Plasticity of human motion processing mechanisms following surgery for infantile esotropia

Decorrelation of cerebral visual inputs as the sufficient cause of infantile esotropia

BACKGROUND AND PURPOSE

Human infants at greatest risk for esotropia are those who suffer cerebral insults that could decorrelate signals from the two eyes during an early critical period of binocular, visuomotor development. The authors reared normal infant monkeys under conditions of binocular decorrelation to determine if this alone was sufficient to cause esotropia, and associated behavioral as well as neuroanatomic deficits.

METHODS

Binocular decorrelation was imposed using prism-goggles for durations of 3-24 weeks (control monkeys wore plano goggles), emulating unrepaired strabismus of durations 3 months to 2 years in human infants. Behavioral recordings were obtained, followed by neuroanatomic analysis of ocular dominance columns and binocular, horizontal connections in the striate visual cortex (area V1).

RESULTS

Concomitant, constant esotropia developed in each monkey exposed to decorrelation for a duration of 6-24 weeks. The severity of ocular motor signs (esotropia angle; dissociated vertical deviation; latent nystagmus; pursuit / optokinetic tracking asymmetry; fusional vergence deficits), and the loss of V1 binocular connections increased as a function of decorrelation duration. Stereopsis was deficient and motion visually evoked potentials were asymmetric. Monkeys exposed to decorrelation for 3 weeks showed transient esotropia, but regained normal alignment, visuomotor behaviors, and binocular V1 connections.

CONCLUSIONS

Binocular decorrelation is a sufficient cause of infantile esotropia when imposed during a critical period of visuomotor development. The systematic relationship between severity of visuomotor signs and severity of V1 connectivity deficits provides a neuroanatomic mechanism for these signs. Restoration of binocular fusion and V1 connections after short durations of decorrelation helps explain the benefits of early strabismus repair in humans.

Outcome of surgery in long-standing infantile esotropia with cross fixation

BACKGROUND

This is a retrospective study to determine the outcomes of the surgical correction in long-standing infantile esotropia with cross fixation.

METHODS

Medical charts of a group of patients with esotropia who had cross fixation and underwent surgery for strabismus between January 1991 and December 2004 were reviewed. The mean follow-up time was 4.7 years. Binocularity was measured by the Worth 4-dot test and Titmus stereo test. Twenty-six patients underwent surgery for strabismus. Twenty-one patients aged 8 to 26 years with a minimum 3-year postoperative follow-up were included. Five patients were excluded because they were lost to follow-up after surgery.

RESULTS

Bimedial recession and resection of one lateral rectus muscle were performed in all patients. Recession of the inferior oblique muscle with anteriorization was performed in patients who had inferior oblique overaction. Orthotropia was attained in 14 patients, whereas residual esotropia was diagnosed in 5 patients. Two patients were diagnosed as having exotropia. Two patients required a second surgery for dissociated vertical deviation. Overall, 9 of the 21 patients had indications of binocular function and 12 remained the same in their stereoacuity.

CONCLUSION

Surgical correction of long-standing infantile esotropia with cross fixation in young adults may improve binocular function and allow long-term alignment stability.

Timing of surgery for infantile esotropia: sensory and motor outcomes

Infantile esotropia is a common ophthalmic disorder in childhood. It is often accompanied by profound maldevelopment of stereopsis, motion processing, and eye movements, despite successful surgical realignment of the eyes. The proper timing of surgery has been debated for decades. There is growing evidence from clinical and animal studies that surgery during the early critical periods enhances sensory and ocular motor development. The Congenital Esotropia Observational Study has defined a clinical profile of infants who will benefit most from early surgery, and several other studies have shown that early surgery does not lead to adverse long-term effects. Clinicians now should consider offering early surgery to patients with large-angle, constant infantile esotropia at or before 10 months of age.

Timing of surgery for infantile esotropia in humans: effects on cortical motion visual evoked responses

PURPOSE

Infantile esotropia is associated with maldevelopment of cortical visual motion processing, manifested as directional asymmetry of motion visual evoked potentials (mVEPs). The purpose of this study was to determine whether early surgery at or before age 11 months could promote the development of cortical visual motion processing in human infants, compared with standard surgery at age 11 to 18 months.

