Objective vs subjective measures of fixation disparity for short and long fixation periods

Topical Review: Methodological Variables in Clinical and Laboratory Measurements of Fixation Disparity

SIGNIFICANCE

Fixation disparity is a small vergence error that does not disrupt fusion. Fixation disparity measures correlate with binocular symptoms. This article covers methodological differences between clinical fixation disparity measurement devices, findings when objective and subjective fixation disparities are compared, and the potential impact of binocular capture on fixation disparity measurements. Fixation disparity is a small vergence error that occurs in nonstrabismic individuals and does not disrupt fusion. This article reviews clinical fixation disparity variables and their clinical diagnostic value. Clinical devices that are used to measure these variables are described, as are studies in which the output from these devices has been compared. Methodological differences between the devices such as the location of the fusional stimulus, the rate at which judgments of dichoptic alignment are made, and the strength of the accommodative stimulus are all considered. In addition, the article covers theories of the neural origins of fixation disparity and control system models incorporating fixation disparity. Studies in which objective fixation disparities (oculomotor portion of fixation disparity assessed with an eye tracker) and subjective fixation disparities (sensory portion of fixation disparity assessed psychophysically with dichoptic Nonius lines) have been compared are also examined, and consideration is given to why some investigators find differences in these measures, whereas other investigators do not. The conclusion thus far is that there are likely complex interactions between vergence adaptation, accommodation, and the location of the fusional stimulus that lead to differences in objective and subjective fixation disparity measures. Finally, capture of the visual direction of monocular stimuli by adjacent fusional stimuli and the implications for fixation disparity measures are considered.

Eye tracking: empirical foundations for a minimal reporting guideline

In this paper, we present a review of how the various aspects of any study using an eye tracker (such as the instrument, methodology, environment, participant, etc.) affect the quality of the recorded eye-tracking data and the obtained eye-movement and gaze measures. We take this review to represent the empirical foundation for reporting guidelines of any study involving an eye tracker. We compare this empirical foundation to five existing reporting guidelines and to a database of 207 published eye-tracking studies. We find that reporting guidelines vary substantially and do not match with actual reporting practices. We end by deriving a minimal, flexible reporting guideline based on empirical research (Section "An empirically based minimal reporting guideline").

Do standard optometric measures predict binocular coordination during reading?

In reading, binocular eye movements are required for optimal visual processing and thus, in case of asthenopia or reading problems, standard orthoptic and optometric routines check individual binocular vision by a variety of tests. The present study therefore examines the predictive value of such standard measures of heterophoria, accommodative and vergence facility, AC/A-ratio, NPC and symptoms for binocular coordination parameters during read-ing. Binocular eye movements were recorded (EyeLink II) for 65 volunteers during a typical reading task and linear regression analyses related all parameters of binocular coordination to all above-mentioned optometric measures: while saccade disconjugacy was weakly pre-dicted by vergence facility (15% explained variance), vergence facility, AC/A and symp-toms scores predicted vergence drift (31%). Heterophoria, vergence facility and NPC ex-plained 31% of fixation disparity and first fixation duration showed minor relations to symp-toms (18%). In sum, we found only weak to moderate relationships, with expected, selective associations: dynamic parameter related to optometric tests addressing vergence dynamics, whereas the static parameter (fixation disparity) related mainly to heterophoria. Most sur-prisingly, symptoms were only loosely related to vergence drift and fixation duration, re-flecting associations to a dynamic aspect of binocular eye movements in reading and poten-tially non-specific, overall but slight reading deficiency. Thus, the efficiency of optometric tests to predict binocular coordination during reading was low - questioning a simple, straightforward extrapolation of such test results to an overlearned, complex task.

