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- •Preface to the Fourth Edition
- •Preface to the First Edition
- •Contents
- •Extraocular Muscles and Orbital Fascia
- •Anatomy of Third, Fourth and Sixth Cranial Nerves
- •Basic Kinematics
- •Mechanics of Actions of Extraocular Muscles
- •Ocular Movements
- •Agonist, Synergists, Antagonists and Yoke Muscles
- •Fundamental Laws Governing Ocular Motility
- •Components of Visual Acuity
- •Measurement of Visual Acuity
- •Contrast Sensitivity
- •4. Binocular Vision
- •Binocular Vision: Definition and Grades
- •Psychophysics and Sensory Aspects of Binocular Vision
- •Development of Binocular Vision
- •Binocular Vision Tests
- •Definition and Classification
- •Etiology of Strabismus: An Overview
- •Evaluation of a Case of Strabismus
- •Orthoptic Instruments
- •Computer-based Orthoptic Vision Therapy Programs and Instruments
- •Convergence
- •Divergence
- •Accommodation
- •Sensory Adaptations
- •Amblyopia
- •Motor Adaptations
- •9. Heterophoria
- •Concomitant Esotropias
- •Concomitant Exotropias
- •Vertical Strabismus
- •Cyclodeviations
- •12. Incomitant Strabismus
- •Paralytic Squint
- •Restrictive Ocular Motility Defects
- •Supranuclear Control of Eye Movements
- •Supranuclear Disorders of Eye Movements
- •14. Nystagmus and Related Oscillations
- •Nystagmus
- •Non-surgical Management
- •Surgical Management
- •Outlines of Strabismus Management
- •Index

56 Theory and Practice of Squint and Orthoptics
Fig. 3.23 Cambridge low-contrast gratings score sheet
and conversion table.
to a photographic exposure between 1/15 and
1/30 second at f/5.6 with an ASA of 100. The
luminance is determined with the help of a light
meter.
While recording, the subject sits directly in
front of the chart at a distance of 1 m (with the
best distance correction) (Fig. 3.25). The subject
is made to name or outline each letter on the
chart, starting from the upper left corner and
reading horizontally across the line. Subject is
made to guess, even when he or she believes
that the letters are invisible. The test is
concluded when the subject guesses two of the
three letters of the triplet incorrectly. The
subject’s sensitivity is indicated by the finest
triplet for which two of the three letters are
named correctly.
4. Vistech chart. This chart consists of sine wave
gratings and is used at a distance of 3 m from
the subject. In this test, contrast is assessed at
several spatial frequencies (distance of the
separation of the grating bars) and the subject
has to identify the orientation of the grating, i.e.
whether vertical or 158 clockwise, or anticlockwise.
Fig. 3.24 Pelli-Robson contrast sensitivity chart.
(A) Photograph; (B) Log contrast sensitivity score of each
triplet.
5. Vector vision chart. Vector vision CSV 1000
(USA) chart test frequency of 3,6,12 and 18 cpd.
6. Functional acuity contrast testing.
Dr Arthur Ginsburg first described functional
Acuity Contrast Testing (FACT). This includes
a chart of sine-wave grating with varying
frequencies. With the help of this chart, five
spatial frequencies and nine levels of contrast

Fig. 3.25 Measurement of contrast sensitivity with Pelli-
Robson chart.
can be tested. The contrast of the letter change
in the row and decreases from left to right. The
spatial frequency increases from top to bottom,
and the test is performed at a distance of 10 feet.
The patient sees the grating in each row like A,
B, C, and D and then reports the orientation
right, up, or left (Fig. 3.26). The last grating for
57Visual Acuity and Contrast Sensitivity
each spatial frequency is then plotted for the CS
curve.
7. Regan low contrast sensitivity letter charts.
This consists of three-letter charts printed on
white cardboard, having a contrast of 97%, 7%,
and 4% (Fig. 3.27). It is tested at 3 meters with
eight letters in each line. The patient is told to
start from the top of the row until they can no
longer identify the letter on the line. The letter
size goes on reducing, and the contrast remains
the same. Regan, in 1988 said that this has a role
in detecting early vision loss in glaucoma and
diabetes.
8. Spaeth Richman contrast sensitivity test.
Spaeth Richman contrast sensitivity test
(SPARCS) is a computerized test to assess CS. It
can be accessed online with good internet access.
The patient being tested is provided an
identification number and instructed regarding
the test. The test can be performed in 5 to 10
minutes for each eye and measures the central
and peripheral CS. This test can also be
employed in illiterate patients as this is based
on gratings (Fig. 3.28).
Fig. 3.26 Functional acuity contrast testing chart.

