands for a variety of
between the clinical and objective measurements reasons (e.g., physiologic variation, medication,
was high (r - 0.89), indicating good concurrent visual demands, and general health). Clinical expe-
validity. (Other studies are shown in Table 2-15.) rience has shown, however, that accommodative
There is no consensus on developmental norms stamina can be improved in most cases in which
from childhood to adulthood for accommodative the cause is functional in nonpresbyopic patients.
facility. As to referral criteria for facility, Hoffman Therapy is the same as for accommodative facility.
and Rouse10 recommended the following: flipper Monocular, biocular, and binocular accommoda-
test of 2.00 D monocularly and binocularly tive rock procedures are performed in the office
showing less than 12 cycles per minute, with the and at home. The only difference is that sustaining
patient viewing a 20/30 Une at 40 cm, or a differ- ability is emphasized to a greater extent than other-
ence of more than 2 cycles per minute between wise. (Therapy is discussed in Chapter 15.)
the two eyes. In light of the results shown in Table For testing of accommodative stamina, we rec-
2-15, these referral criteria may be too stringent, ommend using the ranking shown in Table 2-17.
especially for young children. Retesting or lowered These are clinical empiric observations; fully
initial standards should be considered during the researched norms await further reports. The clini-
routine testing of new patients. We recommend cian flips the lenses at a constant rate, 6 seconds
the following cutoff criteria for failing such a test: A per cycle. If this rate is maintained for 36 seconds
subject is considered to have failed the test if under binocular conditions, the patient passes
monocular facility is less than 10 cycles per this recommended standard for accommodative
minute or if the difference between the eyes is stamina. Stability is emphasized, as opposed to
greater than 2 cycles per minute; failure also is rec- frequency of correct calis as in facility testing. It is
ognized if binocular facility with suppression mon- one thing to be fast for a while but, in real life, an
itoring is less than 6 cycles per minute. Table 2-16 individual will not do well if he or she lacks stam-
provides clarification and ranking of accommoda- ina. This is as true for the accommodative system
Chapter 2 49

as it s for saccades, pursuits, and position main-

tenance (discussed previously). TABLE 2-17. Ranking of Accommodative Stamina
If a patient meets the recommended criteria for
accommodative facility testing with a consistently Binocular
Monocular (secs)
good rate of responses throughout the test, there is Rartk Description
(secs)*
no need for stamina testing. 5 Very strong 2:108
Strong >60
84-108
4 Adequate 48-59
60-S3
Summary of Weak Very 36-47
3S-59 24-35
Accommodation Testing 3 weak <36 <24
Accommodative nsufficiency s tested n several
Note: Testing s at the rate of 6 secs/cycle (i.e., 3
ways. The amplitude of absoluta accommodation 2
secs per each corred responso) with 2.00-D tenses. The cutoff
s found by monocular push-ups and, possibly, by point s desig-nated as a response time exceeding 3 secs on any
bracketing between push-ups and push-aways 1 flip or whenever there is an incorrect response. *Suppression
lens
should be monitored using either anaglyphie or vectographic
when necessary. PRA and NRA are binocular tests targets when binocular testing is done.
of relativa accommodation. Dynamic retinoscopy
under binocular viewing conditions, conducted
with either the Nott or MEM method, determines
an accommodative naccuracy. tion) mus be taken nto account in visin therapy.
Testing for infacility introduces the element of These are discussed in relation to case examples
time, which relates to the efficiency of accommo- (along with the Maddox components) in Chapter 3
dative responsiveness. The standard testing proce- and also later n this book.
dure is to use 2.00-D lenses, first monocularly
and then binocularly. At least 10 cycles per minute Absolute Convergente
are necessary for monocular adequacy and 6
The total amount of convergence of the visual
cycles per minute binocularly (with suppression
axes (Unes of sight) from paral lesm at far to a
monitoring). Testing for ll-sustained accommoda-
bifixated target at near is called absoluta conver-
tion also involves the element of time. The differ-
gence, often also called "gross" convergence.
ence between this and testing for infacility is that
Absolute convergence may involve all four com-
the quality of accurate responses as to stability and
ponents of Maddox.
endurance is assessed, rather than the mere quan-
tity of accurate calis.
Testing Techniques
The clinical test for absolute convergence is per-
formed with a small target, traditionally a pencil
VERGENCES
tip, for measuring the nearpoint of convergence
Vergences are disjunctive eye movements (rather (NPC). The patient views a target in the midline as
than conjgate movements, as n the three other it s moved closer to the spectacle plae. Any
movement systems). The occipitomesencephalic object for fixation can be used, but a target requir-
neural pathway for vergences, at least for conver- ing accurate accommodation s recommended. A
gence, extends from rea 19 to the third nerve small isolated letter // E // ofapproximately 20/30
nuclei. Vergence movements are slow (as com- (6/9) size at 40 cm (1.5 minutes of are) has become
pared with saccades) and mainly involuntary. a clinicai standard. The examiner moves the target
According to the traditionally used Maddox classi- steadily at a rate of approximately 3-5 cm per sec-
fication, there are four components of conver- ond toward the bridge of the patient's nose. The
gence: tonic, accommodative, fusional (disparity), patient s asked to look at the letter and report
and proximal (psychic). Although authorities may when t first becomes blurred and then when it
disagree about whether this classification s the appears doubled. Despite blurring, some patients
only true classification, the consensus s that the may be able to maintain bifixation on the target all
Maddox concept is useful for clinical purposes. the way to the bridge of the nose (i.e., approximat-
Nevertheless, factors other than those considered ing the spectacle plae). Most patients, however,
in the Maddox classification (e.g., prism adapta-
50 Chapter 2

TABLE 2-78. Ranking of Resulte ofNearpoint of

be expressed in prism diopter (A) units. If, for exam-
Convergence Testing ple, the breakpoint is 7 cm from the spectacle plae,
the magnitude in prism diopters of absolute conver-
gence can be calculated trigonometrically. The follow-
ing formula, however, isconvenient for clinical purposes:
Recovery to 100
Breakpoint Singteness Prism diopters = IPD
Rank Descripton (cm) (crn)
X + 2.7
5 Verystrong 4 <5 5- <8 8-9
where IPD is the interpupillary
Strong 3 6 7-8* 10-11
distance. If, for example, the IPD is 60 mm (6 cm)
Adequate 2 9-15 12-18
and the NPC in breakpoint is 7 cm, then
Weak
1 Very weak >15 >18 A = 6 100 7 +
*A breakpornt distance more remote than 8 ctn s consldered 2.7
fallure, as is a recovery more remote than 11 cm.
A = 62

will have a breakpoint several centimeters from the Note that the 2.7-cm distance is the approximate
spectacle plae. (Refer to Table 2-18 for ranking distance from the center of rotation of the eyes to
criteria.) After the blurpoint is reported (although the spectacle plae (Figure 2-19).
not reported by many patients) and the breakpoint
is measured, the target is withdrawn in a similar Functions and Norms for
manner and at the same speed to determine the Absolute Convergence
point of recovery. Supplementary testing in up- NPC testing allows assessment of three functions
gaze and down-gaze may be included as war- of absolute convergence: sufficiency (amplitude),
ranted (e.g., in cases of A or V patterns). (See the facility (flexibility), and stamina. Norms listed
discussion on comitancy in Chapter 4.) below are from Griffin,43 Hoffman and Rouse,10
These clinical measurements usually are recorded and our clinical experience.
in centimeter vales, although they may alternately

7cm

2.7 cm

FIGURE 2-19Example of nearpoint-

of-convergence conversin from cen-
timeters to prism diopters. (E = fixation
target; IPD = interpupillary distance.)
Chapter2 51

Sufficiency of absolute convergence is deter- most likely has significant binocular problems, and
mined by the usual testing method of pencil push- referral for visin therapy should be considered. In
ups, as described earlier, although a small detailed summary, the evaluation of stamina, as well as
target s recommended rather than a pencil tip. The facility and sufficiency of absolute convergence, is
blurpoint is so variable among the normal popula- important.
tion that norms have not been established. Ideal ly, Although NPC normative data are not well
however, blurring should not occur until the target established for infants and preschoolers, practition-
approaches a distance n the range of 10-15 cm. In ers of visin therapy are well aware that infants of
contrast, the breakpoint should be much less 1 year of age can converge their eyes to view a tar-
remote, normally 7-8 cm or closer. Either diplopia get at very cise distances. Wick44 reported this in
of the target (as reported by the patient) or loss of a patient not quite 1 year od.
bifixation (as observed by the examiner) at a dis-
tance exceeding 8 cm is considered "failing," Developmental Considerations
which can be used as a cutoff point for referral Absolute convergence, as measured during NPC test-
considerations (seeTable 2-18). Certainly a remote ing, s composed of Maddox's four components:
NPC greater than 10 cm is a failing test result. tonic, accommodative, proximai, and fusiona! ver-
The reporting of diplopia s a subjective test. gence. The developmental period of each of these
Subjective NPC results should be corroborated components differs and should be taken into account
with objective test results (observation of exam- by clinicians examining infants and toddlers.
iner). Ordinarily, direct observation of the patient's Schor45 summarized that tonic vergence is stim-
eyes will suffice, but greater accuracy s possible ulated by intrinsic innervation, accommodative
by observing the corneal reflexes from an auxiliary vergence responds to blur, and psychic vergence
penlight source held a few centimeters above the depends on perceived distance. These are "open-
letter f fixation target, a modified Hirschberg test. loop" responses and do not demand much of
(See Chapter 4 for discussion of Hirschberg test- visual feedback mechamsms. For example, one
ing.) Suppression may be indicated if there is no eye may be occluded, but convergence will occur
report of diplopia and the clinician observes a lack f the unoccluded eye responds to the accommo-
of bifixation. dative demand of a minus lens, which would
Facility of absolute convergence can be assessed cause accommodative convergence. Fusiona! (dis-
indirectly by the patient's ability to recover bifix- parity) vergence, on the other hand, is a "closed-
ation. Only singleness, not necessarily clearness of loop" response requiring sensory feedback from
the target, s demanded for normative evaluation retinal image disparity. Tonic vergence can be
purposes. The patient should be expected to recover measured at birth and s often a "low tonic" con-
singleness (and recurrence of bifixation should be vergence resulting n an exo deviation. Accommo-
objectively observed by the examiner) at a distance dative vergence is evident, to some extent, within
of 10-11 cm or closer as the target is withdrawn. a few weeks after birth. Prxima! convergence s
Poor vergence recovery is indicated if the distance is evident n the neonate as shown by the difference
more remote. In other words, a recovery beyond 11 between the deviation in lighted surrounds (usu-
cm s considered "failing," and referral for visin al ly exo deviation) and the deviation of the visual
therapy should be considered (seeTable 2-18). axes in darkness (usually eso deviation).
Stamina of absolute convergence is assessed by According to Schor,46 however, "It s clear that the
repeating the break and recovery testing four binocular disparity vergence system s the last of the
times, for a total of five routines. Poor stamina is oculomotor functions to develop. Little is known
ndicated f the endpoints are more remote on rep- about the age at which the response s adultlike."
etition. Any decrement in performance over this The following section on disparity vergences, there-
period s considered failing or, at least, s sugges- fore, presents established norms for adults. We
tive of a dysfunction of gross convergence. Note believe these are applicable also to older children
that the training effect of repeated NPC testing may and perhaps to those as young as 7 years. Although
result in prism (vergence) adaptation, which theo- children are physiologically capable of responding
retically should help the patient to converge more to testing, attentional problems may cause unreli-
sufficiently. If, however, sufficiency s reduced on able results n many cases. Nevertheless, our clini-
repetition because of lack of stamina, the patient cal impression is that a 7-year-old child should have
52 Chapter 2

approximately the same magnitudes of sufficiency, Clinical testing of relative vergence should begin
facility, and stamina of vergence functions as do with divergence testing. This is so because prism
older children and adults, assuming that attention is adaptation to BO is relatively strong and prism
good and optimal performance is attained during demands may contamnate the Bl findings, making
testing. In general, testing of very young children the fusional divergence response appear falsely
must be objective to a large extent. much weaker than otherwise. According to the
hypothesis of Schor,46 ". . . [T]he stimulus to ver-
Relative Convergence gence adaptation is the effort, or output, of the fast
fusional vergence controller." In other words, the
Testing and Norms
reflex-disparity-vergence output resulting from Ris-
Convergence is the term traditionally applied to ley BO prisms can induce prism adaptation during
both convergence and divergence. However, in actual clinical testing. Therefore, fusional diver-
discussions of relative vergences, the general term gence testing should precede testing of fusional
vergence probably is preferable to inclusin of convergence. By tradition in clinical practice, how-
the semantically restrictive prefix con-. Use of ver- ever, farpoint Bl and BO vergence testing precedes
gence would avoid the need for awkward or nearpoint Bl and BO vergence testing. The clinical
superfluous denotations such as negativa fusional sequence is (1) fusional divergence at far, (2) fusional
convergence and positiva fusional convergence. convergence at far, (3) fusional divergence at near,
The terms relative vergence, fusional vergence, and (4) fusional convergence at near. Despite the
and disparity vergence may be used interchange- possible contaminant of prism adaptation (espe-
ably for most clinical purposes. (Refer to Chapter cially with BO prism), clinicians find it more con-
3 for further discussion on relative vergences.) venient to finish farpoint testing before moving on
The stimulus for fusional vergence eye move- to nearpoint testing. Therefore, we recommend
ments is ret'mal disparity, with other intervening maintaining the traditional sequence, for the sake
variables excluded: This means that a constant of clinical ease and expediency.
testing distance is maintained during increasing
prismatic stimuli. Relative vergence is conve-
niently measured from the orthophoric demand Fusional Vergences at Far
point, which simplifies clinical recording. For Fusional divergence at far is also. known as nega-
example, a patient views a target at 40 cm while tive fusional vergence, negativa fusional conver-
base-out (BO) demand is increasingly introduced gence, and negativa disparity divergence, among
with Risley prisms.The blurpoint, breakpoint, and other designations for this function. For the sake
recovery point are recorded directly from the of consistency and historical precedent in this
scale on the instrument as though the patient (and text, we adhere to negative relative convergence
every patient) is orthophoric. The actual magni- (NRC} at 6 m as the clinical nomenclature of
tude of the disparity vergence response, however, choice. The stimulus to fusional divergence is ret-
must take into account the fusion-free position of 'mal image disparity (which is Bl demand). The
rest, which involves the effects of tonic, accom- responses of tonic, accommodative, and proximal
modative, and proximal vergence. If, for example, vergences must be minimized, to the extent possi-
a patient has exophoria of 6A at 40 cm and the ble, so that only fusional vergence is measured.
blurpoint with BO demand is 10 A, the total Fusional divergence can be measured by several
fusional (disparity) vergence response would be clinical methods. The most common method for
16A. Suppose another patient has an esophoria at measuring NRC is by the use of Risley prisms in a
40 cm of 4A: The total fusional (disparity) vergence phoropter. From a distance of 6 m, the patient is
response would be only 6 A for the 10 A BO instructed to view a vertical column of letters, nor-
demand. This method of measurement compli- mally of 20/20 (6/6) acuity demand, but the letter
cates establishment of norms for clinical useful- size may vary depending on the best attainable
ness. Conveniently, however, relative vergences acuity of the patient. If, for example, the patient's
measured from the common-denominator ortho- best corrected visual acuity is 20/40 (6/12), that
phoric position allow for standardizaron of particular mnimum angle of resolution for letters
norms. Henee, re/af/ve vergence is the preferred should be used for testing. For reliability of all
term and testing procedure for clinical purposes. visual skills testing, CAMP lenses for mximum
Chapter 2 53

visual acuity at far must be used for all baseline 5.

testing. TABLE 2-19. Ranking of Results of Negatve Relatve
When vergence ranges are tested with Risley Convergence Testing ai 6 m (Base-ln)
prisms, the speed of prism induction should be
standardized. If the rate s too slow, the patient
may have an excessive degree of prism adapta-
tion and may falsely pass the test. In contrast, if
the prism demand is ntroduced too rapidly, the Recoveryto
A
Rank DescriptionBreakpoint ( ) Singleness ()
patient may falsely fail the test. Most clinicians
5 Very strong 8 6
have found that the best overall rate of ntroduc-
tion of Risley prism power is approximately 4 A 4 Strong 7 5
per second. We recommend this rate for all slid- 3 Adequate 6 4
ing vergence testing, whether with Risley prisms, 2 Weak 5 3
Vectograms, anaglyphs, or targets n stereo- 1 Very weak 4 2
scopes. As Grisham 40 pointed out, "Test results
are markedly influenced by such procedural fac-
tors as speed and smoothness of prism power not necessarily clearness) is reported. A good
induction, amount of contour in the fixation tar- nstruction is, "Tell me when the double images
get, and phrasing of nstructions (i.e., Tell me join again into one."This endpoint is recorded for
when the target doubles,' as opposed to Try to the recovery valu.
keep the target single.')."
We recommend the following standard routine: Once the breakpoint and recovery vales for
NRC are recorded, these findings may be evalu-
1. Have the patient view a column of 20/20 ated n terms of their normalcy. Table 2-19 shows a
(6/6) letters (or the patient's minimum angle of res- ranking system whereby ranks of 2 or less are
olution f acuity is worse). abnormal and, thus, failing. Ranks of 3 or more are
2. Instruct the patient to try to keep the let passing. This ndicates that 6A break and 4A recov-
ters clear and report whether there is any blur ery are passing, which s n accord with Morgan's
ring. The Risley prisms are rotated symmetrically. norms (discussed n Chapter 3).
Note: Be skeptical if a blur is reported on Bl test Positive relative convergence (PRC) at 6 m s
ing at far. Blurring couid be due to an ncorrect tested in a manner similar to that used for NRC.
refractive status, such as latent hyperopia, or the The difference s that BO rather than Bl prism
patient may be over-minused. Therefore, it is vital demands are given. Unlike NRC at 6 m, a blur-
to perform vergence testing with the patient look- point usually s expected when BO prism demand
ing through CAMP lenses. The first sustained blur (PRC at 6 m) s ncreased. Some patients, how-
exceeding 2 seconds s recorded. Blurring should ever, do not report blurring, only breakpoint and
be that amount of degraded form acuity that recovery. We have found that with proper nstruc-
would be caused by +0.25-D overcorrection at 6 tion and demonstration, more than 90% of non-
m. Demnstrate this to the patient, if necessary, presbyopic patients are able to appreciate the
for reliable reporting for "blur." Again, blurring blurpoint at 6 m with BO prism demand. A blur-
should not normally occur with Bl prism testing at point of 7 A s "weak"; it should be at least 8 A
6 m. (Table 2-20). The breakpoint should be at least
3. Instruct the patient, "Try to keep the tar 1 6A, and recovery should be at least 9 A; other-
get single but tell me when the target doubles." wise, the cutoff criteria for passing are not met for
The first sustained diplopia is recorded. If the breakpoint and recovery.
patient reports a momentary diplopia that does
not exceed 5 seconds, that s disregarded. The Fusiona/ Vergences at Near
amount of prism causing a "sustained" diplopia The nearpoint testing procedure for fusional diver-
s recorded for "breakpoint." gence is similar to that at farpoint, except a blur-
4. After the endpoint of sustained diplopia is point is expected. It is known simply as NRC, the
reached, reduce the prismatic demand (at the rate 40-cm testing distance being implied. Ranking
of 4A per second) until sustained singleness (but standards are shown n Table 2-21. All nearpoint
testing of fusional divergence is conducted at 40
54 Chapter 2

TABLE 2-20. Ranking of Resulte of Positive Relative Convergence Testing at 6 m (Base-Out)

Recovery to
Rank Description Bturpoint (A) Breakpoint (&) Singleness (4)
5 -~ Very strong >14 >24 >15
- A .' Strong 11-14 21-24 12-15
. 3: - - . Adequate 8-10 16-20 9-11
Weak 7 15 8
\ Veryweak <7 <15 <8

cm. The Bl demand is presented to the patient in zontal vergence facility of fusiona! divergence
the same manner as was discussed previously for and convergence.) Grisham40'47 studied the ver-
other fusiona! vergence testing. The blurpoint gence tracking rate, using 2 A jump-vergence
should be at least 12A for passing, the breakpoint steps in eight subjects, four of whom had "nor-
should be at least 20A, and recovery should be at mal vergence characteristics" and four of whom
least 11A. had "abnormal" heterophoric or vergence char-
Fusional convergence at 40 cm is conducted as acteristics, based on clinical data. Grisham
discussed earlier. BO prism demand is increased found that the group with normal vergence char-
gradually until the endpoints of blur, break, and acteristics had an average minimum stimulus
recovery are reached. The blurpoint is PRC. Pass- duration of 0.84 seconds per step, whereas the
fail criteria are shown in Table 2-22, along with group with abnormal characteristics had a signif-
rankings from very strong to very weak. A blur- icantly longer duration of 1.67 seconds per step.
point of less than 15A is failing, as is a breakpoint Grisham47 cited the observation of Rashbass and
of less than 19A and a recovery of less than 8A. Westheimer "that normal disparity vergence eye
These findings are entered in the patient's record. If movements take on the order of 1 sec to com-
a blur is not reported, place an X to denote this plete independent of step stimulus amplitude"
(e.g., X/18/7). and claimed that his study "compares well with
the observation of Rashbass and Westheimer."
Grisham also found that the two groups of sub-
Vergence Facility
jects could be differentiated according to other
Vergence facility depends on both amplitude dynamic properties of fusiona! vergence response,
and speed of vergence movements. The quantity including percentage of completion of step
and quality of disparity vergences should be responses, response velocity, and divergence
evaluated. (Discussion will be limited to hori- latency (but not convergence latency).

