Ocular Motility/Binocular Vision

Eva Lindahl C.O.M.T.

Types of Deviations
Eso - in
Exo - out
Hyper - up
Hypo - down
Phoria - a latent tendency of eyes to deviate that is
prevented by fusion. A deviation occurs only
when a cover is placed over an eye; when
uncovered, the eye straightens (heterophoria)
Tropia - eye misalignment caused by extraocular
muscle imbalance; one fovea is not directed at
same object as the other. Deviation is present
even when both eyes are uncovered (heterotropia)

X, E, H - phoria XT, ET - stronger tropia than phoria

XT, ET, HT - manifest X(T), E(T), H(T) - intermittent

Muscle Abbrev. Main Actions Cranial N Testing Position

Medial Rectus MR Adduction III straight nasal
Lateral Rectus LR Abduction VI straight temporal
Superior Rectus SR Elevation III up and temporal
intortion
Adduction
Inferior Rectus IR Depression III down and temporal
Extortion
Adduction
Superior Oblique SO Intortion IV down and nasal
Depression
Abduction
Inferior Oblique IO Extortion III up and nasal
Elevation
Abduction
Abduction - monocular movement of an eye outward (away from the nose)
Abnormal/Anomalous Retinal Correspondence (ARC) - adaptation to compensate for a long-standing eye
deviation; fovea of the straight (non-deviated) eye and a non-foveal retinal point of the deviated eye work
together, sometimes permitting single binocular vision despite misalignment of the eyes.
Criteria for ARC:
1. Patient must have manifest esotropia (monocular or alternating) - hardly ever exo
2. Must be the same amount of crossing all the time (no accommodation)
3. The patient has the desire to fuse, but because of manifest deviation is unable to do so. If he fuses, it is
abnormal.
4. May or may not have amblyopia
AC/A ratio (accommodative convergence/accommodation ratio) - numerical expression for relationship between
the amount both eyes simultaneously turn inward (converge) and the amount their lenses increase in power
(accommodate). In normal individuals this ratio averages 5:1. Accommodative convergence is expressed in
prism diopters (∆), and accommodation is expressed in diopters (D).
Distance-near method : AC/A = 1/3 (n∆-d∆) + interpupillary distance (in cm) (Wilson p 121)
n∆ = near deviation
d∆ = primary position deviation
Accommodation - increase in optical power by the eye to maintain a clear image (focus) as objects are moved
closer.
Accommodative convergence - that portion of the range of inward rotation (toward nose) of both eyes that occurs
in response to an increase in optical power for focusing (accommodation) by the eyes' lenses.
Accommodative esotropia - excessive turning of an eye inward (toward nose) caused by an overactive
convergence response to the accommodative effort necessary to keep vision clear. Eyeglass correction for
the hyperopia relaxes accommodation, allowing eyes to remain properly aligned. Sometimes bifocals are
necessary to correct excessive inturning at near.
Adduction - monocular movement of an eye inward (toward the nose).
Afterimage Test - evaluates retinal correspondence in a horizontal deviation. With the opposite eye occluded, the
macula of each eye is marked with an afterimage using a linear light flash with the fixation point blocked.
Horizontal orientation is used OD, vertical OS. Then the patient reports the composite binocular image
perceived (eyes open or closed).
• Interpretation:
NRC: a symmetrical cross with a central area void of an afterimage
esotropic ARC: a vertical line asymmetrically displaced to the right in a crossed fashion
exotropic ARC: a vertical line asymmetrically displaced to the left in an uncrossed fashion
Agonist, primary mover - extraocular muscle mainly responsible for moving eye into desired position.
Alternating - a deviation which can be encouraged to hold fixation with either eye.
Alternate Cover Test - measures the entire deviation (tropia plus phoria). Test in all appropriate positions of gaze
to explore for incomitance.
Amblyopia, ("lazy eye") - decreased vision (two lines of vision or more) in one or both eyes without detectable
anatomic damage in the eye or visual pathways. Uncorrectable by optical means (e.g., eyeglasses).
Including strabismic, anisometropic, refractive, ex anopsia.
Amblyopia Ex Anopsia, amblyopia of disuse - reduction of vision from
not seeing or disuse
Angle Kappa - the angle between the visual axes and the anatomic
(pupillary) axes. Can be positive or negative. A slightly positive
angle kappa is physiologic due to usual foveal positioning
temporal to the anatomic axis.