Effects of aligning prisms on the objective and subjective fixation disparity in far distance

Fixation disparity (FD) refers to a suboptimal condition of binocular vision. The oculomotor aspect of FD refers to a misadjustment in the vergence angle between the two visual axes that is measured in research with eye trackers (objective fixation disparity, oFD). The sensory aspect is psychophysically tested using dichoptic nonius lines (subjective fixation disparity, sFD). Some optometrists use nonius tests to determine the prisms for constant wear aiming to align the eyes. However, they do not (yet) use eye trackers. We investigate the effect of aligning prisms on oFD and sFD for 60 sec exposure duration of prisms determined with the clinically established Cross test in far distance vision. Without prisms, both types of FD were correlated with the aligning prism, while with prisms the FD was close to zero (these analyses included all base-in and base-out cases). The effect of base-in prisms on oFD was proportional to the amount of the aligning prism for the present 60 sec exposure, similar as for the 2- 5 sec exposure in Schmid et al. (2018). Thus, within 1 minute of prism exposure, no substantial vergence adaptation seems to occur in the present test conditions. Further studies may investigate intra-individual responses to different exposure times of aligning prisms in both prism directions.

Eye movement analysis using a binocular video-ophthalmoscope

This paper describes an application of binocular video-ophthalmoscope for binocular eye movement analysis during target fixation. We analyze eye movements during monocular and binocular fixation and the changes in eye position for 73 subjects. We show that the standard deviations of differences between eye shifts for vertical and horizontal movements are higher for binocular fixation with respect to monocular fixation. We also present different examples of eye movement visualization.

An automated and objective cover test to measure heterophoria

Heterophoria is the relative deviation of the eyes in absence of fusional vergence. Fusional vergence can be deprived by, for example, occluding one eye while the other fixates a visual target. Then, the occluded eye will presumably deviate from its initial position by an amount that corresponds to the heterophoria. Its assessment in clinical practice is crucial for the diagnosis of non-strabismic binocular dysfunctions such as convergence insufficiency. Traditional clinical methods, like the cover test or the modified Thorington test, suffer from practitioner's subjectivity, impossibility to observe the occluding eye or unusual viewing conditions. These limitations could be overcome by using eye tracking systems to measure objectively the heterophoria. The main purpose of this study was to compare the performance of an automated and objective method to measure near heterophoria using an eye-tracker with two conventional methods: the cover-uncover test and the modified Thorington test. The eye tracking method gave us the possibility to measure the heterophoria as the deviation of the occluded eye (mimicking the cover test) or as the deviations of the occluded and fixating eyes (adhering to the theoretical definition of heterophoria). The latter method provided smaller results than the former, although on average the differences might not be clinically relevant. The proposed objective method exhibited considerably better repeatability than the two conventional clinical methods. It showed better agreement with the modified Thorington test than with the cover-uncover test, and a similar level of agreement was obtained between the two clinical methods. To conclude, the use of eye-trackers to measure heterophoria provides objective and more repeatable measures. As eye-trackers become common tools in clinical settings, their use to measure heterophoria should be the new gold standard.

Individual objective versus subjective fixation disparity as a function of forced vergence

Inaccuracy in the vergence eye position ("fixation disparity") can occur despite a fusion stimulus. When measured with eye trackers, this inaccuracy is referred to as "objective fixation disparity". It is a matter of debate whether objective fixation disparity can be estimated with a technically simple psycho-physical procedure, i.e. the perceived offset of aligned dichoptic nonius targets, referred to as "subjective fixation disparity". To investigate the relation between these two measures, simultaneous tests were made in far vision when placing prisms in front of the eyes (for a few seconds) in order to induce forced vergence, i.e. to vary the absolute disparity (from 1 deg divergent to 3.4 deg convergent). Frequent repeated measurements in 12 observers allowed for individual analyses. Generally, fixation disparity values and the effects of prisms were much smaller in the subjective than in the objective measures. Some observers differed systematically in the characteristics of the two types of prism-induced curves. Individual regressions showed that the subjective vs. objective slope was 8% on the average (with largest individual values of 18%). This suggests that sensory fusion shifts the visual direction of the (peripheral) binocular targets by the full amount of objective fixation disparity (since single vision was achieved); however, for the (central) monocular nonius lines this shift was more or less incomplete so that the dichoptic nonius targets indicated an individual percentage of objective fixation disparity. The subjective-to-objective ratio seems to be an individual characteristic of fixation disparity in terms of the amount and in terms of the effect of prism-induced forced vergence. Therefore, on the group level the subjective measures do not allow for a precise prediction of the objective measures.