TABLE 2-21. Ranking of Resulte of Negative Relative Reflex Fusin

Convergence Testing at 40 cm (Base-ln) Clinically, we recommend evaluating vergence
facility by direct observation. A small-power prism,
the vergence stimulus, is inserted in front of one
Rank Blurpoint Breakpoint Recovery to eye as the patient fixates a detailed target. The
Description {*) Singleness latency, velocity, accuracy, and stamina of vergence
responses can be directly observed and assessed.
5 Very strong >18 >26 >18 Without eye movement-recording equ-ipment,
4 Strong 14-18 22-26 14-18 these dynamic components cannot be quantified
3 Adequate 12-13 20-21 11-13
but, with practice, the clinician can make accurate
2 Weak 11 19 10 and valid judgments regarding the quality of reflex
1 Very weak <1 1 <19 <10 vergence function by closely noting the eye move-
ments stimulated by the prism. A virtue of this tech-
Chapter 2 55

TABLE2-22. Ranking of Resulte of Positiva Relativa Convergence Testing at 40 cm (Base-Out)

Rnk Description Blurpotnt (A) Breakpoint {A) Recovery to Singleness (A)

5 Very strong , >23 >28 >18

4 Strong 18-23 22-28 13-18
3 Adequate 15-17 19-21 8-11
2 Weak 14 18 7
<?
1 Very weak <14 <18

ique s that it s objective, relying only on tester subjective responses of sensory fusin (singleness
observations. It can be used to confirm subjective versus diplopia) by the patient may be helpful.
vergence testing or for patients who have unreliable Using 10 cycles of 6A BO, the norm s 22 seconds
subjective responses (e.g., young children, some 3 standard deviations and, for 6A Bl, it is 21 sec-
aged patients, and some handicapped patients). onds +4 standard deviations. Using the standard
The procedure is simple, but accurate observa- deviation as the basis for clinical evaluation, a
tion and interpretaron require practice. A 6A prism patient's vergence responses are considered slow f
is nserted before the sighting dominant eye as the the completion time s 25 seconds or longer.
patient fixates a target at 40 cm. In exophoric In many cases of vergence infacility, the com-
cases, convergence s evaluated first with a BO pletion time s considerably longer than 25 sec-
prism and then with a Bl prism. Conversely, with onds. Prolonged latency, slow velocity, and
esophoric patients, a Bl prism is used initially, fol- inaccuracy can all contribute to increasing the
lowed by a BO prism. Because the patient s view- total time. Some patients experiencing vergence
ing binocularly, the prism is a vergence stimulus. fatigue may not even complete the 10 cycles and
Usually, there is a mixed versin and vergence manifest diplopia or suppression during the test.
response to a small-mcrement prism. A normal Diplopia is noted subjectively by the patient's
vergence response would represent little or no report. Objectively, the clinician observes the
movement of the eye without the prism; most of patient's failure to make a correct vergence
the vergence movement would be by the eye with response. A suppression response is noted f there
the prism. The larger the response of the non- is no movement of either eye to the vergence
prismed eye, the longer is the latency of the ver- stimulus. In this case, the patient has suppressed
gence system. Velocity of the vergence component the eye behind the prism. In summary, a pro-
s directly observed and rated as slow, modrate, longed completion time, soiated versin, altr-
or fast on the basis of clinical experience with this nate versions, or no movement to the prism are
test. If there is one smooth vergence movement to all responses considered to be abnormal and
the prism, the response is considered accurate, indicative of a fusional vergence dysfunction.
whereas f a series of vergences are observed, inac- Kenyon et al.48 studied "dynamic" vergence
curacy is evident. Stamina can be noted by rapid, responses to stimuli at two different distances, 25
repeated observations of the speed and accuracy and 50 cm. They actually were testing fusional facil-
of vergence responses n a particular direction. ity of vergence, because disparity vergence was
An attempt to quantify the reflex fusin test has being tested as in "jump" vergences, in contrast to
been made by establishing norms for teenagers and "sliding" vergences, as tested with Risley prisms. An
adults. Ten cycles of prism rock are timed in a par- absence of disparity vergence was found in all stra-
ticular direction, BO or Bl. The clinician insers and bismic individuis and in some who had amblyopia
removes the prism when each vergence response s with no strabismus. Accommodative convergence,
completed. Direct observation of responses is the rather than fusional (disparity) vergence, was used
basis for reintroducing the prism but, in cases in to attempt to bifoveate the target.
which the responses are particularly slow and visu- From the literature and clinical experience, we
alizing the point of complete bifixation is difficult, believe clinical testing of vergence facility can be
56 Chapter 2
I
TABLE 2-23. Partial Listof Studies on Vergence Fadlity

Study Fusfonal (Dlsparity) Vergence Fadlity (c/min) Comments

Kenyon et al.48 None in strabismks Also none in some amblyopc sub-

jects without strabsmus
Pierce49 8a Bl and 84 BO, 10 c/mln (median); screening Median for chtldren; 7.5 c/min rec-
criteron of 7.5 c/rnin ommended as cutoff for "nor-
mal" versus "learning-
disabled" childrert
8A B! and 8a BO, approx, 7 c/min S4 Bl Mean for sixth gradees
Styckle and Rouse50 and 8a BO, approx. 5 c/min 8* Bl and Mean for third gradees
Mitehell et al.51 8A BO, 6.53 c/min 8a Bl and 8&BO, Mean for sixth graders
5.05 c/min Mean for third graders {cutoff cr-
teron of 3 c/min recorr-
mended)
Moser and Atkinson52 8a Bl and 8A BO, 8.14 c/min Screening: 6 Young adults
Rosner53 Bl and 12ABO, 3 c/0.5 min 12A il and 14* At farpoint
BO 3 c/Q.5 min Goals At nearpoint
6* Bl and 1ZA BO, 18 c/1.5 min 12A B! and 14A
BO, 18 e/1.5 min 5A Bl and 15A BO in relation to At farpoSnt
the phoric posi-ton of each subject, 8,6 c/rmn At nearpoint
Jacobsow et al.54 Young adulto wth no visin prob-
54 Bl and 15A BO or 8A Bl and 8a BO lems; jump vergences wth two
seto of vectographtc targets
Delgadllo and Griffin55 Approximately same results (adult
subjects)
SI = base-in; BO = base-out

useful in evaluating the quality of a patient's bin- Jacobson et al.54 studied vergence facility in 41
ocular status and, possibly, the patient's develop- young adults with no referable visin problems or
mental-perceptual status. Pierce49 reported a significant binocular problems. Two sets of Quoits
difference in vergence facility between normal vectographic targets were used, the upper pair having
and learning-disabled children. Other studies50'51 a Bl demand and the lower pair a BO demand. Test-
reported developmental differences between ing was done at 40 cm. A 5A Bl demand was pre-
schoolchildren in the third and sixth grades, the sented relative to the patient's nearpoint heterophoric
results being approximately 5 and 7 cycles per eye positioning. (A nearpoint phoria s also known as
minute, respectively, using 8A Bl and 8A BO flip- fusional supplementary convergence valu.) For
pers (Table 2-23). Moser and Atkinson52 found an example, f the patient had an esophoria of 4A at
average of 8.14 cycles per minute in young adults nearpoint, only 1A Bl was set n the upper Quoits
using 8A Bl and 8A BO flippers in vergence facility sudes. Similarly, a 15A BO demand relative to the
testing. Rosner53 proposed the following criteria near phoria was set in the lower Quoits slides, so
for screening (for referral): 6 A Bl and 12A BO that, in this example, the setting would be at 19A BO.
demands at farpoint and 12 A Bl and 14 A BO The investigators found it necessary to make these
demands at nearpoint. For ultmate goal, Rosner53 adjustments for the heterophoria because many sub-
suggested at least 18 cycles in 90 seconds at far- jects could not perform a range of 20A using absolute
point and nearpoint using free-space orthopic and 5A Bl and 15A BO demands. The principal problem
chiastopic fusin without instrumentation or fil- for many subjects was with Bl demands, particularly
ters. (These types of fusin are discussed in Chap- if the subjects were esophoric at near. A mean of 8.6
ters 13 and 14.) cycles per minute was found, which would indcate a
Chapter 2 57

TABLE 2-24. Vergence Fadlity Tested with 8A Bl TABLE 2-25. Vergence Stamina with 8A Bl and 8A BO at
and 8A BO at 40 cm and with 4A Bl 40 cm and with 4A Bl and 8A BOat6m at the Rate of
and8 A BOat6m
6 Seconds per Cycle

Rank Description Cycles per Minute

Rank Oescription Cycles per Minute
5
Very strong Strong Adequate 11-15 5 Very strong >90
Weak Very weak 5-10
4 4 Strong 66-90
fll - base-in; BO = base-out. 3-4
3 Adequate 30-65
3 Note: Suppression should be <3
monitored with anagJyphic or vec- 2 Weak 18-2&
tographic targets with targets equivalent to 20/30 being clear and 1 Very weak <19
single 2with each prisrn flip. The Vectographic SBde is recom-
rnended for 6 m, and Vectograms, as used for accommodative Bl = base-n; BO = base-out.
faclity, are recommended for testing at 40 cm. Note; Suppression should be m onftored as n vergence faelity
1
testing.

Vergence Stamina
Analogous to accommodative stamina, vergence
rather low recommended number for screening and stamina s tested when vergence facility s assessed
referral purposes. If absolute Bl and BO powers of 5A over a period of time at a constant rate of stimulus
and 15A, respectively, are used, we believe a screen- change. (Slowing of responses should be noted.)
ing criterion of 5 cycles per minute is useful as a cut- Vergence stamina s tested at 40 cm with 8A Bl and
off valu, particularly for children. A training goal, 8A BO demands at the rate of 6 seconds per cycle
however, would be much higher. (3 seconds per clear fusin response). The patient
Delgadillo and Griffin 55 found that 5 A Bl and is instructed to see the target as clear and single.
15 BO gave approximately the same results as 8A
A Testing at 6 m is performed with 4A Bl and 8A BO
Bl and 8A BO; therefore, either test can be used at flip prisms every 3 seconds, so hat testing is at the
nearpoint, at least n adults with normal binocular rate of 6 seconds per cycle. The cutoff point s 30
visin. seconds (Table 2-25). The patient should be able to
Considering the aforementioned reports and on maintain clear and single fusin with each flip for
the basis of our clinical experience, we recom- at least 30 seconds.
mend evaluating vergence facility as shown n
Table 2-24. For children of ages 7-11 years, a Summary of Vergence Testing
lenient cutoff criterion for failing s 4 or fewer As with accommodation, vergences are classified
cycles per minute; 5 cycles per minute or more as either absolute or relative and testing helps to
would be passing and would obvate the need for determine sufficiency, facility, and stamina. Accu-
referral for visin therapy. These criteria apply at racy of vergence is assessed with fixation disparity
40 cm with 8 A Bl and 8A BO prism demands as testing (discussed n Chapter 3), which s analo-
well as at 6 m with 4 A Bl and 8 A BO prism gous to accommodative accuracy as assessed with
demands. Although these criteria appear to be dynamic retinoscopy.
lenient, some of the earlier reports recommending
greater vales for cycles per minute did not
include suppression monitoring. We have found
SENSORY FUSIN
that patients general ly are much slower when vec-
tographic targets and viewing filters are used, From a clinical perspective, the systems of saccades,
reduced perhaps by as many as 3-5 cycles per pursuits, fixation, accommodation, and vergences
minute, whether n children or adults. We believe, are principally motoric. However, there must be
therefore, that the criteria in Table 2-24 can apply sensory (and usual ly perceptual and often cognitive)
to both children and adults for evaluation of ver- input so that visual functioning can occur. Clinical
gence facility. testing of sensory fusin also nvolves a motoric
Chapter 2

iponent. Nevertheless, for instructional pur-s, it in front of the deviating eye to elicit a diplopic
is convenient to deal with motor fusin and sensory response. If a sufficiently large base-down prism is
fusin as though they were seprate, keep-ing in placed before the right eye, the dioptric image of
mind that this distinction is artificial and that they the light is located below the suppression zone
are really indissoluble. (inferior retina) and will be perceived (in the visual
On a clinical basis, motor fusin can be consid- field) above the fixated one. When suppression is
ered basically to involve the amplitude and speed very deep, this technique is useful in determining
of various ranges of vergences. In contrast, the the horizontal subjective angle of deviation.
basic clinical concern in sensory fusin is suppres- Simultaneous perception testing may also be car-
sion. Sensory fusin is classified according to the ried out by using two objects rather than one. These
Worth taxonomy into three categories: first-, sec- targets usually are stereograms designed for use in a
ond-, and third-degree fusin. (Refer to Chapter 1 stereoscope. A familiar example is the Keystone
for theoretic discussions of these degrees of sen- Test 1 (referred to by the manufacturer as DB-10A),
sory fusin.) in which a picture of a pig is seen only by the left
In clinical diagnosis, sensory fusin of form can eye and a dog by the right eye. If the suppression
be classified into four levis, a modification of the zone is great and encompasses one picture, one of
categories of fusin recommended by Worth (as the animis will appear to be missing.
cited by Revell56):

Simultaneous perception (diplopia) Superimposition

Superimposition (first-degree fusin) The Superimposition of two dissimilar targets is
Fat fusin (second-degree fusin) known as first-degree fusin. However, when this
Stereopsis (third-degree fusin) occurs, confusin rather than true sensory fusin
exists, because similar targets are not being inte-
These categories of binocular sensory status can be grated; they merely have common oculocentric
conveniently tested by using vectographic tech- directions. Because two dissimilar objects stimu-
niques, colored filters, and the numerous stereo- late corresponding retinal points and are perceived
scopic methods employing septum arrangements. as superimposed, the definition of Superimposition
Many methods and instruments are presented in is satisfied.
this book, particularly in case examples. With the exception of the Maddox rod test,
Superimposition testing usually requires more
Simultaneous Perception instrumentation than a penlight in free space. Ste-
reoscopes containing a different target for each eye
Although Simultaneous perception is classified as
(e.g., a fish seen only by the left eye and a tank
one of the levis of sensory fusin, there is actually
seen by the right eye) are usually necessary (see
no real fusin with this particular binocular
Figure 5-6).
demand. Simultaneous perception is determined
to be present merely by the patient's awareness of
binocular images at the same time. In clinical Fat Fusin
usage, Simultaneous perception refers to the stimu- Fat fusin is true sensory fusin and is the integra-
lation of noncorresponding retinal points that give tion of two similar ocular images into a single per-
rise to diplopia. An example is shown in Figure 1- cept. There may be one target in free space, such
10, in which the fixated light is seen diplopically as a page of print, or there may be two identical
because the dioptric image is on a noncorrespond- targets in a stereoscope. In any event, to be classi-
ing point of the deviated right eye. fied as a flat-fusion stimulus, this type of target
The usual test applied in determining whether a must be two-dimensional and identical in form for
patient can appreciate Simultaneous perception is each eye.
to elicit a diplopic response when one object (e.g., Such targets are the most frequently employed
a penlight) is fixated. When deep suppression inter- in testing and evaluating motor fusin (fusiona!
feres with diplopia testing, stimulating a noncorre- divergence and convergence). Usually Snellen let-
sponding point somewhere outside the suppression ters or printed words are used as targets, to be
zone may be desirable. This is conveniently accom- fused with the incorporation of unfused suppres-
plished by placing a vertically oriented lose prism sion clues in the test design. (An example of a fat-
Chapter 2 59

fusin target with a test design for extrafoveal sup-

pression s shown in Figure 5-7.) If the angular sep- TABLE 2-26. Frequently Used Vectographic
aration from the center of the target to a Tests of Stereoacuty
suppression clue is greater than 5 degrees, testing
for peripheral suppression is being accomplished. Contoured (local Stereopsis) Stereo tests
Testing for foveal suppression requires that a sup- (Fly) (nearpoint testing) Stereo reindeer
pression clue be located in or near the center of test (nearpoint testing) Vectographic
the target. Therefore, the location of the clues that Slide (farpoint testing)
are suppressed determines the size of the suppres-
Noncontoured (global Stereopsis) Randot
sion. These specifications regarding targets for
stereotest (nearpoint testing) Random dot E
determination of suppression size are Usted in
stereotest (near to far testing)
Table 5-1.
In cases of heterophoria, however, foveal sup-
pression, rather than larger suppression zones
occurring in strabismus, is usually the concern.
Similarly, depth of suppression is necessarily eval- not fall exactly on corresponding retinal points.
uated n cases of strabismus but rarely s evaluated This is due to the allowance in disparity afforded
in heterophoria. (Testing for depth of suppression s by Panum's rea. It s this small fused disparity that
discussed in Chapter 5.) is responsible for Stereopsis.
As in flat-fusion testing, there are suppression
clues in Stereopsis testing, which are those portions
Stereopsis of the stereogram that are supposed to be seen in
Stereopsis is the perception of three-dimensional depth, relative to a fixated point. In the preceding
visual space due to binocular disparity clues. Test example, the clues are the fused lines. The lack of
targets for Stereopsis are similar to those for fat depth may be an indication of suppression.
fusin with one exception; n the former, there s
lateral displacement n certain portions of the tar- Vectographic Methods
get. The displacement of a set of paired points Applying the principie of poiarization to the testing
(referred to as homologous points) s relative to the of visin allows the use of suppression clues during
position of other pairs of homologous points on the fairly natural conditions of binocular viewing. For
stereogram. For example, n Figure 1-14, consider vectographic testing, the patient wears polarizing
the star as the figure that s fixated and fused. The filters in the form of spectacles. The polarizing filter
small vertical lines are displaced inwardly (BO, or for one eye must be rotated to an angle 90 degrees
crossed disparity effect) relative to the fused star. different from the filter for the other eye, thereby
Assume that the patient is concentrating on the achieving mutual exclusin of light coming to each
fused star. The vertical lines are maged on each eye. Thus, when the test targets are also polarized,
retina temporally in relation to the star, which one eye cannot see certain portions of the test target
causes the fused image of the lines to appear that are visible to the other eye. In the United States,
closer than the star. The opposite would be true if the filters n commercially available polarizing
the lines were disparately nasalward on each ret- spectacles usually are oriented at 45 and 135
ina. The rule to remember is that f the retinal dis- degrees; those manufactured in some other coun-
parity is temporalward ("templeward") from the tries are often set at 90 and 180 degrees.
center of each fovea, the stereoscopic image will Severa! frequently used vectographic tests for ste-
appear closer, whereas if the retinal disparity is reoacuity are usted in Table 2-26. Examples of vec-
nasalward, the image will appear farther. tographic tests are depicted in Figures 2-20 through
If the disparities become too far separated, the 2-24. Other nonvectographic tests (e.g., Frisby,
lines can no longer be fused (by remaining within Lang) are illustrated in Figures 2-25 and 2-26.
Panum's reas) and are seen diplopically. Because
they fall on points too disparate, they cause diplo- Linear Displacement Methods
pia in the same manner as n simultaneous percep- Stereoacuity may also be evaluated by comparing
tion testing. However, if the disparities are not very the relative distance of two objects in free space,
great, the targets are fusible even though they do such as n the traditional Howard-Dolman pe
60 Chapter 2

FIGURE 2-22Random dot E stereopsis test noncontoured targets.

(Courtesy Stereo Optical Co.)

FIGURE 2-20The "Fly" stereopsis test contoured targets. (Courtesy

Stereo Optical Co.)
tance of 6 m from the rods and s nstructed not to
move his or her head. Otherwise, lateral parallax
test, which s designed for farpoint measure- will be nduced, thereby nvalidating testing pro-
ments. The test consists of two black, movable cedures. The rods are moved by the patient, either
vertical rods viewed through an aperture against nearer or farther from each other, by means of
a white background. The patient is seated at a dis- strings, until they appear to be equidistant (i.e., n
the same plae). The distance error is determined
from an average of several triis and s converted
from millimeters nto seconds of are; this valu
represents stereoacuity (Table 2-27). For example,
Chapter 2 61
FIGURE 2-26Lang test. Images for the eyes are separated by the fine
FIGURE 2-25Frisby test. Random patterns are printed on each side parallel cylindrical strips to crate perception of stereopsis by way of
of a transparent pate. The patient s instructed to lcate in which of lateral displacement of images seen by each eye. Note that this is Lang
the four squares is the stereoscopically perceived circular target. test 1; another versin, Lang test 2, is also available.

if the error (the distance the patient misaiigns the

two pegs) is 60 mm, the stereoacuity is 20 sec-
onds of are. Because there may be a constant Stereoacutty
(seconds of are)
error due to a skewed or tilted horopter, however,
Alignment Error (mrn)
testing results may be invalid. The standard devia-
tion of the mean would represent a truer ndex of 5 2
stereoacuity, but acquiring this nformation would 10 3
require completion of approximately 15 triis; 20 7
henee, it seldom is done on a routine clinical 30 10
basis. An apparatus of the Howard-Dolman type 40 13
may be custom-made or obtained through com- 50 16
mercial sources. 60 20
For similar nearpoint testing, the Verhoeff Stere- 80 100 200 300 400 500 26
optor (formerly made by the American Optical 33
NatetAn taterpuptHary distance of 60 mm is
Corporation but no longer manufactured; see Appen- assumed, Stereoacuities were determined by 66
dix ]) has been widely used by many government the foHowing formula: T\ = IPD (x)/ef2 x 99
206,000, where i\ (eta) is the symbol for 132
agencies (e.g., military). It has an illuminated white stereoacuity in seconds of are; P0 is the
window in which three vertically placed black strips interpupillary distance n rnillime-ters; x is 165
are centered. One of the strips is displaced from the the alignment error in millimeters; and d is
the testing distance from patient to rods in rnillirneters.
plae of the other two, either forward or backward,
and the patient is asked to tell for which strip the
distance differs from the other two. The instrument
can be adjusted to form eight different strip arrange-
ments (i.e., eight different targets). A patient with a
stereoacuity of 31 seconds of are or better should be
able to report all eight targets correctly at a testing

TABLE 2-27. Howard-Dolman Test for Stereopsis,

Performed at 6 m
Chapter 2 63

TABL E 2-28. Verhoeff Stereopter Testing Distance TABLE2-29. Approxmate Corresponding Vales
and Corresponding Stereoacutes for Stereoacuity n Seconds ofArc and Shepard
Percentages

