Sagung G.

Indrawati
Refractive and Contact Lenses Division
Ophthalmology Department
Faculty of Medicine Gadjah Mada University
Sardjito General Hospital
Definition
 Binocular vision is vision in
which creatures having two eyes
use them together.

 The word binocular comes from

two Latin roots, bini for double,
and oculus for eye.
 Binocular Single Vision
The state of simultaneous vision,
which is achieved by the coordinated
use of both eyes.

Separate and slightly dissimilar

images arising in each eye are
appreciated as a single image by the
process of fusion.
Thus binocular single vision

implies fusion, the blending of

sight from the two eyes to form a
single percept.
According to Fahle (1987),
having two eyes confers six
advantages over having one.
 Gives a creature a spare eye in case
one is damaged

 Gives a wider field of view

190 degrees with two eyes
(approximately 120 degrees of which makes up
the binocular field of view seen by both eyes)

uniocular fields (seen by only one eye) of

approximately 40 degrees.
 Give stereopsis in which binocular
disparity (or parallax) provided by the two
eyes' different positions on the head gives
precise depth perception.

 Allows the angles of the eyes' lines of

sight, relative to each other (vergence),
and those lines relative to a particular
object (gaze angle) to be determined from
the images in the two eyes.
 Allows a creature to see more of, or
all of, an object behind an obstacle.

Leonardo da Vinci
“vertical column closer to the eyes
than an object at which a creature is
looking might block some of the
object from the left eye but that part
of the object might be visible to the
right eye”
 Gives binocular summation in
which the ability to detect faint
objects is enhanced
The advantages of a Binocular
Vision are:
1. The first and the foremost advantage of a
binocular vision is single vision.
2. In addition to single vision it results in
stereopsis – the most precise kind of depth
perception
3. Enlargement of the field of vision
4. Compensation for blind spot and other
differences
FUSION

The unification of visual

excitations from the
corresponding retinal images
into a single visual percept.
Sensory Fusion
 It is the ability to appreciate two similar
images, one with each eye and interpret them
as one.

 Single visual image is the hallmark of retinal

correspondence. For sensory fusion to occur,
the images not only must be located on
corresponding retinal areas but also must be
sufficiently similar in size, brightness and
sharpness to permit sensory. Unequal images
are a severe obstacle to fusion.
Motor Fusion
 It is the ability to align the eyes in such a
manner that sensory fusion can be
maintained.
The stimulus for these fusional eye
movements is retinal disparity outside
Panum’s area and the eyes moving in opposite
direction (vergence).

Unlike sensory fusion, motor fusion is the

exclusive function of the extra foveal retinal
periphery.
Fusion, whether sensory or motor,
is always a central process,
it takes place in the visual cortex.
Normal Binocular Single
Vision requires:
1. Clear Visual Axis.

2. Equal refractive states in both

eyes.

3. The precise co-ordination of the

two eyes for all direction of
gazes.
1. Clear Visual Axis

 Clear Visual Axis leading to a

reasonably clear vision in
both eyes.
2. Equal refractive states in
both eyes

 The ability of the retino-cortical

elements to function in
association with each other to
promote the fusion of two slightly
dissimilar images i.e. Sensory
fusion.
Uncorrected anisometropia produces
unequal image size, or anisokonia

Prismatic effect of the glasses will

vary in different direction of gazes,
inducing anisophoria

This effect become increasingly

noticeable as lens power increase
Management
 Decreasing vertex distance disminishes
both the magnifying effect of plus lenses
and minifying of minus lenses
 Contact lenses provide better solution than
spectacle

Intolerable anisokonia of about 25% for

spectacle
Tolerated anisokonia produces by Contact
lens about 7%
Rigid Gas Permeable contact lens
3. Co-ordination of the two
eyes for all direction of gazes

The precise co-ordination of the two

eyes for all direction of gazes, so
that corresponding retino-cortical
element are placed in a position to
deal with two images i.e. Motor
fusion.
 Theposition of each eye in its orbit is
controlled by six extraocular muscles.

 Slight differences in the length or

insertion position or strength of the
same muscles in the two eyes can lead
to a tendency for one eye to drift to a
different position, especially when one
is tired causes phoria.
 One way to reveal it is phoria with
the cover-uncover test.

 Thecover-uncover test can also be

used for more problematic
disorders of binocular vision, the
tropias.
Binocular Vision
anomalies
 Diplopia (double vision), visual
confusion (the perception of two
different images superimposed onto
the same space)

 Suppression (where the brain ignores

all or part of one eye's visual field)
 Horrorfusionis (an active avoidance
of fusion by eye misalignment)

 Anomalous retinal correspondence

(where the brain associates of the
fovea of one eye with an extra
foveal area of the other eye)
Symptoms
 Headaches
 Asthenopia
 Eye pain
 Blurred vision
 Diplopia

About 20% of patients who come to clinics

will have binocular vision anomalies.
INVESTIGATIONS for
BINOCULAR VISION

All the tests are aimed at assessing the

presence or absence of:
􀂙 Normal or abnormal retinal
correspondence
􀂙 Suppression
􀂙 Simultaneous perception
􀂙 Fusion with some amplitude
􀂙 Stereopsis
Before any test is undertaken it is
essential to assess the:
􀂙 visual acuity
􀂙 fixation in the squinting eye
􀂙 direction and size of deviation
1. TEST for RETINAL
CORRESPONDENCE
Clinically the tests used can be based on
either of the two principles:

