Fusional Responses of Strabismics to Foveal

and Extrafoveal Stimulation

Duane K. Boman* and Andrew E. Kerresz
Horizontal fusional responses of 11 strabismics, with normal or anomalous retinal correspondence, were
studied. These included four small-angle esotropes with amblyopia, one intermittent esotrope (overcorrected intermittent exotrope), two intermittent exotropes (preoperative esotropes), one accommodative
esotrope, and three microtropes with amblyopia. Fusional stimuli (with a constant accommodative demand)
ranging from very small, central stimuli to those that cover the central, the peripheral, and both the
central and the peripheral visual fields were used. All 11 strabismics produced fusional vergence responses.
Many of the fusional responses included large nonmotor components. Small central stimuli were not
effective in producing fusional vergence, whereas stimuli that covered the visual periphery produced
fusional responses that were similar to those by subjects with normal stereoscopic vision. Invest
Ophthalmol Vis Sci 26:1731-1739, 1985

von Noorden 6 claim that even patients with ARC are

capable of performing fusional movements. Parks5
disagrees and maintains that ARC has no fusional motor component. It is emphasized by strabismologists,
however, that, especially in the presence of central
suppression scotomas, stimuli projected onto macular
areas evoke minimal fusional vergence response; they
should be projected onto the retinal periphery as well
to produce fusional vergence responses.5'6 Kenyon et
al3-4 used small central stimuli, a factor which may
explain why they failed to elicit fusional vergence responses.
Previous studies in this laboratory have shown that
some strabismic patients with ARC are able to fuse,
without blurring, large horizontal convergent disparities
of up to 22 contained in wide-angle (57) stimuli presented at a constant viewing distance.7 In order to
maintain singleness of vision without blur, these patients would have had either to produce fusional vergence eye movements or to possess large Panum's fusional areas or some combination of the two. Since eye
positions were not monitored in that study, it cannot
be stated what combination of these actually occurred.
It is the objective of this report to study the horizontal
fusional responses of strabismics using an objective eye
movement monitoring device and stimuli with constant accommodative demand. Fusional stimuli ranging from small, central stimuli to those that cover the
central, the peripheral, and both the central and the
peripheral visual fields were used to study the influence
of different areas of the visual field on the fusional responses of strabismics. These responses are compared
to responses of subjects with normal stereoscopic vision.

The existence of fusional vergence movements in

strabismus is controversial. They were postulated on
the basis of subjective measurements by Burian,' who
studied the response to peripheral fusional stimuli. Although Maraini and Pasino,2 who used an afterimage
technique, noted the presence of vergence movements
(not necessarily fusional), they nevertheless pointed out
that changes in the angle of anomaly rather than fusional vergence movements may have accounted for
some of Burian's findings. Kenyon et al3'4 used a binocular eye movement measuring device to monitor
vergence responses of strabismics to a small fixation
cross moving in depth. They reported the absence of
fusional vergence response in all of their strabismics
and postulated a disparity blocking mechanism, which
allows for accommodative vergence responses only.
The findings of Kenyon et al3'4 were most surprising
because the existence of fusional vergence response in
strabismics with normal retinal correspondence (NRC),
even if it coexists with anomalous retinal correspondence (ARC), is well accepted by strabismologists if
only on the basis of subjective evidence.5 Burian and

From the Biomedical Engineering Division, Northwestern University, and Division of Ophthalmology, Evanston Hospital, Evanston, Illinois.
Supported in part by research grant EY-1055 from the National
Eye Institute.
* Currently in the Department of Neurology, Stanford University
School of Medicine and Santa Clara Valley Medical Center, San
Jose, California.
Submitted for publication: December 4, 1984.
Reprint requests: Dr. Andrew E. Kertesz, Biomedical Engineering
Division, Northwestern University, 2145 Sheridan Road, Evanston,
IL 60201.

1731

Downloaded From: http://iovs.arvojournals.org/ on 06/28/2016

1732

INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE / December 1985

Vol. 26

Table 1. Clinical profile of the strabismic patients"

Case history
Patient,
sex, age
1,M, 16

2, F, 17

3, M, 13

Deviation/age of
detection
RET/7 yr

RET/Infancy

LET/6 yr

Amblyopia

Yes

Yes

RET/Birth

Yes

5, F, 18

X(T)/?