Stereoacuity
Test Distance (cm) (seconds of are) Stereoacuity in Seconds of Stereoacuity in Shep-
Are ard Percentages
10 3,090
20 772 1,000 400 200 100 4
30 343 50 16
50 124 40 31
60 86 20 51
80 100 110 130 48 15 72
150 200 300 31 10 78
26 95followlng
Note: Shepard percentages are calculated using the
Note: Response to all eight trgets must
be correct. The stereo-threshold vales 18 formula of Fry57: 100
in this tafole are calculated for an
14 Percentage stereopsis = '^r106 -5
interpupillary distance of 60 mm, The f\
valu (stereoacuty) is calculated using 8 ti+ 81
an x valu of 2,5 mm, which s the 3 where f[ is trie symbol for Stereoacuity.
displacement of one strip from the
plae of the other two strips. Verhoeff stereoacuites are
calculated according to the same formula used for the Howard-
Dolman test (see footnotes to Table 2-27).
parity cells. Hie58 cited a study by Richards59 that
reported that 30% of subjects showed inabilities to
detect disparity, comparing crossed and uncrossed
disparity processing. It was implied that such
distance of 1 m. The better the Stereoacuity, the far-
stereoanomalies are genetic in origin. If lack of
ther away the test apparatus can be held for the
both types of disparity detectors (.e., crossed and
eight correct responses (Tabie 2-28).
uncrossed) are nherited, an individual may lack
normal binocular visin and be at risk for strabis-
Percentage of Stereopsis
mus. Hie58 stated, "It s important in developing
Occasionally, practitioners are asked to report per- and mproving motor fusin ranges." This s partic-
centage vales of stereopsis rather than vales ularly so n small-angle strabismics, who can
recorded in seconds of are. Percentage scales were develop good fusional amplitudes but yet may
empirically determined by Dr. Cari F. Shepard for have a poor prognosis for developing bifixation
such purposes, and calculations and Information (with central, fine stereopsis).
pertaining to this method were presented by Fry.57 In light of this discussion, one may wonder why
Table 2-29 gives percentage vales corresponding random-dot stereo tests, even gross ones, apparently
to Stereoacuity n seconds of are. seem to be effective n detecting sensory binocular
anomalies of suppression, anomalous correspon-
Screening for Binocular dence, and amblyopia. Conversely, the stereo tests
Problems wth Stereopsis with contoured patterns must be within relatively
The level of stereopsis determines the level of bin- sensitive criteria to be effective n this regard. The
ocular status in most cases: Stereopsis s the difference in criteria between the two types of ste-
"barometer" of binocularity, If stereopsis is good, reopsis tests may have something to do with
the binocular status is good, but the opposite can- "local" versus "global" stereopsis. Hofstetter et
not always be said with certainty. That s, a patient al.21 defined local stereopsis as a "very simple dis-
may be found to have no stereopsis but have nor- parity stimulus pattern such as, for example, a ste-
mal sensory and motor fusin n all other respects. reogram with two parallel vertical une segments
Some individuis may lack cortical binocular dis- seen by each eye with slightly differing lateral sep-
64 Chapter 2

STEREOACUITY AND LEVEL OF INDUCED

ANISOMETROPIA
CONTOURED TARGETS SEMICONTOURED TARGETS NONCONTOURED TARGETS

NUMBER OF SUBJECTS 16 NUMBER OF SUBJECTS 16 NUMBER OF SUBJECTS

I
c
o
o
Q
Ltl
(O
(f) O +1.00 +2.00 +3.00 O +1.00 +2.00 +3.00
o LEVEL OF INDUCED ANISOMETROPIA LEVEL OF INDUCED ANISOMETROPIA O +1.00 +2.00 +3.00
al LEVEL OF INDUCED ANISOMETROPIA
o
NUMBER OF SUBJECTS 16 NUMBER OF SUBJECTS 16 NUMBER OF SUBJECTS 16

i
e
n
o
o
LU
co
05
O +1.00 +2.00 +3.00 O +1.00 +ZOO +3.00 O +1.00 +ZOO +3.00

LEVEL OF INDUCED ANISOMETROPIA LEVEL OF INDUCED ANISOMETROPIA LEVEL OF INDUCED ANISOMETROPIA

70" OR BETTER 140" OR SETTER 400" OR BETTE

arations." This same group defined global stereopsis as that global requiring more "visual perception" than does local.
"elicited by the disparity of portions and/ or clusters within It may be that people with poor binocularity have a lack of
relatively large stereogram pat-terns, nvolving complex development n this regard, which might explain why
textured surfaces and repetitive elements for which many they do relatively poorly on random-dot types of stereo
61
disparately paired details might provide ambiguous or tests. A study by Griffin et al. corroborates this con-cept
even conflicting stereopsis clues without destroying the by showing that induced optical anisometro-pia degrades
overlying percept of depth, believed by Julesz to represent global stereopsis more rapidly than local stereopsis (Figure
a perceptual interpretation process dif-ferentiable from local 2-27).
stereopsis."
60
Hamsher confirmed the hypothesis that "the right Norms for Stereoacuity
hemisphere is dominant for global stereopsis but not Rankings of stereoacuity scores are clinically practi-cal for
local stereopsis. The additional mech-anism(s) needed to possible referrals and for assessment of stereopsis before
achieve global stereopsis, while working with and after visin therapy. These rankings are usted in
stereoscopic mechanisms, may not be of a strictly Table 2-30 for contoured (local) and noncontoured
stereoscopic but of a more general visuoperceptive (global) stereopsis. Note that leniency is given for global
nature, perhaps those involved in utilizing subtle cues to stereopsis. These rankings apply to patients at least 7 years
achieve form recognition." od. Pro-
There may indeed be two different types of stereopsis,
Chapter 2 65

TABLE 2-30. Ranking of Resulte ofStereopss Testng (Seconds o Are)

Rank Deserlption Contouret Noncontoured

5 Very strong >20 >30

4 Strong 20-30 31-50
3 Adequate 3t-60 51-100
2 Weak 61-100 OI-iOO,
1 Very weak <100 <00

fessional judgment s required when evaluating test For example, suppose a patient is found to have
results of children younger than age 7. Because it s asthenopic symptoms when reading, exophoria of
an overall indicator of the patency of binocular 14A, insufficient PRC, and vergence infacility. The
visin, stereoacuity has been used as part of a visin doctor can be reasonably confident that there is
screening test battery. A preschool test that has good fusional vergence dysfunction. It is mportant to
inter-rater test-retest reliability is the Randot Pre- have guidelines, however, as to what is normal and
school Stereoacuity Test.62 This test can be used for what is abnormal for each function. It would be
children as young as 2 years and samples stereoacu- ludicrous for internists who are checking choles-
ity from 800 to 40 seconds of are (see Figure 2-24). terol levis not to know what is considered nor-
mal. Similarly, we have assigned norms to these
visual skills as tentative guidelines for eye care
Summary of practitioners. We believe they are reliable and
Sensory Fusin Testing practical for clinical use. Rankings define n com-
In cases of heterophoria, flat-fusion testing s per- mon terms what is strong or weak, so that each
formed for purposes of measuring binocular visual skill function can be assessed and docu-
accommodative facility, relative vergence ranges, mented before and after visin therapy.
and testing for fixation disparity. Stereopsis gener- Referral to other professionals is indicated if the
al ly s an ndex to binocular status, although some patient's symptoms are not fully abated, despite suc-
patients are stereoblind even though other visual cessful completion of the visin therapy program.
skills may be normal. Ranking of stereoacuity may (Therapy for VSE is covered n Chapter 16.) For
be done in a manner similar to ranking of other example, f the patient has an attention dficit or
visual skills. hyperactivity disorder, medical referral may be ndi-
cated. If a child has Streff syndrome63-64 and contin-
es to experience psychological problems even
RECOMMENDATIONS ON THE after visin dysfunctions are abated, appropriate
BASIS OF TEST RESULTS referral to a mental health professional is indicated.
Similarly, if a patient is found to be dyslexic,65~68
Referral for visin therapy is appropriate if there referral for educational therapy s necessary.
are symptoms of discomfort and performance
problems related to poor visual skills, including
saccades, pursuits, fixation, vergences, and sen-
sory fusin. Referrals should take into account REFERENCES
these considerations and should not be made 1. Revell MJ. Strabismus: A History ofOrthoptic Techniques.
merely because a finding (or even several) s below London: Barrie and Jenkins; 1971:21-22.
average. Professional judgment is necessary when- 2. Policy statement. Pediatras. 1998; 102:1217-1219.
3. Vision, learning and dyslexia. J Am Optom Assoc. 1997;
ever referral decisions are being made. Isolated
68:284-286.
abnormal findings may be spurious. A general pat- 4. Griffin JR, Christenson GN, Wesson MD, Erickson GN.
tern of binocular dysfunction provides the stron- Optometric Management of Reading Dysfunction. Bos
gest basis for making a diagnostic statement. ton: Butterworth-Heinemann; 1997.
chapter 3 / Heterophoria Case Analysis

Tonic Convergente and Accommodative- Measurement 79

Convergence/Accommodation Ratio 70 Prescribing Prism 85 Validity of
Calculated Accommodative-Convergence/ Diagnostic Criteria 87 Recommendations
Accommodation Ratio 70 for Prism Prescription 90 Vergence
Gradient Accommodative-Convergence/ Anomalies 92
Accommodation Ratio 72 Zone of Convergence Insufficiency 93
Clear, Single Binocular Vision 72 Basic Exophoria 93
Morgan's Normative Analysis 76 Gritera Divergence Excess 94
for Lens and Prism Prescription 76 Divergence Insufficiency 94
Morgan's Expected Criterion 77 Basic Esophoria 95
Clinical Wisdom Criterion 77 Convergence Excess 95
Sheard's Criterion 77 Basic Orthophoria with Restricted Zone 96
Percival's Criterion 78 Normal Zone with Symptoms 96
Fixation Disparity Analysis 78 Bioengineering Model 97
Definition and Features 78

Most clinical systems used n the analysis of ver- By convention, the graph is plotted with
gence disorders are conceptually based on the accommodative stimulus, in diopters, on the ordi-
interaction of the four Maddox components of nate (y axis) and vergence stimulus, in prism
vergence: tonic, accommodative, fusional, and diopters on the abscissa (x axis). A diagonal line
proximal. Graphical analysis, with roots extend- (Donders' line) is drawn representing conver-
ing from Donders 1 and Maddox 2 in the nine- gence for all points in space along the midsaggital
teenth century, uses a cartesian coordnate plae, with no prism or lens addition. This s also
system to Ilstrate relations between accommo- called the detnand line (Figure 3-1). The exact
dation and vergence. To this day, clinicians may positioning of the demand line on the graph is
find t helpful to draw a graph of phorometry influenced by the interpupillary distance (IPD) of
measurements (i.e., heterophoria, relative ver- the patient but, for standard diagrammatic pur-
gence, and relative accommodation) to visualize poses, the graph is traditionally scaled for an IPD
better the interactions. A graph can readily of 60 mm. In cases of a large IPD (e.g., 70 mm),
reveal various clinical syndromes and alert the the convergence demand for binocular eye align-
clinician to inconsistencies n the data. The ment becomes greater with increasing accommo-
analysis implies relation between accommoda- dative stimuli for nearpoint targets. Conversely,
tive response and vergence eye position, n the convergence demand s less for a small IPD
which changes in accommodation affect ver- (e.g., 50 mm). For fixation distances beyond 20
gence and, conversely, changes in vergence cm, however, the error is small and can be
affect accommodation. ignored for clinical purposes.
70 Chapter 3

BASE IN Prora icol* ot 40 cm. ASE OUI 35 25

15 5 0 5 15 25 35 45 55 65 75 tS
i
tn. MO
j} q-i IEAK JO -
A-J ECOVEIW
to xn <OR1A 7.50

9 y s JO
3 ^
87 o X

4JO
65 o J / ^o

43 1 / s
3

21
/ 1
w
.6
v> / s -1.50

/ 1 OJO

/> 4-0.50

/ -.
i
4-1.50

/
20 10 0 10 20 30 40 50 60 70 0 90 100 BASE FIGURE 3-1Craphical llustration
IN Priun tcoU ot 6 m. SASE OUT Farm 1.1 .49
of the demand une (dashed Une).

TONIC CONVERGENCE AND while keeping the target perfectly clear. For small
ACCOMMODATIVE-CONVERGENCE/ children, precise focus can be ensured by asking
ACCOMMODATION RATIO them to identify a small letter or figure as the mea-
surement is taken. Proper dissociation of the eyes and
Tonic vergence position of the eyes s ndicated by relaxation of fusional vergence are necessary to mea-
the farpoint heterophoria measurement. The altr- sure the angle of deviation at near. When fusional
nate cover test at far (6 meters) with corrected vergence is completely inhibited, the near hetero-
ametropia most plus (CAMP) lenses s the standard phoria measurement represents a combination of
method of establishing this position. Unless other- tonic vergence and accommodative convergence
wise specified, this rule of testing with CAMP lenses being stimulated at the near testing distance. There
in place applies to all testing procedures involved in may also be psychic vergence effects that are stimu-
the investigaron of binocular anomalies. lated by testing at a near distance, but these are usu-
In some cases of excessive heterophoria or inter- ally small and essentially ignored during routine
mittent strabismus, prolonged occlusion of an eye s clinical evaluation.
necessary to reveal the full magnitude of the tonic The relation between accommodative conver-
deviation. This is because the effects of fusional vergence and accommodation is known as the AC
gence responses do not always immediately or, more commonly, AC/A ra/o. The ratio means
decrease on momentarily covering one eye. that for every diopter of accommodative response,
Measurement of the farpoint heterophoria posi- a certain amount of accommodative convergence
tion through a phoropter can introduce other (dependng on the valu of the AC/A ratio) is
sources of error through psychic and accommoda- brought into play. For instance, f the AC/A is 6A per
tive vergence effects. Nevertheless, phorometry 1.00 diopter (D) of accommodation, a patient who
measurements of heterophoria are usually valuable, accommodates 2.50 D will have an increased con-
because these data are compared with other clin cal vergence of the visual axes of 15A.
data obtained under similar testing conditions.
Nearpoint heterophoria s conventionally mea-
sured at 40 cm in the primary position. It s measured Calculated Accommodative-
with either the altrnate cover test (objectively) or by Convergence/Accommodation Ratio
phorometry (subjectively). During testing, control-
There are several ways to calclate the AC/A ratio
ling the influence of accommodation s extremely
from far and near deviations. The general formula s
mportant. The patient should be instructed to fixate a
detailed nearpoint target requiring precise focus AC/A = IPD (n centimeters) + ([Hn - Hf\/[An -Af\)
Chapter 3 71

TABLE 3- 7. Calculated Accommodative- Convergence/Accommodaton Ratio Depending on Far and Near Mag-
nitudes of the Angle ofDeviaton foran Interpupillary Distance of60 mm

Angle H at Far
Exo Eso
35 30 25 20 15 10 5 0 5 10 15 20 25 30 35
35 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6
30 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4
25 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2
20 28 26 24 22 20 18 16 13 12 10 8 6 4 2 0
1S 26 24 8 6 4 2 00
i 24 22
22
20
20
18
18
16
16
14
14
12
12
10
10 8
6 4 2
z 105 18 16 14 12 10 8 6
e 22 20 4 2 0
01 0 20 18 16 14 12 10 8 6 4 2 0
5
g 5 18 16 14 12 10 8 6 4 2 0
** 10 16 14 12 10 8 6 4 2 0
15 14 12 10 8 6 4 2 0
20 12 10 8 6 4 2 0
25 10 8 6 4 2 0
30 8 6 4 2 0
35 6 4 2 0
Eso = either esophoria or esotropa; ixo = either exophoria or exotropa; H - the objective horizontal angle of deviation of the visual axes.

where An = accommodative demand at near n from 4/1 to 7/1. An AC/A ratio greater than 7/1 is
diopters; Af = accommodative demand at far in high and less than 4/1 is low. If another patient
diopters; Hn = objective angle of deviation at near has 15A exophoria at near as well as at far, the AC/
(A); and Hf= objective angle of deviation at far (A). A ratio s 6/1. Note that the size of the IPD
Note that eso deviations have positive (+) vales, directly affects the magnitude of the calculated
whereas exo deviations have negative (-) vales. AC/A ratio; the larger the IPD, the larger s the AG/
This formula assumes that the CAMP lenses are A ratio.
n place and that the AC/A ratio is linear. Any two Table 3-1 gives the calculated answers for vari-
viewing distances can be used, but they are cus- ous angles of deviations at far and near. Looking at
tomarily 6 m and 40 cm. Flom 3 offered a clinically this table makes two useful rules readily apparent.
useful form of this general formula: First, the AC/A ratio s equal to the patient's IPD
when the deviations at far and near are the same.
AC/A = IPD + M (Hn - Hf)
For nstance, orthophoria (0) on both scales for
where M is the fixation distance at near in meters. In angle H ntersects at 6/1. The AC/A ratio is 6/1 on
this case, the distant fixation (Hf) must be at 6 m or the chart wherever the angles of deviation are
farther. For example, assume that a patient with a 60- equal. Also, a zero AC/A ratio s very improbable,
mm IPD has 15A of exophoria at far and is ortho- and a negative ratio is probably impossible. The
phoric at the near fixation distance of 40 cm. The AC/ table indicates those spurious combinations that
A would be 12A/1 D, which s calculated as follows: could produce either a zero or negative AC/A ratio.
If these questionable combinations occur, the mea-
AC/A = 6 + 0.4(0-= 6
sured magnitudes of deviation for far and near
+ 0.4(15) = 12 (i.
should be rechecked. For example, if the patient
e., 12A/1 D)
has an IPD of 60 mm and a measurement of 0A at
An AC/A ratio of this magnitude s considered far and 15A exo deviation at near, the combination
very high. Normal calculated AC/A ratios range indicates an AC/A ratio of zero, which suggests an
72 Chapter 3

error in clinical testing. However, this deviation of AC/A magnitude, particularly f low-powered lens
0A at far and 15A exo deviation at near s possible if additions are used. The calculation method usually
the IPD is larger. If, for nstance, the IPD s 70 mm, yields a higher valu, because proximal conver-
instead of 60 mm, the AC/A ratio would be 1/1, gence is a factor when fixation s shifted from far to
which is possible. near. Both methods are useful, however. In general,
the calculated AC/A ratio s more reliable than the
gradient method, but the gradient valu may be
Gradient Accommodative- more useful for prognosis, because it directly shows
Convergence/Accommodation the effect of added lenses on the angle of deviation.
Ratio Added lenses often are used in visin therapy to
The magnitude of the AC/A ratio may also be deter- change the magnitude of deviation, n cases of both
mined by measuring the effect of spherical lenses phoria and strabismus. For example, n cases of
on vergence. At far, minus lenses are used for this esotropa, t is often useful to measure the AC/A
purpose; at near, either plus or minus lenses will ratio in children by the gradient method using large
give the valu. Regardless of the testing distance, lens changes such as +3.00 D and -3.00 D to
the AC/A ratio should be determined with the observe the effect of added lenses on the angle of
patient wearing CAMP lenses. strabismus at near.
The following is an example of how the gradient In graphical analysis, the far and near hetero-
method may be used. Assume that a patient has phoria measurements taken through a phoropter
exophoria of 15A at far, as determined by objective are plotted; then a straight line s drawn to con-
means such as the cover test or, possibly, by sub- nect them. This line s called the phoria line. The
jective diplopia testing (e.g., Maddox rod). A AC/A ratio can be determined by direct inspec-
spherical lens of -2.00 D s placed before each tion by noting the change n the deviation per
eye. The patient is nstructed to focus and clear the unit change n accommodative stimulus. The pho-
fixation target while looking through the lenses. ria line is clinically useful because it predicts the
When the patient reports that the target is clear, magnitude of the heterophoria at various testing
another measurement of the angle of deviation is distances (Figure 3-2).
made. If the lenses cause the angle to changefor
example, from 15A exo deviation to 5A exo devia-
tion, the gradient AC/A ratio is 5/1. This s deter-
ZONE OF CLEAR, SINGLE
mined by dividing the change in the deviation by
BINOCULAR VISION
the change of accommodative stimulus (i.e., the
power of the added lenses). Thus, 10 divided by The zone of clear, single binocular visin (ZCSBV) is
2.00equals5 A/1 D. a graphical representaron of the functional relations
Clinically, the gradient AC/A ratio is most often between accommodation and vergence. The ZCSBV
determined at near by using a phoropter. The near- is enclosed by the extremes of accommodation and
point heterophoria s measured subjectively by vergence that can be elicited while maintaining
either the von Craefe method or Maddox rod. clear, binocular fusin. The vertical limits of the zone
Spheres of +1.00 D are added, and the heteropho- are traditionally defined by the absolute amplitude
ria is remeasured. The magnitude change of the of accommodation. (Monocular testing results are
angle bf deviation indicates the gradient. Greater used because of well-established norms.) This
precisin is gained by using +1.00-D, then -1.00- monocular amplitude is determined by the push-up
D added lenses to evalate the amount of devia- accommodation test. At each particular viewing dis-
tion change. If there is a large depth of focus, tance, the horizontal limits of the zone represent the
either +1.00 D or -1.00 D may be an insufficient base-in (Bl) and base-out (BO) blurpoints, usually
stimulus to elicit a sufficient accommodative measured with Risley prisms. Ideal ly, the diver-
response. In such cases, larger increments of lens gence limit s measured before the convergence
power might be required. limit (at each viewing distance), to reduce the
The gradient method will usually give a lower effect of prism adaptation. Relative vergence blur-
AC/A ratio than will the near-far calculation points are indicated by circles. They are plotted for
method. A gradient valu of more than 5/1 is con- at least two viewing distances, customarily at 6 m
sidered high. The depth of focus causes the reduced and 40 cm. At 40 cm, they are designated by circles
Chapter 3 73

BASE IN 35 25 15 Prm col* o 40 o. M SfOUt

50 15 25 35 45 55
i m
1 i
1211 Ow*
109
D BUEAIC n VF
A tEOOVEXY
TW
8 xPHOSIA
Sft
76
I
/ y
t
9
54
/ /
s
32
/ j
3 /
1 / !
/ 1 2J
3
1 /
/ -u
*
X / 2

/! A.
A/ --AM
_/* /
// :
^IflB

FIGURE 3-2Phoria Une (salid

Une). The X marks represen! direct
measurements of the phoria.
20
IN
10 "
y 0

/
10 20 30 40
Pri,KaUol6m.
50 M 70 BO
BASE OVT
M MO BASE
Fwm M*4*

for negative relative convergence (NRC), which is Bl blurpoint s reported by the patient, the breakpoint
to blur, and positive relative convergence (PRC), (diplopia) is charted; this s symbolized by a square.
which is BO to blur; at 6 m, they are the Bl to break The blurpoints of negative relative accommodation
(designated by a square, as blur should not normally (NRA) and positive relative accommodation (PRA)
occur) and the BO to blur findings (Figure 3-3). also are designated by circles and often are added
During prism vergence testing, t is customary to to the charting of the ZCSBV (not illustrated n Fig-
record the blurpoint (and the breakpoint and recov- ure 3-3 but shown in Figure 3-5).
ery point) in a particular vergence direction, conver- The zone of single binocular visin can also be
gence or divergence, at each viewing distance. If no plotted (Figure 3-4). This enclosure is formed by
BASE IN frota icol o 40 cm. BASE OUT 35 25
15 5 0 5 15 25 35 45 55 5 75 BS
9.50
O BA D
1
\
1110 MEAK A 8JO
KEOOVEKY X
9t FHOKIA 7JO
J s
76 i / S s-
7
/ s / ^
34

\ /
/ / s
c
SM

32
! / s
s 4JO

1
i
z /
:

/ / 11
8 3M
-"8
/ / /\
/
9
-2JO

I
/ /
/
-UO

y
%

/ ?
(i
/! / ^
/ OJO
v/

\^,
T 4.ACA
r- s* s*
/ / \s / 4.1 ca
/

FIGURE
20
IN
"10 "
y 0
W
10
^, 20 30 40
Pmm KaU o> 6 m.
50 0 70 BO
BASE OUT
0 100 BASE
Farm |.|*-4

3-3Zone of clear, single binocular

visin. Vision is blurred outside the
enclosure.
74 Chapter 3

BASE IN Frisa MaUot 40 era. BASE OUT 35 35 15

S O S 15 25 35 4S 55 45 75 5

12 11 MO
u*.
Q-l tEAJC
10 9 -JO
A-W :covEX
87 xn Y
fOUA
43
/ / i -&50
^ - ?
43 o
i
1 / s SJO

s
\ /
1
I
.