• If positive, the pupillary reflex will be seen on the nasal side
of the midline. (Exo type of deviation).
• If negative, the pupillary reflex will be seen to the temporal
side of the midline (Eso type of deviation).
• Use the cover - uncover test to distinguish if deviation is
pseudo.
Antagonist - extraocular muscle whose action opposes that of the
contracting muscle (agonist) that moves the eye.
Contralateral - extraocular muscle on the fellow eye whose action
 opposes the action of a contracting muscle of an eye (e.g., RSR and LSO)
Ipsilateral - extraocular muscle whose action opposes the action of another muscle on the same eye (e.g.,
MR and LR)
A/V Patterns - eye deviations in which the deviation is more pronounced in the up or down gaze.
A pattern - more convergent in upgaze or divergent in downgaze (10 P.D. difference necessary)
• Either more eso up or more exo down
V pattern - more convergent in downgaze or divergent in upgaze (15 P.D. difference necessary)
• Either more eso down or more exo up
Bagolini lenses - finely striated clear lenses used for evaluating retinal correspondence. The lenses are placed with
the best correction in a trial frame in a manner such that the light streak produced by viewing the target light
is oriented at 135° OD and 45° OS. The patient views a white fixation light at 20 ft or 13 in. under normal
room lighting.
• Interpretation:
NRC (orthotropia, central fusion) = 2 light streaks crossing at a light without a break in either
line.
strabismus > 9 ∆with NRC = 2 separated light streaks, each passing through its own light in
either a crossed (exotropic) or uncrossed (esotropic) manner
strabismus > 9 ∆ with ARC = 2 light streaks crossing at a light with either a 5° to 6° break in
one line (esotropia) or a much larger break in one line (exotropia)
absence of binocular vision = one light streak passing through a light
Bielschowsky Three Step Test (B3ST) -
- a test which helps isolate which of the eight
cyclovertical muscles may be at fault in a
vertical muscle palsy
Step 1: Determine the presence of a RHT
or LHT in the primary position.
Step 2: Determine if the HT is larger in
right or left gaze
Step 3: Determine if the HT is larger
when measured during head tilt to the
right or left.
(See attached worksheet)

Binocular vision, single binocular vision -

blending of separate images seen by each
eye into one composite image
Blowout fracture - break of bony orbital floor
or walls caused by blunt trauma to eye or
orbit; intraorbital contents are pushed into
one or more of the nasal sinuses
Both Eyes - OU, Oculus Uterque
Brown's syndrome - sheath of superior oblique
muscle that does not, or cannot, relax
when the eye attempts to look upward and
inward, mimicking a palsy of the inferior
oblique muscle. Unilateral; may be
congenital or acquired.
Comitant (Concomitant) - eye misalignment in
which the amount of deviation remains
the same in every direction of gaze
Confusion - erroneous perception that two
different objects occupy the same position
in space. Short term, leads to suppression.
Conjugate movement - parallel movement of
both eyes in same direction of gaze
Convergence - simultaneous inward movement of both eyes (toward each other) usually in an effort to maintain
single binocular vision as an object approaches
Convergence amplitudes - amount, in prism diopters, that the eyes can simultaneously turn inward (toward nose)
before double vision ensues
Convergence insufficiency - eye muscle problem in which the eyes cannot be pulled sufficiently inward (toward
nose) to maintain single vision when attempting to fixate on a near object. Characterized by eye fatigue or
double vision.
Corneal Light Reflex Tests - general tests of muscle deviation by approximating the displacement of the corneal
light reflex in the nonfixating eye. Including the Hirschberg and Krimsky Tests. See Quantitative Diagnosis
of Strabismus.
Cover - Uncover Test - monocular test, interrupting binocularity by covering one eye. Look for movement of one
eye or other. Do 2 - 3 times. Determines: type of deviation (tropia, phoria), direction of deviation (eso, exo),
alternating or monocular, constant or intermittent, preferred eye, fixation pattern, nystagmus. Done wearing
full correction at 20 ft., the patient fixates on a target slightly above the acuity threshold. For near, fixates at
an accommodative target (letters) at 16".
