Clinical

Binocular Single Vision

Dr. Sathya, Medical Officer, Aravind Eye Hospital, Madurai

The current tendency is to overemphasize

stereopsis as the only important reason for having
binocular vision. Bishop1 stated that with the
exception of stereopsis, seeing with both eyes
is marginally, if any better than seeing with
one - absolute threshold, differential threshold,
and visual acuity being about the same. Indeed
binocular summation experiments show no
monocular-binocular differences or at best give
only equivocal results.2 On the other hand there
are certain advantages to having binocular vision
in addition to stereopsis that are not readily
appreciated by the clinician.
Parents of strabismic children whose eyes have
been aligned surgically will often volunteer the
information that the childs visuomotor skills have
suddenly and vastly improved. This improvement
does not seem to depend on the presence of
stereopsis. It is noted as long as gross binocular
vision on the basis of normal or abnormal
retinal correspondence is reestablished. Jones
and Lee3 substantiated this clinical observation
by evaluating human binocular and monocular
performance through a variety of exteroceptive
and visuomotor tasks. The results indicated that
binocular concordant information provides better
exteroception of form and colour and better
appreciation of the dynamic relationship of the
body to the environment, thereby facilitating
control of manipulation, reaching, and balance.
Also the advantage of an intact binocular field,
which is larger than a monocular field, and of
central visual field overlap become obvious as soon
as the function of one eye becomes impaired by
a disease process.
Pre-requisites for development of
binocular vision
Optical apparatus should be approximately
equal in both eyes

Visual fields of the two eyes should overlap

Visual pathways should be uninterrupted
Fixation reflex and fusional reflexes should be
intact
Proper extra-ocular muscle co-ordination
Eye at birth and normal postnatal
development
Orbits continue to change their size and shape
throughout childhood, and the angle between
them decreases from fifty degrees at birth to
forty five degrees later in life. The inter-pupillary
distance increases from an average of 45 mm at
birth to about 58 to 66 mm in adulthood.
The extraocular muscles although not of
ultimate size are fully functional at birth. Bifoveal
fixation does not exist at birth since binocular
movements are not co-ordinated. Fixation,
therefore at first is only monocular. Furthermore,
conscious fixation requires awareness of the
presence of an object and enough interest in the
object to occupy an individual's attention for a
certain length of time.19
At about 2 to 3 weeks of age, the infant turns
his head to fixate an object. At about 4 to 5 weeks
of age, he can sustain monocular fixation of large
near objects. Only after the age of 3 months does
fixation become conscious rather than reflexive.
Initially pursuit movements are saccadic in
character but become smooth and gliding between
3 to 5 months of age.
Maturation of binocular function
It is unequivocal that basic visual function is
innate and therefore present at birth. But their
co-ordination, maturation and refinement take
place during the early postnatal period.
In the first 1 to 3 months of life, infants do
not alternately suppress each eye but instead

AECS Illumination

superimpose images. At age 3 months, they begin

to show binocular fusion in the form of rivalry
avulsion. 4 Between 3 and 6 months their sensitivity
to stereoscopic disparities systematically improves.
Females, on an average, demonstrate stereopsis 4
weeks earlier than males.5 Thus the time course
of postnatal development of fusion and stereopsis
in human infants parallels the hierarchal ranking
of clinical binocular fusion proposed by Worth in
1903.6 Worth ranked binocular function at three
distinct ascending levels: simultaneous perception
of binocular images as the lowest, fusion of images
as intermediate and stereopsis as the highest.
Inter pupillary distance changes from an
average of 4 cm in the neonate to 6.5 cm in the
adult7. The greatest change takes place in the
first year of life. Greater inter pupillary distance
causes greater angular disparity and thus increases
stereoacuity.
If the eyes are normal and the neuromuscular
mechanism for moving the eye is normal, depth
perception will follow automatically. Stereopsis
seems to be in a class by itself. As Ogle has stated,
Stereopsis is a sensory phenomenon in its own
right, with its own physiological mechanisms. It
seems to be an all-or-none phenomenon, in that
in a given person it is either present or not present.
Training does not seem to develop stereopsis as
such, but training may increase ones ability to
discriminate depth differences just as the visual
acuity may be slightly improved by training.

Parvocellular neurons are more sensitive to

colour, high spatial frequencies, fine two-point
discrimination, and fine stereopsis, and they
project to areas of the central visual field and
fovea. Magnocellular neurons, on the other hand,
are sensitive to direction, motion, speed, flicker,
gross binocular disparities and gross stereopsis.
Magnocellular neurons project to parafoveal and
more peripheral retina.
Even though the two pathways are distinct,
they overlap; and both systems interact to process
visual information. From the striate cortex,
information from M cells goes pre-dominantly
to parieto-occipital area, while information from
P cells goes to tempero-occipital areas.