58 Theory and Practice of Squint and Orthoptics
Fig. 3.27 Regan contrast sensitivity chart.
Fig. 3.28 Spaeth Richman contrast sensitivity test
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Binocular Vision
Binocular Vision
61
4
BINOCULAR VISION: DEFINITION AND GRADES
• Definition
• Grades
PSYCHOPHYSICS AND SENSORY ASPECTS
• Visual directions and the horopter
• Binocular fusion
• Dichoptic stimulation
• Stereopsis
• Depth perception
• Integration of the motor and sensory system into
binocular vision
BINOCULAR VISION:
DEFINITION AND GRADES
DEFINITION
Romano and Romano1 defined binocular vision
as that state of simultaneous vision with two
seeing eyes (neither of which needs necessarily
be normal) that occurs when an individual fixes
his visual attention on an object of regard. By
and large binocular vision implies binocular
single vision (fusion) and a high level stereoacuity.
Though, cursorily binocular vision may be
defined as the coordinated use of the two eyes
to produce a single mental impression, its full
definition includes its full scope, i.e. grades of
binocular vision.
GRADES OF BINOCULAR VISION
Thus, binocular vision may be defined to consist
of following:
DEVELOPMENT OF BINOCULAR VISION
• Prerequisites
• Eye at birth and normal postnatal development
• Maturation of binocular function
• Neurophysiology of development
• Theories of binocular vision
• Disturbances in the development
BINOCULAR VISION TESTS
• Simultaneous perception
• Fusion
• Stereopsis
Simultaneous perception
(first grade of binocular vision)
Simultaneous perception exists when signals
transmitted from the two eyes to the visual
cortex are perceived at the same time. The term
simultaneous perception does not imply that
both eyes see the same object and transmit
identical information to the visual centre, nor
does it imply that the two pictures can be seen
superimposed. It consists of power to see two
dissimilar objects simultaneously. It can be
demonstrated by presenting separate stimuli to
the two eyes, such as a picture of a cage to one
eye and a picture of bird to the other eye. If both
cage and the bird are seen at the same time, then
simultaneous perception is present (Fig. 4.1A).
Further, there is a fundamental difference
between seeing with two eyes alternately and
simultaneous binocular perception. An animal
whose eyes are situated laterally in the head so
that the visual fields of the two eyes never

62 Theory and Practice of Squint and Orthoptics
overlap or overlap in only a very small portion
and thus can use one eye at a time. This is
alternate use of the two eyes, rather than
simultaneous use of the two eyes. It can be
further clarified by the typical example that,
when a bird sees a worm on the ground and
tilts its head so that it obtains a clear image of
the worm with the right eye, the left is directed
upward. Since the simultaneous image of this
eye would detract considerably from the
perception of the worm, there is a reason to think
that one image is suppressed mentally. The bird
may direct its attention at will to the image of
the left eye and ignore the image of right eye
temporarily. This would surely happen, if under
these circumstances a hawk were to fly
overhead. Under certain conditions, human
beings suppress the image from one eye with
both eyes open. Simultaneous perception ceases
to exist under these circumstances. For example,
when using a monocular microscope, one
suppresses the image of the other eye.
Fusion (second grade of binocular vision)
Fusion constitutes second grade of binocular
vision. It implies the ability of the two eyes to
produce a composite picture from two similar
pictures, each of which is incomplete in one
small detail. For example, there are two rabbits
each lacking either a tail or a bunch of flowers.
If fusion is present, one rabbit complete with tail
and holding a bunch of flowers will be seen
(Fig. 4.1B). It should not be confused with the
superimposition of two dissimilar (but not
mutually antagonistic) pictures, such as a cage
and a bird. So, when a person sees the bird inside
the cage (Fig. 4.1A), it is not fusion, but simply
a simultaneous perception in the same direction.
Stereopsis (third grade of
binocular single vision)
Stereopsis implies the ability to obtain an
impression of depth by the superimposition of
two pictures of the same object which have been
taken from slightly different angles, such as a
bucket that is appreciated in three dimensions
(Fig. 4.1C). Stereopsis should not be considered
synonymous with the depth perception, since,
depth perception is the perception of distances
of objects from each other or from the observer.
Even a monocular observer is quite capable of
judging distances and of obtaining an
impression of spatial order. Therefore, stereopsis
refers to the visual appreciation of three
dimensions during binocular vision.
PSYCHOPHYSICS AND SENSORY ASPECTS OF BINOCULAR VISION
The various facts about the psychophysics and
sensory aspects of the binocular vision (revealed
Fig. 4.1 Grades of binocular single vision: (A) simultaneous perception; (B) Fusion; (C) Stereopsis.

