Vergence adaptation in esotropia

Vergence adaptation and anomalous fusional movements have been used by strabismics to overcome prism. There has been controversy in the literature regarding the nature of the vergence responses by esotropes to prism, i.e., fusional, avoidance of fusion, and/or anomalous fusion. This paper reviews the various types of movements made by esotropes to prism and attempts to explain the mechanism. In addition, the relation of these vergence movements to prismatic, orthoptic, and surgical correction is discussed.

Clinical implications of vergence adaptation

Placement of a prism in front of an eye results in a change in the tonic position of the eyes, a shift in the forced fixation disparity curve, and a shift in fusional amplitudes. These changes remain in effect as long as motor fusion is maintained. Elimination of fusion by occlusion or by removal of the prism results in a slow movement of the eyes back to the preprism position. This phenomenon, known as prism adaptation or slow fusional vergence, has important clinical implications in maintaining binocular vision with anisometropic prescriptions, age-related physiological changes in the positions of the eyes, blinking, high phorias, etc. Vergence adaptation is useful in explaining previous discrepancies between alternate and unilateral cover test, pre- and postorthoptic ACA ratios, stimulus and response ACA ratios, changes in phorias after orthoptics, and the observation of patients "eating up prism." Vergence adaptation anomalies have been implicated in causing asthenopia. Adaptation has been shown to change after orthoptic therapy. This paper reviews the clinical findings associated with vergence adaptation.

A dynamic model of cross-coupling between accommodation and convergence: simulations of step and frequency responses

The near triad consists of an increase in accommodation, vergence, and pupillary constriction. All three motor systems exhibit phasic and tonic responses. The tonic response adapts readily to phasic efforts of accommodation and vergence. Cross-coupling between accommodation and vergence provides a means of dynamically adjusting the tonic set points of the two motor systems to a common near or far working distance. Accommodative vergence cross-links play a dominant role in coordinating proximal changes in accommodation and convergence. The magnitude of cross-link interactions can be modified by imbalanced strength of tonic adaptation by accommodation and vergence. Reducing adaptation of tonic accommodation increases the AC/A ratio and decreases the CA/C ratio. Reducing adaptation of tonic vergence has the opposite effect. A model is able to predict these and other interactions simply by reducing the decay time constant of one of the two motor systems. For example, reducing the time constant for tonic accommodation results in an increased AC/A ratio and decreased CA/C ratio. Reducing the time constant for tonic vergence has the opposite effect. The model predicts transient step responses by accommodative vergence when the AC/A ratio is low and transient step responses of vergence accommodation when the CA/C ratio is low. It also predicts a reciprocal relationship between the AC/A and CA/C ratios. When one cross-link ratio is high the other cross-link ratio is low. Simulated frequency responses predict the low frequency roll off of low AC/A and low CA/C ratios. The step and frequency responses of cross-link ratios are shown to be the same for proximal (perceived distance) and retinal (blur and disparity) stimuli. The model suggests that physiological variations of tonic decay time constants may play an important role in determining clinically abnormal values of AC/A and CA/C ratios.

The effect of orthoptic treatment upon the vergence adaptation mechanism

This paper is a review of the research work that has been carried out over the past few years investigating the ability of the oculomotor system to adapt to prism-induced heterophoria. Our results show that subjects with normal binocular vision can adapt to horizontal and vertical prism-induced heterophorias whether fixating at distance or near. Further studies have shown that subjects with symptomatic abnormal binocular vision have an abnormal adaptation mechanism. Finally, we have found that when orthoptic treatment results in relief from the symptoms, there is an associated improvement in the subjects' ability to adapt to prism-induced heterophoria.

[Congenital nystagmus and intermittent exotropia. Suppression of nystagmus by fusional convergence]

We report on a patient with a combination of congenital nystagmus and intermittent exotropia. When the exotropia became manifest, a gross nystagmus appeared. When, however, the exotropia was overcome by fusinal convergence, the nystagmus was largely suppressed. The angle of squint was surgically reduced by such an amount that the exodeviation was just compensated, and the fusional convergence required to overcome the remaining angle sufficed to suppress the nystagmus.