Neurophysiology of development

Pattern deprivation amblyopia, which is a failure to

develop fine two-point discrimination, is probably
associated with abnormal P-cell development.
M-neuron maldevelopment occurs predominantly
in case of strabismus and may be contributed to
associated motor abnormalities such as latent
nystagmus and asymmetrical horizontal smooth
pursuit often seen in patients with congenital or
infantile strabismus.
It has been observed that neuronal cell growth
in the lateral geniculate nucleus is markedly
reduced in the laminae in a visually deprived
eye9,10. The large cells of the binocular segment
are much more affected than either the large cells

The M and P cell neurophysiology

Neurophysiological animal studies have identified

two specific pathways used to process visual
information. Ganglion cell stimulation from
a retinal image results in simultaneous parallel
processing through these two different pathways.
In the lateral geniculate nucleus, the nuclei can be
divided into parvocellular (P cells, or small cells)
and magnocellular (M cells, or large cells). In the
striate cortex, parvo- and magno-recipient lamellae
are segregated; however, there are interconnecting
pathways, so the information commingles.

Receptive field

The basic receptive field organization of neurons

and cortical architecture are present since birth,
although the retina and optic pathway are not
completely developed. The excitatory connections
of receptive fields located in both retinae or
retinotopic projections are largely present at birth8.
However, simultaneous occurrence of patterned
visual input to both eyes during development is
necessary to maintain their associations.
The early plasticity seems to be vital for the
formation of cells with closely matched receptive
field properties in the two eyes, which is a necessary
substrate for stereoscopic vision.
Maldevelopment of M versus P pathway

Vol. XIII, No.2, April - June 2013

of the monocular system or the small cells found

mainly in the projection of the central area.

Theories of binocular vision

Theory of correspondence and disparity
This is the most widely accepted theory of
binocular vision. Salient features are
- Corresponding elements of retina form the
frame work of zero system of binocular vision.
Simultaneous stimulation of the corresponding
points by one object transmits single visual
impression with no depth quality.
- Simultaneous stimulation by two objects
points that difference in character results in
binocular rivalry.
- Diplopia occurs when disparate elements are
stimulated by one object.
- Binocular single vision with stereopsis results
when the horizontal disparity remains within
the limits of Panums area.
Neurophysiological basis
Hubel and Wiesel being the pioneers11,12 have
corroborated the correspondence theory. The
following are neurophysiological evidences:
- Approximately 80 percent neurons of striate
cortex are derived from both eyes, 10 percent
are from the contralateral eye and 10 percent
from the ipsilateral eye only. The two receptive
fields of binocularly driven cortical cells are
found to have corresponding location in the
two retinae.
- Of the binocularly driven cortical neuron, only
25 percent are stimulated equally well from
each eye, while the remaining 75 percent show
graded degrees of influence from the right or
left eye (disparity sensitive binocular cells).
- Stereopsis has been linked with horizontal
disparity sensitive binocularly driven cortical
neurons13.
- It has also been demonstrated that the
distribution of cortical neurons is easily upset
when animals are reared with experimental
strabismus, anisometropia, or from visual

deprivation by lid suture. This observation

corroborates the fact that the properties of
neurons in visual cortex are greatly influenced
by the visual experience during the few
post-natal months14,15.
Older theories of binocular vision
Alternation theory of Binocular Vision

This theory states that sensory fusion is perceptual

unification of images perceived in corresponding
location in the two retinae. It assumes that
corresponding retinal units are represented
separately in the brain but that each of every
pair is represented in consciousness by the same
single unit. This conscious unit would receive the
stimulus from only one retinal unit at a time the
other being excluded16. This theory fails to explain
many phenomena of binocular vision, particularly
stereopsis.
Projection theory of Binocular Vision

This theory is based on the concept that the

visual stimuli are exteriorized (projected to
physical space) along the lines of directions17. This
theory does not explain even the fundamental
observation such as physiological diplopia and so
was abandoned.
Motor theory

This theory conceptualizes that the spatial

orientation is obtained from the movement
of the head, conjugate movements of eye and
convergence. The eyes are made aware of their
movements by muscle sense. It is this awareness
that produces spatial localization. The sensations
arising from the convergence effort determine
whether one object is nearer or farther away than
the others. This theory again fails to explain many
sensory aspects of the binocular vision especially
stereopsis.
Theory of isomorphism

This theory states that there exists a one-toone relationship between the retina and cortex
and strict conformity or isomorphism between

AECS Illumination

the distribution of objects in space and cortical

events forms the basis of spatial orientation.
Subjective visual directions as a property of the
retinal elements do not exist and that retinal
correspondence cannot change18. However, there
is no evidence of physiological rigidity of the
retinocortical relationship or the convergence of
the pathways on which this theory is based.