Binocular Vision
63
by psychophysical and experimental physiological studies), for the purpose of descriptive
convenience, can be compiled as below:
1.Visual direction and the horopter
• Visual space versus physical space
• Visual directions
• Corresponding points and normal retinal
correspondence
• Horopter
• Physiological diplopia
2. Binocular fusion
• Sensory fusion
• Concept of Panum’s area
• Fixation disparity
• Theories of binocular fusion
3. Dichoptic stimulation
• Depth with fusion
• Depth with diplopia
• Diplopia without depth
• Binocular rivalry and suppression
4. Stereopsis
• Physiological basis of stereopsis
• Stereopsis and fusion
• Stereoscopic acuity
• Neurophysiology of stereopsis
5. Depth perception
• Stereopsis
• Nonstereoptic binocular clues
• Monocular clues
• Influence of accommodation and
convergence
6. Integration of motor and sensory systems into
binocular vision.
VISUAL DIRECTION AND THE HOROPTER
VISUAL SPACE VERSUS PHYSICAL SPACE
Perception of space and spatial localization are
extremely intricate functions that are not fully
understood. The perception of spatial order is a
mental phenomenon based on innate anatomic
and physiologic systems, on visual clues, and
on learning. The order in which objects are seen
in visual space is a subjective perception.
Therefore, visual space is referred to as
subjective space. The subjective space is distinct
from the physical space of real objects. Location
of an object is its position in physical space,
whereas localization is the position of an object
in the subjective visual space. The experiments
of Hering
7,8
demonstrate that objects, which may
be widely separated in physical space, may have
a common direction in subjective space. It is
important to recognize that the anatomic
distribution of retinal elements and the
physiologic distribution of spatial values do not
coincide. There are many examples that
demonstrate the difference between physical
space and its subjective interpretation. For
example, if a vertical line is presented to a single
eye in the absence of other visual clues, it
appears to be slanted or tilted. Disclination
(temporal shift) or conclination (nasal shift) of
the vertical meridian in subjective space will
occur. This demonstrated that the spatial values
of the retinal receptors above and below the
horizontal midline differ.
Another example of the difference between
subjective space and physical space is the
Kundt-Münsterberg illusion. In this illusion, the
temporal half of a horizontal line, when viewed
monocularly and kept at right angles to the line
of sight at the point of bisection, will appear
shorter than the nasal half of that bisected line.
Because of this illusion, when an attempt is
made with one eye to bisect the horizontal line,
the temporal segment will be longer than the
nasal. This is the famous partition experiment
of Kundt, a German physicist of the mid
nineteenth century. The opposite phenomenon,
described by Münsterberg, occurs only rarely.
Similarly, the lower line segment (imaged
retinosuperiorly) is shorter than the upper
(retinoinferior) segment. In subjective space,
therefore, the equivalent of a true circle fixated
centrally is a somewhat irregular round figure,
the smallest radius of which points outward.
Accordingly, a subjectively true circle does not
correspond to a true circle in physical space
(Fig. 4.2). In general, the discrepancies in the two
eyes are symmetrical. They compensate each
other, and the partition of a line into two equal
segments is more nearly correct in binocular
fixation. The distribution of the subjective retinal
spatial values differs between the nasal and
temporal halves of the retina.