Effects of long-term visual display terminal usage on visual functions

Since their rapid introduction into the workplace visual display terminals (VDT's) have been the source of a number of studies aimed at detecting effects on office workers. The published studies have been either short-term or cross-sectional, with one exception. The results have shown varying degrees of relation but by not having a comparable control group all have been limited in their value. We set out to monitor at regular intervals over a 2-year period specific visual functions that have been reported to be affected by VDT usage, and to compare VDT and non-VDT users in the same office environment. By assessing the VDT operators from the time the systems were introduced we have an accurate baseline to work from when assessing change due to the introduction of the VDT.

[Vertical accommodative vergence]

Five patients showed vertical accommodative vergence during which the strabismic eye deviated either up- or downwards. Additional components of strabismus included intermittent or constant exotropia, dissociated vertical divergence, and various incomitancies. There were no signs of misdirected regeneration after oculomotor palsy. We interpret vertical accommodative vergence as a supranuclear abnormality, most likely congenital.

Stereopsis, accommodative and vergence facility: do they relate to dyslexia?

The relation between visual functions and reading performance has been the subject of conflicting opinion over the years. The purpose of this study is 2-fold: first, to examine factors other than visual acuity, i.e., stereopsis, accommodative facility and vergence facility, which might show a greater impact on reading achievement; and second, to utilize well defined dyslexic and normal controls to ensure that the reading deficits were not caused by overt neurological, psychological, educational, or environmental factors. Thirteen normal readers and 13 dyslexics were carefully matched by rigorous quantitative criteria. The performance of both groups on tests of visual acuity and stereopsis was similar. The dyslexic readers tended to show better accommodative facility. Dyslexics performed significantly worse than the matched normal readers on a test of vergence facility. These results, in agreement with those reported by other studies, indicate that less efficient dynamic vergence facility may contribute to reading impairment, unlike other static functions such as visual acuity and stereopsis. It may be that the vergence problems of the dyslexics are related to sequential oculo-motor abnormalities. The dyslexics' vergence problems may also be partly responsible for their large number of small eye movements.

The effect of monovision lenses on the near-point range of single binocular vision

Monovision (MV) contact lenses are commonly used to provide optical correction for presbyopia. Based on their review of the literature on fusional mechanisms, Erickson and Schor predicted that monocular blur associated with MV should not be sufficient to disrupt binocular fusion. We found that fusional vergence ranges in presbyopes corrected with MV were not substantially different from those measured under full binocular nearpoint correction. There were small but statistically significant tendencies for the phoria and base-in vergences to be less exo under MV conditions. Comparisons of findings between a group of successfully adapted MV patients and a group of patients who were unsuccessful with MV indicated no significant differences, suggesting that there is no adaptation effect for these performance variables and that these tests are not effective predictors of MV success.

Sighting dominance and monovision distance binocular fusional ranges

Clinicians typically apply the distance correction to the dominant sighting eye in fitting presbyopic patients with monovision (MV) contact lenses. We evaluated the effect of this fitting strategy on distance binocular fusional ranges for 23 presbyopic subjects. This sample was composed of successful and unsuccessful MV wearers. Fusional ranges for the two MV fitting possibilities (distance lens on the dominant eye, near lens on the dominant eye) were compared to fusional ranges in which both eyes were fitted with the distance correction. A greater esophoric shift and greater reduction in vergence ranges were demonstrated when the non-dominant eye received the clear image compared to when the dominant eye received the clear image. Successful MV patients demonstrated these effects to a lesser degree than did unsuccessful patients. In general, effects of MV on distance binocular fusional ranges were fewer when successful MV subjects received the clear image in the dominant eye.