No

7, F, 15

I, M, 14

9, M, 21

10, F, 18

11, M, 25

Alternating
ET/2 mo

No

Accommodative
ET/4 yr

No

None/5 yr

Yes

ET/infancy

16 yr

26 mo

E(T)

-0.75 + 0.75 X 180

Occlusion

-1.50-2.00X90

* Tropia measurements were obtained with simultaneous cover and prism

tests. Phoria measurements were obtained with the alternative cover test.
t No eye movements were detected with the cover and the alternate cover
tests.
$ Flick movement of the right eye was detected with the cover test. A 4-6
p.d. deviation was measured with the alternate cover test.
The patients were wearing red-green glasses (red over the left eye). They
were shown the near Worth 4-dot stimulus (flashlight) at a distance of 10 ft.
At this distance, most patients with suppression scotomas reported seeing either
2 or 3 dots. As the flashlight was brought closer, at viewing distances of 1-4

-0.75 + 0.50X 155

therapy

-2.25 - 2.00 X 90

Occlusion

- 1 . 5 0 - 0 . 7 5 X95

therapy

-2.00 X 0.50 X 90

Fusion exercises
16 yr

None

-3.25
-2.75

Straight,
years later
RX(T)

Fusion exercises

-0.75

23 yr

-0.50

Straight,
years later
LXT

Fusion exercises

-1.00 + 0.25 X45

12 yr

-0.75 + 0.25 X 90

Occlusion
therapy

Yes

0 D
r
,
Correction
-

Occlusion
therapy

Correction
reducing
regimen

& 2 yr

Downloaded From: http://iovs.arvojournals.org/ on 06/28/2016

Orthoptics/age

Occlusion
therapy

ET/3 yr

RET/10 yr

Post-op
condition

Yes

4, M, 13

6, F, 28

Age at
surgery

_
+ 1.25

u. / J aaa

-0.75 + 1.0 X 130

-1.00 + 2.0 X 25

Occlusion
therapy

-1.00 + 2.75 X 120

Occlusion
therapy

-1.25
- 1 ?<5

-1.25 +0.75 X 78

feet, the patients saw 4 dots. Patients RW and CA saw 4 dots at 10 feet and
only when the viewing distance was increased to 25 ft. did they report that
some of the dots disappeared.
H The 4 diopter test was inconclusive.
** The abbreviations in this table represent: ET = esotropia; RET = right
esotropia; LET = left esotropia; E(T) = intermittent esotropia; E = esophoria;
LXT = left exotropia; X(T) = intermittent exotropia; RX(T) = right intermittent
exotropia; X = exophoria; LH = left hyperphoria; RH = right hyperphoria; D
= measurement at distance; N = measurement at near; ARC = anomalous
retinal correspondence; NRC = normal retinal correspondence.

No. 12

1733

FUSIONAL RESPONSES OF STRADISMICS / Domon ond Kerresz

Present condition
Visual
Acuity
OD
OS

Stereoacuity

Current Deviation in
p.d.*

Amblyopia

Correspondence

Suppression
scotoma/tests

Capsule description

20/50
20/20

TNO
None
Titmus
800"

D:RET: = 8sc
N:RET: = 8sc

Yes

ARC

Yes/Bagolini
Worth 4-dot
4 diopter

Esotrope with
amblyopia

20/30
20/20

TNO
Titmus
None
TNO
None
Titmus
200"

D: RET
N: RET

= 4-6
=6

Yes

ARC

Yes/Bagolini
Worth 4-dot
4 diopter

Esotrope with
amblyopia

D: LET
N: LET

=6
=8

Yes

ARC

Yes/Bagolini
Worth 4-dot

Esotrope with
amblyopia

Yes

ARC

Yes/Bagolini
Worth 4-dot
4 diopter

Esotrope with
amblyopia

No

NRC

No/Bagolini
Worth 4-dot

No

NRC

Yes/Bagolini
Worth 4-dot
4 diopter

Occasional E(T)
[overcorrected X(T)]
occasional uncrossed
diplopia
Occasional X(T),
occasional crossed
diplopia or
suppression
Occasional X(T),
occasional crossed
diplopia

20/20
20/25

20/30
20/15

TNO
None
Titmus
Fly

20/20
20/20

TNO
240"
Titmus
100"
TNO
Qual.
Titmus
400"