64 Theory and Practice of Squint and Orthoptics
Fig. 4.2 Retinal discrepancies. Subjective appearance of circles (broken lines) contrasts with objective circle (solid lines).
VISUAL DIRECTIONS
Oculocentric visual direction (monocular vision)
When an object is viewed, its image falls on the
foveola. The visual direction of the object can be
represented by a line joining the object to the
centre of foveola—principal visual line or visual
axis. The position of all other objects in the
monocular field can be fixed by their oculocentric
visual directions with respect to the visual axis.
Thus each point on the retina can be thought of
as having its own particular visual direction or
visual line passing out through the nodal point
of the eye. A visual line is, therefore, the locus of
all points fixed relative to the eye whose images
stimulated a given point on the retina.
For a given position of the eye, objects having
superimposed retinal images will be seen as
being in alignment in the visual field (law of
oculocentric visual direction), although at
different distance from the eye along the same
visual line.
Egocentric visual direction (binocular vision)
7, 8
Retinal points in the two eyes are said to be
corresponding, if, when stimulated separately,
they appear to have the same common visual
direction.
Because each eye sees the world from different
view point, the oculocentric frame of reference
is necessarily different for the two eyes.
However, in binocular vision, a single system
of visual direction is needed whose frame of
reference is related to the head (egocentric)
rather than two eyes. When we use two eyes
we seem to see the visual space through some
imaginary single eye (cyclopean eye) situated
in the head midway between the two eyes
(Fig. 4.3).
9
Foveae have a common subjective visual
direction (Hering's law of identical visual
direction). Hering8 described it by the following
classical experiment (Fig. 4.3): Let the observer
stand 1/2 metre from a window which affords
a view of outdoors, hold his head very steady,
close the right eye and direct the left eye to an
object located somewhat to the right, e.g. a
triangle. While fixing the triangle with the left
eye, a black mark (F) is made on the window
pane at a spot in line with the triangle. Now left
eye is closed and the right eye is opened and
directed at the spot (F) on the window and
beyond that to some object in line with it, e.g. a
hut. Then with both eyes open and directed at
the spot, the latter will appear to cover parts of
the triangle and the hut both, which will be seen
simultaneously.
CORRESPONDING POINTS AND
NORMAL RETINAL CORRESPONDENCE
8
Each retinal element has a directional or spatial
value without which localization in space is

Fig. 4.3 Concept of cyclopean eye. (diagrammatic represen-
tation of Hering's law of identical binocular direction) (Alter
Howard and Templeton9).
impossible. These are intrinsic, not learned,
values. The spatial value of retinal elements is
relative, not absolute. They are related to the
spatial value of the fovea in each eye. The fovea,
therefore, is the principal spatial value or
principal directional value of each eye. This
function of the retinal elements may be
characterized by saying that they have a
retinomotor value. This retinomotor value of the
retinal elements increases from the center
toward the periphery. The retinomotor value of
Binocular Vision
65
the fovea itself is zero. Once an image is on the
fovea, there is no incentive for ocular rotation.
The fovea, then, in addition to its other
functions, is also the retinomotor center or
retinomotor zero point.
In order to understand normal retinal
correspondence, it must be clearly understood
that correspondence refers only to the relative
localization of objects in space to each other
under binocular conditions. The relationships
of objects in space to ourselves—that is, to a
coordinate system surrounding our person or
our "ego centre"—is called absolute localization.
The information gained from relative
localization is only one of many clues used in
the process of absolute localization. Other
information related to the vestibular mechanism,
an ocular motor monitoring system, and
possible proprioceptive feedback mechanisms
is utilized by the brain to make the subjective
interpretation of absolute localization.
Burian10 states that corresponding retinal
elements are those elements of the two retinae,
the stimulation of which in binocular vision,
gives rise to the localization in one and the same
visual direction, no matter whether the stimulus
reaches the retinal elements in one eye alone, or
its corresponding partner in the other eye alone,
or both simultaneously.
The fovea normally determines the principal
visual direction. The correspondence mechanism
is based on the assumption that each retinal
receptor, when stimulated under monocular
conditions, dictates a subjective visual direction
determined by the relationship of that receptor
to the fovea. The retinal receptors in both eyes
that dictate a common visual direction under
binocular conditions are called corresponding
points or elements. Bagolini11 has shown that
this is an area-to-area relationship rather than a
point-to-point relationship. Under binocular
conditions, the correspondence process analyses
the information relayed from each eye and may
modify it in making the determination of
absolute localization.
In normal retinal correspondence, both foveae
have the same space value—zero—the value of
the principal visual direction. The other receptor
elements correspond to each other in fair
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