METHODS

Sixteen children with a constant, infantile esotropia >or=30 prism diopters and onset before age 6 months were recruited prospectively. Eight of them underwent early surgery at

RESULTS

The mean asymmetry index and interocular phase difference in the early surgery group were comparable to that in age-matched control subjects, and they were significantly lower than those in the standard surgery group.

CONCLUSIONS

Early surgery for infantile esotropia promotes the development of cortical visual motion processing, whereas standard surgery is associated with abnormal mVEPs. The results provide additional evidence that early strabismus repair is beneficial for cortical development in human infants.

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Key Words Collapse

MESH Headings

• Evoked Potentials, Visual/physiology
• Eye Movements/physiology
• Female
• Humans
• Infant
• Male
• Motion Perception/physiology
• Nystagmus, Congenital/physiopathology
• Nystagmus, Congenital/surgery
• Oculomotor Muscles/surgery
• Prospective Studies
• Tendons/surgery
• Time Factors
• Visual Cortex/physiology

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Grants

• 67104 CIHR

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Affiliation(s)

Christina Gerth Department of Ophthalmology and Vision Science, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
Giuseppe Mirabella
Xiaoqing Li
Thomas Wright
Carol Westall
Linda Colpa
Agnes M F Wong

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A primer on motion visual evoked potentials

Motion visual evoked potentials (motion VEPs) have been used since the late 1960s to investigate the properties of human visual motion processing, and continue to be a popular tool with a possible future in clinical diagnosis. This review first provides a synopsis of the characteristics of motion VEPs and then summarizes important methodological aspects. A subsequent overview illustrates how motion VEPs have been applied to study basic functions of human motion processing and shows perspectives for their use as a diagnostic tool.

Motion detection in normal infants and young patients with infantile esotropia

The purpose of this study was to investigate asymmetries in detection of horizontal motion in normal infants and children and in patients with infantile esotropia. Motion detection thresholds (% motion signal) were measured in 75 normal infants and in 36 eyes of 27 infants with infantile esotropia (ET), using a forced-choice preferential looking paradigm with random-dot patterns. Absolute motion detection sensitivity and asymmetries in sensitivity for nasalward (N) vs. temporalward (T) directions of motion were compared in normal and patient populations, ranging in age from 1 month to 5 years. In normal infants, N and T thresholds were equivalent under 2.5 months of age, whereas a superiority for monocular detection of N motion was observed between 3.5 and 6.5 months of age. The nasalward advantage gradually diminished to symmetrical T:N performance by 8 months of age, matching that of adults. No asymmetry was observed in 15 normal infants who performed the task binocularly, hence, the asymmetry was not a leftward/rightward bias. In the youngest infantile ET patients tested, at 5 months of age, a nasalward superiority in motion detection was observed and was equivalent to that of same-age normal infants. However, unlike normals, this asymmetry persists in older patients. This greater asymmetry in infantile ET represents worse detection of T than N motion. This is the first report of an asymmetry in motion detection in normal infants across a wide age range. Initially, motion detection is normal in infants with infantile esotropia. Cumulative abnormal binocular experience in these patients may disrupt motion mechanisms.

Surgery and botulinum toxin in congenital esotropia

BACKGROUND

In a previous study we investigated the advantages and drawbacks of early and delayed injection of botulinum toxin as primary treatment of infantile esotropia with nystagmus in abduction (IENA). We carried out a further study to investigate the role and efficacy of surgery in this condition and to determine the possible effect of previous injection of both medial recti with botulinum toxin in patients requiring a final horizontal surgical correction.

METHODS

Review of the records of 44 patients (24 girls and 20 boys) with IENA seen between 1979 and 1998 who had undergone at least one horizontal surgical procedure. The outcomes in the 16 patients who had previously received botulinum toxin were compared with those in the 28 patients for whom surgery was the primary treatment.

RESULTS

There was a negative correlation between the pretreatment esotropic angle and age (Pearson's r = -0.45, p < 0.05). The first visit to a surgical specialist took place very late (mean age 43 months [standard deviation (SD) 39 months]). Of the 35 children seen during the period in which botulinum toxin was available, 20 (57%) had additional factors inducing unsteadiness of binocular vision (e.g., moderate to severe initial relative amblyopia, initial ametropia). Administration of 5 units of botulinum toxin before 18 months of age destabilized dissociated vertical deviation. Overall, 39 patients (89%) had a final residual deviation of less than 10 prism dioptres. The first surgical correction was horizontal and vertical-torsional in 30 patients (68%). A total of 23 patients (52%) required some retreatment (botulinum toxin or surgery or both). Children treated initially with botulinum toxin had less surgery than those with initial surgery (mean recession or resection 8.9 mm [SD 4.5 mm] vs. 14.2 mm [SD 4.0 mm]) as well as fewer horizontal muscles operated (mean 1.6 [SD 0.6] vs. 2.3 [SD 0.6]).