• tropia - Cover test - opposite eye moves to fixate when covered
• phoria - Uncover test - same eye moves to fixate as uncovered
for hyperopes - done cc and sc
for patients with bifocals - done c and s bifocals
for patients with vertical deviations - 3° positions and head tilt
(remember to position the prism parallel to the floor of the patients orbit, not the floor of
the room)
for patients with head turn to R or L, measure R and L gaze before up and down
for patients with chin up or down position, measure up and down gaze before R or L
for patients with ET, measure down before up
for patients with XT, measure up before down
Cranial Nerve Innervation
# 3. Oculomotor SR, MR, IR, IO, levator, pupil
constriction
# 4. Trochlear SO
# 6. Abducens LR
Depressor - muscle which moves the eyeball downward, IR, SO
Deviation - misalignment of eyes caused by extraocular muscle
imbalance: one fovea is not directed at the same object as the
other.
Differential diagnosis - the thought process that leads an examiner
through the exam to a final diagnosis through a process of
elimination. The history provides clues, the examination tests
to either prove or disprove the tentative diagnosis.
Diplopia - erroneous perception that the same object occupies two
different positions in space.
Homonymous Diplopia (uncrossed) - seen when a patient has esotropia. A nasal retinal element is
stimulated and is projected temporally. The greater the deviation, the greater the disparity of images.
Heteronymous Diplopia (crossed) - seen in exotropia. A temporal retinal element is stimulated and the
image is projected nasally.
Paradoxic Diplopia - double vision, with unexpected spatial localization of images relative to the actual
position of the eyes. Usually found after strabismus surgery; caused by the presence of abnormal retinal
correspondence. (Incorrect diplopia for the type of deviation i.e., eso - heteronymous, or exo - homonymous).
Diplopia Fields - any visual field done to show areas of single and double vision.
Dissociated vertical deviation (DVD) - either eye elevates under cover occlusion, yet never drops below the
midline. Generally asymmetrical and unilateral. Simulates an IO overaction, except when occluded while
abducted will elevate. Overactive IO will not.
Divergence - eyes that simultaneously rotate outward (away from each other), usually in an effort to maintain single
binocular vision.
Divergence amplitudes - amount both eyes can simultaneously rotate outward (away from each other) before
inducing double vision. Measured in prism diopters.
Divergence excess - type of outward deviation (exotropia) that is greater when the target is at a distance (20 ft) than
at near (16 in).
Divergence insufficiency - type of inward deviation (esotropia) that exists only for distances beyond about 5 feet.
Dominant eye - preferred eye for sighting. The eye that leads and controls the other during binocular eye
movements. Usually on same side of body as dominant hand.
Double Maddox Rod - useful for quantitation of a cyclodeviation. A red horizontal line is formed OD with a red
Moddox rod while a white horizontal line is
formed OS with a clear Maddox rod. If the two
lines are not parallel, the patient neutralizes the
deviation by turning the red Maddox rod until
the red line is parallel and the corresponding
degrees of correction are read off the trial frame.
Duane's Classification of Horizontal Strabismus:
Convergence insufficiency - exo is greater at
near than in the distance
Convergence excess - eso is greater at near
than distance
Divergence excess - exo is greater in the
distance than at near
Divergence insufficiency - eso is greater in
the distance than at near
•(All horizontal strabismus is one of these
except accommodative esotropia)
Duane's retraction syndrome - narrowing of the lid
fissure and glove retraction during attempted
adduction. Additionally:
Type 1 - decreased abduction
Type 2 - decreased adduction
Type 3 - both decreased abduction and adduction
Ductions - monocular rotations of the eye in six diagnostic positions of the eye. Done with pursuit movements in
the diagnostic positions with a muscle light or penlight.
abduction – out

adduction - in
supraduction - up
infraduction - down
incycloduction - tortional rotation
of 12 o'clock meridian
toward the nose
excycloduction- tortional rotation
of 12 o'clock meridian
toward the temple
Eccentric fixation - visual abnormality in which a retinal area other than the fovea
is used for visual fixation. Occurs as an adaptive mechanism of some
patients with amblyopia or when the fovea has been destroyed by some
pathologic process. The patient has amblyopia. The eye still fixates eccentrically (turns) when the other eye
is covered. Always monocular.
Elevator - muscle which moves the eye upward, SR, IO.