Errors in distance appreciation and binocular night vision

Studying binocular vergence in relation to luminance levels, we isolated two types of behaviour which may explain differences in distance appreciation: 1. Underestimation of distances in subjects with overconvergence in darkness. 2. Overestimation of distances in subjects with underconvergence in darkness. Progression towards the limiting value of convergence varies from one individual to another for each mesopic and scotopic luminance level and for different experimental conditions: variable discrepancy between the observation distance and the tonic vergence distance; accommodative or fusional stimuli at varying degrees of eccentricity; mobile stimuli in the observer's peripheral field. The study of bipartition in depth of a given interval for different observation distances confirms the existence of two major categories of individuals. Over- or underestimation of the nearer subjective half correlates to the binocular dark convergence capacity of each individual. These findings may explain errors in distance appreciation for road users in night vision.

The linearity of proximally induced accommodation and vergence

This study sought to determine the linearity and amplitude of both proximally induced accommodation (PIA) and vergence (PIV) by comparing the open-loop accommodation and vergence responses, respectively, to individual stimuli located at viewing distances ranging from 0.20 m to 1,500 m. For the measurement of PIA, the vergence and accommodation loops were opened by subjects (N = 10) monocularly viewing the target through a 0.5-mm pinhole, while accommodation was assessed concurrently using an infrared optometer. In the assessment of PIV, the accommodation loop was opened either by subjects (N = 10) viewing a low-frequency difference of Gaussian (DOG) grating or by viewing the targets binocularly through 0.5-mm pinholes. For both PIV methods, the vergence loop was opened by vertical dissociating prisms while the heterophoria was assessed for the various target distances using the von Graefe technique. The results demonstrated significant changes in both PIA and PIV for stimuli located closer than 3 m. However, both proximal components attained a minimum level and remained constant for targets at or beyond 3 m. Furthermore, the magnitudes of PIA and PIV were linearly related to the target distance measured in diopters and meter angles, respectively. These findings clearly demonstrate the influence of target proximity on the oculomotor system.

Effect of aniseikonia on fusion

Physiological aniseikonia is the basis of stereopsis but beyond certain limits it becomes an obstacle to fusion. It is not well established as to how much aniseikonia can be tolerated by the fusional mechanism. Different tests under different testing conditions have given a wide range of variation. On the synoptophore we had observed tolerance upto 35% aniseikonia in some cases. Under more physiological conditions on a polaroid dissociation stereoprojector we observed lesser baseline fusional vergences but tolerance in about 70% of the cases upto 30% aniseikonia while 25% could tolerate even 35% aniseikonia. However we realise that these indicate the maximal potential and not the symptom free tolerable limits.

Retinal eccentricity of fusion detail affects vergence adaptation

Adaptation of tonic vergence ("vergence adaptation" or "prism adaptation") may be produced by sustained accommodative, disparity, or proximal vergence innervation. Phoria measures were used in the present study as indices of tonic vergence adaptation to convergence and divergence stimuli in five subjects. Amblyoscope targets stimulated fusion either over the central or peripheral retina while holding accommodative and proximal stimuli constant. The magnitude and rate of tonic vergence adaptation were greater under the central fusion condition than under the peripheral fusion condition, even though the vergence stimuli were matched between central and peripheral fusion conditions. These results show that tonic vergence adaptation is influenced by the retinal eccentricity of target fusional patterns. However, additional work is required to identify the mechanism(s) underlying this eccentricity effect.

Alternating hyperphoria. Dissociated vertical deviation (DVD) 'occlusion hyperphoria'

Alternating hyperphoria (synonyms: dissociated vertical deviation (DVD) or occlusion hyperphoria) and variants like 'unilateral patching hyperphoria' ('periodic vertical squint') and monocular vertical nystagmus, which may arise after strabismus operations or loss of the function of one of the eyes, have dynamic properties which differ from those of the vertical vergences or fusional movements in normal binocular vision. Alternating hyperphoria is the result of an early intense disturbance of binocular vision, leading to the absence of vertical fusional vergence or the detection of disparity necessary for this. Vertical disparity vergence is essentially a stabilizing and adaptive system.