INTERPRETATION

Surgery with or without further interventions is a reasonable approach for IENA with delayed diagnosis and in cases associated with unsteadiness of binocular vision or with nonhorizontal deviations. Initial treatment with botulinum toxin, injected into both medial recti, is effective, reducing the amount of further horizontal surgery and favouring postoperative stability, except in children under 18 months, in whom injection of 5 units induces unbalanced dissociated vertical deviation.

Test-retest reliability of swept visual evoked potential measurements of infant visual acuity and contrast sensitivity

The aim of the study was to describe variations in swept visual evoked potential (SWEEP-VEP) assessment of visual acuity and contrast sensitivity in infants and to evaluate the best way to estimate visual performance from obtained SWEEP-VEP data. The visual performance of 92 infants (6-40 wk of age) was measured in two separate visits. Results were verified with repeated tests in seven adults. There was a strong association between the two measurements of infant visual acuity (r = 0.91, p < 0.001), with no constant bias and an inter-assay coefficient of variation of 8.4%. The intra-assay coefficient of variation was 17% and in repeated sessions all obtained acuity measures were normally distributed, indicating that the mean and not the maximum threshold best estimates visual acuity. This estimate of visual acuity also had lower test-retest variability than those calculated from the maximum threshold or threshold from the average EEG signals (p = 0.001). Test-retest measures of infant contrast sensitivity had a correlation coefficient of 0.72 (p < 0.001) and an inter-assay coefficient of variation of 23%. With the observed test-retest variability, SWEEP-VEP is less valid for estimating the visual performance of individual subjects, but it can give reliable group means. This method was well suited to describe visual development in the infants, which for acuity as well as contrast sensitivity increased by 0.64 octave per doubling in age. However, the variability of the SWEEP-VEP method can be a limiting factor, for example, in the assessment of the potential effect of dietary docosahexaenoic acid in a homogeneous group of infants.

Marshall Parks lecture. Binocular sensory outcomes in accommodative ET

PURPOSE

To review what is known about the normal maturational sequence for fusion and stereopsis and the binocular sensory deficits associated with accommodative esotropia (ET) and to explore the clues that accommodative ET provides about critical periods for binocular sensory function.

METHODS

Studies of binocular sensory function during infancy and early childhood are presented.

RESULTS

Most of the maturation of binocular sensory function occurs during the first year of life, yet a later abnormal visual experience-such as the onset of accommodative ET--can profoundly and permanently disrupt fusion and stereopsis.

CONCLUSIONS

Some binocular sensory deficits may exist before the onset of accommodative ET, but others may result directly from abnormal binocular experience. The functional organization of the maturing visual system appears to be maximally sensitive to disruption by abnormal visual experience during the first months of life, but susceptibility continues until at least 4 years of age.

Incidence of stereopsis after treatment of infantile esotropia with botulinum toxin A

PURPOSE

The incidence of stereoscopic vision following surgery for infantile esotropia has been reported, but not from patients treated with simultaneous bimedial injection of botulinum toxin A. We previously reported other findings from 41 patients treated with botulinum toxin A before the age of 12 months. The purpose of this study was to report the incidence of stereopsis in these patients after long-term follow-up.

PATIENTS AND METHODS

Data were acquired by recording the response to subjective stereoscopic testing during the postinjection follow-up period when reliable subjective responses could be obtained. At least 5 years had passed following injection, and the mean age of the patients was 8 years.

RESULTS

Of the 41 patients, 11 were lost to follow-up, 10 had no stereopsis, 9 had gross stereopsis (according to Titmus fly tests), 1 had 800 seconds of stereoscopic vision, 2 had 400 seconds, 2 had 200 seconds, 1 had 60 seconds, and 5 had 40 seconds.