Individual Objective and Subjective Fixation Disparity in Near Vision

Binocular vision refers to the integration of images in the two eyes for improved visual performance and depth perception. One aspect of binocular vision is the fixation disparity, which is a suboptimal condition in individuals with respect to binocular eye movement control and subsequent neural processing. The objective fixation disparity refers to the vergence angle between the visual axes, which is measured with eye trackers. Subjective fixation disparity is tested with two monocular nonius lines which indicate the physical nonius separation required for perceived alignment. Subjective and objective fixation disparity represent the different physiological mechanisms of motor and sensory fusion, but the precise relation between these two is still unclear. This study measures both types of fixation disparity at viewing distances of 40, 30, and 24 cm while observers fixated a central stationary fusion target. 20 young adult subjects with normal binocular vision were tested repeatedly to investigate individual differences. For heterophoria and subjective fixation disparity, this study replicated that the binocular system does not properly adjust to near targets: outward (exo) deviations typically increase as the viewing distance is shortened. This exo proximity effect-however-was not found for objective fixation disparity, which-on the average-was zero. But individuals can have reliable outward (exo) or inward (eso) vergence errors. Cases with eso objective fixation disparity tend to have less exo states of subjective fixation disparity and heterophoria. In summary, the two types of fixation disparity seem to respond in a different way when the viewing distance is shortened. Motor and sensory fusion-as reflected by objective and subjective fixation disparity-exhibit complex interactions that may differ between individuals (eso versus exo) and vary with viewing distance (far versus near vision).

Effects of Prism Eyeglasses on Objective and Subjective Fixation Disparity

In optometry of binocular vision, the question may arise whether prisms should be included in eyeglasses to compensate an oculomotor and/or sensory imbalance between the two eyes. The corresponding measures of objective and subjective fixation disparity may be reduced by the prisms, or the adaptability of the binocular vergence system may diminish effects of the prisms over time. This study investigates effects of wearing prisms constantly for about 5 weeks in daily life. Two groups of 12 participants received eyeglasses with prisms having either a base-in direction or a base-out direction with an amount up to 8 prism diopters. Prisms were prescribed based on clinical fixation disparity test plates at 6 m. Two dependent variables were used: (1) subjective fixation disparity was indicated by a perceived offset of dichoptic nonius lines that were superimposed on the fusion stimuli and (2) objective fixation disparity was measured with a video based eye tracker relative to monocular calibration. Stimuli were presented at 6 m and included either central or more peripheral fusion stimuli. Repeated measurements were made without the prisms and with the prisms after about 5 weeks of wearing these prisms. Objective and subjective fixation disparity were correlated, but the type of fusion stimulus and the direction of the required prism may play a role. The prisms did not reduce the fixation disparity to zero, but induced significant changes in fixation disparity with large effect sizes. Participants receiving base-out prisms showed hypothesized effects, which were concurrent in both types of fixation disparity. In participants receiving base-in prisms, the individual effects of subjective and objective effects were negatively correlated: the larger the subjective (sensory) effect, the smaller the objective (motor) effect. This response pattern was related to the vergence adaptability, i.e. the individual fusional vergence reserves.

Monocular Versus Binocular Calibrations in Evaluating Fixation Disparity With a Video-Based Eye-Tracker

When measuring fixation disparity (an oculomotor vergence error), the question arises as to whether a monocular or binocular calibration is more precise and physiologically more appropriate. In monocular calibrations, a single eye fixates on a calibration target that is taken as having been projected onto the center of the fovea; the corresponding vergence state represents the heterophoria (the resting vergence position), which has no effect on the calibration procedure. In binocular calibrations, a vergence error may be present and may affect the subsequent measurement of the fixation disparity during binocular recordings. This study includes a test of the precision of both monocular and binocular calibrations and an evaluation of the impact of the calibration procedure on the measurement of fixation disparity during a dot scanning task. Our results show that 11 participants (out of 19) each exhibited a significant difference in fixation disparity with the two types of calibration procedures. In addition, the fixation disparity was more strongly affected by heterophoria undergoing monocular calibration, as opposed to binocular calibration. This serves as additional evidence showing that the monocular calibration produces a physiologically more plausible fixation disparity and seems to be more appropriate for studying the full extent of fixation disparity.