Esodeviations - deviations where the eye turns inward. Including, pseudostrabismus, infantile and congenital
esotropia, accommodative esotropia, monofixational syndrome, acquired esotropia, consecutive (after muscle
surgery) esotropia, 6th nerve (LR) palsy, divergence paralysis, strabismus fixus, Duane's retraction syndrome
Etiology - causes of a disease or abnormal condition
Excycloduction, extortion - tortional rotation of 12 o'clock meridian away from the nose
Exodeviations - deviations where the eye turns outward. Including pseudoexotropia, congenital exotropia,
divergence excess, MR (3rd nerve) palsy, uniocular blindness, consecutive (after muscle surgery),
convergence insufficiency, infantile XT, Duane's type 2.
Fixation Reflex (CSM) - tests the ability to fixate and follow a light source in a central, steady, and maintained
manner (birth to 2 1/2 years)
Forced duction test - mechanical rotation of eyeball to determine presence of any mechanical restrictions to
movement; anesthetized conjunctiva and episclera at the cornea scleral junction (limbus) are grasped with
forceps, and the eyeball is forcible moved into different positions. Positive - resistance, negative - moves
freely.
Four Diopter Base-Out Prism Test - tests for fusion or suppression in a minimally deviated eye; a 4-prism-diopter
prism is held base-out in front of eye while patient fixates on a light. Absence of convergence movement
indicates suppression. Positive - suppression, negative - fusion.
Fovea - central pit in the macula that produces sharpest vision; contains a high concentration of cones and no retinal
blood vessels
Fresnel prism (freh-NEL) - series of flexible plastic lenses with smooth adhesive side that enables them to adhere
to eyeglass lenses. Used for correcting eye deviations or refractive errors.
Fusion - ability to blend two similar images into one
Fusion potential - using prisms to neutralize deviation, then testing fusion
Fusional amplitudes - amount the eyes can simultaneously move inward (converge) added to the amount they can
simultaneously move outward (diverge), while maintaining single vision. Measured by increasing BO, BI,
BU or BD prisms and measured at distance (20 ft) and near (13 in) using a Risley rotary prism or prism bar.
Distance divergence - use 20/40 letters, add larger BI prism until break point (patient sees
double), then less prism until recovery (fuses again). Results are recorded as
break/recovery
Near divergence - same as distance BI with near accom. target
Distance convergence - record "blur", break, and recovery pt, and (when blurring occurs =
accommodative conv, not fusional convergence)(a normal patient may have fusional
convergence measurements of 18/14) using a BO prism.
Near convergence - same as distance BO with near accom. target
*(near usually = 2X distance, convergence usually = 2X divergence)
*(recovery usually = 1 notch down prism bar from break point)
Jump convergence = largest BO prism that can be immediately overcome
(usually same as recovery point)
• base-down OD for positive vertical vergence
• base-up OD for negative vertical vergence
Graves' disease - eye signs that may occur with excessive thyroid-related hormone concentration. Includes eyelid
retraction, eyelid lag on downward gaze, corneal drying, eye bulging (proptosis), fibrotic extraocular
muscles, and optic nerve inflammation
Harmonious ARC - Binocular adaptation of the retinas to a long-standing eye deviation. Fovea of the straight
(non-deviated) eye and a non-foveal point of the deviated eye (that corresponds to the deviation) work
together permitting poor quality, single binocular vision..
Hering's Law of Motor Correspondence
- (law of equal innervation), Innervation to one extraocular muscle to
contract generates an equal innervation to contract its yoke muscle
(that muscle performing the same function in the other eye). For
example, RLR and LMR. See

Hess Screen - similar to the Lanaster Red-Green Test, except many fixed
lights are illuminated by the examiner sequentially at a testing
distance of 0.5 m.
Heteronymous diplopia - crossed diplopia, located on the opposite side
Homonymous diplopia - uncrossed diplopia, located on the same side
Horopter - the imaginary arc formed by the group of points in space that fall
on corresponding retinal points in each eye which are therefore seen
singly
H2S - mnemonic: Hering's law (H) applies to innervation of extraocular
muscles of both (2) eyes while Sherrington's law (S) refers to
innervation of extraocular muscles in one (1) eye.
Incomitant (noncomitant) - deviation that varies in amount depending on the direction of gaze. Can be due to
EOM paresis, Cranial nerve palsy, or restrictive strabismus
Incycloduction, intortion - tortional rotation of 12 o'clock toward the nose
Innervation - nerves giving stimulus to muscles (LR-6, SO-4, the rest are 3)
Lancaster Red - Green Test - a red-green sensory motor test to create a graphic representation of the incomitance
of a strabismic deviation in the various positions of gaze. The patient wears dissociating red-green glasses.