Egocentric localization
When we see with one eye, the direction of the
object is judged in relationship to the visual axis
of that eye. But when we see with both eyes, we
localize the objects in the visual space in relation
to an imaginary eye centered between the two
eyes, the cyclopean eye21. This is called egocentric
localization.

Mechanism of binocular vision

Horopter
Horopter is defined as the locus of all object
points that are imaged on corresponding retinal
elements at a given fixing distance. When we fix
our eyes on an object close to or far away from our
eyes, the objects in the same plane are perceived
single without any diplopia. This plane is called
horopter22,23. It can be plotted by joining the
points of intersection of the lines drawn from the
corresponding points through the nodal points.
Originally, Vieth Muller proposed that such a
plane should be a part of a circle, formed by joining
the nodal points of both the eyes and the fixation
point. However, experiments have proven that the
Vieth Muller circle is only theoretical.
Horopter is a very thin toric plane in space
with its centre being the fixation point. The
concavity of the distant horopter is almost nil, but
it increases with increased nearness of the object.
If the eye maintains a fixed degree of convergence
and then moves up and down in space, it creates
a plane known as the horopter torus of ViethMuller.

Photoreceptors in the retina have the innate

ability to identify the direction of a stimulus.
Photoreceptors in the fovea register a zero
directional value and the object seen within the
fovea is considered to be centered in the visual
fields.
A line passing from the fovea through the
nodal points of the eye is called the visual axis
and the direction is called the visual direction.
The visual direction of all other retinal elements
is relative to this principal visual direction. For
example, stimulation of a retinal area temporal
to the fovea, locates the object to be on the nasal
side of the object of fixation. Thus the ability to
identify the direction is innate.
Correspondence
If retinal areas in the two eyes share a common
subjective visual direction (i.e.) their simultaneous
stimulation results in the subjective sensation that
the stimulated target or targets come from the
same direction in space these retinal areas or points
are said to be corresponding20.
If corresponding retinal areas in the two eyes
bear identical relationships to the fovea in each eye,
normal retinal correspondence exists. Dissimilar
relationship between two corresponding areas and
their respective foveas indicate anomalous retinal
correspondence.
It is found that nerve fibers from the
corresponding points pass to the same optic tract
and consequently terminate in a single visual
cortical neuron. Hence, the stimulus is perceived
to be single by the visual cortex.

Pannums space
Not only are the objects placed in the horopter
perceived single, but also the objects found
for a small distance in front of and behind the
horopter do not produce diplopia. This space
is called Pannums fusional area. This is enabled
because of the fact that a point in the retina of
one eye has a corresponding area in the other eye
(than a corresponding point). Thus a line drawn
from the temporal border of the corresponding
area intersects the line from the retinal point

Vol. XIII, No.2, April - June 2013

proximal to the horopter and vice versa. Drawing

the proximal and distal points for various
corresponding regions results in the Pannums
space. Corresponding areas become larger in size
toward peripheral retina. This results in widening
of the Panums space in the periphery.
Physiological diplopia
All object points lying on the horopter curve
stimulate corresponding retinal elements. By
definition, all points not lying on the horopter
curve are imaged disparately, and with certain
qualification, are seen as double. When an object
is located closer than the horopter, it is imaged
temporal to the fovea in each eye, resulting in a
crossed diplopia. Conversely, when an object is
located beyond the horopter, it is imaged nasal
to the fovea in each eye, resulting in uncrossed
diplopia.19

Grades of binocular single vision

Worth classified binocular single vision to be of
three grades
Simultaneous Macular Perception
Fusion
Stereopsis
Simultaneous Macular Perception
Simultaneous perception exists when signals
transmitted from the two eyes to the visual
cortex are perceived at the same time. It consists
of the ability to see two dissimilar objects
simultaneously.
Fusion
Fusion is the cortical unification of visual objects
into a single percept that is made possible by the
simultaneous stimulation of corresponding retinal
areas.
Sensory Fusion It is based on the innate
orderly topographic relationship between the
retina and the visual cortex, whereby corresponding
retinal points, project to the same cortical locus,
and corresponding adjacent retinal points have
adjacent cortical representation.