/ s s J
s^\ c
4.50

3JO
^
i / o
I 1 ^
/
........ _ 2 JO
t
o
1
vi
1 V / / ^
^ 1

/l"t~ A /
OJO

r^
f

- J B +OJO

*^/
-^^
21 i ^
s
20
~t J
0 *"" 0
//
/ J" 10 " 20 30 40 SO 0 70 W 0 100 ASE
+1.SO
FIGURE 3-4Zone of single binoc-
ular visin. Vision s diplopic outside
IN
I Prim cok ot < m. ASE OUT Form 1-19-49 the enclosure.

connecting the breakpoints, and t s larger than the 1. The ZCSBV approximates a parallelogram
ZCSBV. The rea difference between these two slanting toward the right, owing to the
zones represents the use of accommodative ver- influence of the AC/A. The AC/A line serves
gence to maintam a single mage (at the expense of as the axis of the zone. If there is a large
clarity). As BO prisms are ntroduced, alignment of deviation from a parallelogram, then spuri-
the eyes s maintained by fusional convergence. ous data points should be suspected, and
Similarly, the accommodative posture of the eyes s retesting s ndicated.
stimulated through the convergence-accommoda- 2. The slope of the zone is influenced by the
tion/convergence (CA/C) reflex. A normal accom- slope of the AC/A. The slope of the zone
modative lag can often become a small lead of often deviates slightly from the demand
accommodation without the patient reporting line. Large deviations, however, probably
accommodative blur, due to the effect of an eye's are associated with binocular anomalies
depth of focus. At some point of increasing prism (e.g., very steep slope ndicating excessive
demand, however, fusional convergence is exhausted; esophoria at near).
the only way a patient can then maintain binocular 3. The vertical limits of the zone represent the
alignment and fusin is to recruit accommodative amplitude of accommodation, which can
convergence. This results in excessive accommoda- be judged as either sufficient or insufficient
tion for the fixation distance. Target blur then s for the patient's work requirements.
reported when the depth of focus is exceeded. As 4. The horizontal limits of the zone represent
BO prism induction s continued, a point is reached the ranges of fusional divergence and con
at which even accommodative vergence is inade- vergence, which can be judged as either
quate. At this point (i.e., the breakpoint), binocular sufficient or insufficient for the patient's
fusin is lost and diplopia s reported (see Figure work requirements.
3-4). 5. The BO blur limit of the zone s steeper (i.e.,
A number of characteristics of the ZCSBV can be fans out) from the Bl to blur line and the pho-
useful in clinical interpretation. A plot of the zone ria line, primarily owing to the influence of
allows the clinician to predict how a patient will proximal (psychic) convergence for nearpoint
respond to various prisms, lenses, and viewing dis- targets but also possibly related to conver
tances. Some of the important attributes of charting gence (prism) adaptation with nearpoint
a ZCSBV are llustrated n Figure 3-3 and are Usted stress and during testing with BO prism
here: demands.
Chapter 3 75

BASE IN Prm eoU ot 40 ere. 35 25 15 BASE ota

5 15 25 35 45 5. I 65 75 U
i 140
n O BLUK D
u 1HEAK
10 A RECOVEty -7 JO
XmOKIA
?
r *
8
.S
/ Si
/ /" / ^
7
s
|

3 /
/
/*
1 : / /
/ C
Ti
-4JO
*
43
/ : / / / f
0

21
a
E / /
: S 9
7IW
-USO

FIGURE 3-5Zone of clear, single

S /
/
V S

3
AJO

binocular visin showing charting of / V Ai^ / ^ ^

the negative relative accommodation /
X
/ f _i_n<ft

,y>*
+130
(lower circle) and the positive relative / /
accommodation (upper circle).
, /A
i
20
IN
yr
"10 - 0 10 $ 20 30
Pmmttob tm.
40 50 O 70
tASE OUT
0 0
Foon I-19-49
100 BASE

6. Normally, there s no blurpoint for fusional divergence at far.

y sented
Thatbylimit
the amplitude
is between the phoria line
and the
ndicated by a breakpoint (diplopia). If a blurpoint s found, then the most likely Bl to blur line (divergence blur limit).
4
explanation is that the refractive error s not fully corrected with most Sheardplusemphasized
for the relation between the
hyperopia or is overcorrected with minus in a case of myopia. Suchphoria direction
blurring usuallyand the compensating fusional
indicates a spasm of accommodation. (disparity) vergence range. When discussing
Sheard's concept, the term reserve vergence
The horizontal limits are the same as were drawn previously n this example, but the
s used. For example, if there is an exophoria as
limits of relative accommodation are added (Figure 3-5). (Refer to Chapter 2 for
rep-resented n Figure 3-3, then positive
discussion of NRA and PRA.)
fusional reserve convergence s the distance
The clinically relevant features of the ZCSBV are the relations between its constituent
between the phoria and the opposing blurpoint.
parts (i.e., demand Une, phoria une, range of fusional vergence, and amplitude of relative
Similarly n an esophoric case, the negative
accommodation). Custom dictates specific ames for each of these features. PRC and
fusional reserve convergence s the distance
NRC are the ranges of fusional (disparity) vergence to the blurpoint that are measured
from the phoria line to the Bl to blur line. It is the
relative to the demand une (see Figure 3-3). These are the vales directly measured using the
relation between the phoria position and the
Risley prism vergence technique in both convergence and divergence direc-tions. Another
compensating vergence range that has clinical
way to describe the horizontal extent of the ZCSBV s to refer to the vergence ranges rela-
relevance according to Sheard.4 The
tive to the phoria line. Positive fusional convergence s the amount of convergence
significance and utility of these relations will be
measured between the phoria at any particular viewing distance to the BO blurpoint (or
discussed later.
breakpoint, if no blurpoint is found). Similarly, negative fusional convergence is repre-
Gross convergence (nearpoint of
convergence, or NPC) is not usually charted but
may be calcu-lated. A conversin formula
(centimeters to A) for clinical use is
Gross convergence (A) = IPD
100
Note that 2.7 is a correction factor for the
distance from the spectacle plae to the center
of rotation of the eyes.
For example: If the IPD = 60 mm and the
push-up NPC = 5 cm from the spectacle plae
(bridge of the nose), then A = 6 x (100/5 + 2.7) =
78A.
76

TABLE 3-2. Clinical Norms of Morgan TABLE 3-3. Morgan's Correlations among Selected
CHnical Findings

Acceptable Range
Test Mean 0.5 SO Furvctions
Phora, far 1Aexo 1 Ortho 2* exo
Age and amplitude of accommodation -0.80
iO blur, far Q&
2 ?Ho11A PRA and amplitude of accom modation
TO brk, far 1QA
4 154to23A PRC blur and break +0.80
BQ rec> far 10** 2 84tOl2A NRC blur and break
11 brk, far 7A 2 5H09* NRA and PRC +0.70
Bl rec, far 4* 1 3a to 5a PRA and NRC +0.50
A
Phoria, near 3 ' 3 Ortho to 6 exo NRA and PRA +0.50
BO btur, near 17* 3 W td ZO* +0,50
214 NRA = negative relative accommodation; NRC
iO brk, near 3 18a to 24A -0.50
= negative relative convergence, base-n to blur
IO rc, near 11a 4 7Ato15A atnear; PRA = positive reiative accommodation; PRC = positive
Bl blur, near 13a 2 1Pto15 A relative convergence, base-out to blur at near.
Sitarte, near 21A 2 19a to 23A
Bl rec, near 13A 3 Wtolo^
PRA -2.37 D 0,62 -1.75Dto-3.00 D
NRA +2.00 D 0.25 +1.75Dto+2.25 D

.MORGAN'S NORMATIVE ANALYSIS

Morgan, a principal founder of binocular visin case analysis, accumulated and analyzed clinical
phorometry data on 800 nonpresbyopic adults, ages 20-40 years.5 He established clinical norms for his
patient group, suggested expected vales for clinical evaluation (Table 3-2), and recommended using
one-half of a standard deviation from the mean to represent clinically suspicious findings. (These
expected vales are factors in the vergence clinical ranking system recommended in Chapter 2.) Morgan
also evaluated the pattern of clinical findings by determining correlation coefficients for various zone
components.6 His results are presented n Table 3-3. His important contribution demonstrated the
quantitative strength of these relations. Other findings also deserve interpretaron. For example, the
correlation between PRC and NRA was +0.5, a modrate correlation. A direct association exists between
these two features of the zone; the larger the PRC, the larger is the NRA. In many cases, accommodation
can limit vergence; conversely, vergence can limit accommodation. This relation
suggests the possibility of clinical syndromes, as Morgan astutely pointed out.
Morgan demonstrated that certain features of the ZCSBV tend to be congregated. Morgan's group A
findings are amplitude of accommodation, PRA, and NRC. Group B findings are NRA and PRC.
(Morgan also proposed another classification, group C, which includes the far and near phorias, the gra-
dient AC/A ratio, and the calculated AC/A ratio.) When group A findings are low, group B findings tend
to be high; Morgan refers to this case type as accommodative fatigue. The treatments of choice are
often a plus add for reading or visin training that would better balance A and B findings. When group
B data are found to be low and group A high, then the case type is referred to as convergence fatigue.
The recommended treatment would be either Bl prism to balance the two groups or fusional
convergence (BO) visin training.

GRITERA FOR LENS AND PRISM PRESCRIPTION

Many people have contributed to graphical case analysis over the years. Several researchers and cli-
nicians have recommended various criteria for the prescription of prisms and adds to balance various
elements with i n the ZCSBV. However, little research has been done to check the validity or reliability of
these criteria. Their clinical popularity has waxed and waned over the years, depending on the fash-
77

on of the time. The selection of one criterion criteria for evaluating lateral phoria imbalance is Sheard's
over another usually is based on a particular criterion. In 1929, Charles Sheard, a biophysicist at
clinician's training, experiences, and biases. Ohio State University, suggested that the clinically
Several criteria currently in use are reviewed significant relation n assessing vergence dysfunc-tions
here. is the magnitude of heterophoria as compared with the
range of compensatory fusional vergence. He
proposed that the compensating vergence "reserve"
Morgan's Expected Criterion should be at least twice the demand (heterophoria) to be
Morgan's expected ranges for near and far physiologically sufficient.4 Therefore, the PRC should be
hetero-phorias have been used as clinical at least twice the magnitude of an exophoria, and the
vales for the prescription of prism or added NRC should be at least twice the amount of an
lens power. The idea is that f a patient has an esophoria. Sheard's criterion proposes that f the reserve
excessive phoria falling outside the expected is less than this amount, a patient s likely to develop
vales, a prism or spherical lens addition s asthenopic symptoms with sus-tained visual activity
prescribed to compnsate for the phoria. The (e.g., reading a book). If, indeed, a patient does report
lens or prism shifts the demand line rel-ative to visual symptoms and fails to meet Sheard's criterion,
the phoria line, so that the measured phoria then compensating prisms (or a lens addition, in some
then falls within expected limits, as can be cases) can be deter-mined. The goal is to prescribe suff
shown graphically. We will refer to this prism icient prism (or added lens) so the compensating relative
prescription criterion as Morgan's expected vergence would be twice the demand. This can be
criterion. For exam-ple, if a patient reports accom-plished by either inspection of the graph or by
eyestrain while reading and has an exophoria calcu-lation. The formula for calculating Sheard's prism
of 10A at near, the spectacle prescription would s: Sheard A = ([2 x demand] - compensating relative
be 4A Bl to reduce the phoria to 6A exophoria vergence)/3. That is, A = (2D- R)/3.
with respect to the new demand; this s a Two examples are offered to demnstrate the use of
limiting expected valu. Sheard's criterion. If a symptomatic patient has a
Clinical Wisdom Criterion nearpoint exophoria of 9A and PRC ranges of 6/10/4
Another criterion based on the amount of the taken through the phoropter, then analysis would
hetero-phoria is called the clinical wisdom indcate that Sheard's criterion at nearpoint is not met.
criterion. Its ori-gin s obscure, but it seems to The demand is 9Aexophoria, and the PRC (blur-point) s
be passed from one generation of clinicians to 6A. The reserve is much less than twice the demand. The
the next. The criterion vares with the direction PRC in this case should be 18A BO to blur to satisfy
of the deviation. If a patient has visual Sheard's criterion. A prism can be prescribed to meet the
symptoms and poor performance associated theoretcal criterion. Sheard's prism = (2D- K)/3 or ([2 x
with an excessive exophoria, then clinical 9] - 6])/3 = 12/3 = 4A Bl. With 4A Bl in place, the
wisdom would recommend prescribing prism n measured phoria would be reduced from 9A exophoria to
the amount of one-third the angle of deviation to 5A exophoria, and the reserve of 6A would be increased to
bring symptom-atic relief. For example, if the 10A. This prism, therefore, satisfies Sheard's criterion
exophoria measures 12A by cover test, then 4A (i.e., 2D = R, or 2 x 5 = 10). In the spectacle
Bl would be prescribed. The prism amount prescription, the prism would be split, 2A Bl each eye.
would usually be split between the two lenses The patient may expe-rience mproved visual comfort
(.e., 2A Bl each eye), to reduce weight and and efficiency. There is evidence that Sheard's criterion
optical distortion. However, n the cases of eso- s clinically effec-tive, particularly in exophoric cases. 7
phoria and hyperphoria associated with signs A better approach when feasible, n lieu of prism
and symptoms, clinical wisdom would compensa-tion, s to prescribe convergence visin
recommend neu-tralizing the entire angle of training with the goal of building the PRC to at least 18A
deviation with prisms or adds, if appropriate. For BO to blur, which would satisfy Sheard's criterion.
example, if 4A esophoria and 2A right The second example is a far and near esophoric
hyperphoria were found by cover test in a patient reporting visually related headaches at the end
symptomatic patient, the prism prescription of a workday. Phoropter findings indcate a far
would be: oculus dexter 2A BO and 1A base- esophoria of 5A wth 3A farpoint Bl to break and, at near,
down; oculus sinister 2A BO and 1A base- esophora of 7A with an NRC of 5A (to blur). Henee,
up.Sheard's Criterion Sheard's criteron is not met at either far or
One of the oldest and most widely used clinical
78 Chapter 3

near. Chapter 3

near.The Sheard prism atfar would be: A= (2D- R)/ graph. The amount may necessarily be different for
3 = ([10 - 3]/3) = 7/3 = 2 1/3A BO. The Sheard prism near and far viewing.
at near would be: A = (14 - 5)/3 = 3A BO. One Percival's criterion can also be applied by calcula-
approach is to prescribe 3A BO in single-vision tion. A useful formula is: Percival's A = 1/3 L - 2/3 S,
spectacles, as this prism would satisfy Sheard's crite- where L = larger relative vergence range and S =
rion at far and near. However, if the symptoms were smaller relative vergence range. For example, if the
related primanly to nearpoint work, another PRC is 24A (L) and the NRC is 9A (S), the prism neces-
approach could be taken using plus added lenses. sary would be
The Sheard's prism at near, 3A BO, could be satisfied Percival's A = 1/3 L-2/3 S
by prescribing a plus add for near, based on the gra- --= 1/3 (24) - 2/3 (9) =
dient AC/A ratio. If the gradient AC/A ratio measured 8-6 = 2ABO
4A/1 D in this case, then a +0.75-D add would also
balance the relationship between the demand and A visin training approach in this case would cali for
reserve to satisfy Sheard's criterion. (Sheard add = fusional divergence training (also called Bl training}
required Sheard prism/gradient AC/A ratio.) This add to increase the NRC to satisfy Percival's criterion.
combined with the lens correction for any existing FIXATION DISPARITY ANALYSIS
farpoint refractive error might be prescribed in sin-
gle-vision lenses for nearpoint (e.g., reading or com- Besides evaluating the relation between hetero-
puter work). A bifocal prescription could also phoria and vergence ranges, vergence disorders
achieve the desired results if appropriate for the can be identified and managed using the clinical
work needs of the patient. In addition, fusional ndex of fixation disparity.
divergence training should be considered as either Definition and Features
an altrnate clinical approach in such cases or in Fixation disparity is a slight manifest misalignment
combination with optical treatment. of the visual axes (minutes of are) even though there
is single binocular visin with central sensory
fusin. The misalignment can be horizontal, verti-
Percival's Criterion cal, or torsional; however, the magnitude of the
Percival's criterion differs from the other criteria in deviation is within Panum's fusional reas, resulting
that it ignores the phoria position. Percival pro- in a single binocular percept of a target. Ogle9 sug-
posed that the clinically important relationship in gested that the magnitude of the fixation disparity
the ZCSBV is the position of the demand Une with depends on the amount of the innervation to the
respect to the limits of convergence and diver- extraocular muscles during fusin. This innervation
gence blur unes.8 He delineated a zone of comfort is related to the magnitude of heterophoria, the
resting within the middle third of the ZCSBV, lim- strength of compensating fusional vergence, and the
ited horizontally by the blur lines on either side complexity and detall of the visual target.
and extending vertically from O to 3 D of accom- Fixation disparity is not always considered to be
modative stimulus. Percival believed that the abnormal. It may represent an individual's physio-
demand line should ideally fall within or at a limit logic habitual set point from which other binocular
of this comfort zone. If it did not, then prism, disparities are registered (e.g., for stereoscopic
added lens correction, or visin training was indi- depth perception and as a stimulus for vergence eye
cated. The clinician can assess whether Percival's movements). In fact, for fusional vergence error cor-
criterion is satisfied by direct inspection of the
rection, it serves a useful purpose. Schor and
plotted ZCSBV and by adding the NRC and PRC
Ciuffreda10 indicated that fixation disparity may be a
findings and dividing by three. This trisects the
purposeful error signal that provides a stimulus to
total range of fusional vergence and defines the
zone of comfort, the inner third. Does the demand maintain a particular level of vergence innervation.
line fall within the zone of comfort for all viewing Nevertheless, fixation disparity often indicates stress
distances? If not, the amount of prism necessary to on the fusional vergence system and can be associ-
shift the demand line to the nearest limit of the ated with excessive heterophoria, deficient fusional
comfort zone can be easily determined from the vergence compensation, and asthenopic symp-
Chapter 3 79

a. p --------------------SEEN BY O.D. ONLY

X - --------------- -SEEN BV BOTH O.D. AND ANQLE f
O.S.
!. ------ -SEEN BY O.S. ONLY VISUAL AXIS ORTHO

DEMAND UNE
POLARIZED TARGET
POLARIZED FILTERS

RGURE 3-6Illustrations of fixation

disparity. a. Target viewed by patient.
h. Theoretical posterior view of eyes C.
illustrating angle Fin exo fixation dis-
parity. c. Ratient's perception. (OD =
X
oculus dexter; OS = oculus sinister.) I O.S. lovra
O.D. fovea
POINT ZERO
PATIENTS PERCEPTION
(CYCLOPEAN PROJECTION)

11
toms. Both abnormal and normal aspects of fixa- considered a fixation disparity.
tion disparity can, therefore, occur n the same
individual. Forexample, a heterophoric patient with
deficient vergence compensation can have a large
fixation disparity, indicating vergence stress but,
after visin therapy, there may be only a small resid-
ual fixation disparity that indicates a normal set
point for that individual.
An example of an exo fixation disparity s llus-
trated in Figure 3-6, which depicts a posterior view
of the eyes. If the error of vergence for the fixated X
target is very small and fusin of X is possible
because of Panum's reas, the X will appear to be
single and not diplopic. The vertical lines (which are
seen independently by each eye), however, will not
be perceived by the patient as being n vernier
alignment. This manifest deviation from exact align-
ment is too small to be detected by the cover test
(i.e., unilateral cover test). For this practica! reason,
fixation disparity is not considered to be a small-
angle strabismus, despite a manifest misalignment
12
of the visual axes. Morgan summed up the quanti-
fication of fixation disparity by stating, "Normally,
fixation disparity rarely exceeds 10 minutes of are,
although it may be somewhat greater when a sub-
stantial degree of heterophoria exists, and probably
any deviation approaching 30 minutes should be
considered abnormal." Because 30 minutes of are s
regarded as being a limiting valu, and t is approxi-
mately the magnitude (0.9) of a prism diopter, it is
A
practica! to consider any manifest deviation of 1 or
greater as being a strabismus. If the deviation s less
A
than 1 and there is foveal fusin, the condition s
Clinical evidence suggests that excessive fixa-
tion disparity tends to reduce stereopsis. Col and
13
Boisvert conducted a study and reported that
the nduction of fixation disparity on otherwise
normal binocular subjects caused an increase n
stereothreshold (decrease in stereoacuity). In
14
another study, Levin and Sultn neutralized
existing fixation disparities in 12 subjects by
means of prisms to determine the effect on stere-
oacuity and found that stereoacuity improved n
10 of the subjects.