20/20
20/20

D: RET = 12
LH
=4
N: RET = 15
LH
=4
V PattenI
25 down
ET
ET
8 up
D:E
18-20
RH
= 5
N:E
8-10
D: X
LH
N:X
LH

10
=4

=2

20/20
20/20

TNO
Titmus
None

D: X
18
RH
4-6
N:X
10
RH
=4
A Patterni
X
14 up
X(T) = 35 down

No

NRC

No/Bagolini
Worth 4-dot

20/20
20/20

TNO
None
Titmus
100"

D:E
N: E

No

NRC

Yes/Bagolini
Worth 4-dot
4 diopteril

Accommodative
esotrope

20/20
20/40

TNO
240"
Titmus
140"

Yes

Yes/Bagolini
Worth 4-dot
4 diopter

Microtrope with
amblyopia

20/20
20/60

TNO
None
Titmus
400"

Yes

Yes/Bagolini
Worth 4-dot
4 diopteril

Microtrope with
amblyopia

20/60
20/20

TNO
None
Titmus
400"

Yes

Yes/Bagolini
Worth 4-dot
4 diopteril

Microtrope with
amblyopia

18
6

Microtropef

Microtrope f

Microtrope:(:

Downloaded From: http://iovs.arvojournals.org/ on 06/28/2016

1734

INVESTIGATIVE OPHTHALMOLOGY G VISUAL SCIENCE / December 1985

Materials and Methods

Two display devices were used in these experiments.
The first was a computer-controlled, projection-type,
video display device. This device displayed a 256 by
256 dot matrix (dot luminance was 3.2 mL., mesopic
range) to each eye allowing for dichoptic (red/green)
presentations. The viewing distance was 115 cm, and
the display subtended 40 of arc vertically and 50
horizontally. Stimulus disparity could be changed in
increments of 0.5. A detailed description of this device
is provided elsewhere.8 The second display device consisted of two targets that could be independently illuminated and were placed along the subject's visual
midline at distances of 40 and 100 cm. The two targets
consisted of 2.8-cm by 2.8-cm lucite plates with small
crosses etched onto their surfaces. The near and far
targets subtended 4 and 1.6 and the etched crosses
were 2.5' and 1' of arc wide, respectively. The targets
were carefully adjusted in both the horizontal and vertical directions to minimize eye movements due to target misalignment. Each target was illuminated by two
computer-controlled, yellow, light emitting diodes.
Horizontal eye movements were monitored by an
infrared reflection method.9 This device has a resolution of 15' of arc and is linear within a range of 8
of arc. The eye positions were sampled at a rate of 20
Hz, digitized, and stored for later processing. The disjunctive component of the eye movement recordings
was calculated by subtracting the right eye's position
from that of the left. Movements in the same direction
as that of the stimulus were defined to be positive.
Eleven strabismics participated in these experiments,
whose informed consent was obtained prior to their
participation. They were either patients of the Binocular Function Center at Evanston Hospital or students
of Northwestern University. Each was given a visual
examination to make certain that they had fusion, a
deviation of 20 p.d. or less in primary position, hyperdeviations not exceeding 10 p.d., and corrected visual acuity of 20/60 or better in each eye. In addition,
intermittent exotropes were only admitted if their condition developed subsequent to surgery that was undertaken to correct esotropia. A summary of clinical
profiles is presented in Table 1.
Each patient wore his correction, except patient 8,
who was tested in his distance correction (without the
+0.75 D add). Patients were seated in a darkened room
to eliminate conflicting visual clues. Chin and headrests
were employed. First, the patient's superimposition
point was determined, which provided the horizontal
and vertical baseline for all subsequent stimulus presentations. Cover-uncover and alternate cover tests
were performed with stimuli at the patient's superimposition point while eye positions were being mon-

Downloaded From: http://iovs.arvojournals.org/ on 06/28/2016

Vol. 26

itored. The superimposition point for all 11 patients

was at zero disparity. The patient's tropia, tropia plus
phoria, subjective angle, and objective angle were recorded.