Postural stability and stereo-ambiguity in man-designed visual environments

Our modern rectilinear visual environment contains visual stimuli for which evolution has not had time to optimally shape visual processing. One such stimulus, periodic stripes, is known to lead to visual depth ambiguity. In this paper we show that postural instability, as measured by the variance of fore and aft sway, is increased by viewing such stimuli. This instability may be the precursor of falls. Designers must evaluate the visual impressions conveyed by their systems in order to avoid postural instability due to visual ambiguity.

Trochlear unit activity during ocular convergence

1. Ocular convergence is usually accompanied by excyclotorsion of the eyes. Furthermore, the magnitude of cyclotorsion is dependent on the elevation of the eyes. The reason for this excyclotorsion during convergence is not understood. 2. Excyclotorsion could be produced by either increased activity in the inferior oblique muscle or decreased activity in the superior oblique muscle. An earlier study indicated that convergence may also be accompanied by a temporal (lateral) translation of the eye. This observation is more consistent with a relaxation of the superior oblique than contraction of the inferior oblique. 3. This hypothesis was tested by recording the activity of 31 neurons in the trochlear nucleus, which contains the superior oblique motoneurons. This was done in alert monkeys that were trained to make both versional and vergence eye movements. In addition, the cyclotorsion associated with convergence was measured in one of these monkeys. 4. A consistent excyclotorsion associated with convergence was observed. Trochlear unit activity decreased during convergence in all cells tested. The magnitude of this decrease was significantly greater than that seen with conjugate adduction. Furthermore, the size of the decrease varied systematically with ocular elevation in a manner that was consistent with earlier measures of cyclotorsion during convergence. 5. These results suggest that the excyclotorsion seen during convergence, and perhaps the lateral translation of the eye, are due to a relaxation of the superior oblique muscle. This relaxation during convergence is greater than that which accompanies similar conjugate movements of the eyes. We hypothesize that this peculiar pattern of muscle innervation has a motor rather than sensory function.(ABSTRACT TRUNCATED AT 250 WORDS)

Disconjugate adaptation to long-standing, large-amplitude, spectacle-corrected anisometropia

A 12-yr-old anisometropic patient had worn corrective eyeglasses (right eye, -0.50 +1.50 x 125; LE, -9.75 +2.50 x 60) for 7 yr, and then changed to contact lenses. Eye movements were recorded before and after the change to contact lenses using binocular search coils. In habitual spectacle viewing, the patient showed disconjugate adaptation. During monocular viewing, for example, ocular alignment changed by as much as 4 degrees during a 20 degrees saccade. Also, during monocular viewing, with either eye, placing the spectacle lens in front of the eye caused an increase in the disconjugate adaptive response compared with viewing without lenses. This finding emphasizes the context specificity of adaptive responses. After switching to contact lenses, the patient still wore his spectacles for 20-40 min each day. Although there was little residual disconjugate adaptation for vertical saccades, he showed considerable adaptation for horizontal saccades, especially for gaze changes that required divergence. The persistence of a partial state of disconjugate adaptation allowed the patient to use immediate, disparity-induced, horizontal vergence to aid ocular alignment in either the contact-lens-viewing or the spectacle-viewing condition. A more complete reversion to conjugacy occurred after nine days of exclusive use of his contact lenses. Then, in a short-term experiment, two minutes of binocular viewing through the eyeglasses induced a considerable reversion toward the previous state of disconjugate adaptation (up to 1.25 degrees of vergence change during monocular viewing). Finally, the waveform of the adapted (to spectacles) intrasaccadic vergence change with monocular viewing was similar to the waveform of the unadapted intrasaccadic vergence change during binocular refixations between targets that required a combined saccade and vergence. This finding suggests a common mechanism for adaptation to spectacle-corrected anisometropia and for normal binocular vergence-saccade interactions.