Measurement
Fixation disparity testing can be done at both far
and near. Instruments for such testing have in com-
mon the same general principies. The patient fuses
a flat-fusion target under natural lighting condi-
tions. Such tests incorprate vernier fiducials,
clued to each eye by means of crossed polarizing
filters, so that the patient can report any noticeable
misalignment. These vernier markings also serve as
suppression clues. Central suppression is indicated
f one line s not seen. Generally, two types of
nstruments are usedthose that give a direct mea-
sure of fixation disparity (e.g., Saladin Card [Figure
3-7]) and the Wesson Card (Figure 3-8). The Sala-
din Near Point Balance Card allows for both disso-
ciated and associated phoria measurements. The
numbers 20 exophoria to 20 esophoria are for hor-
izontal phoria testing with the modified Thorington
method using a Maddox rod; the 10-10 scale s for
vertical measurements. The associated phoria, hor-
izontal or vertical, can be measured using the two
80 Chapter 3

RJU.

iva

ADTS
Mons
NOdTI ATd
anos
A '" M "~" X ~"~ A ~~ Z
SnHn Eq. LogMAR
e7
i HZDiV -
RtHyper
80 RKCOS O-6

t 63 ZSDNG O.S
v c o i HI Hypo

YEMA
8 50 0EKVR 0.4

*
40 C D N K H 0.3
. ZH v ns 0.2
32
25 ..... 0.1

SLOW
*4 20 0.0
'2 18 0.1
S A C

1B 1R 1d 19 1O R K A O = > /i e e A lo 4A -IB 1O O

UTO
THEN

UPON

SatadJn Near Point Balance Card Ver 1.0

Hold card at 16"(40cm) Mlehlgwi College of Optometry
HoldMaddoxrodbeforerighteye vttu FERRIS STATE UMIVERSITY

K J I H G F E 2X C B A
18X 14X 10X 8X 6X 4X 18 2S 4S

S8t SH SOI- ss 9 S* 2 XV X*
4
Z A X AA A i y
E
n
FD

ClRtHyper

DO
Horizontal Analvsis 1. Assume
t'of are Fixation Disparity (F0)
measurement error 1. PD sbcrnW
bebetween 4' so ande' mss Aialsts E1
3. FD and phoria should be in the sane direction . Assume O tneaswement error 2.
given 2' of FD measurement error VeoicaFDshouWbeiessthan l'of
4. Noticeable variability for either FD or phoria is gfe and in the same direction as the
abnonnal vertieal phoria

64
Chapter 3 81

Red

Orange Green , Green Orange

DISTANCE: 40 CM (1 6 INCHES) 25 CM (1 0 INCHES)

t F.D.(MIN.ARC) F.D. (MIN. ARC)
RED 0 0 0
1/2 4.3' 6.9'
GREEN 1 8.6' 13.7'
1-1/2 12.9' 20.6'
ORANGE 2 17.2' 27.5'
BLACK 3 25.8' 41.2'
BLACK 4 34.4' 55'
ESO F.D.: ARROW TOLEFT
ESO F.D.: ARROW TORIGHT

FIGURE 3-8Representation of the Wesson Card for fixation disparity (F.D.) testing.

targets n the upper left-hand crner, in which a phoria are the Bernell test (Figure 3-9) and the Vec-
foveal fusin lock appears n each center (see Fig- tographic Slide (Figure 3-10) or similarly designed
ure 3-7). The other circles are without a foveal targets. Vertical associated phoria can be measured
fusin lock and are used for targets to plot a fixa- with either test; the Bernell test can be rotated 90
tion disparity curve (FDC; discussed later). Exam- degrees to test for vertical fixation disparity (see
ples of those tests that indcate only an associated Figure 3-9b).

DISPARITY

FIGURE 3-9Bernell Fixation Dis-

parity Test (a) oriented for horizontal
fixation disparity and (b) oriented for
vertical fixation disparity.
82 Chapter 3

I- SEEN BY O.D. SEEN BY O.S.

a. O e. --Oy
KSEEN BY O.S. SEEN BY O.D.

b. u

c. o 9-

O ame
m E ui
E a u E
d.O h. O n

-e

oo oo o oo oo o
oo oo o oo oo o
oo oo o oo oo o
oo oo o oo oo o A

FIGURE 3-10Results of fixation disparity testing with the Vectographic Slide. a. No fixation disparity. b. Eso fixation disparity (oculu s dexter
[OD] dominant eye). c. Eso fixation disparity (mixed dominance). d. Exo fixation disparity (OD dominant). e. No vertical f ixation disparity.
f. Hyper fixation disparity (OD dominant). g. Incyclo fixation disparity (OD dominant). h. Foveal suppression of oculus sinis ter (OS), i. Adult ver-
sin of the Vectographic Slide. (Courtesy of Stereo Optical Co.) j. Children's versin of the Vectographic Slide. (Courtesy Stereo Optical Co.)

The associated phoria is the minimum amount having the patient focus on the reading portion of
of prism that is necessary to neutralize a fixation the test and then look at the central target when t
disparity. Theoretically, this is the X intercept (XIN, is lluminated. The vernier perception at that
pronounced "zin"). For example, an exo fixation moment is used for clinical purposes. The pris-
disparity would be neutralized with Bl prisms (Fig- matic power that produces alignment for the
ure 3-11). Knowing the direction of fixation dispar- patient is the XIN measurement.
ity and the amount of prism required to reduce it to Fixation disparity targets similar to the vecto-
zero (measurement of the associated phoria) are of graphic slide (see Figure 3-10) are good for deter-
clinical importance. The XIN (associated phoria) mining the farpoint-associated phoria. The patient
should not be confused with the magnitude of the wears crossed polarizing viewers and is instructed
fixation disparity, theoretically the Yntercept (YIN, to keep fixation on the center of the bull's-eye tar-
and pronounced as such). The XIN is measured by get and to report any noticeable misalignment of
Chapter 3 83

DIPLOPIA

BASE-IN BASE-OUT
DEMAND DEMAND(A)
24

DISSOCIATED PHORIA
OF 8A EXO
BLUR
o

15
15 *!
^~ ^-

DISSOCIATED PHORIA OF 5
8A EXO ^^^^
BASE-IN . . V
DEMAND ' ' "/"N.
24 18 12 /6 \ 6 12 18 24
ance Card.

RCURE 3-11Fixation disparity

curves plotting angle F as a function BASE-OUT
DEMAND(A)
plotted against horizontal prismatic
demand to vergence. a. Good ver-
gence ability in case of 8A exophoria. AT ZEROA (ORTHO)DEMAND
b. Poor vergence ability in case of 8A THE EXO FIXATION DISPARITY
IS 5 MINUTES OF ARC.
exophoria with Y intercept of 5 min-
utes of are (min are) exo fixation dis-
parity and X intercept of 6 A exo ASSOCIATED PHORIA OF6A EXO
fixation disparity. This graph could be (FIXATION DISPARITY 10'
applicable to available instruments NEUTRALIZED WITH 6A BASE-IN)
such as the Saladin Near Point Bal-
15"

11
the vertical or horizontal Unes. If there is no mis- test. The Mallett Unit is held by the patient at the
alignment, the clinician can conclude that there is preferred working distance and position as when
foveal fusin with no fixation disparity. If there s reading. The centrally fused target s an X. Two verti-
misalignment, compensating prisms are used to cal bars (one above and one below the binocularly
crate vernier alignment. The power of the neutral- seen X) are covered with mutually exclusive polar-
izing prism is not the magnitude of the fixation dis- izing filters. One line s seen only by the right eye
parity (YIN) but, rather, the measurement of the and the other only by the left eye. As in farpoint test-
associated phoria (XIN). ing, any horizontal associated phoria (XIN) should
A good example of target design for nearpoint fix- be measured using the mnimum amount of neutral-
ation disparity testing s the Mallett fixation disparity izng prism. The fixation target s flashed for each
84 Chapter 3

measurement, and the patient is instructed to look The FDC is plotted by measuring the magnitude of
mmediately from the reading material to the X. fixation disparity that corresponds with varying
(Some clinicians prefer to have the patient continu- amounts of Bl and BO prism. Risley prism increments
ally fixate the X.) Any vertical associated phoria of 3A are advised to produce clinically useful curves.
should also be measured, using a target at another Fixation disparity is measured initially with an ortho
location for that purpose. demand. Subsequent measurements are taken in the
An associated phoria measuring 1A or more may following orden 3A Bl, 3A BO, 6A Bl, 6A BO, and so
be clinically significant if accompanied by hetero- on. The limit of forced vergence in each direction is
phoria and deficient fusional vergence ranges, partic- indicated when a prism results in either diplopia of
ularly if the patient reports asthenopic symptoms. In the target or suppression of one fiducial. The instru-
contrast, an associated phoria independent of symp- ment is designed for measurement of both horizontal
toms or other signs may be clinically insignificant. and vertical fixation disparity.
Generally, the direction of the fixation disparity is The Wesson Fixation Disparity Card (see Figure
consistent with the direction of the dissociated het- 3-8) is a relatively inexpensive device but less pre-
erophoria (e.g., eso fixation disparity often occurs cise than the Disparometer. It can be hand-held or
with esophoria). However, as Ogle9 showed in his attached to a phoropter nearpoint rod; it also
classic studies of fixation disparity, the two occasion- yields an approximate FDC. One study indicated
ally occur in opposite directions (e.g., an exophoric that curves taken with the Wesson Card and Dispa-
patient might exhibit an eso fixation disparity). In rometer correlated highly if esophoric and exo-
such cases, the direction of the fixation disparity is phoric subjects were analyzed separately.17
considered to be the more important clinical indica- Figure 3-11a illustrates an FDC of a patient with
tor of the underlying oculomotor stress pattern. In normal binocular visin, whereas Figure 3-11b
such a case, BO prism may possibly be prescribed to shows an FDC of a patient with vergence dysfunc-
neutralize the eso fixation disparity, even though the tion reporting asthenopic symptoms. Note the fol-
patient has an exophoria (under dissociated testing lowing clinically relevant features of the abnormal
conditions). Vision therapy to improve motor fusin curve: (1) the significant fixation disparity at the
ranges is, however, usually preferred in such cases ortho demand position; (2) the relatively large asso-
over prism prescription. ciated phoria (XIN); (3) the steep slope (exceeding
It is sometimes advisable to plot a fixation dispar- 45 degrees) of the curve at the ortho demand posi-
ity-forced vergence curve, clinically called the fixation; and (4) the limited range of fusional vergence.
tion disparity curve. The Sheedy Disparometer was These features of the curve confirm the presence of
the first clinical instrument commercially available a vergence dysfunction. Another feature of the FDC
for this purpose.15 This instrument has a series of that has been suggested to be indicative of a ver-
preset vernier lines that allows direct measurement gence dysfunction is variability of the amount of fix-
of the fixation disparity magnitude (YIN). The Dispa- ation disparity and the curve over time (i.e., large
rometer can be attached to the nearpoint rod of a day-to-day variation). In individuis having normal
phoropter at the 40-cm viewing distance, although binocular visin, the FDC appears to be quite stable
t can also be hand-held by the patient with nearly or reliable over time within a limited range of forced
the same accuracy.16 Crossed polarizing filters are convergence and forced divergence.18
used to clue the fiducials to the right and left eyes. The Saladin Near Point Balance Card allows for
Fixation disparity is measured by the examiner dial- measurement of angle F (YIN) as well as the associ-
ing in the particular vernier lines for the patient's ated phoria (XIN). Testing is more convenient than
perception of exact alignment. The horizontal fixa- with the Disparometer, because dialing of each pre-
tion disparity magnitude (YIN) can be determined to set vernier displacement is unnecessary, as they are
an accuracy of 2 minutes of are, using the bracket- all exposed.The horizontal array measures eso devi-
ing (method of adjustment) technique. The patient is ations or exo deviations, and the ranges can be
asked to focus on the letters adjacent to the circular extended for each direction by rotating the card 180
target containing the vernier lines. The vernier lines degrees; similar features apply to the vertical array
are transilluminated with a penlight by means of (hyper or hypo deviations) measurements, for which
fiberoptic tubes. The examiner illuminates the lines ranges also can be extended by rotating the card.
intermittently, and the patient is instructed to look Four basic types of FDCs were described by Ogle
from the letters to the illuminated vernier lines and et al.9 and are believed to have differential diagnostic
report any misalignment of a line and its direction. valu (Figure 3-12). The type I curve has a sigmoid
Chapter 3 85

shape and s considered to be the most prevalent,

found in approximately 60% of the population (64%
by Kwan et al.19). A type I curve having a steep slope
(crossing at the ortho demand position) often s asso-
ciated with visual symptoms. In these cases, visin
training often is successful in flattening the slope of
the curve while ncreasing fusional vergence ranges,
usually relieving symptoms due to vergence dysfunc-
tion. These cases have an excellent prognosis for
improvement. Type II and III curves have a fat seg-
ment that may or may not cross the x axis (see Figure
3-12). Type I! s often associated with esophoria
(although occasionally exophoria) and s the second
most prevalent type, found in approximately 25% of
the population. Type III, which s often associated
with exophoria (although occasionally with esopho-
ria), s found in approximately 10% of the popula-
tion. It should be noted that all FDCs should be FIGURE 3-12Four types of fixation disparity curves.

plotted from break to break (diplopia limits). A type I

FDC sometimes is incorrectly labeled as type II or III;
induced by lens stimulation that are analogous to,
this occurs when the examiner takes too few points
but not totaliy consistent with, the types found by
and fails to find a segment that crosses the x axis.
Ogle et al.,9 who used prism stimulation. They sug-
True types II and III often respond well to prism
gested that these lens-induced curves have diagnos-
prescription. Many type III cases that are exo fixa-
tic valun some cases. Furthermore, the lens
tion disparities can be treated with fusional conver-
power that reduces the near fixation disparity to
gence training. Type IV cases, the least prevalent
zero may help to determine the proper near pre-
(approximately 5%), have the worst prognosis for a
scription, particularly with prepresbyopic patients.
functional cure as compared with the other FDC
For example, if a +1.25-D addition lens reduces a
types. Figure 3-12 Ilstrales type IV exo fixation dis-
nearpoint eso fixation disparity to zero, this could
parity, but eso fixation disparity is also possible.
be the optimum prescription.
Individuis with this FDC type seem to adapt to
Although generating an FDC is recommended,
prism so that the fixation disparity cap never be
the clinician can get a general sense of whether the
neutralized. In other words, there may be no stable
FDC is normal or abnormal merely by measuring
XIN. Such binocular dysfunctions are not clearly
the associated phoria and evaluating the total range
understood. In type IV curves, sensory and motor
of fusional vergence. For example, f no fixation dis-
fusin disorders may be resistant to therapeutic
parity s induced over a relatively large range of Bl
attempts; the prism adaptation found during testing
and BO prism demand (e.g., 6A Bl and 9A BO at
s characteristic of many strabismic patients. Vision
near), then the clinician can assume the presence of
therapy s frequently ineffective in such cases.
a normal type I FDC. However, if eso fixation dis-
It is apparent that establishing the curve type and
parity and eso associated phoria are present with an
characteristics aids the clinician n making a diag-
ortho demand, the eso fixation disparity increases
nosis of a vergence dysfunction and points toward
with small amounts of Bl prism, and an exo fixation
certain therapeutic options. The clinician mus be
disparity s induced with relatively small amounts of
aware that the type of curve can change from far to
BO prism, then the clinician can visualize a steep
near fixation n many cases.9-20 It is mportant to
FDC. A three-dimensional model of fixation dispar-
evalate the FDC at the distance at which the
ity, vergence, and accommodation can also be con-
patient is experiencing binocular visin problems.
ceptualized (Figure 3-13).
Ogle et al.9 demonstrated that FDCs can also be
generated using lens additions to stimulate forced
vergence. By comparing the FDC found with prism Prescribing Prism
stimulation and that found with lens stimulation, a Two principal criteria have been recommended for
derived AC/A ratio can be computed. Building on the prescription of prism on the basis of fixation dis-
this work, Wick and Joubert21 found four FDC types parity: Sheedy's cterion22and the associated pho-
86 Chapter 3

FD at near

Demand Line

FD at far FAIR

POOR
Chapter 3 87

Demand
Line

FD at f ar GOOD
FD at near

FIGURE 3-13Three-dimensional models of binocular visin showing the relations of accommodation, vergence, and fixation disparity (FD).
a. Indication of fairly good fusional vergences for clear, single, comfortable binocular visin, b. Poor fusional vergences indicating lack of good,
clear, single, comfortable binocular visin, c. Good fusional vergences ndicating excellent binocular status as to clarity and comfort.

ra criterion." Sheedy's criterion for the prescription clinical measurement are found with Instruments
of prism is based on nspection of the FDC. If the similar to the Mallett Unit, Bernell Unit, and Saladin
curve is steep where it crosses the YIN (ortho Card with ortho demand target for near testing or
demand position) and the patient has fusional prob- the Vectographic Slide for far testing. These targets
lems and symptoms, Sheedy recommends prescrib- contain central fusin contours. We believe a cen-
ing the least amount of prism that places the ortho tral fusin lock is necessary when the associated
demand position on the flattest portion of the curve. phoria criterion is used for the prescription of prism.
If, for example, the FDC s steep at the ortho The associated phoria is determined by adding
A
demand position but flattens out at the 4 BO loca- prisms until neutralization occurs. The patient
A
tion of the x axis, the prescription would be 4 BO should be instructed to determine whether vernier
prism. This would shift the ortho demand position to alignment is achieved with each prism power
the flattest segment of the FDC, f there s no prism within a time limit of 20 seconds after the prism has
adaptation. If there is no completely fat portion, been ntroduced. Beyond this time, there may be
Sheedy would recommend prescribing sufficient significant prism adaptation to invaldate the mea-
10
prism to place the patient's ortho demand on the surement of the associated phoria.
flattest portion of the curve. We believe, however, VALIDITY OF DIAGNOSTIC GRITERA
that visin training s of great valun such cases, to
Validity and reliability of diagnostic criteria need
flatten the curve near the ortho position.
to be established before the clinician can securely
The associated phoria criterion s the least
apply them to patient management. However,
amount of prism that neutralizes the fixation dispar-
ity (XIN). Typically, the targets used to make this
88 Chapter 3

most of the diagnostic criteria used in the prescrip- this problem are discussed: (1) a comparison of
tion of prism and lens additions n cases of ver- subjective and objective vergence measurements
gence dysfunction have not been subjected to and analysis, (2) clinical criteria that discrimnate
rigorous tests of concurrent validity; their use has subjects with and without binocular symptoms,
evolved slowly by experience n clinical practice. and (3) prism prescription clinical triis.
A measure of face validity accrues to the criteria of Grisham25 objectively recorded the dynamics of
Sheard, Percival, Sheedy, and associated phoria, vergence eye movements n two groups of sub-
because they are al I based on notions that have jects. One group had clinically determined ver-
physiologic credibility, but much of the evidence gence dysfunctions and asthenopic symptoms and
supporting their clinical use is anecdotal. the other had normal binocular visin. An auto-
Craphical case analysis can be criticized on the mated vergence stimulus was presented on a mod-
basis of the subjective methods used in clinical ified haploscope, and an infrared eye monitor was
testing of accommodation and vergence through a used to record the vergence responses. Vergence
phoropter. Phorias, relative accommodation, and latency, velocity, and tracking rate were objectively
vergence endpoints can be influenced by a num- determined variables that discriminated between
ber of nonphysiologic factors, including a patient's the two clinical groups. Grisham reported accept-
(1) understanding of the instructions, (2) attention able concurrent validity between the clinical and
level, (3) cooperation level, and (4) conscious objective analyses of these subject groups and
effort expended. In addition, (5) rate and smooth- demonstrated that the objective analysis estab-
ness of prism or lens power induction by the exam- lished the same categories of differential diagnosis
iner, (6) elapsed time between tests, and (7) the as did a clinical analysis of vergence and hetero-
amount of central and peripheral contour n the phoria characteristics.
fixation target affect these parameters. The way that Sheedy and Saladin26 also evaluated the validity of
instructions are phrased also can make a signifi- case analysis diagnostic criteria; however, they used
cant difference in the measurement of vergences: the statistical technique of stepwise discriminant anal-
For example, "Report when the image splits into ysis to rank the effectiveness of many commonly used
two" may elicit a quite different response than clinical criteria in differentiating symptomatic from
might "Try to keep the image single, but report asymptomatic nonstrabismic subjects. The symptom-
when it doubles."23 With several nherent sources atic subjects all had clinically determined hetero-
of nonphysiologic variation and error, how can the phoric and vergence disorders. Phorias, vergences,
examiner trust the validity and reliability of these and FDCs were measured on all subjects. Sheard's cri-
clinical methods? More important, can any crite- terion proved to be the best single discriminant vari-
rion for distinguishing a disorder from normal able for the entire population, particularly for the
functioning, based on these endpoint measure- subgroup of exophoric subjects. For esophoric sub-
ments, be considered valid and reliable? Fortu- jects, however, the magnitude of the deviation (pho-
nately, these questions can be answered, at least ria) was the most discriminating factor (Table 3-4).
for clinical purpose. The power of these individual variables in success-
Morgan23 found that tests for the farpoint phoria fully discriminating between the two subject groups
showed high reliability even when the interval (90% correct) supports the overall validity of binocu-
between tests was many years. Most standard clin- lar visin case analysis as an effective clinical
ical tests of far and near heterophoria have accept- approach.
able reliability and concurrent validity, with the One direct approach for assessing the use of a
exception of the Maddox rod test at nearpoint. 24 particular clinical criterion for the prescription of
The reliability may be mproved, as Saladin sug- prism is to allow the patient to choose between two
gested,24 by having the patient hold or touch the comparable spectacle prescriptions, one including
penlight to stabilize accommodation at the 40-cm the particular prism amount and the other similar in
test distance. However, little has been reported on all respects except for the prism. Worrell et al.27
the test-retest reliability of Risley prism vergence were the first to use this technique when they
ranges. assessed the prism prescribed by Sheard's criterion
There is evidence to support the overall validity in 43 subjects with oculomotor imbalance and
of graphical analysis and other clinical criteria of asthenopic symptoms. They found that the Sheard
vergence assessment. Three different approaches to prism was accepted at a statistically significant level
Chapter 3 89