Results
Experiment 1
In this experiment, the patients' horizontal fusional
responses to convergent and divergent disparity presentations were studied using wide-angle fusional
stimuli with a constant accommodative demand. The
influence of different areas of the visual fields on fusional response was also studied by using stimuli that
covered the central, the peripheral, and both the central
and the peripheral visual fields. The video display device was used throughout this experiment with stimuli
based on the stimulus shown in Figure 1. It consisted
of a 128 by 128 element, random-dot (RD) stereogram
upon which a 40 long, binocularly visible, vertical
line, composed of three sections, and two, 25 long,
horizontal nonius lines were superimposed. The intersection of the vertical and horizontal lines provided a
fixation point. The perceived appearance of the vertical
line also provided a clue for the presence of fusion or
diplopia, while the nonius lines were used as suppression controls. Two 4 wide, horizontal, RD stripes,
one 4 above the fixation point and the other 4 below
it, were presented at a 1 crossed disparity with respect
to the rest of the pattern, thus providing a depth cue.
Three stimuli were used: (1) Full-field stimulus which
was identical to that shown in Figure 1; (2) 10 stimulus
which consisted of the central 10 portion of the stimulus shown in Figure 1. The entire stimulus was presented at the same depth plane; (3) Left annular stimulus, which was the same as the full-field stimulus, with

LEFT EYE

20

RIGHT EYE

9
9

W///////////AV/////////////A

W////////////,
W////////M

20

Fig. 1. A random-dot stereogram subtending 50 by 40 was the

basis for the stimuli used in the experiments. The horizontal and
vertical coordinates of stimulus features are indicated relative to the
fixation point. The random-dots within the crosshatched areas were
presented at a 1 crossed disparity relative to the rest of the stimulus.
A vertical line, composed of three segments, that was seen by both
eyes, and two horizontal nonius lines were superimposed on the random-dot stereogram.

No. 12

FUSIONAL RESPONSES OF STRADISMICS / Domon and Kerresz

1735

FULL-FIELD STIMULUS

RIGHT EYE ^ - T ^

Fig. 2. Responses by four strabismics to 5 convergent or divergent disparity presentations contained in the full-field stimulus.
The overall motor compensation
and the change in each eye's line
of sight are given in degrees of arc.
A Patient 9; a microtrope. B Patient 6, an intermittent exotrope.
C Patient 8, an accommodative
esotrope. D Patient 1, a small-angle
esotrope with amblyopia.

"2.2

^ * ~ W ,

J j COMPONENT
VK ^ V . ^
.
0*

^ W * * /

the central 10 portion of the left stimulus blanked.

Diffuse scattered light within the blanked region produced a luminance of 0.06 mL.
First, the patient's horizontal fusional amplitudes
were tested in both the convergent and divergent disparity directions using the full-field stimulus. Experimental runs with either 3 or 5 disparity presentations
were employed, depending on the patient's fusional
amplitude in that direction. No test was run in a disparity direction in which the patient's fusional amplitude was less than 3. If the patient was available for
only a few sessions, his responses were only tested in
one disparity direction. This direction was either randomly chosen, or it coincided with the direction in
which the patient was able to fuse a 5 disparity.
Each experimental run began with the stimulus at
the patient's superimposition point. The patient was
instructed to maintain fixation throughout the run on
the intersection of the nonius lines and the vertical
line. He was to report the presence of diplopia,
suppression, loss of stereopsis, or blurriness within the
stimulus. The patient initiated a run by pressing a button. After 8 sec a symmetric, 3 or 5, convergent or
divergent, horizontal disparity was introduced in the
form of a staircase with a 0.5 disparity step occurring
each second. The 3 or 5 disparity position was maintained for 10 sec before the disparity was reduced to
zero by another staircase. Each run was 45 sec long.
In each sitting, each of the three stimuli were presented
four times in a random order along with two calibration
runs. Each run was replicated 12 times.
All 11 strabismics who were tested produced fusional