The eye with the red lens perceives only red targets on a visual field screen, and the eye with the green lens
perceives only a projected green pointer that the patient is requested to superimpose on red targets in the
visual field. Goggles are reversed to compare primary and secondary deviations. The testing distance is 2 m.
Latent deviation - a deviation that is only apparent when fusion is broken
Left eye - OS, oculus sinister
Macula - small area in the retina surrounding the fovea
Maddox Rod - dissociating test to provide vertical or horizontal line type
image by the eye that has the rod in front of if. Easily dissociates both
eyes but does not differentiate between phorias and tropias. . If red line
is centered through the white light, no deviation is present. The image is
seen opposite where the eye is looking. Test is done D (20 ft) and N (13
in), in a dark room. The patient is instructed to "look at the white light
and tell where the red line is"
uncrossed diplopia = eso
crossed diplopia = exo
Manifest deviation - one that is present at all times
Monocular - one eye turns in or out constantly. Will not hold fixation with
other eye unless good eye is covered
Monocular diplopia - multiple images seen with one eye. Commonly caused
by early cataract or irregular cornea
Motility - study of extraocular muscles ad their effect on eye movements
Near Point of Convergence (NPC)- a small target stimulating accommodation
is moved along the midline toward the patient until a break point, and
back until recovery of fusion. A receded NPC can indicate convergence
insufficiency.
Normal retinal correspondence - binocular condition in which both foveas
work together as corresponding retinal points, with resultant images blended (fused) in the occipital cortex of
the brain.
Nystagmus - involuntary, rhythmic side-to-side or up and down (oscillating) eye movements that are faster in one
direction than the other. Use alternate forms of occlusion (+6.00 - +10.00 trial lens) if there is any
nystagmus.
Objective angle - the actual measurement of the patient's eye turn
Occlusion - covering of the eye by an opaque membrane (patch)
Orthophoric - absence of eye deviation (or tendency toward deviation); no
ocular movement is elicited by covering an eye while other eye views a
visual target.
Orthoptics - study and treatment of defective eye coordination, binocular vision,
or functional amblyopia by non-surgical methods, e.g., glasses, prisms, or
exercises. Results in improved comfort and efficiency of binocular
function.
Panum's fusional space - zone immediately to front and back of fixation object,
in which single binocular vision with depth perception is possible.
Outside this area, diplopia occurs.
Paralysis, palsy - complete or partial loss of muscle function, usually due to
nerve damage. In paralytic deviations with face turns, the nose points
toward the direction of gaze in which the palsied muscle is supposed to
work.
Paretic, paresis -extraocular muscle weakened by damaged nerve supply, which
needs more than usual amount in innervation to perform its normal
function.
Physiological diplopia
 - normal binocular function. Fixing on a near object, the distant object is seen uncrossed (homonymous);
fixing on a distant object, near object is seen crossed (heteronymous)
Positions of Gaze:
Nine Diagnostic Positions - primary, secondary and
tertiary (oblique) positions (30° horizontal and 30°
vertical from primary)
Six Cardinal Positions - the six diagnostic positions of
gaze in which one of the six "yoked" muscles in each eye
is primarily responsible for the eye's rotation. Left gaze,
right gaze, and the four tertiary positions of gaze.
Near Position - primary position with a near fixation
target and 13 in.
Bielschowsky positions - 30° left or 30° right head tilt
Preferential Looking (PL) - tests the ability to prefer to fixate on a grid requiring a calibrated degree of visual
discrimination
Preferred eye - eye that takes up fixation
Primary deviation - amount of deviation found when an extraocular muscle has been paralyzed and the normal eye
is used for fixation. Is always less than the secondary deviation
Prism - transparent triangular wedge that bends, but does not focus, light rays toward the position of its base. A
one ∆ prism deflects a ray of light at an angle corresponding to 1 cm displacement at a distance 1 m from the
prism. 1° (arc degree) of deviation = 1.7 prism diopters. Measure objectively (what you see) and
subjectively (what the patient says). The eye does not move, only the incidence of light or the reflex.
• The point of the prism goes in the direction of the deviation. Use:
ET - base out (BO) (either eye)
XT - BI
HT - BD (on high eye) or BU (on low eye)
Hypo – BU
• Image is seen toward the apex.