Asthenopia, Associated Phoria, and Self-Selected Prism

PURPOSE

The vergence position of rest (phoria) has been found to vary over time. We asked whether the vergence position of rest is correlated with discomfort on reading.

METHODS

We examined 20 subjects who reported strain on prolonged reading ("asthenopes") and 20 subjects who did not ("non-asthenopes"). The eyes were normal in all subjects. Associated phoria (AP) was determined by asking the subjects to align monocular markers in the Mallett Near Vision Unit. In addition, subjects were asked to adjust Risley prisms so that viewing appeared most relaxing while they were looking at fully fusionable pictures (self-selected prism=SSP). Both AP and SSP were determined at near. Each subject participated in 6 sessions. Before each session, the subjects read a text for 30 minutes. Immediately afterwards they indicated on a visual analogue scale the discomfort they had experienced during the 30 minutes.

RESULTS

In asthenopic individuals, AP fluctuated up to 19Δ, SSP up to 20Δ. In non-asthenopic individuals, AP fluctuated up to 17Δ, SSP up to 20Δ. The correlation between AP and SSP was r=0.73 (p<0.001) in the non-asthenopes and r=0.81 (p<0.001) in the asthenopes. Neither AP nor SSP were significantly larger in the asthenopes than in the non-asthenopes. Intra-individually, among the 6 sessions, the magnitude of discomfort was not significantly correlated to AP or SSP, neither in the asthenopes nor in the non-asthenopes. Asthenopes who rated their discomfort higher did not have a larger heterophoria.

CONCLUSION

The lack of a significant correlation between discomfort and (horizontal) heterophoria (determined as AP or SSP), especially intra-individually among repeated measurements, does not support a causal relationship.

The changes in phoria and convergence to divergence peak velocity ratio are correlated

PURPOSE

Phoria is used in the diagnosis of binocular dysfunctions, such as convergence insufficiency. A common treatment for convergence insufficiency is vision therapy, yet it is controversial whether the phoria changes as a result of rehabilitation. Phoria can vary due to the duration and/or the type of prior visual tasks. The variability potentially observed within phoria measurements leads to difficulties in confidently assessing changes within longitudinal studies. Hence, we propose to measure phoria and vergence peak velocities on separate days to evaluate whether a more robust measurement can be attained.

METHODS

Eleven subjects with normal binocular vision participated in two identical experimental sessions. Four-degree convergence and divergence steps stimulated from targets at far, middle, and near initial vergence positions were recorded using a limbus tracking system. Near dissociated phoria was measured after a set of step stimuli. The vergence ratio was defined as the convergence peak velocity divided by the divergence peak velocity. Linear regression analyses calculated the correlation between the phoria and the vergence ratio, and the difference between phoria measurements and vergence ratio measurements, recorded on different days.

RESULTS

Near dissociated phoria measurements and vergence ratios were highly correlated for all three initial vergence positions (r > 0.85, p < 0.005). The change in phoria was significantly correlated to the change in vergence ratio (r > 0.94, p = 0.0001). The slope of the linear regression analysis between the phoria and the vergence ratio using individual subject data was repeatable between the sessions (r = 0.99, p < 0.00001) despite large changes in phoria observed in a few individuals.

CONCLUSIONS

The change in phoria is significantly correlated to the change in vergence ratio. For longitudinal studies including the efficacy of vision therapies for patients with binocular dysfunctions, we suggest assessing both phoria and vergence velocities to reduce the variability potentially observed from different days.

Single vision during ocular deviation in intermittent exotropia

Intermittent exotropia is a common oculomotor anomaly where one eye intermittently deviates outwards. Patients with this type of strabismus are often not aware of the exodeviation and do not usually experience diplopia. In this review, we discuss what is known about the cortical mechanisms which achieve single vision during exodeviation in this condition, and highlight some outstanding questions.