CONCLUSIONS

In this study, two-thirds of the patients acquired stereopsis following simultaneous bimedial injection of botulinum toxin A for infantile esotropia. Stereopsis acquisition following injection of botulinum toxin A had a success rate comparable with that reported for surgically corrected infantile esotropia. Bimedial injection of botulinum toxin A accompanied by alternate patching prior to injection and diligent attention at ages ranging from 4 to 12 months is a simple and efficacious method for the management of infantile esotropia.

Motion processing asymmetries and stereopsis in infants

These experiments used forced-choice preferential looking to test infants for preferences between pairs of random-dot patterns that moved in opposite directions. With monocularly-viewed horizontally moving patterns, 6-12-week-old infants showed a preference for nasalwards motion. With binocularly-viewed vertical motion, there was no overall preference, but the results did show a significant correlation between upwards bias of OKN and preference for downwards motion. In a longitudinal experiment, the nasalwards preference first appeared at 7-8 weeks, and thereafter persisted until the end of testing (23-25 weeks). In this experiment the infants were also tested for stereopsis, under conditions that were as nearly as possible identical to the direction preference test. There was no evidence that the onset of stereopsis had any effect on the directional asymmetry. The directional asymmetries revealed by these experiments appear to be distinct from the asymmetries of OKN and motion VEPs. It is possible that they reflect asymmetrical directional responses in extrastriate visual cortex (e.g. area V5/MT).

Early versus delayed repair of infantile strabismus in macaque monkeys: I. ocular motor effects

INTRODUCTION

The appropriate age for surgical correction of esotropic strabismus in human infants is controversial; some clinicians advocate surgery before age 6 months, and others recommend observation and surgery at older ages. Infantile (congenital) esotropia in humans and monkeys is known to be accompanied by a constellation of eye movement abnormalities caused by maldevelopment of cerebral visual motor pathways. The purpose of this study was to determine how early versus delayed correction of strabismus influences development and/or maldevelopment of these eye movement pathways.

METHODS

Optical strabismus was created in infant macaques by fitting them with prism goggles on day 1 of life. The early correction group (2 experimental and 1 control) wore the goggles for a period of 3 weeks (the equivalent of 3 months before surgical repair in humans). The delayed correction group (3 experimental and 1 control) wore the goggles for a period of 3 or 6 months (the equivalent of 12 or 24 months before surgical repair in humans). Several months after the goggles were removed, the monkeys were trained to perform visual fixation, smooth pursuit, and optokinetic nystagmus (OKN) tasks for a juice reward. Eye movements were recorded using binocular search coils. The performance of the early versus delayed infant monkey groups was also compared with that of a group of adult monkeys who had unrepaired, naturally occurring infantile esotropia.

RESULTS

Early correction monkeys developed normal eye movements and exhibited ocular motor behaviors that were indistinguishable from normal control animals. They regained normal binocular eye alignment and showed stable fixation (no latent nystagmus). Monocular horizontal smooth pursuit and large field OKN were symmetric. In contrast, delayed correction monkeys showed persistent esotropia, latent fixation nystagmus, dissociated vertical deviation, and pursuit/OKN asymmetry. Animals who had the longest delay in correction of the optical strabismus exhibited eye movement abnormalities as severe as those of adult animals with uncorrected, natural esotropia.

CONCLUSIONS

Early correction of strabismus in primates prevents maldevelopment of eye movements driven by cerebral motor pathways. Our results provide additional evidence that early strabismus correction may be beneficial for brain development in human infants.

Comitant strabismus

A review of the literature on comitant strabismus of the period from April 1999 until April 2000 is presented. A rather new and increasingly important issue is the psychosocial aspect of strabismus. Two studies have demonstrated that strabismus creates a significant negative social prejudice on the patients and that it can significantly reduce an applicant's ability to obtain employment. Subsequently, strabismus surgery can no longer be called "cosmetic". Concerning the timing of surgery in congenital esotropia, it was reported that early surgery does not ensure continued alignment, but frequently requires additional operations. The increased risk of early-onset strabismus in prematurely born children was confirmed by several studies, and the importance of regular ophthalmologic controls of all preterm infants screened for retinopathy of prematurity was stressed. It was reported that risk factors are cicatricial retinopathy of prematurity, refractive error, family history of strabismus, and poor neurodevelopmental outcome, rather than low gestational age and regressed acute retinopathy of prematurity. A number of other aspects of interest concerning exotropia, esotropia, and dissociated vertical deviation are presented in this review.