• Incidence of light is seen toward the base.

Prism and Cover Test - doesn't work on restrictive strabismus (Graves', etc.)
Use 20/40 or smaller for distance fixation
Pseudostrabismus - large epicanthal folds in young children which simulate an eso type of deviation. Cover-
uncover testing gives a differential diagnosis.
Quantitative Diagnosis of Strabismus - Three ways of measuring muscle imbalance: Hirschberg, Krimsky, and
Alternate prism and cover test.
1. Hirschberg - least accurate. Using gross observation when the
patient is fixating on a penlight at 33 cm or 12". Not very accurate
because pupils may be of different sizes. Used with very young
children, or patients who can't fixate.
pupillary margin =15° = 30 ∆
between pupil and limbus = 30° = 60 ∆
limbus = 45° = 90 ∆
2. Krimsky - next most accurate. Use penlight at 33 cm. Neutralize reflex with a prism used either base
in, out, up or down, depending on deviation. Increase amount of prism until pupillary reflex recenters.
3. Alternate Prism and Cover Test - most accurate. The prism is placed on the deviating eye. The good
eye is covered. The cover is switched. This determines the amount of deviation.
Recession - a surgical weakening procedure for overactive muscles
Red Filter/Red Glass Test - Method of testing for diplopia, fusion and ARC vs NRC. The red filter is placed over
the right eye. The targets are a white fixation light at 20 ft and 13 in.
Responses: 1 white - OD suppression
1 red - OS suppression
1 pink = fusion
2 uncrossed (homonymous) = esotropic diplopia
2 crossed (heteronymous) exotropic diplopia
2 vertically separated = vertical diplopia
Resection - a surgical strengthening procedure for weak muscles
Restrictive strabismus - eye deviations caused by mechanical obstructions in the orbit involving extraocular
muscles; prevents free eyeball movements (blowout fracture, Brown's syndrome, Duane's syndrome, Graves'
disease)
Retinal Correspondence - relationship between retinas in two eyes. Images from one object stimulate both eyes,
which transmit the information to the brain, permitting a single visual impression localized in the same direction in
space.
• Normal NRC Homonymous - Eso (uncrossed)
• Normal NRC Heteronymous - Exo (crossed) (rare)
Abnormal ARC (paradoxic) - Homonymous - Exo
Abnormal ARC(paradoxic) - Heteronymous - Eso
Right eye - OD, oculus dexter
Secondary deviation - amount of deviation found when an extraocular
muscle has been paralyzed and eye with that muscles is used for
fixation. Is always greater than primary deviation
Sherrington's law of Reciprocal Innervation
- as one extraocular muscle receives an impulse from the brain to
contract, its opposing muscle (direct antagonist) in the same eye
receives an impulse to relax.
Simultaneous perception - perception of two images simultaneously (one
formed on each retina) that are not necessarily superimposed.
Simultaneous Prism and Cover Test (S P + C)- used to identify
microtropias. The fixating eye is covered with an occluder while
simultaneously covering the tropic eye with a prism. (Only measures
the tropia that is normally manifest)
Single Binocular Vision - ability to use corresponding points of the two
retinas simultaneously to obtain a single, clear image
Spiral of Tillaux – distance in mm of four rectus
muscles from limbus to insertion.
Stereoacuity Test (Titmus Stereo Test) - to evaluate
sensory fusion. Done at 16" with reading
illumination and special polarized spectacles.
Bifoveal stereopsis > 67 seconds of arc. If
turned 90° has no stereo effect (can use to
document malingerers)
• fly = 6000 sec of arc
• animal line A = 400 sec of arc
• animal line B = 200 sec of arc
• animal line C = 100 sec of arc
• circles 1 - 6 = 800 - 80 sec of arc
• circles 7 - 9 = 60 - 40 sec of arc
Also: Random dot E (RDE) (near)
AO distance vectograph slide (c polaroid glasses) (also tests suppression)
Pencil point to pencil point test
Stereopsis - blending of two similar but not identical images (one falling on each retina) into one, with resulting
three-dimensional perception.
Strabismus - eye misalignment caused by extraocular muscle imbalance: one fovea is not directed at same object as
the other. Can be comitant (no muscle paralysis-same in all directions of gaze) or incomitant (muscle
paralysis-amount of deviation varies in positions of gaze)
Subjective angle - the eye position where the patient indicates fusion occurs
Suppression - the retinal image transmitted by one eye is ignored to avoid diplopia. Occurs in childhood.