Downloaded From: http://iovs.arvojournals.org/ on 06/28/2016

V'^
0*

vergence eye movements with all of the stimuli. These

patients included four small-angle esotropes with amblyopia, one intermittent esotrope (overcorrected intermittent exotrope), two intermittent exotropes (preoperative esotropes), one accommodative esotrope, and
three microtropes with amblyopia. Figure 2 shows fusional responses by four of these patients to the fullfield stimulus: patient 9, a microtrope; patient 6, an
intermittent exotrope; patient 8, an accommodative
esotrope; and patient 1, a small-angle esotrope. Significant motor and nonmotor (sensory) components
can be seen in each of these responses.
Patient 4 and 7 usually produced unsteady recordings due to head and body movements, so their eye
movements were not studied quantitatively. The vergence responses of the other nine patients were analyzed to determine the overall motor compensation to
the disparity (disjunctive component) and the angular
change in each eye's line of sight from the beginning
of a run to the middle (during the presence of the 3
or 5 disparity). Occasional runs in which suppression
or diplopia occurred for over 5 sec were deleted from
this analysis. Table 2 presents the averages and standard
deviations of these measurements for each patient under the different stimulus conditions. The percentage
of overall motor compensation to the full-field stimulus
ranged from 94% to 22%. In similar experiments with
stereonormal subjects, this range was from 102% to
70%. For the small-angle esotropes with amblyopia,
this range was from 66% to 44%; for the microtropes
it was from 73% to 22%; while for the other patients it
was from 94% to 64%.

1736

INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE / December 1985

Vol. 26

Table 2. Averages and standard deviations (in degrees) of eye movement responses
to horizontal disparities contained in fusional stimuli
Stimulus typef
Stimulus
disparity

Motor
component

FF

10

LAN

5 convergent

Disjunctive
Left
Right

2.2 1.5
1.9 l.Of
0.4 1.0

2.0 0.6
1.2 0.6
0.8 0.8

1.4 0.8
-0.1 1.3f
1.5 0.8

5 convergent

Disjunctive
Left
Right

2.3 1.0
1.90.7f
0.4 0.8

2.3 1.1
1.5 0.8
0.9 1.4

1.0 1.0*
1.7 l.5f
-0.7 2.1

5 divergent

Disjunctive
Left
Right

3.3 0.8
1.4 0.9
1.9 1.5

3.1 0.9
0.7 1.4
2.4 1.4

3.9 1.4
1.5 1.4
2.5 0.9

5 convergent

Disjunctive
Left
Right

4.7 1.0
2.6 1.0*
2.0 0.9

4.3 1.1
2.7 1.2
1.6 1.6

4.7 1.0
1.3 1.7
3.4 2.7

Disjunctive
Left
Right

3.2 0.6
2.0 0.8
1.3 0.9

2.6 0.9
1.3 0.8
1.3 0.7

1.2 0 . 7 f
2.9 0.8

4.1 0.8
2.8 0.8t
1.3 0.5

4.0 0.6
2.3 1.0
1.7 0.7

Patient
number

5 divergent

1.7 0.9*

5 convergent

Disjunctive
Left
Right

4.2 0.3
2.6 0.6f
1.7 0.6

3 divergent

Disjunctive
Left
Right

2.6 0.3
1.2 0.3
1.4 0.4

NR
NR
NR

0.9 0.6*
-0.3 1.3f
1.1 1.1

5 convergent

Disjunctive
Left
Right

3.0 0.6
1.00.8f
2.0 0.5

3.1 0.6
1.7 0.7
1.4 0.4

1.9 0.8*
-0.2 0.7 f
2.1 0.4

3 divergent

Disjunctive
Left
Right

2.2 0.3
1.1 0.4
1.1 0.2

1.9 0.4
0.8 0.6
1.1 0.5

1.8 0.3*
0.4 0.41
1.4 0.2

5 convergent

Disjunctive
Left
Right

1.1 1.1
0.4 2.2
0.6 2.5

0.5 0.7
0.8 1.6
-0.3 1.5

-1.7 1.5f
3.0 1.2

10

1.4 1.0

11

5 convergent

Disjunctive
Left
Right

3.7 0.3
2.1 0.4f
1.6 0.3

3.5 0.6
2.2 0.5 f
1.4 0.7

3.6 0.4
1.40.5f
2.2 0.6

11

3 divergent

Disjunctive
Left
Right

2.0 0.2
0.8 0.5
1.2 0.5

1.5 0.4*
1.0 0.7
0.5 0.5

1.6 0 . 4 *
0.4 0.4f
1.2 0 . 3

* Cases with significantly different overall motor compensation than the

full-field case (P < 0.01).
t Cases with significantly asymmetric monocular motor responses (P < 0.01).

$ Stimulus types: FF = full-field stimulus; 10c = 10 stimulus; LAN = 10c

left monocular annulus.