A) Assesment of relationship between the

fovea of the fixing eye and the retinal area
stimulated in the squinting eye
􀂙 Bagolini's striated glasses test
􀂙 Red filter test
􀂙 Synaptophore using SMP slides
􀂙 Worth's 4 dot test
B) Assessment of the visual directions
of the two foveas. Included in this are:
􀂙 After image test
(Hering Bielschowsky)
􀂙 Cuppers binocular visuoscopy
test
(foveo-foveal test of Cuppers)
Bagolini's Striated Glasses Test
 For this the patient fixates a small light, after being provided
with plano lenses with narrow fine striations across one
meridian (micro Maddox cylinders)
 The fixation light is seen as an elongated streak.

􀂙 Crossing of the lines at right angles to each other

- If cover test reveals no shift and fixation is central,
the patient has NRC
- If cover test reveals a shift, harmonious ARC is present
􀂙 Foveal suppression scotoma (fixation point scotoma) with
peripheral fusion
- If no shift occurs with cover test, NRC exists
- If shift occurs, ARC exists
􀂙 Single line represents suppression
BAGOLINI’S TEST
Red Filter Test
 If one examines the visual field of a patient with heterophoria by
placing a red filter in front of the habitually fixating eye while the
patient is looking at a small light source. The patient may report that
two lights are seen, a red one and a white one.

In esotropia the images appear in homonymous (uncrossed) diplopia,

with the red light to the right of the white one when the red filter is in
front of the right eye.
In exotropia the images appear in heteronymous (crossed) diplopia,
with the red light to the left of the white light when the red filter is in
front of the right eye. This represents NRC.

The patient may report that only one pinkish light in the position of
the white fixation light is seen i.e. the red and white images appear to
be superimposed. This is clearly an abnormal response in presence
of heterophoria. This is termed Harmonious ARC.
The patient may report that two lights in uncrossed or
crossed diplopia are seen, depending upon the
direction of deviation but the measured distance
between the double images proves to be smaller
than expected from the magnitude of deviation.
This represents unharmonious ARC.

Suppression is said to occur when the patient reports

only a single light (usually the white light) but
occasionally red depending upon the density of the
red filter and the degree of the dominance of the
fellow eye.
Worth ‘s Four Dot Test
 A box containing four panes of glass, arranged in diamond
formation, which are illuminated internally.
 The two internal panes are green, the upper one is red and
lower one is white. The patient wears red and green goggles
(as a convention red in front of right and green infront of
left).

A) The patient sees all the four dots.

􀂙 Normal binocular response with no manifest deviation
(NRC with no heterotropia)
􀂙 Harmonious ARC with manifest squint.
B) The patient sees five dots.
􀂙 Uncrossed diplopia with esotropia, red dots appear to the
right
􀂙 Crossed diplopia with exotropia, red dots appear to the
left of the green dots.
C) The patient sees three green dots, suppression of right eye.
D) The patient sees two red dots, suppression of left eye.
WORTH’S FOUR DOT TEST
2. TEST for SUPPRESSION
 Suppression is the active cortical
inhibition of the unwanted stimuli, to avoid
binocular diplopia and confusion.

Tests used to diagnose the suppression

are:
❑ Worth's four dot test
❑ Synaptophore
❑ Friend test
❑ Amsler Grid
❑ 4 Δ prism base out test
❑ Red filter test
❑ Bagolini’s striated glasses
3. TESTS for FUSION
Fusion is demonstrated by using slides
in which similar pictures with different
controls are presented to the eyes
simultaneously
e.g. :
letter L and F fused into E
rabbit with a tail and rabbit with
flower in hand, fused into one rabbit
having tail and flower
Normal fusion amplitudes are:
A) Horizontal vergences:
• Convergence→ 35 Δ to 40 Δ
• Divergence → 5 Δ to 7 Δ

B) Vertical vergence:
• Supravergence→3 Δ
• Infravergence→3 Δ

C) Cyclovergence →2-3 Δ
Fusion assessment is essential both for
the prognosis and management of
strabismus.

Fusion is essential for the restoration of

BSV.

Various tests used to find out the

presence of fusion are:
• Worth’s 4-dot test
• Bagolini’s striated glasses
• Synaptophore
SYNAPTOPHORE TEST
4. TESTS for STEREOPSIS
 Stereopsis is measured in seconds of arc
 Tests on stereopsis can be based on two
principles

1. Using targets which lie in two planes , e.q :

▪ Circular perspective diagram such as the
concentric rings
▪ Titmus fly test, TNO test, Random dot
stereograms, Polaroid test , Langs stereo
test
2. Using 3 dimensional targets, e.g.
Lang’s two pencil test
Stereopsis tests may be qualitative or
quantitative.

• Qualitative tests for Stereopsis:

❑ Lang’s 2 pencil test
❑ Synaptophore

• Quantitative tests for Stereopsis:

❑ Random dot test
❑ TNO Test
❑ Lang’s stereo test
STEREOPSIS TEST
MADOCK ROD TEST
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