Synergist - extraocular muscle that assists primary muscle in same eye for making a particular eye movement
25 ∆Base In Test -
Unharmonious ARC - Binocular adaptation to a long-standing eye deviation. Fovea of the straight (non-deviating)
eye and a non-foveal point of the deviated eye work together.
Vectograph - Test chart or picture composed of two polarized images that can be separated visually when viewed
with polarized glasses, allowing each eye to see letters or figures that are invisible to the other. For
measuring stereo acuity (e.g., Titmus chart) and testing visual acuity.
Vergences
- disjugate movement, simultaneous
movement of both eyes in opposite directions
(toward or away from each other, or one up
and one down), to obtain or maintain single
binocular vision (ex: convergence,
divergence)
convergence - toward the midline (nose)
divergence - away from the midline
positive or negative vertical divergence -
one eye up, one eye down
incyclovergence - tortional rotation toward
nose
excyclovergence - tortional rotation toward
temple

Versions
- conjugate movement, simultaneous parallel movement of both eyes in the same direction. Version testing
assesses how well a pair of yoke muscles work
together.
dextroversion - right
levoversion - left
supraversion - up
infraversion - down
dextrocycloversion - tortional rotation of 12 o'clock
meridian to right
levocycloversion - tortional rotation of 12 o'clock
meridian to left
Visual acuity - sharpest point of vision
Preferential looking - birth to 2 1/2
Allen pictures - age 2 1/2 to 4 years
Illiterate E's - 4 to 5 1/2 years
Snellen - > 5 1/2 years
• Record which test and if full line presentation was used
• If nystagmus is noted, use +6 D to + 10 D lens to "occlude" the other eye
Worth 4 Dot - gross test in determining fusion ability (also tests suppression and
diplopia). Four lights ( one red, two green, and one white) viewed at 20 ft.
Or a flashlight viewed at 13 in. The patient wears red/green filtering lenses
(red OD, green OS) over the best spectacle correction. The red lens filters
out green lights (sees red), the green lens filters out red light, the white light
is red when OD fixates, green when OS fixates, and alternating red and
green with retinal rivalry.
Possible sensory perceptions:
2 red = suppression (OS)
3 green = suppression (OD)
3 (2 red/1 green) = suppression (OS)
3 alternating with 2 = alternate suppression
4 total = Worth 4-dot fusion
5 total = diplopia
Worth's Three Grades of Fusion
1st grade - superimposition of dissimilar images - (simultaneous macular perception). Tested with Maddox
rod or haploscope (lion and cage, etc.)
2nd grade - motor fusion - simultaneous foveal perception. True fusion. Tested with similar images
assessing vergence amplitudes (prism bar or Risley prism)
 3rd grade - stereopsis - blending of slightly dissimilar images from two eyes with the perception of depth
Yoke muscle - the pair or extra-ocular muscles (one in each eye)
which work as a team
 Examining The Motility Patient
Order of Examination (General Guidelines)
Fusion-subjective (Stereo test, Random dot E, Worth 4 Dot)
( test before: removing glasses, VA, versions, red filter, MR or W4D))
4 ∆ Diopter Base Out Prism test (suppression) or W4D
Fusional Amplitudes
Distance divergence BI prism until break (use 20/40 letter)
Near divergence BI prism until break
Distance convergence BO prism until blur
Near convergence BO prism until blur
• Always test distance before near, and divergence before convergence
• near usually = twice distance, convergence usually = twice divergence
Cover-uncover test (determines tropia or phoria)
• distance and near
Alternate cover test (cross cover) (determines direction of deviation)
• Movement of less than 5° (10 ∆) is normal in alternate cover)
Prism and cover test (measures amount of deviation)
• Do eyes simultaneously if tropic
Prism and Cover Test (P + C)
Simultaneous Prism and Cover Test (S P + C)
Maddox Rod
Double Maddox Rod
Hess Screen/Lancaster Red-Green Test
Diplopia Fields
Bielschowsky Three Step Test (B3ST)
Versions (two eyes)
Ductions (one eye)
Visual Acuity
Refraction
Manifest (without dilating or cycloplegic drops)
Cycloplegic (with drops)