One-tailed t-tests were employed at the 99% confidence level to compare each patient's average overall
motor compensation under different stimulus conditions and the average change in the left eye's line of
sight to that of the right under each stimulus condition.
There was significantly less overall motor compensation in 1 of 11 cases (Table 2 entries) with the 10
stimulus and in 6 of 12 cases with the left annular
stimulus. Patients in each category showed significant
reductions in overall motor compensation with the left
annular stimulus. There was significant asymmetry
between the changes in the lines of sight by the two
eyes in 5 of 12 cases with the full-field stimulus and in

2 of 11 cases with the 10 stimulus. In each case, the

patient's nondeviating eye moved more than its fellow.
There was also asymmetry in 9 of the 12 cases with
the left annular stimulus. In eight of these cases, the
right eye moved more than the left, regardless of
whether it was the nondeviating eye or not. Occurrences
of asymmetry were found with patients in each category.

Downloaded From: http://iovs.arvojournals.org/ on 06/28/2016

Experiment 2
In the first experiment, horizontal vergence responses
to large stimuli were measured. Many of the patients

FUSIONAL RESPONSES OF STRADISMICS / Doman ond Kerresz

No. 12

1737

Table 3. Averages and standard deviations (in degrees) of fusional amplitudes and vergence compensation
to a fusional stimulus subtending 1.5
Divergence

Convergence
Patient
number

Fusional amplitude

Vergence compensation

Fusional amplitude

Vergence compensation

9
11
8

0.8 0.3
1.1 0.2
0

0.3 0.5
0.3 0.7

1.1 0.2
1.0 0.0
0

0.6 0.4
0.1 0.5

in experiment 1 have small suppression scotomas that

are restricted to the center of their visual field. The
scotomas are much smaller than 10 in diameter, and
hence, even the 10 diameter fusional stimulus (the
smallest used in experiment 1) was stimulating nonscotomatic regions which could have given rise to the
observed fusional vergence responses. In this experiment, the vergence responses of three of the patients
with scotomas (patients 8,9, and 11) were studied using
a fusional stimulus subtending 1.5 of arc (a 1.5 cross).
First, the patient's horizontal fusional amplitudes
were determined with this stimulus. None of the patients were able to fuse disparities of greater than 1.5
in either direction, although they fused 3 to 5 disparities in the first experiment.
Each run began with the stimuli at the patient's superimposition point. The experimenter slowly increased the disparity until the patient's maximum fusible disparity (fusional amplitude) in that direction
was reached. Subsequently, the experimenter started
to record eye positions. After 10 sec, the disparity was
slowly returned to the superimposition point with a
0.5 step occurring every sec. Eye movement recording
continued for 10 sec after the superimposition point
was reached. Five convergent and five divergent runs
were performed in each session along with two calibration runs. Vergence response was measured by
comparing the first 10 sec of the disjunctive component
to the last 10 sec in each run. Each run was repeated
ten times.
Table 3 presented the average fusional amplitudes
and vergence responses of each patient to the 1.5 cross.
Only one patient produced a significant vergence response in one disparity direction (patient 9, divergence).
In the other cases, the average vergence response was
not significantly different from zero. Two subjects with
normal stereoscopic vision were also tested under these
conditions. One had fusional amplitudes of 5.2 in each
disparity direction and averaged 94% motor compensation. The other had a divergent fusional amplitude
of 5.8 and a convergent fusional amplitude of 17.7
and averaged 92% motor compensation.
Experiment 3
Kenyon, et al 34 found that strabismic patients produced horizontal vergence responses that resembled

Downloaded From: http://iovs.arvojournals.org/ on 06/28/2016

accommodative vergence when presented with small,

midline targets. In the present experiments, strabismics
produced fusional vergence responses to wide-angle
stimuli with constant accommodative demand, but had
greatly reduced fusional amplitudes and usually produced no vergence response to small central stimuli.
Therefore, it was decided to test whether these strabismics would also resort to accommodative vergence
under conditions that resembled those employed by
Kenyon, et al.3-4
The three patients that participated in experiment
2 also participated in this experiment. The second
f^

TWO TARGET STIMULUS

TW10 RUN 1

STIMULUS:
NEAR

FAR

NEAR

Fig. 3. Responses by two strabismics to changes in stimulus position

of a small, midline target. The right eye was the nondeviating eye
with each of these patients. The deflections on the stimulus trace
mark the times at which stimulus illumination changes occurred,
first, from the near to the far target and, second, from the far to the
near target. A Patient 9, a microtrope. B Patient 8, an accommodative
esotrope. Please note that disparity changes were introduced in a
single step in this experiment, whereas they were introduced more
gradually, with changes lasting several seconds, in the two previous
experiments.