in preference to no prism in esophoric subjects (par-

ticularly for farpoint viewing) and in presbyopic, TABLE 3-4. Ranking of Discrminatng Factors between
exophoric subjects. However, nonpresbyopic adults Symptomatc and Asymptomatic Subjects
with exophoria did not prefer the prism beyond a
chance level. Fortunately, visin training techniques Rank
Exophores Esophores
for ncreasing fusional convergence are very effec-
12 Sheard's criterion Y Phoria amount Fixation
tive in such cases.
ntercept
Payne et al.28 provided two sets of lenses to 10 3
disparity
patients with asthenopia and fixation disparity at 4
curve slope Recovery
X ntercept
near. The prism amount was determined by measur- range Break range
Vergence
ing the associated phoria using a nearpoint Mallett
opposing phoria Vergence opposing phoria
Unit, and a double-blind (masked) procedure was
Vergence recovery
employed. By this criterion, all patients (eight non- Source: Reprinted with
presbyopic exophores and two esophores) chose to permission from JE Sheedy, J Saladin. Validity of Diagnostic
keep the prism prescription. Grisham29 reported Crtena and Case Analysis in Binocular Vision Disorders. In:
Vfefgence fye Movements. CM Schor, KJ Ciuffreda, eds.
prism acceptance in a group of symptomatic pres- Boston: Butterworths; 1983:517-540.
byopic exophores using associated phoria as the
prism criterion. Of the 12 patients, 10 chose to keep
the prism that neutralized their fixation disparity at
near. On the basis of theoretical considerations, the FDC, the overall shape and type of the FDC
some clinicians do not believe in the use of associ- remains stable over time. This principie apparently
ated phoria alone for prism prescription. However, applies to the vertical FDC also. One study found
the preceding evidence suggests that this method that the shape of the vertical FDC (approximating a
has clinical utility, at least when determined by a straight Une) remains stable over time, whereas its
test that has a central fusin stimulus (i.e., "lock") slope varied significantly, more so over weeks and
for example, the Mallett unit, Bernell fixation dis- months than during the day.31
parity slide, or the Saladin Card. Variability in the FDC in patients with binocular
The three approaches just described for evaluating problems has not been adequately studied. There
the validity of graphical case analysis have all, in gen- are, however, ndications that symptomatic patients
eral, supported its clinical utility. However, any clini- with abnormal FDCs show increases in curve slope
cal analysis system based solely on subjective and magnitude of fixation disparity when reading
response indicators suffers from inherent limitations. for short periods.32 Yekta et al.33 found that a large
In coming to a particular diagnosis of a binocular fixation disparity (YIN) and associated phoria (XIN)
dysfunction, the clinician s advised to base judgment are related to visual symptoms n patients of all
on a pattern of findings rather than on any specific ages, ncluding presbyopes. They also reported that
attribute of the ZCSBV. Several clinical Gritera should by the end of a working day, there is a significant
be applied in case analysis when looking for a pat- increase in both of these ndices that correlates with
tern of responses indicative of a functional binocular increased asthenopic symptoms.34 Although more
visin dysfunction. Fixation disparity analysis is an studies are indicated, it appears that several
alternative system of evaluation that often s used in attributes of the FDC are clinically reliable and valid
addition to graphical analysis to establish the diagno- ndicators of vergence dysfunction.
sis and management of vergence disorders. Certain advantages and disadvantages are asso-
An evaluation of fixation disparity and the ciated with each particular clinical instrument
attributes of the FDC has become a popular mode used in the evaluation of fixation disparity. The
of vergence case analysis. Ogle et al. 9 initially Sheedy Disparometer, the Saladin Near Point Bal-
reported good reliability of fixation disparity mea- ance Card, or the Wesson Card can be used to plot
surements, and subsequent studies of the FDC n the FDC. Several features of the FDC have clinical
individuis having normal binocular visin indi- significance in identifying a vergence dysfunction,
cated only a small amount of measurement drift as reviewed previously. The FDC measured with a
over days and weeks.18'30 Although increases in Disparometer was shown to have acceptable con-
convergence or divergence fusional demand current validity with a laboratory horopter method
(prism demand) may result in some variability of
90 Chapter 3

for measuring the curve35 and gives consistent XIN from being excessive, but t allows the clini-
Information whether the device is mounted before cally significan! fixation disparity component due
a phoropter or s hand-held.16 Sheedy's criterion to fusional vergence stress to be revealed. Fortu-
for the prescription of prism can be applied, there- nately, the Saladin Card provides a target with a
fore, with some assurance of a reliable and valid foveal fusin lock for measuring the associated
method of evaluation. We recommend using the phoria (XIN). In other words, the foveal fusin lock
Disparometer, Saladin Card, or Wesson Card as an might elimnate the appearance of the physiologic
adjunct diagnostic procedure in cases of suspected fixation disparity, but t allows the clinically signifi-
vergence dysfunction when applying Sheedy's cri- cant fixation disparity component due to fusional
terion for the prescription of prism. The Saladin vergence stress to be revealed.
Card is based on the targets used in the Disparom-
eter, and we presume its effectiveness is compara-
ble. Further research is needed for confirmation.
RECOMMENDATIONS FOR
Dowley36 has concluded, however, that the
PRISM PRESCRIPTION
associated phoria measured with a Disparometer
(and, by implication, the Wesson Card), s not as Other than the studies by Sheedy and Saladin,26 lit-
reliable as the Mallett Unit. The Disparometer has tle research has been conducted to compare the
a fusin stimulus, an annulus that s 1.5 degrees in relative effectiveness of the various criteria for pre-
diameter, but no centered foveal binocular stimu- scribing prisms and adds to alleviate vergence dys-
lus, which the Mallett Unit does have. Studies have functions. In the absence of abundant research
demonstrated that the FDC s less variable and the data, clinicians adopt treatment preferences based
associated phoria has a smaller magnitude if the on their own clinical experiences. From our expe-
target contains a foveal fusin stimulus.37'38 Agree- riences, we make the following recommendations
ing with Dowley, we recommend that clinicians regarding the relative effectiveness of prism pre-
use a Mallett Unit, a Bernell polarized nearpoint scription criteria (Table 3-5). Our initial bias in
testing unit, or the Saladin Card to measure associ- most cases of significant heterophoria, or ntermit-
ated phoria if prisms or adds are to be prescribed tent strabismus, is to recommend visin training for
by the associated phoria criterion. Our experience improvement of fusional vergences. Prism com-
indicates that associated phoria prisms identified pensation may also be necessary as a supplement
by the Disparometer are often excessive and to training. When visin training is an unaccept-
rejected by patients. By contrast, the Mallett Unit able alternative or training results are unsuccessful,
prism amount usually is accepted by patients and prism therapy becomes the treatment of choice.
proves to be beneficia! if there are asthenopic The clinical wisdom criterion for prism prescrip-
symptoms and other signs of a vergence dysfunction works well for exophores, esophores, and
tion. The foveal fusin lock prevents the measured hyperphores at both far and near. Generally speak-

TABLE 3-5. Clinical Methods for Prescribing Prisms

Exophoria Esophoria Hyperphoria

Clinical vwisdom 3 3 3
Sheard's crterton 3 3 NA
Perdyal's criterion 1 2 NA
Associated phoria 3 3 3
Ftatportion @f fixation disparity curve 2 2 NA
{iheed^'s eriterion)
Pfismconfirmtri pro eedur 3 3 3
Prlsmsptation test 1 1 1
3 ^ tHartjTSN"! faoA 1 ''= Imf, NA = not applicable.
Chapter 3 91

ing, exophores require less prism than esophores, foveal and peripheral fusin stimuli, such as are
angles of deviation being equal, due to the greater found on the Bernell slide, Mallett Unit, and the Sal-
relative strength of fusional convergence. Prescrib- adin Card. When a series of prism amounts is found
ing a compensating prism that is one-third the angle to neutralize the fixation disparity, the minimum
of deviation is often appropriate for exophoria, up amount s prescribed with good effect; asthenopic
to a deviation of 30 A . The prism can be split symptoms usual ly are ameliorated and the patient
between the eyes and usually does not present a adapts well to the prism spectacles. Care must be
serious probiem (i.e., optical distortion, weight, or taken, however, when prescribing a prism for one
cosmesis) f the eye size (spectacle dimensin) is distance to ensure that a fixation disparity is not
kept small. In cases of symptomatic esophoria and induced at another distance. For example, Bl prism
hyperphoria, clinical wisdom calis for a prism equal may neutralize a fixation disparity at 40 cm for
to the angle of deviation as measured by the cover reading but induce a large eso fixation disparity and
test. However, in cases of relatively great magni- associated phoria for viewing televisin at 3 m with
tudes, this criterion becomes impractical due to that same prism. In this case, the prism spectacles
optical considerations. Lesser amounts of prism may be unacceptable and rejected for general wear
should be applied and evaluated empirically. but suffice for sustained nearpoint activity. There-
The studies of Sheedy and Saladin26 and Worrell fore, testing of associated phoria should be done at
et al.27 generally support the use of Sheard's crite- both far and near to judge the effect of a particular
rion and conform to our clinical experience. We prism amount. Sometimes, prism spectacles
have found t useful in both esophoria and exo- should be given for a specific viewing distance.
phoria patients but not in hyperphoric patients. It This management principie is applicable to pre-
seems to be particularly valuable in cases of symp- scribing prism by any criterion, but the associated
tomatic presbyopic exophoria, a class of patients phoria is a convenient criterion, because the prism
who often are neglected clinically. amount can easily be assessed by testing with far
Percival's criterion is used less frequently than and near targets.
Sheard's criterion in clinical practice, although Diagnosis of a binocular visin dysfunction
Sheedy and Saladin26 found it may have validity in rarely s made on the basis of a single test; like-
many esophoria cases. wise, a prism seldom is prescribed unless a num-
Prism prescribed by the associated phoria crite- ber of criteria indcate the necessity for \\The
rion has been shown to be accepted by symptom- amount of prism power recommended by ech cri-
atic esophoric and exophoric patients in clinical terion often vares, and the clnician must use pro-
studies,27'28 but it is mportant that the test target fessonal judgment. When there is coherence
have both central and peripheral fusin contours. among cnteria, the decisin s relative easy, but
Sheedy's criterion (i.e., the fat portion of the when there s wide varation, the validity of each
FDC) has clinical utility, although we generally use criterion should be questioned. Often, retesting or
t when the other cnteria are inconsistent or they additional testing s required. Particularly n these
indcate unreasonable prismatic prescriptions. This situations, a prism confirmation procedure should
criterion lacks popularity largely because measure- be carried out.
ment and plotting of the FDC s time-consuming. We recommend the following procedure to test
Clinicians often work around this time-demanding the suitability of any particular prism: Many
obstacle by visualizing the FDC based on fairly patients with an oculomotor imbalance will imme-
routine findings (i.e., dissociated phoria, associ- diately experience some relief of their symptoms
ated phoria, and fusional vergence ranges). (See when a compensating prism of appropriate magni-
the discussion on visualizing the FDC n the sec- tude is ntroduced. If an esophoric patient's symp-
tion Fixation Disparity Analysis.) toms are related to reading, for example, a reading
We have had good experience using the associ- test card is given to the patient to view. Let us
ated phoria criterion (i.e., the minimum prism that assume that the associated phoria criterion indi-
neutralizes the fixation disparity) for the prescription cates 4A BO, so a lose prism of this amount would
of prism in esophoria, exophoria, and hyperphoria be used n the confirmation test. With the prism n
cases, although some clinicians disagree.39-40 The place, the patient s asked whether the print
prism amount we prescribe s derived from clinical appears to be clearer or whether visin s more
testing on fixation disparity targets having both comfortable than without the prism. The prism
92 Chapter 3

power that neutralizes a fixation disparity will usu- spectacle lens. This is best performed after the
ally make print appear closer.41 A valid prism pre- membrane and lens are washed and still wet. (Also
scription is ndicated when there is a strong see Chapter 11, under Optical Therapy, for discus-
acceptance response by the patient. To check for a sion and llustration.)
placebo effect, however, the prism direction is
reversed surreptitiously and again tried. Validity is
confirmed if there is strong rejection of the
VERGENCE ANOMALIES
reversed prism. If, however, the patient accepts the
reversed prism, further triis with different prisms The predominant classification system for ver-
are necessary. If no prism is accepted by this con- gence disorders is based on the tonic deviation of
firmation procedure, the prescription of prism is the eyes and the AC/A ratio. It is used to describe
often unwarranted. Other approaches to resolving both strabismic and heterophoric cases and is
the patient's problem might be recommended widely accepted in optometry and ophthalmology
(e.g., visin training, lens power additions, chang- and by interested third-parties (e.g., insurance
ing viewing conditions, or referral for a general companies). Duane42 first proposed this model of
health examination). classification, which clinically is called the Duane-
If, after applying these prism-prescribing meth- White classification. Schapero43 also used this
ods, a question still remains regarding whether a model as a basis for his 10 case types. Duane pro-
prism is appropriate, a prism adaptation test may be posed that a difference of at least 10A between the
helpful in resolving the issue. Heterophoric patients far and near deviations was necessary before a
having normal binocular visin with no ocular patient should be classified into one of his four
symptoms typically show strong prism adaptation. original categories. Other writers have suggested a
After wearing a prism for approximately 10 minutes, 15A difference between far and near, and many cli-
they often will have the same, or nearly the same, nicians use 5A. We prefer to use a 5A difference or
phoria as originally measured. For example, if a 6A greater between the deviations at far (6 m) and
exophoric patient with normal binocular visin near (40 cm) to indcate the presence of an abnor-
wears a 6A Bl prism (which initially neutralizes the mally high or low AC/A ratio.
angle of deviation) for a short period, the examiner The larger vales typically are used by oph-
typically finds the phoria to be increasing, resulting thalmic surgeons, as the desired level of accuracy
in another 4A to 6A of exo deviation. The prism in surgical procedures is approximately 10A. Com-
would be ineffective, because that patient reverts to pensation of the angles of deviation with prisms
the habitual phoria through the spectacles. Con- and added lenses, however, is more refined and
versely, symptomatic patients with vergence prob- often the therapy of choice. For example, if a
lems usually benefit from prism compensation and symptomatic patient with an IPD of 60 mm mani-
do not typically show significant prism adaptation. fests orthophoria at far and 10A esophoria at near,
If a prism, worn for 10 minutes, contines to neu- the calculated AC/A ratio is 10A/1 D. This conver-
tralize the angle of deviation, then that prism estab- gence excess often is treated with a bifocal add,
lishes an acceptable physiologic relation between using the effect of the high AC/A ratio to reduce the
the heterophoria and the compensating vergence, near deviation. However, if the same symptomatic
relieving the oculomotor stress. Complete prism patient measured ortho at far and 5A esophoria at
adaptation, when it occurs, usually is complete near, the calculated AC/A ratio would be 8 A/1 D,
within 24 hours, but most of the adaptation occurs which is considered to be high by Morgan's nor-
within the first 10 minutes. This test is, therefore, a mative data. Added lenses at near remain an ideal
relatively quick clinical procedure. The results of management approach. We believe a 5A difference
this test are not always clear-cut, and interpretation between near and far deviations is consistent with
often is difficult. At times, this can be a good backup optical treatment approaches, and so we prefer
test of prism acceptance, but professional judgment this amount for the sake of clinical categories of
remains necessary. vergence anomalies. This assumes that there are
Applying Fresnel prisms to spectacle lenses can symptoms and visin inefficiencies resulting from
also be used for prism adaptation testing and, the vergence anomalies. Implicit in any of the
occasionally, for permanent wear. The smooth side Duane-White categories is poor compensatory
of the membrane is placed on the ocular side of a fusional vergences.
Chapter 3 93

This classification system usually s based on

angles of deviation measured by the altrnate
cover test, not phorometry. The angles of deviation
should be measured in an open-space environ-
ment. Instrument convergence and accommoda-
tion effects may invaldate the measurements of
tonic vergence and accommodative convergence.
Although the categories apply to cases of strabis-
mus as weli as heterophoria, the following discus-
sion of management recommendations is primarily
for cases of heterophoria. -2O -1O 10 20 30 40 50
CONVERGENCE (A)

Convergence Insufficiency FIGURE 3-14Convergence nsufficiency representad graphically.

Convergence insufficiency (Cl), or convergence Classic graphica! analysis, which is a two-dimensional model of
binocular visin in terms of the relation between accommodation
insufficiency exophoria as it is sometimes called, is
and vergence. (AC/A = accomodative-convergence/accomodation.)
characterized by a low AC/A ratio resulting in an
increased exophoria at near viewing distances
(Figure 3-14). A symptomatic patient showing
orthophoria at far and 5 A exophoria at 40 cm symptomatic presbyopic patients are untreated.
would be an example. Other clinical findings asso- This neglect is nappropriate. Two extensive studies
ciated with Cl include a reduced PRC, a reduced showed very positive outcomes with visin train-
NPC (poor gross convergence), and deficient ing.45'46 Further evidence was supplied by Grisham et
accommodative responses.44 Vision training is the al.29 who prescribed two pairs of bifocal specta-cles
treatment of choice for most Cl cases. There s to symptomatic presbyopic individuis with
abundant evidence in the literature that this s exophoria. One pair had a prism amount equal to
effective.44 Because the AC/A ratio is low, added the associated phoria at near and the other was
lenses (e.g., minus power) are of little valu. Prism identical except there was no prism. The individu-
prescriptions have the disadvantage in these Cl is wore the two pairs of spectacles alternately for 2
cases by inducing an esophoria at far. Sometimes t weeks and then had to return one pair. Of the 12
is advisable for patients presenting with accommo- subjects, 10 chose to keep the prism spectacles for
dative insufficiency and Cl to have a reading add reasons of visual comfort, a result that Ilstrales
together with Bl prism for nearpoint use only. our point. It was also found that the two individuis
However, these patients also respond well to who returned the prism spectacles were uncomfort-
visin training. Some Cl cases sometimes present abie because the prism, although helpful at near,
with a large exo deviation (low tonic convergence) had induced a significant esophoria at far. Those
at far, combined with a low AC/A ratio. These are two would have been better managed with single-
the cases that most likely benefit from a Bl prism vision reading lenses that included the Bl prism.
prescription (relieving the exo deviation at far) in
conjunction with visin training to improve
fusional convergence at near. Basic Exophoria
Another similar Cl case type, usually ignored in Basic exophoria refers to cases n which the tonic
most classification systems, is presbyopic exopho- position is exophoric at far and the AC/A ratio is
ria. Most aging presbyopes show increases in their normal. The far and near exo deviations are
exophoria at near. Often there is reduced PRC, and approximately equal in magnitude. An example
these patients develop classic symptoms of Cl (e.g., would be a symptomatic patient who presents with
tired eyes, sleepiness when reading, and avoidance 8A exophoria at 6 m and 8A exophoria at 40 cm
of near work). Unfortunately, most clinicians and (Figure 3-15). The basic exophoria patient may
the patients nterpret these symptoms as part of the experience visual symptoms at both far and near.
normal aging process. If a young person presented Much clinical literature indicates that significant
with typical Cl symptoms, visin training would exophoria is more prevalent in people experienc-
likely be recommended. We believe that many ing reading difficulties.47 Because fusional conver-
Chapter 3

_
For example, with prolonged occlusion, a nearpoint
S
S 7 BLUR O / / ,' deviation of 3A exophoria may increase to 10A exo-
Z A
RECOVCRY
PHORIA X / ( / /
phoria. If the far exo deviation is 10A, the correct
/ diagnostic category would be basic exophoria. A
Q / \/ ' /
1 e
' s spasm of fusiona! convergence at near is one possi-

^
y
f ble explanation for a spurious result from the initial
o* / ' f ' /
S3 J S s .^ c^ cover test. Prolonged occlusion is necessary for
0 convergence to decrease sufficiently to reveal the
5 /^ s r'"
01 /
2
y / ' / full magnitude of the exo deviation at near. There-
y
fore, these apparent cases of divergence excess are
<1 - -f
0
^Xc/
)
0
'
D 0 0 0 called s/mu/aed divergence excess, also known as
0 1
3
(C ONV 3 2 4 5 pseudo-divergence excess.
E RGE 2E ( In the case of true divergence excess, which
N
A indeed has a high AC/A ratio, the patient may experi-
ence esophoric problems at very near viewing dis-
FIGURE 3-15Basic exophoria representad graphically.
tances (see Figure 3-16). If fusin is maintained most
of the time at far and the AC/A ratio is not extremely
gence can easily be expanded, visin training for high, divergence excess patients often respond well
exophoria (and intermittent exotropia) is effective to visin training, but they are not generally as suc-
in tnese cases. Bl prism is also effective in manag- cessful as patients with other types of exo deviations.
ing basic exophoria if there is little prism adapta- In some cases, a minus add prescribed overall helps
tion, because it reduces the convergence demand the patient to control the far deviation, acting through
equally at all distances, and the amount of needed the high AC/A ratio, but the amount of overminus
prism usually is not excessive. must be carefully considered so as not to induce an
esophoric problem at near. Bl prisms, too, may be
useful, but there remains the same reservation about
Divergente Excess inducing an esophoria at near. Many clinicians rec-
Divergence excess exophoria is indicated when a ommend plus-add bifocals along with visin training
significantly large exo deviation at far is combined in the management of divergence excess cases (see
with a high AC/A ratio. If a patient presents with Chapter 14).
10A exophoria at far and 3A exophoria at near and,
after a prolonged occlusion test of 10 minutes, the
deviations do not significantly change, then diver- Divergence Insufficiency
gence excess is indicated (Figure 3-16). Divergence insufficiency esophoria is the least
Some patients presenting with divergence excess prevalent of the esophoria cases. It is defined as a
actually nave s/mu/ated (pseudo) divergence excess. significant esophoria (high tonic convergence) at
far, combined with a low AC/A ratio. An example
would be 12A esophoria at far and 3A esophoria at
near (Figure 3-17). These patients can lapse into an
occasional esotropa at far if fusiona! divergence is
BUO
/
(,/' poor. For them, driving a vehicle, particularly at
ACCOMMODATION (D)

BMUK Q
RECOVeilY
&PHORIA X
/ /y ' s night, can be a serious problem.
/^ Successful management of some cases of diver-
/ f ' s
S ^S
/ s gence insufficiency is difficult. One approach that
3-<>s>U<tkUiO-S09

S / s*~
t
seems moderately effective is to prescribe BO prism
y ^ correction in single-vision lenses for general wear.