Botulinum treatment of infantile esotropia with abduction nystagmus

PURPOSE

To examine the effect of botulinum toxin type A (BTA) on the final correction of esotropia, A and V patterns, overaction of the oblique muscles, and dissociated vertical deviation (DVD) in infantile esotropia with nystagmus in abduction.

METHODS

This retrospective study examined 54 patients treated with simultaneous bilateral medial injection of BTA. Subjects were divided into two groups: group 1 (first injection <18 months of age) and group 2 (first injection >18 months of age).

RESULTS

Pre-BTA, group 1 patients had an angle of esotropia noticeably higher and fewer A patterns than group 2 patients. Post-BTA, group 2 received significantly fewer injections of BTA than group 1. The magnitude of the A patterns improved. Prior frequency of DVD increased significantly in group 1 (100%): 79% of DVD was decompensated compared with 47% in group 2. Overall success was obtained in 14% and 58% of groups 1 and 2, respectively.

CONCLUSION

We do not support BTA treatment in infantile esotropia with nystagmus in abduction prior to age 18 months. After 18 months, the horizontal results are excellent and neither the incidence nor the degree of previous DVD are decompensated, resulting in high success rates for overall deviation and improving anisotropy in A.

Visually evoked potentials evoked by moving unidimensional noise stimuli: effects of contrast, spatial frequency, active electrode location, reference electrode location, and stimulus type

We determined the relative importance of electrode derivation, stimulus type, spatial frequency and contrast in determining the relative size of the late negative and early positive responses of motion elicited VEPs. Seven subjects aged 22-48 years with normal vision were tested binocularly. Motion onset and motion reversal were employed as modes of stimulus presentation. For both, pseudo-random one-dimensional noise patterns whose peak power was at 5.2, 2.6, 1.3, 0.325 and 0.1625 cycles per degree (cpd) were stimuli. Contrasts were 70% and 5%. Active electrodes were placed at Oz, 5 cm to the left of Oz, 5 cm to the right of Oz and a frontal midline position (Fpz) and referenced to linked mastoids. Transient motion reversal elicited a prominent positive response present in all subjects and at low contrasts. Motion onset VEPs have a complex waveform which may be either predominantly positive or negative. The most important variables in determining whether a prominent positivity or negativity is present in the motion onset VEP are the contrast and the spatial frequencies. Data such as these are first efforts in developing recommendations for the motion VEP.

Oscillatory motion but not pattern reversal elicits monocular motion VEP biases in infantile esotropia

Patients with early disruptions of binocularity show cortical directional asymmetries in their steady state monocular VEP response to oscillatory motion. The VEP directional asymmetry is characterized by significant first harmonic components that show a 180 degrees difference in the response phase between the two eyes. By contrast, the normal response is dominated by even-order response harmonics, although some normal observers also have measurable responses at the first harmonic. Experiments and simulations were conducted to determine if the first harmonic in patients could reasonably be attributed to direction selective mechanisms. A secondary goal was to determine whether the first harmonic response of normals was also due to imbalances in direction selective mechanisms. Monocular steady state VEPs were elicited by oscillating 3 c/deg gratings presented at 6 and 10 Hz in normal observers and observers with infantile esotropia. Responses were also obtained to phase-reversing gratings of the same spatial and temporal frequencies. Phase reversal eliminated the majority of first harmonic responses which were recorded for normal observers to oscillatory motion. However, phase reversal did not elicit the cortical motion asymmetry in infantile esotropia. Modeling results suggest that the first harmonic response to oscillatory motion arises due to non-linearities in both direction selective and non-direction-selective mechanisms, with the latter being dominant in patients with early onset strabismus.

The timing of surgical alignment for congenital (infantile) esotropia

At this time, the beneficial effect of accurate alignment by age 2 in congenital esotropia has been well established by clinical and laboratory studies. There is, however, only scanty clinical evidence that alignment before age 1, much less before 6 months of age, may yield a better quality of binocularity (i.e., refined stereoacuity) than alignment by age 2. Pitfalls of very early alignment are present. In addition, the ophthalmologist must be vigilant in following the initially aligned patient and be ready to treat vertical motor defects, amblyopia, and acquired refractive errors. The need for additional horizontal surgery after initial alignment is also common. The optimum result in the surgical treatment of congenital esotropia generally shows binocularity that is within the confines of a monofixation syndrome, and refined stereoacuity remains an elusive target and a rare outcome, no matter at what age the alignment is achieved.