1738

INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE / December 1985

stimulus display device (consisting of independently

illuminated, near and far, midline targets) was employed. Only one target was illuminated at a time. Each
run was 30 sec long, and target illumination was
switched every 10 sec. Therefore, each run began and
ended with the same target illuminated. The patient
was instructed to fixate on whichever target was illuminated. A session consisted of two calibration runs,
five runs with the near target initially illuminated, and
five runs with the far target initially illuminated. Please
note that disparity changes were introduced in a single
step in this experiment, whereas they were introduced
more gradually, with changes lasting several seconds,
in the two previous experiments.
All three patients produced vergence responses that
were similar to those described by Kenyon, et al.3'4
Typical responses by patients 8 and 9 are shown in
Figure 3. In each of these responses, the vergence amplitude of the patient's nondeviating (right) eye is
smaller than that of the other eye. A binocular saccade
is employed to fixate the nondeviating eye on the target
while the other eye completes the vergence movement.
Each patient had a longer average reaction time for
the saccade than for the vergence movement. The average vergence reaction time ranged from 170 to 260
msec, while the average reaction time for the saccade
ranged from 325 to 645 ms. The amplitudes of the
saccade produced by each eye tended to be unequal
with the nondeviating eye producing the larger saccade,
although patient 11 produced symmetric saccades during convergence. The amplitudes of the monocular
vergence contributions also tended to be asymmetric
with the nondeviating eye producing the smaller
movement, averaging 10% to 29% of the vergence
movement.
Two subjects with normal stereoscopic vision produced vergence responses that resembled fusional
vergence when tested under these conditions. This observation was also reported by Kenyon, et al.10 The
subjects with normal stereoscopic vision produced
smooth equal vergence movements by the two eyes.
Patients 8 and 9 occasionally produced smooth equal
vergences when converging but never showed this type
of response while diverging.

Discussion
All eleven strabismics that were tested produced fusional vergence responses to stimuli subtending at least
10 of arc. These patients included small-angle esotropes with amblyopia, intermittent exotropes (preoperative esotropes), an intermittent esotrope (overcorrected intermittent exotrope), an accommodative
esotrope, and microtropes with amblyopia.
At least four of the strabismics who exhibited fusional vergence have anomalous retinal correspondence

Downloaded From: http://iovs.arvojournals.org/ on 06/28/2016

Vol. 26

(ARC). This supports Burian and von Noorden's claim

that patients with ARC are capable of producing fusional movements, provided the stimulus includes peripheral visual areas. These results also agree with
Schoessler's findings that it is possible to initiate fusional vergence responses in strabismics with ARC."
It has been suggested that strabismics have a disparity
blocking mechanism that results in a lack of fusional
vergence.34 The results of this study suggest that, for
the strabismics in this study, the disparity blocking
mechanism was restricted to the central visual fields.
This mechanism was able to prevent disparity information from being utilized even when the stimulus
image was not being suppressed. The patients in this
study were often able to perceive diplopia in small,
centrally located stimuli but were unable to initiate
vergence movements. Sireteanu, et al12 have shown a
loss of binocularity in the central visual fields of strabismic amblyopes which manifested in a loss of binocular summation, interocular transfer of grating adaptation, and dynamic local stereopsis. This loss of
binocularity may account for the lack of vergence response by our patients to small central stimuli.
Two differences were observed between the responses
of strabismics and stereonormal subjects. The first difference was that the esotropes and the microtropes
produced less overall motor compensation to full-field
stimuli than subjects with normal stereoscopic vision.
The strabismics produced nonmotor components of
up to 3.9. Second, the strabismics had small fusional
amplitudes and usually had no measurable vergence
response to a 1.5 cross, while the subjects with normal
stereoscopic vision produced large vergence responses
with this stimulus. The patients did not suppress the
image of this stimulus. When fusion was lost they perceived diplopia. The 1.5 cross was a poor fusional
vergence stimulus for these strabismics; however, the
10 stimulus was usually as effective in evoking vergence responses as the full-field stimulus.
The small-angle esotropes and the microtropes in
this study were also amblyopic, unlike the strabismics
in the other categories. It cannot be ascertained from
this study whether amblyopia, strabismus, or the combination of these affected the fusional responses of these
patients, but previous studies have shown that strabismus has a greater effect on fusional vergence than amblyopia. 34
Subjects with normal stereoscopic vision and many
of the strabismics in this study show less overall motor
compensation with the left annular stimulus than the
full-field stimulus. In stereonormal subjects, this decrease is attributed to the fact that Panurrf s fusional
areas increase with increasing retinal eccentricity.1314
Measurements by Bagolini15 also show an increase in
Panum's fusional area with increasing eccentricity in
strabismics with ARC.