* ^
------- ------- -------
/
-
^ A
~
^ ^ For example, this may be 8A BO if the far esophoria
'
-X
X-
S / ^ is 12A. If there is no prism adaptation, the resulting
-2O "-IO o" 1O
^ _^
Jf**r

20
^ 3O 4O SO farpoint esophoria would be 4A, which considerably
CONVERGENCE (A) reduces the fusiona! divergence demand. However,
with these spectacles in place, the near eso devia-
tion would measure 5A exophoria instead of 3A eso-
FIGURE 3-16Divergence excess represented graphically.
Chapter 3 95

8
BLUR O BRf
27 / 1
ts
AK Q
RECOVEflY A BLUR O
,f

ACCOMMODATION (D)
PHORIA X ! 1 BREAK Q / y
RECOVERY A

s: / /
PHOHIA X
1 S'/
1 1 / / / ,'
/ S
/
4
o J ' / ',' / /
1

3->N>UklnO>NCD
0 / / /
9
fi
~Y
sL
/ f^
/
-j
~Y
/,
3 ^ - -
u '
1 s - */ -S 7>-
/
^' J /s 10" J
^
/.'
Y/
/
//
-20 -10 "O 20" 30 4O 50 n
-20 -10 "0 *s ^20 3O 40 50
CONVERGENCE (A) ^
CONVERGENCE (A)

RGURE 3-17Divergence insufficiency represented graphically. FIGURE 3-18Basic esophoria represented graphically.

phoria. This amount s not excessive by Morgan's report experiencing nearpoint problems because
norms, but caution is needed in that an nduced exo the esophoria increases dramatically as the view-
deviation at near s not compatible with the esopho- ing distance becomes closer. Eyestrain, blurring,
ria at far. A visin training goal to necease diver- and ntermittent diplopia often are reported. These
gence ranges would be preferable, but sometimes patients are vulnerable to developing an accom -
BO prism s required to maintain comfortable fusin modative esotropa. Associated findings include
fbr sustained viewing at far distances. (Therapy for low NRC, low PRA, high NRA and, possibly,
divergence insufficiency is discussed in Chapter 13.) esotropa at very near fixation distances. Latent
hyperopia also s frequently associated with con-
Basic Esophoria vergence excess; therefore, cycloplegic refraction
is advisable n most cases of convergence excess.
Bas/c esophor/a is characterized by a significant eso
Usually the full hyperopic refractive error must be
deviation at far and a modrate AC/A ratio, so that
corrected f it measures +1.00 D or more. Because
the far and near angles of deviation are approxi-
of the high AC/A ratio, plus-add bifocals usually
mately equal. An example would be esophoria of
are indicated for reading and other nearpoint
1P at all viewing distances (Figure 3-18). Other
activities. The amount of the add should be deter-
associated findings often include reduced NRC, a
mined empirically by measuring with the cover
low PRA, and high NRA. BO prism s an obvious
test and listening to subjective reports of improve-
and safe treatment approach in basic esophoria and
ment of visin and comfort. BO prism may also be
usually is effective, because most symptomatic eso-
phores do not adapt to prisms. Vision training s also
useful in combination with prism prescription.
Without the prism, completion of divergence train- BLUM O
SCOMMODATION (D)

ing often takes several months, and there can be fre-

quent regression of fusional divergence skills. If the
BREAK
BECOVERT
PNOMA
Q
^
X
^
basic esophoria patient is symptomatic only at near
'S ^
due to work requirements (e.g., computer or desk
'K>U4>UiO>S|Ca|

work), a reading add (either single-vision lenses or

^^
* s >
^
bifocals) may also be considered. s. ^ ^.
------- ------- ------- &-^ : ___ a^L_.

S' ^/-. ^- ^

1

Convergence Excess ^ r^
< ^ ^
Convergence excess esophoria is the case that typ- -2O -1O "( ^
id" 2O 30 40 50
cally presents with little or no esophoria at far but CONVERGENCE (A)
with a high AC/A ratio. An example would be
A
orthophoria at far and 7 esophoria at near (Figure
3-19). Patients with convergence excess often FIGURE 3-19Convergence excess represented graphically.
96 Chapter 3

MODATION (D)
/; ' / /
BLUR O

ACCOMMODATION (D) 3-
BHEAK O
HECOVERV A
i* * Wi 0> S 09 | PHORIA X
/
/
/
^
BLJUR
BdtAK
O
O
/ / S
'
y// RECOVEflT A
/
PHOBIA X J /
,'

/S J S / /
//.
ty / /

<iouuio>Nea
/ / ,
S /

5 & / /,
*
O
0 2
y' -^ <^f s'
^f

V'' rV
0 J
^ / ^ '

/'
-20
CONVERGENCE (A)
-1O ""$"10 2O 3O 40 5O
' X
-20 ^ 0 O" 20 30 40 SO
CONVERGENCE (A)

FIGURE 3-20Restricted zone representad graphically. FIGURE 3-21Symptomatic patient with normal zone of clear,
single, binocular visin represented graphically.

necessary if there s a significant eso deviation at If the condition proves to be caused by accom-
far. Vision training is recommended to break any modative and vergence dysfunctions, visin train-
suppression and to expand the range and facility of ing is recommended. This mode of visin therapy
fusional divergence. Frequent progress checks after is usually successful within a matter of a few
training usually are indicated, as regression may weeks. The visin training goal would be to
occur in the absence of an active home mainte- expand the range of the entire ZCSBV and
nance program of visin training. improve the facility of all oculomotor functions.

Basic Orthophoria with Normal Zone with Symptoms

Restricted Zone Schapero43 also discussed the case of symptoms
43
Schapero discussed restricted zone cases, which but no s/gns, in which a patient presents with
he described as basic ortho cases with restricted symptoms that sound uniquely binocular in nature
fusional vergences and patient-reported visual but clinical testing fails to find any component of
symptoms. Heterophoria may be present, but its the ZCSBV that is deficient by clinical standards
magnitude is insignificant at far and near. The (Figure 3-21). Accommodative and fusional ampli-
NRC or PRC or both are deficient, as can be the tudes are normal. No significant heterophoria is
NRA and PRA. Sometimes the entire zone is measured, and the NPC s within 8 cm of the
found to be restricted (Figure 3-20). These bridge of the nose. The clinician must search for
patients often report visual fatigue after prolonged other possibilities before concluding that the
detailed visual activity and intermittent blurring, patient has psychogenic problems (e.g., hysteria,
particularly when changing fixation distance. malingering, or emotional instability). Some ques-
Reduced accommodative amplitude and facility tions and recommendations follow: Is there either
are often found. The etiology usually is functional latent hyperopia or pseudomyopia? Presence of
in that the patient's visual demands surpass his or either condition can be assessed with cycloplegic
her physiologic oculomotor and fusional capabil- refraction. Is there a latent phoria? Testing for this
ities. It must be kept in mind that the same clini- condition is by prolonged occlusion. Is there poor
cal findings and visual symptoms can result from accommodation or vergence stamina? The patient
drug side effects and general health conditions should be tested at the end of the workday.
(similar to those affecting accommodation that To determine whether the symptoms are truly of
were discussed in Chapter 2). Carefully obtaining binocular origin, the patient should be instructed
a patient history is necessary for differential diag- to wear a patch over the nondominant eye on
nosis. There may also be refractive causes of a altrnate days and to keep a log of resulting symp-
restricted zone, such as uncorrected astigmatism, toms. If symptoms decrease, some type of binocu-
uncorrected anisometropia, and aniseikonia. lar dysfunction is indicated. If symptoms remain
Optical management is ndicated n these cases. the same or increase, then other causes must be

Sst
Chapter 3 97

dentified (e.g., general health problems, drug One of the most useful research tools of bioengi-
reactions, or psychological distress). Sometimes neers is to build mathematic control models of bio-
diagnostic visin therapy can be undertaken to logical systems and then to compare them with
determine whether symptoms decrease. If the final empiric physiologic evidence. The model s modi-
conclusin s that the symptoms are not of binocu- fied until ts features accurately simlate physio-
lar origin, a referral for a medical or psychological logic responses and are consistent with what s
evaluation s n the best interest of the patient. known aboutthe anatomy of the biological system.
Several mportant insights have evolved from the
relation between control systems modeling and
physiologic evidence.
BIOENGINEERING MODEL The accommodative system of the eyes and the
Maddox48 believed that the vergence system could vergence system are cross-linked and dynamically
be categorized by four additive components tonic, influence each another. Accommodation drives
accommodative, proximal (psychic), and fusional convergence (AC/A) and convergence drives
(disparity) vergence. Graphical analysis based on accommodation (CA/C). When both systems are
this concept was developed gradual ly by several stimulated simultaneously, the cross-links interact
notable individuis such as Percival, Sheard, Mor- and respond differently from when either system is
gan, Fry, and Hofstetter and became the scientific stimulated n isolation.49 Classic graphical analysis
bundation for binocular case analysis. We have has not taken into account this dynamic relation-
emphasized the graphical analysis perspective in ship and has largely gnored the influence of the
this chapter and adapted the Duane-White classifi- CA/C. Nevertheless, clinicians have long been
cation scheme to heterophoric disorders. We also aware that disorders of accommodation and ver-
applied Morgan's normative analysis, which s con- gence often are associated.
sistent with classic graphical analysis. In Chapter 2, Stimulation of some adaptive mechanisms for
the emphasis was on evaluating various oculomotor the AC/A, CA/C, and fusional vergence result in
systems over time, testing the dynamic components tonic changes n both accommodation and ver-
of each system. Accuracy, speed, and stamina were gence. Therefore, there are both momentary and
distinctive clinical features n that analysis. These more lasting adaptations to prism and lens stimuli;
two perspectives, graphical analysis and visin effi- a particular patient's physiologic responses to
skteA toes os ^'ms cm^te 3m\u\aty \K&-
each delinales visual functions, and disorders dicted in all conditions of clinical management.
thereof, that the other may neglect. For example, Schor50 suggested that the lack of vergence adapta-
disorders of accommodation, other trian accommo- tion s an mportant, if not the most mportant,
dative insufficiency, are ignored by classic graphical characteristic of patients having vergence disor-
analysis. Vision efficiency analysis of accommoda- ders. Clinical observations that are consistent with
tion, however, includes evaluation of lag of accom- this viewpoint include the finding that a steep FDC
modation (accuracy), facility (speed), and stamina s one indicator of resistance to "good" vergence
(sustainability). adaptation and that good vergence adaptation may
Originating in the 1950s, fixation disparity anal- increase when visin training s successfully com-
ysis tended to reinforce and supplement the ver- pleted.51 In other words, prism adaptation does
gence evaluation of graphical analysis. Graphical increase and the FDC tenas to flatten with train-
analysis and fixation disparity analysis emphasized ing.52 What we mean by "good" vergence adapta-
different aspects of vergence and accommodative tion must be distinguished from "bad" prism
dynamics, but the systems were intimately related, adaptation, which normally takes place n symp-
as they both described the same underlying oculo- tom-free individuis with normal binocularity n
motor physiology. What has become clear since which a compensating prism will be "eaten up."
the time of Maddox s that vergence and accom- For this reason, prisms are considered poison for
modative physiology, and disorders thereof, are compensaron unless they are absolutely neces-
substantially more complex than Maddox origi- sary. A prism should not be prescribed n cases of
nally formulated. This realization has largely come heterophoria unless there are symptoms (associ-
to light through a bioengineering systems control ated with vergence dysfunction) that can be
approach used in basic research. relieved by lessening the vergence demand with
98 Chapter 3

^ +

Desired
Accommodative . Accommodative
Level Response

Desired ""
Vergence
Level
Vergence
^ Response

Ciliary
+ Blur
Detectors
Accommodative
Controller
Slow
Adaptation
Musce and
Leus

FIGURE 3-22Theoretical bioengineering model llustrating interaction between accommodation and vergence in a closed-loop system. (Mod-ified
from JJ Saladin. Horizontal Prism Prescription. In: Clinical Uses of Prism. SA Cotter, ed. St. Louis: Mosby; 1995:123.)

this optical compensation. Cood vergence adapta- (e.g., fixation disparity testing). Wick and London54
tion relates to visin training n which increased suggested that an improved graphical analysis
prism demand (rather than compensating prism) s approach would result from plotting and evaluat-
introduced for the purpose of increasing fusional ing a graph of the associated gradient AC/A ratio
vergence ability and, ultimately, favorably affecting (derived from FDCs), the proximal vergence ratio,
tonic vergence. and far and near FDCs. Such an approach may
The influence of proximal vergence on near- indeed prove to be a significant mprovement over
point vergence eye position has been largely traditional methods, but ts incorporation into a
ignorad n classic case analysis, yet in some practica! clinical examination probably awaits
patients the amount of proximal vergence can sig- technologic advances that would allow oculomo-
nificantly influence the associated phoria status, tor measurements to be easily taken and tran-
for better or worse.53 Wick and London54 proposed a scribed directly nto a computer program for
versin of the Hung-Semmelow model of nter- analysis.
actions between accommodation and vergence We have drawn our concept of a very simplified
that takes into account the influence of proximal hypothetical model (Figure 3-22)modified from
convergence. They emphasized that one difficulty other bioengineering models, particularly that of
with the traditional system of binocular case analy- Saladin56to Ilstrate the possible interaction
sis is that the vergence deviation that exists under between accommodation and vergence and the
binocular (associated) conditions often s not the ways in which responses may be affected by the
same as that measured under dissociated viewing nteraction between accommodative convergence
conditions (e.g., Maddox rod test). They joined and convergence accommodation as well as feed-
Saladin55 in a strong appeal for evaluating binocu- back nformation, accommodative and vergence
larity under closed-loop (associated) conditions adaptations, and proximal convergence.
Chapter 3 99

We believe it s expedient to evalate binocular Soulhern California College of Oplometry, Fullerlon,

visin using the techniques of classic case analysis Calif., 1972.
15. Sheedy JE. Fixalion disparily analysis of oculomotor
and visin efficiency analysis. If clinical findings
imbalance. Am J Optom Physiol Opt. 1980;57:623-639.
point to a dysfunction of accommodation, ver- 16. Franlz KA, Scharre JE. Comparison of Disparomeler fixa
gence, or their interactions, a complete fixation lion disparily curves as measured wilh and wilhoul the
disparity evaluation is recommended. With this phoropler. Optom Vis Sci. 1990;67:117-122.
baseline clinical data and the analysis procedures 17. Dillemore D, Crum J, Kirschen D. Comparison of fixation
disparily measuremenls oblained wilh Ihe Wesson Fixa
recommended n this chapter, we believe the clini-
lion Disparily Card and Ihe Sheedy Disparomeler. Optom
cian has sufficient tools for successful and efficient Vis Sci. 1993;70:414-420.
treatment of the vast majority of nonstrabismic bin- 18. CooperJ, FeldmanJ, Horn D, DibbleC. Reliabilily of fixa
ocular anomalies. In patients who do not respond lion disparity curves. Am J Optom Physiol Opt.
to visin therapy as expected, t is always prudent 1981;58:960-964.
to retest, re-evaluate, and reconsider other 19. Kwan LK, Lam AK, Kwan CK, Yeung PH. The characlerislics
of near prism induced fixalion disparily curve in Hong
approaches to visin therapy, including referral to Kong Chnese. Ophthalmic Physiol Opt. 1999;19:393-
other professionals when indicated. Flexibility n 400.
the clinical approach s another lesson to be 20. Wick B. Forced vergence fixalion disparily al dislance
learned from our new appreciation of the com- and near n an asymplomalic young adull populalion. Am
plexity of binocular visin nteractions, as sug- J Optom Physiol Opt. 1985;62:591-599.
21. Wick B, Jouberl C. Lens-induced fixalion disparily curves.
gested by bioengineering models.
Am i Optom Physiol Opt. 1988;65:606-612.
22. Sheedy JE. Aclual measuremenls of fixalion disparily and
ils use in diagnosis and Irealmenl. J Am Optom Assoc.
REFERENCES 1980;51:1079-1084.
1. Donders FC. On the Anomalies of Accommodation and 23. Morgan MW. Anomalies of Ihe Visual Neuromuscular
Refraction of the Eye, trans. Moore WD. London: The Syslem of Ihe Aging Patient and Their Correclion. In:
New Sydenham Society; 1864. Vision of the Aging Patient. Hirsch M, Wick R, eds. Phila
2. Morgan MW. The Maddox classification of vergence eye delphia: Chilln; 1960:125.
movements. Am J Optom Physiol Opt. 1980;57:537-539. 24. Saladin JJ. Phoromelry and Slereopsis. In: Borish's Clinical
3. Flom MC. Treatment of Binocular Anomalies of Vision. In: Refraction. Benjamn WJ, ed. Philadelphia: WB Saunders;
Vision of Children. Hirsch M, Wick R, eds. Philadelphia: 1998:729.
Chilln; 1963:216. 25. Grisham JD. The dynamics of fusional vergence eye
4. Sheard C. Ocular discomfort and its relief. EENT. movemenls in binocular dysfunction. Am J Optom Phys
1931;7. iol Opt. 1980;57:645-655.
5. Morgan MW. Analysis of clinical data. Am J Optom Arch 26. Sheedy JE, Saladin J. Validity of Diagnoslic Crileria and
Am Acad Optom. 1944;21:477-491. Case Analysis in Binocular Vision Disorders. In: Vergence
6. Morgan MW. Accommodation and convergence. Am J Eye Movements. Schor CM, Ciuffreda KJ, eds. Boslon:
Optom Arch Am Acad Optom. 1968;45:41 7-491. Bullerworlhs; 1983:517-540.
7. Sheedy JE, Saladin JJ. Phoria, vergence, and fixation dis 27. Worrell BE, Hirsch MJ, Morgan MW. An evalualion of
parity in oculomotor problems. Am J Optom Physiol Opt. prism prescribed by Sheard's crilerion. AmJ Optom Phys-
1977;54(7):474-478. iolOpt. 1971;48:373-376.
8. Percival AS. The Prescribing of Spectacles. Bristol, U.K.: 28. Payne CR, Grisham JD, Thomas KL. A clinical evalualion of
JohnWright; 1928. fixalion disparily. AmJ Optom Physiol Opt. 1974;1:88-90.
9. Ogle KN, Martens TG, Dyer JA. Oculomotor Imbalance 29. Grisham JD. Trealment of Binocular Dysfunclions. In:
in Binocular Vision and Fixation Disparity. Philadelphia: Vergence Eye Movements. Schor KM, Ciuffreda KJ, eds.
Lea & Febiger, 1967:145-151, 328-331. Boslon: Bullerworlhs; 1983:626-627.
10. Schor CM, Ciuffreda KJ, eds. Vergence Eye Movements: 30. Daum KM. The stability of Ihe fixalion disparity curve.
Basic and CHnical Aspects. London: Butterworths; Ophthalmic Physiol Opt. 1983;3:13-19.
1983:467. 31. Rulslein RP, Eskridge JB. Sludies in vertical fixalion dis
11. Mallett RFJ. The invstigation of heterophoria at near and a parily. AmJ Optom Physiol Opt. 1986;63:639-644.
new fixation disparity technique. Optician. 1964;148:547- 32. Garzia RP, Dyer G. Effecl of near-poinl slress on Ihe hori-
551. zonlal forced vergence fixalion disparily curve. Am J
12. Morgan MW. Anomalies of Binocular Vision. In: Vision of Optom Physiol Opt. 1986;63:901-907.
Children. Hirsch MJ, Wick RE, eds. Philadelphia: Chilln; 33. YeklaAA, Pickwell LD, JenkinsTCA. Binocular visin, age
1969:176. and symploms. Ophthalmic Physiol Opt. 1989;9:115-
13. Col RG, Boisvert RP. Effect of fixalion disparity on ste- 120.
reo-acuily. Am] Optom. 1974;51:206-213. 34. Yekla AA, Jenkins T, Pickwell D. The clinical assessmenl
14. Levin M, Sullan B. Unpublished snior sludent research of binocular visin before and afler a working day. Oph
study. On file in Ihe M.B. Kelchum Memorial Library, thalmic Physiol Opt. 1987;7:349-352.
chapter4 / Strabismus Testing

History 101 = Signs and Symptoms 121 -"

Time of Onset 102 Diplopia 121
Modeof Onset 102 Abnormal Head Posture 121 .
Duration of Strabismus 103 Subjective Testing 122 Single-
Previous Treatment 104 Object Method 122 Two-Obfect
Developmental History 104 Method 123 Frequency^f the
Summary of Clinical Questions 105 Deviation 126 Classifcation
Measurement of Strabismus 105 126 Evaluation 127 Patient
Direct Observation 105 History 127 Testing 127
Angle Kappa 105 Direction of the Deviation 128
Hirschberg Test 106 Classification 128 Obective
KrimskyTest 107 Testing 128 Subjective Testing
Unilateral Cover Test 107 129 Magnitude of the Deviation
Altrnate Cover Test 108 130 Classification 131 Testing
Four Base-Out Prism Test 109 Procedures 131
Brckner Test 110 Accommodative-Convergence/
Comitancy 110 Accommodation Ratio 132 Eye
Causes 110 taterality 132 Eye Dominancy
Criteria and Terminology 111 133 Variability of the Deviation
Primary and Secondary Deviations 112 133 Cosmesis 133
Ductions 113
Versions 115
Three-Step Method 115
Recording Noncomitant Deviations 118
Spatial Localizaron Testing 121

When the status of a patient's strabismus is evaluated, HISTORY

the first step is to make a diagnosis of the deviation.
Much nformation aboutthe strabismic deviation can Resides giving tentative determinaron for each of
be obtained by a careful case history. After that, the aforementioned variables, a patient history s
objective testing can verify nine mportant diagnostic needed to assess the time of onset of a manifest
variables: comitancy, frequency, direction, magni- deviation, its mode of onset, its duration, previous
tude, accommodative-convergence/accommodation treatment and results, and pertinent developmental
(AC/A) ratio, eye laterality, eye dominancy, variability, history that may have a bearing on the binocular
and cosmesis. status of the patient.
102 Chapter 4