[A new photographic method for measuring squint angles in infants and small children]

A new photographic method for measuring squint angles in children and infants is presented. A photographic picture is taken from the subject, using a camera with the three flashes bulle. One flashbulle is placed vertically over the lens, two other flashbulles are placed symmetrically in an angle of 10 degrees beside the middle flash. Six reflections can be seen on the photographic picture in each pupil. (1. and 4. Purkinje Sanson Images of each light source.) The horizontal distance of two reflections is determined by the distance of the flashguns. If the reflection lines in both eyes are symmetrical, there is no squint. If there is a shift, it can be measured on the slide and by using a simple formula the squint angle can be calculated. The accuracy of the method is between 2 and 3 degrees.

Convergence accommodation: laboratory and clinical evaluation

The accommodation stimulated by convergence, CA/C, was measured under laboratory and clinical conditions. There was a small nonlinearity to the CA/C ratios measured under laboratory conditions for three of six subjects. We found that convergence accommodation decreases with decreasing accommodative amplitude but not as rapidly as has been reported in the literature. Our results suggest that convergence accommodation can contribute substantially to the near accommodative response for many patients.

Dynamic demonstration of proximal vergence and proximal accommodation

The complex interactions between accommodation and vergence have been described by dual interactive models which include influences of convergence accommodation and accommodative vergence. Using an SRI Eyetracker, we investigated changes in vergence and accommodation stimulated while looking through prisms or lenses, and while looking at real targets located at different distances. Our results suggest that both proximal accommodation and proximal vergence are stimulated when looking from a distant to a near real target. We suggest that models of convergence and accommodation interactions include proximal accommodation and proximal vergence before the crosslinks.

Effect of luminance on the relation between accommodation and convergence

When luminance is lowered, both vergence and accommodation tend to shift toward different and individually characteristic resting postures, commonly referred to as dark-vergence and dark-focus. In order to determine the luminance level at which these two mechanisms correspond to a target distance, subjects viewed a light spot 0.4 mm in diameter, corresponding to 1.4 to 2.7 min arc, located at the individually determined dark-focus position. As the luminance of a binocularly viewed spot increased, accommodation did not change significantly from the target distance. However, fusional vergence gradually shifted from the dark-vergence to the target position. The critical luminance level at which the 2 responses were coupled for the 12 observers ranged from 0.01 to 0.45 cd/m2, with distinct individual differences. In a second experiment, the target was positioned at distances different from the dark-focus and luminance was set at 0.5 and 1.0 log unit higher than the subject's critical luminance level. At lower luminance levels, mononuclear focus tended to remain at the individual dark-focus, whereas the binocular focus tended to correspond to the target distance. These differences can be attributed to vergence accommodation. Previous studies on night myopia reported that a negative correction based on one-half of the individual dark focus was superior to a full dark-focus correction. The present results suggest that this difference is due to vergence accommodation and that the optimum correction for night myopia depends, in part, on the critical luminance level for activation of fusional vergence.

Proximal vergence and age

A number of previous investigations have suggested that the relative contribution of proximal vergence to the overall vergence response may increase with age. Accordingly the present study has examined the proximal convergence/test distance (PC/T) ratio in a clinical population of 106 subjects ranging from 6 to 47 years of age. PC/T was assessed by comparing accommodative convergence/accommodative stimulus (AC/As) ratios obtained using the gradient and heterophoria techniques. With the former method, the stimulus to accommodation was produced optically using spherical lenses whereas in the latter technique, the change in accommodative stimulus arose from variation in actual target distance. The difference between these two measurements of AC/As reflected the output of proximal vergence. No significant variation in PC/T was observed with increasing age. It is proposed that increased disparity-vergence, rather than proximal vergence, is more likely to compensate for any age-related decline in AC.