No. 12

FUSIONAL RESPONSES OF STRADISMICS / Boman and Kerresz

Patient 5, an intermittent esotrope, produced the

largest overall motor compensation, yet she was an intermittent exotrope until age 16 when surgery was performed, the patient was overcorrected, and orthoptic
therapy was instituted. These tests were performed 2
yr subsequent to the surgery.
In summary, strabismics were found to produce fusional responses that included both motor and nonmotor components. Stimulation of only the central visual fields was not effective in producing fusional vergence, whereas areas outside the central visual fields
had a similar influence on the vergence responses of
strabismics as they did on the responses of subjects
with normal stereoscopic vision. The overall motor
compensation of small-angle esotropesand microtropes
was less than that produced by subjects with normal
stereoscopic vision.
Key words: strabismus, anomalous retinal correspondence,
fusional vergence, extrafoveal stimulation
Acknowledgment
We wish to thank Judith Kertesz for her help in this project.

References
1. Burian HM: Fusional movements in permanent strabismus; a
study of the role of the central and peripheral retinal regions in
the act of binocular vision in squint. Arch Ophthalmol 26:626,
1941.

Downloaded From: http://iovs.arvojournals.org/ on 06/28/2016

1739

2. Maraini G and Pasino L: Variations in the angle of anomaly

and fusional movements in cases of small-angle convergent strabismus with harmonious retinal correspondence. Br J Ophthalmol 48:439, 1964.
3. Kenyon RV, Ciuffreda KJ, and Stark L: Dynamic vergence eye
movements in strabismus and amblyopia: symmetric vergence.
Invest Ophthalmol Vis Sci 19:60, 1980a.
4. Kenyon RV, Ciuffreda KJ, and Stark L: An unexpected role for
normal accommodative vergence in strabismus and amblyopia.
Am J Optom Physiol Opt 57:566, 1980b.
5. Parks MM: Ocular Motility and Strabismus, Hagerstown, Harper
and Row, Publishers, Inc., 1975.
6. Burian HM and von Noorden GK: Binocular Vision and Ocular
Motility, St Louis, CV Mosby Co., 1974.
7. Kertesz AE: The effectiveness of wide-angle fusional stimulation
in strabismus. Am Orthop J 33:83, 1983.
8. Reuss JL and Kertesz AE: Microcomputer generation of dynamic
stereo graphics for clinical use. IEEE Trans Biomed Eng BME28:15, 1981.
9. Stark L, Vossius G, and Young LR: Predictive control of eye
tracking movements. IRE Transactions on Human Factors
Electronics HFE-3:52, 1962.
10. Kenyon RV, Ciuffreda KJ, and Stark L: Binocular eye movements during accommodative vergence. Vision Res 18:545, 1978.
11. Schoessler JP: Disparity-induced vergence responses in normal
and strabismic subjects. Am J Optom Physiol Opt 57:666, 1980.
12. Sireteanu R, Fronius M, and Singer W: Binocular interactions
in the peripheral visual field of humans with strabismic and anisometropic amblyopia. Vision Res 21:1065, 1981.
13. Ogle KN: Binocular Vision, New York, Hafner Publishing Co.,
1950.
14. Hampton DH and Kertesz AE: The extent of Panum's area and
the human cortical magnification factor. Perception 12:161, 1983.
15. Bagolini B: Anomalous correspondence: definition and diagnostic
methods. Doc Ophthalmol 23:346, 1967.