Time of Onset time of onset is mportant in the prognosis for func-

A vital part of any strabismus diagnosis is to ascertain tonal cure, the clincian must differentiate infantile
whether the strabismus s congenital. More correctly, from later-acquired esotropa. When the history fails
congenital strabismus should be referred to as essen- to pnpoint the onset of esotropa, certain testing may
tial infantile strabismus because, in many such cases, indcate whether the esotropa was essential infantile
the manifest eye turn s not present at the time of or acquired: Some possble characteristics of essen-
birth. In cases of essential infantile strabismus, clini- tial infantle esotropa can be compared with those of
cal experience with visin therapy, including surgery, acquired esotropa (Table 4-1). These findings are
has shown that the prognosis for normal binocular useful when the patient history s insufficient. It also
visin s very poor unless treatment occurs very early. may be helpful to have parents bring early childhood
We believe that the age of 4 months is the critical photographs for nspection, partcularly those taken
cutoff between essential infantile and early acquired before the child reached the ages of 1 and 2 years.
strabismus, because by that time the accommodation The prevalence of essental infantle exotropia s
has developed to a large degree. The classification of lower than that of nfantile esotropa. Onset of
late acquired strabismus pertains to occurrence of acquired exotropia, however, may be early, often
strabismus beyond the age of 2 years. For example, before the age of 2 years.
an infant with intermittent esotropa at 6 months of
age may have an accommodative-convergence com-
ponent that results n the strabismus. For children 2 Mode of Onset
years of age and younger, parents should be ques- It is important to know whether the strabismus was
tioned to determine the specific month of onset. For intermittent or constant when t became apparent. An
example, an essential infantile esotropa at birth intermittent strabismus is relatively more notceable
probably has a poorer prognosis for cure with early than one of equal magnitude that s constant and
treatment (e.g., surgery before age 2 years) than if the unchanging. Although an intermittent strabismus may
onset were at 4 months of age. In the latter case, the cause cosmetic concern, t has a less deieterious
nfant has presumably experienced 4 months of corti- effect on binocular function than does constant stra-
cal development for binocular visin. bismus. Even f treatment were delayed, t can be
To ascertain the time of onset, a complete report assumed that the child with an ntermittent manifest
of previous professional examinations should be deviation did not completely lose central binocular
obtained. However, this is not always possible and fusin, as would happen n constant strabismus. This
information from parents, relatives, and friends is is a particularly important point for consideraron n
often erroneous. Pseudostrabismus can be confused cases of small-angle esotropa with a monofixation
with true strabismus; the appearance of esotropa pattern. Even though the eyes are apparently straight,
can be simulated by epcanthal folds, negative-angle a small constant esotropa may be present. Only
kappa, narrow nterpupillary distance, and other when peripheral fusin breaks down and the larger
cosmetic factors. Any of these factors can cause par- eso component is manifest will the esotropa be cos-
ents to beleve that their baby has esotropa, when n metically notceable. This seemngly ntermittent
fact there s only pseudostrabsmus. Further confu- esotropa s, nevertheless, constant.
sin as to time of onset s introduced when a pseu- Exotropia, on the other hand, tends to be either
dostrabismus later becomes an acquired strabismus. purely intermittent or constant; the deviating eye s
A patent history obtained from the parents s not likely to be either all the way out or all the way
always reliable for accurate tming of the onset. Par- aligned for bifoveal fxation. Mode of onset reported
ents can also be msled by the poorly coordinated in the history s usually more relable n cases of
eye movements usually present n the early postnatal exotropia than n esotropa. Early acquired exo
period, which can cause a report of congenital stra- deviations tend to be intermittent as compared with
bismus when, n fact, the infant's binocular status eso deviatons, which tend to have a sudden con-
was normal with respect to age. stant mode of onset. Typcally, an ntermittent exo
We believe the prevalence of infantile esotropa is devation that begins at approximately 2 years of
approximately 25% of all cases of constant esotropa. age contines to be ntermittent for many months.
In the majority of esotropes (whether constant or Frequently, intermittent exotropia n young children
intermttent), onset is after the age of 4 months and gradually becomes more frequent and may become
usual ly before 6 years but occasionally later. Because constant over time, unless visin therapy s insti-
Chapter 4 103

TABLE 4-1. General Guidelines for Characteristics That Might Differentiate between Essental Infantile
and Later-Acquired Esotropa

Essential Infantile Esotropa (birth^4 mos) Aequired Esotropa

Altrnating devation (often a midline switch) Unilateral deviation (in majority of cases)
Possible lack of any correspondence {often unable to prove Presence of correspoodence (either normal or
any correspondence wtth testing) anomalous)
Often no awareness of diplopta (only altrnate perceptfon of Diplopc awareness possible (true simultaneous
images) pereeption)
Double hyper deviation and often excyclorotation of covered No double hyper deviation (dissociated vertical deva--
eye (dissociated vertical deviation in majority of eases) tion possible but rare)
Insignificant refractive errors (occurring occasionally but as a Sgnifcant refractive errors (e,g., hyperopia causing
seprate component of the strabismus) accommodative esotropa)
Normal or low AC/A ratio (may be high, but usually normal) High AC/A rato (e.g., hgh ratio causing nearpoint
accommodative esotropa)
Little or no functional ambiyopia (alternating fixaton pre- Unilateral functional ambiyopia (constant unilateral
venting unilateral ambiyopia) strabismus causing ambiyopia)
AC/A = accommodative-convergence/accommodation.

tuted. An eso deviation of comparable magnitude, receive sympathy, or for other reasons designed to
however, often begins as a constant strabismus. gain something from others.
Whether the deviation was alternating or unilat- In the event that a patient has not been exam-
eral at the time of onset s an important fact to ined previously by another ophthalmologist or
establish, especially in the evaluation of ambiyo- optometrist and reports of the patient's refractive,
pia. An alternating strabismus is less likely to cause visual acuity, and binocular status are unavailable,
ambiyopia than is strabismus that s unilateral. The the practitioner must depend largely on the
onset of ambiyopia, therefore, cannot be equated patient's or parents' statements for any history. A
with the onset of alternating strabismus; a history good Une of questioning directed to parents of
of unilateral strabismus is more definitive n regard young patients is the following: "When the turning
to time of onset of ambiyopia. of the eye was first noticed, did the eye turn out
Reports of noticeable variations of the strabis- toward the ear or n toward the nose? Was it
mus angle may be useful. Changes of magnitude in always the same eye that turned, or did the other
different positions of gaze suggest an acquired eye turn some of the time? Was the turning more
paresis as the probable cause of strabismus. If, noticeable at different times of the day? Was t
however, the angle in the primary position is more noticeable when the child looked up, down,
reported to vary from time to time, the deviation to the left or right?" Answers to these questions
may be comitant and due to physical illness, emo- may indcate the mode of onset of strabismus.
tional disturbances, or other causes affecting the
tonic angle of convergence. For example, psy-
chogenic strabismus (either eso or exo) s a possi- Duration of Strabismus
bility, although psychogenic esotropas are much The duration of time elapsng between the onset of
more frequent than are psychogenic exotropias. a manifest deviation and therapy is a crucial factor
The conceivable way that an individual could n the re-education and recovery or further develop-
experience a psychogenic exotropia is by letting ment of normal binocular visin. This s particularly
go of fusin to allow the latent deviation to lapse so in the child younger than 6 years. We believe the
into an exotropia. This usually occurs in individu- best surgical results n infantile esotropa, as indi-
is who use this condition to get their way, to cated by long-term random-dot stereopsis, occur
104 Chapter 4

observed in all cases. It is very unwise just to let

TABLE 4-2. Information to Obtain from Patents with a things be, as valuable time is lost. For instance, a
History of Extraocular Muscle Surge/y case in which the onset is early and there is con-
stant unilateral esotropa, altrnate occlusion
might be prescribed as a measure for preventing
Age when surgery performed
amblyopia. Also, base-out (BO) prisms (e.g.,
Eye undergoing operation
Fresnels) should be considered as a holding action,
Right
particularly if the patient is below the orthoptic
Left
training age (younger than 4 years). In certain
Both
cases, the use of BO prisms may be undertaken in
Muscle(s) undergoing operation
conjunction with plus-lens therapy. If good binoc-
Technique (e.g., recession, resecton)
ularity cannot be recovered after a reasonable
Cosmetic appearance
period, extraocular muscle surgery may be the rec-
Preoperatively
ommended treatment.
Immediately postoperatively
Later postoperatively Functional result (much
depending on professional Previous Treatment
reports) Repeat precedng information for additional After questioning regarding time, mode, and dura-
surgeries tion of onset has been completed, another important
fact to determine from the patient history is the
extent and type of previous treatment that the patient
has actually received. However, treatment all too
primarily in those children with a short duration often is recommended but not sufficiently under-
between onset of strabismus and surgical interven- taken. Treatment usually takes the form of patching
tion. Clinical experience indicates that several an eye, but in many cases it is found to have been
months without bifoveal fusin can cause irrepara- inadequate. The lack of proper occlusion therapy
ble loss of central fusin to the infant or very young impedes recovery; in addition, a history of a patient's
child if treatment is delayed. When the duration is having been patched can lead to erroneous conclu-
inordinately long and visin therapy is delayed, sions on the part of a subsequent examining clini-
peripheral fusin may also be irrecoverable. cian. The second doctor may mistakenly conclude
The duration time factor is not as critica! in the that everything possible was done for the patient and
ages beyond the developmental years as it is in the that any existing amblyopia cannot be eliminated by
plstic years below the age of 6. Nevertheless, loss means of patching, as such therapy has been tried
of the faculty of bifoveal fixation is not uncommon without success. To avoid such incorrect assump-
in adults who have had to give up bifoveal fixation tions, questions regarding previous treatment must
over a long period for one reason or another (e.g., be pursued in depth. This rule applies not only to
unilateral cataract of long standing, acquired stra- occlusion therapy but to any of the other various
bismus of many years due to paresis). It is not forms of treatment for binocular anomalies. Table
always possible to regain bifoveal fusin, even 4-2 lists information that should be obtained when a
though the obstacles may cease to exist (e.g., good patient has undergone extraocular muscle surgery.
visual acuity after a cataract operation).
Total duration (time of onset to patient's current
age) and the time elapsing from onset to treatment Developmental History
must be differentiated. Although both time periods The purpose of obtaining a developmental history
are important determinants in prognosis for func- is to determine the important milestones at differ-
tional cure, the period between the time of onset ent ages in a child's Ufe. Of interest are the physi-
and the beginning of treatment is usually more cal, mental, and emotional development of the
important. If effective therapy is wisely and imme- individual mainly in the plstic years before age 6.
diately instituted, the chance for recovery of binoc- A developmental history may explain why a
ularity is greater than if treatment is delayed. This is patient has a particular binocular anomaly.
not meant to imply that treatment (e.g., surgery) Fisher1 stated that gross neurologic dysfunction
should be performed instantly and with reckless has been found in almost 25% of patients with infan-
abandon; rather, caution and discretion should be tile esotropa. In contrast, the prevalence of such
Chapter 4 105

JABLE 4-3. Typcal Questions in Patent History TABLE 4-4. Objective Testing Procedures for
Jfcgarc/fng Time and Mode of Strabismus Onset Detection of Strabismus in Ascending Order
of Sensitivity

i was the eye tyrn frst noticed? titn

inward or outward turning? tit just one Oirect observation
eye, or did either eye turn? Hirschberg test Krtmsky
eye turned, what percentage of time did the t test Four base-out prsm
eye turn, and what percentage did the teft turn? test Unilateral cover test
; turning take place atl the time or just some of Brckner test
time?
! turning was just some of the time, how often ft?
i any particular time or actvity that caused > they are cosmetically noticeable n most cases.
eye turn?
Deviations of less than 10A usually are not detect-
i eye turn gotten worse, more f requent, or r?
able by direct observation alone. Moderately sized
Itreatment was given, and what were the
angles may or may not be noticeable, depending on
s?tare the cosmetic toncerns, symptoms, or
other factors such as angle kappa and epicanthal
other
folds. A great problem with reliance on direct obser-
vation is that pseudostrabismus often is confused
with true strabismus by this method. More sensitive
testing s required, such as the Hirschberg test,
ing anomaiies is low n cases of acquired which involves evaluation of angle kappa.
>ia. Henee, a history of neurologic signs
may i infantile strabismus. A mild lag in
neurologic nent may produce detrimental Angle Kappa
factors n the lent of good binocularity. A Angle kappa s the angle between the visual axis and
developmental ' can be important in many the pupillary axis. It s practically the same as angle
cases of strabismus. alpha, which is the angle formed at the first nodal
point by the intersection of the optic axis and the
visual axis. Because angle alpha cannot be measured
rniary of Clinical Questions
by clinical means, angle kappa is the traditionally des-
4-3 outlines sample questions on a typical il
ignated clinical term, although technically the clini-
form for the purpose of strabismus diagno-
cian is measuring angle lambda (the angle subtended
Each of these questions can be explored n
at the center of the entrance pupii of the eye by the
but the basic format s similar n most cases i
intersection of the pupillary axis and the visual axis).
strabismus testing s begun.
The magnitude of angle kappa (actually lambda)
customarily is referred to in terms of millimeters
UREMENT OF STRABISMUS rather than prism diopters (A) or degrees. Although
the normally expected magnitude s from 0.25 mm
il methods may be used for detection of strabis-Some positive (nasalward) to 0.5 mm positive, there s
are more sensitive than others, meaning tdetection is nothing abnormal about a larger or smaller angle
more likely using those methods. For ampie, the kappa (even a negative, or temporalward, angle)
unilateral cover test s more likely to strabismus provided the magnitude is the same for each eye.
than s direct observation. Objec- methods are The distance in millimeters between the corneal
Usted in Table 4-4, and the relative 9BBtvity for reflection of the fixated penlight and the center of
detection of each is shown. the pupil determines the magnitude (Figure 4-1).
Testing is performed monocularly under dim room
Observation illumination. The patient fixates a penlight at a dis-
Horizontal manifest deviations greater than 20A can tance of approximately 50 cm. The examiner's sight-
be detected by observation alone, because ing eye must be directly behind the light source. The
position of the corneal light reflection n relation to
106 Chapter 4

Hirschberg attempted to quantify the strabismic

FIXATION
PUPILLARY
angle by comparing the first Purkinje image (clini-
LIGHT cally referred to as the corneal reflex), located in the
K! AXIS
entrance pupil of the fixating eye, with the apparent
location of the corneal reflex on the deviating eye.
O.D. Because the cornea acts as a small convex mirror, a
virtual image of the bulb of the penlight is formed.
The reference points for judging the position of the
reflection on the strabismic eye include the center
of the pupil, the pupillary margin, and the limbus. In
the past, guidelines for quantification were used:
For example, a reflex appearing to be on the tempo-
ral limbus of the deviating eye was estimated to rep-
resent 100A of esotropa. This method is not reliable,
b. because factors of corneal size, corneal steepness,
O.S.
OCCLUDED and angle kappa must be taken into account for
accurate measurement.
FIGURE 4-1Illustrations of angle kappa (K). a. Top view of right eye, Various clinicians have proposed simple ratios
illustrating a positive angle kappa. b. Front view of right eye, illustrating a for measuring the magnitude of strabismic devia-
positive angle kappa. The light reflection is displaced nasally by approxi- tions. In the past, the commonly accepted ratio
mately 1 mm. (f = fovea; O.D. = oculus dexter; O.S. = oculus sinister.)
was 12A per 1-mm displacement of the reflex of
the deviating eye, relative to its location on the fix-
ating eye. A much higher ratio of 22A/mm was pro-
the center of the pupil is observed and estimated. For posed by Jones and Eskridge.3 Griffin and Boyer4
example, a finding of 1 mm nasal is expressed as 1 used photographic means to study subjects with
mm positive angle kappa for the eye (+1 mm). The known magnitudes of strabismus. The position of
same procedure is repeated for the other eye. The each corneal reflex in the photographs was deter-
usual causes of an observable difference in angle mined by microscopical analysis.Their results con-
kappa between the two eyes are (1) large eccentric curred closely with those of Jones and Eskridge.3
fixation of an eye; (2) a displaced pupil (corectopia); Studies in children indcate that the ratio of 20-22
and (3) a displaced fovea (macular ectopia). mm is essentially stable throughout development,
except at ages younger than 5 months.5'6 For clini-
Hirschberg Test cal purposes, the same ratio can be used for chil-
In the latter part of the nineteenth century, Julius dren and adults.
Hirschberg2 introduced a quick and practical test Interpretation of the Hirschberg test is illustrated in
for measuring the angle of strabismus. The proce- Figure 4-2 in which a 22/1 ratio is assumed and the
dure has remained the same over the years, pupil size is 4 mm. In Figure 4-2a and 4-2b, angle
although interpretation has varied. The Hirschberg kappa (more correctly, angle lambda) is zero. In Fig-
test is performed by directing a small light source, ure 4-2c and 4-2d angle kappa is +1 mm, and in Fig-
such as a penlight (Hirschberg used a candle ure 4-2e angle kappa is -1 mm. The importance of
fame), onto the patient's eyes. From behind the accounting for angle kappa for Hirschberg testing is
light, the examiner sights the eyes while the patient evident in these illustrations. Angle kappa is normally
is fixating the light. The examiner's dominant eye for between +0.5 and +1.0 mm, and a zero angle kappa
sighting is directly behind the light, preferably less is the exception. Therefore, the center of the pupil
than 10 cm from the light source. Hirschberg rec- and the corneal light reflection usually are not in
ommended approximately a 30-cm distance conjunction; rather, the reflex usually is displaced
between the light and the patient, although this may nasalward from the center of the pupil.
be increased to 1 m and still maintain accuracy. We The sensitivity of the Hirschberg test is limited to
recommend a range between 0.5 and 1.0 m for approximately 5A for horizontal deviations.7 A conve-
clinically measuring an angle of strabismus. nient clinical ratio is 20A/mm, which means that a
relative displacement of 0.25 mm of the corneal
reflex on the deviating eye represents 5A. This is the
Chapter 4 107

O.D. O.S.

FIGURE 4-3Unilateral cover test n an example of esophoria. A

translucent cover paddie (as depicted here) may be used for observa-
tion of the eye behind the occluder; if an opaque occluder is used, the
examiner can look around the paddie to observe the occluded eye.

c.
8
with results by the altrnate cover test. Hirschberg
test accuracy and reliability can be mproved by
video enhancement of the mage of the eyes with a
millimeter scale in the field, so that direct measure-
9
ments can be made. This method may be applica-
ble in infants and small children in whom other
methods are not providing consistent results.
d.
Krimsky Test
The Krimsky test has slightly more sensitivity than
the Hirschberg test, yet t is similar, with one excep-
tion: Prisms are used to reposition the corneal light
reflex of the deviating eye to the same relative loca-
tion as the reflex on the fixating eye. The magnitude
of the prism necessary to accomplish this is the
e.
measurement of the angle of strabismus. A con-
founding factor n the Krimsky test s the possibility
of prism adaptation. Therefore, the testing time must
be brief, 2-3 seconds at most. For this reason and
because the Krimsky test is more complicated and
less natural for the patient, we routinely use the
FIGURE 4-2Interpretation of the Hirschberg test n five examples.
Hirschberg test rather than the Krimsky test.
a. Bifoveal fixation, O angle kappa. b. Oculus sinister (O.S.) fixating,
O angle kappa, and 22A esotropa of oculus dexter (O.D.). c. OS fixat-
ing, +1-mm angle kappa, and 22 A esotropa of OD. d. OS fixatng, Unilateral Cover Test
+1-mm angle kappa, and 44A esotropa of OD. e. OS fixating, -1-mm The unilateral cover test s also known as the
angle kappa, and 22A esotropa of OD.
cover-uncover test. Its main purpose s to detect
strabismus by distinguishing it from heterophoria.
best a clinician can expect, because a displacement For example, assume a patient has an esophoria,
of less than 0.25 mm s almost mpossible to discern.
The accuracy of a Hirschberg estmate tends to and the cover is placed before the patient's right
decrease with the size of the strabismic deviation, eye. The left eye would continu to fixate, but the
even among experienced clinicians. The amplitude right eye would move in a nasal direction behind
of large esotropas and exotropias are most often
underestimated by the Hirschberg test as compared the occluder (Figure 4-3). W hen the occluder s
108 Chapter 4

FIGURE 4-5Examiner's view of eye movements on the unilateral

cover test when the occluder s placed before the fixating left eye. If
an opaque occluder is used, the examiner must look behind the
occluder to see the movement of the covered eye.

FIGURE 4-4Esotropa of the right eye. (f = fovea; H = magnitude of of dissociation, making fusin impossible. The altr-
the horizontal angle of strabismus.) nate cover test cannot determine whether a deviation
s concealed by fusin.
The test is performed by alternately occluding one
removed from the right eye, the eye would move n
eye and then the other while watching for any conj-
a temporal direction for resumption of bifixation.
gate movement of the eyes, which would indcate a
Similarly, when the occluder is placed before the
deviation. The greater the conjgate movement, the
left eye, that eye would move inwardly behind the
greater is the deviation (either strabismic or phoric).
cover and, when the cover s removed, the left eye
An exo deviation will result n conjgate movement n
would move outwardly in the case of esophoria.
the same direction as the movement of the occluder
An esotropa of the right eye is illustrated n Fig-
("with" motion), whereas an eso deviation causes an
ure 4-4. If the cover is placed before the right eye,
"against" motion during the altrnate cover test.
there will be no movement of either eye because
The testing procedure is best explained by using
only the left eye is fixating. When the cover s
an example. Assume that the patient in this exam-
placed before the left eye, however, the right eye
ple has an esotropa of the right eye of 25A. The frst
will have to move outwardly to fixate the target.
step is to occlude the eyes alternately at a rate of
Also, the left eye will make an inward movement
1-2 seconds per occlusion to determine whether
and be in an eso posture behind the occluder (Fig-
there is an eso, exo, or hyper deviation. The direc-
ure 4-5). The movement of the uncovered eye s
tion and magnitude of the conjgate movement of
the distinguishing feature of strabismus on the uni-
the eyes indcate the drecton and magnitude of
lateral cover test.
the deviaton.
Assuming the unilateral cover test was done pre-
Altrnate Cover Test viously, certain information about the deviation of
The altrnate cover test is also referred to as the the visual axes s already known (.e., whether the
Duane cover test. It may be used with prisms to mea- deviation is strabismic or phoric, the dominant eye
sure the angle of deviation of either a strabismus or preferred for fixation, the direction and estimated
phoria. Although t s a very sensitive method for magnitude of the deviation). Bearing in mind the
detecting a deviation of the visual axes, a limitation knowledge gained from the unilateral cover test, the
of the altrnate cover test s that t cannot differentiate examiner's next step is to occlude the nondominant
between heterotropia and heterophoria (i.e., strabis- deviating eye. In this example, the right eye s
mus versus phoria) as can the unilateral cover test. occluded and no movement of either eye is
This s because, during the procedure, only one eye expected, because the left eye remains the fixating
s fixating at any given moment; the eyes are in a state eye and is motionless. When, however, the occluder
Chapter 4 109

FIGURE 4-7Preparing for the four base-out prism test in the case of
FIGURE 4-6Occluder is switched to the left eye. In this example, no