OKN, perceptual and VEP direction biases in strabismus

The present study quantified nasalward/temporalward biases in monocular optokinetic nystagmus (MOKN) and perceived velocity in patients with either early onset esotropia, late onset esotropia and in normals. MOKN was measured with low spatial frequency, small-field gratings drifting at 9.4 degrees/s. MOKN bias was quantified as the ratio of nasalward slow-phase velocity divided by the sum of temporalward and nasalward slow-phase velocities (N/(N + T)). Observers also rated the perceived velocity of gratings moving in nasalward and temporalward directions (3 or 9.4 degrees/s) using a two interval forced choice task. MOKN and perceived velocity biases were correlated negatively in both early onset and late onset groups in the perceptual task--nasalward moving targets were rated as slower than temporalward targets, but in the MOKN task, slow-phase gain was higher for nasalward than for temporalward targets. Oscillatory-motion, visual evoked potentials (VEPs), were recorded in response to 1 c/deg gratings undergoing apparent motion at 10 Hz in a subset of the observers. VEP direction biases were quantified by calculating the ratio of first harmonic response amplitudes to the sum of first and second harmonic amplitudes. Significant correlations were found between the direction biases obtained on all three measures. Perceived velocity and MOKN bias measures were also correlated negatively. Patients with early onset esotropia (infantile esotropia) had larger biases than late onset esotropes or normals on each measure and the biases were more frequently bilateral in the early onset patients. The pattern of result is consistent with early critical periods for the mechanism(s) underlying MOKN, perceived velocity and cortical responsiveness. A single site model for all three asymmetries is unlikely, at least in simple form, because of the negative correlation between MOKN and perceived velocity biases and because of the differences in relative magnitude between the perceptual and MOKN biases.

Development of directional motion symmetry in the monocular visually evoked potential of infant monkeys

Motion processing in humans and monkeys exhibit a directional asymmetry during infancy which is not present in adults except following abnormal visual rearing conditions. To characterize the time course for maturation of a symmetric response, we measured the monocular visually evoked potential (MVEP) response to 0.26 c/deg gratings oscillating horizontally at 6 Hz in 13 infant rhesus monkeys between 1 and 52 weeks of age. An asymmetric (F1) and a symmetric (F2) frequency component were extracted from the MVEP using Fourier analysis. At early ages the asymmetric F1 component measured from the two eyes exhibited a 180 deg interocular phase shift, demonstrating that there was a directional bias in opposite directions between the left and right eyes. Although our methods could not determine whether the bias was in the nasal or temporal direction, our results would be consistent with a nasal bias, as has been observed in previous motion studies. Magnitude of the asymmetry was quantified in the form of an asymmetry index, F1/(F1 + F2). Based on developmental changes in the asymmetry index, and phase and amplitudes of F1 and F2, we conclude that the MVEP loses its directional asymmetry at 6 weeks of age. The development of directional motion symmetry observed in monkeys over the first 6 weeks is similar to that observed in humans over the first 5 months.

Abnormal motion processing and binocularity: infantile esotropia as a model system for effects of early interruptions of binocularity

Infantile esotropia, a common form of strabismus with onset prior to 6 months of age, occurs at a time of rapid visual development. While monocular visual acuity is relatively unaffected in these patients, the majority of them fail to achieve fully normal stereopsis. In addition, these patients show a spectrum of abnormalities in their ocular following responses, visual perception and visual evoked potentials (VEPs) that suggest a failure to develop a normal complement of motion processing mechanisms. While abnormalities of of stereopsis have been studied for many years, motion processing in strabismus is a rapidly evolving area of current research. Motion mechanisms are normally binocular and may form a distinct binocular sub-system. This review summarises which is known about sensory and motor abnormalities in infantile esotropia, with special emphasis on recent motion VEP recordings. The monocular motion VEP shows directional biases early in infancy that are consistent with a nasalward/temporalward response bias. Patients with infantile esotropia maintain their neonatal biases beyond the age at which they normally disappear. The motion VEP biases persist into visual maturity in patients whose strabismus is treated after about 2 years of age. Treatment prior to age 2 can lessen the magnitude of the motion VEP asymmetry and these improvements can be maintained into visual maturity. A recording from the striate cortex of a visually deprived macaque monkey indicates that the motion VEP asymmetry arises early in the visual pathway.