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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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20. Drum B et al. Pattern discrimination perimetry. A new concept in visual field testing. Doc Ophthalmol Proc Ser 1987;49:433.
21. Emsley HH. Irregular astigmatism of the eye. Effect of correcting lenses, Trans. Opt. Soc. Lond. 1925;27:28.
22. Fantz R. Pattern vision in young infants, Psychol, Rec. 1958;8:43.
23. Flom MC, Weymouth FW, Kahneman D. Visual resolution and contour interaction. J Opt Soc Am 1963;53:1026.
24. Hartridge H. The visual perception of fine detail. Philos Trans R Soc Lond (Biol Sci) 1947;232:519–671.
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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