Motor Fusion - It is a vergence movement

that causes similar retinal images to fall and be
maintained on corresponding retinal areas even
the natural (e.g. phorias) or artificial causes tend
to induce disparities.
Testing Convergence Divergence Vertical
Distance Fusional
Fusional Amplitude

Amplitude Amplitude
6 m

14

2.5

25 cm

38

16

2.6

Central and Peripheral Binocular Single

Vision
Central binocular single vision is cortical
integration of the image projected on to each
macula from the area of conscious regard. It
receives highest attention and is the bulk of what
one is visually aware of. Peripheral binocular single
vision is an extra-macular function that serves the
visual space peripheral to the area of conscious
regard. It is of importance for the subconscious
orientation of the surrounding.

Central BSV Peripheral BSV

Simultaneous None
Perception
Fusion
Limited
Stereopsis
Excellent

Excellent
Excellent
Limited

Stereopsis
Allows a subjective ordering of visual objects in
depth; or three-dimension. It is the highest form of
binocular co-operation and it adds a new quality of
vision. It is a binocular sensation of relative depth
caused by horizontal retinal image disparity.

Abnormalities of binocularity
Confusion
When squinting occurs the two foveas view two
different objects that are physically separated in
objective space, and send two different images
to a single cortical perceptual area. This leads to
confusion. But, confusion is not common as the

AECS Illumination

cortex immediately settles for one image with its

inherent strong cortical or retinal rivalry.

about 15 degrees. This is the blind spot mechanism

described by Swan.

Diplopia
When squinting occurs an object in space is
perceived by the fovea of one eye and some other
extra-foveal point of the other eye, which has a
different projection or localization value in space.
Thus an object would be localized twice in space
causing diplopia. Diplopia usually results from
an acquired malalignment of the visual acuity. In
diplopia, an object that has one physical location
has two physiological localizations.

Suppression

Adaptations to Strabismus
Motor Adaptations
Fusion
Head Posture
Blind Spot Mechanism
Sensory Adaptations
Suppression
Anomalous Retinal Correspondence
Fusion

Fusion is the ability of the two eyes to keep in

check a tendency for squint. And as long as fusion
is strong, a squint remains latent (heterophoria).
Fusional convergence is stronger than fusional
divergence, as shown above, and hence a divergent
squint (exophoria) is better controlled.
Head Posture

To tackle a manifest squint which has variable

deviation in different gazes (incomitance), a
compensatory head posture is assumed. It has
three components
Chin elevation or depression
Face turn to right or left side
Head tilt to right or left
Blind spot syndrome

The optic nerve head (physiologic blind spot) is

used to eliminate the diploic image in esotropia of

The image formed in one eye is prevented from

reaching consciousness. This is called suppression.
It occurs when there is strabismic misalignment
of the visual acuity.
It is an adaptation to avoid diplopia and
confusion. There are various types of suppression:
Central and Peripheral Suppression
- Images formed on the fovea of the
deviating eye are prevented from reaching
consciousness in order to avoid confusion.
This is called central suppression.
- The image similar to the one falling on the
fovea of the fixing eye falls on the peripheral
retina of the deviating eye. Suppression of
this image is called peripheral suppression.
Monocular and Alternate Suppression
- If the image from one eye alone is
suppressed, it is called monocular
suppression. This leads to amblyopia in
that eye.
- If the images from the two eyes are
suppressed alternately, it is called alternate
suppression. This occurs in alternating
squints and usually both eyes have fairly
good visual acuity.
Facultative and Obligatory Suppression
- Suppression is called facultative when it
is present only when the eyes are in the
deviated state and absent in all other states.
- Obligatory Suppression is present at all
times irrespective of whether the eyes are
aligned or misaligned.

Tests for suppresion and anomalous

retinal correspondence
All tests are tainted by the inability of the testing
condition to reproduce the patients condition of
casual seeing. The more dissociative the test, the
less the test stimulates everyday use of the eyes24.

Vol. XIII, No.2, April - June 2013

Afterimage test

Most dissociating
Dark Red filter
Worth four dot with room
lights off
Worth four dot with room
lights on
Synoptophore
Bagolini Striated Glasses Least dissociating

Worth Four Dot test

Principle

The test is based on complementary colours. The

white light provides fusional stimulus. Red and
green lights provide dissociation.
Apparatus

Red Green goggles.

Worth Four-dot light Two green, one red,
one white on black background.
Worth Four dot flashlight at 33 cm - Subtends
by 60 degrees Peripheral BSV
Worth Four-dot box at 6 meters subtends by
1.25 degrees Central BSV
Method

Patient sits at desired distance, generally six meters

away. The light box is switched on after the patient
wears the red - green goggles. The patient is asked
to describe the number and colour of dots seen.
Interpretation

Possible responses when goggles are placed with

red before right eye.
Two red, two green Normal
Two red, one green, one light flickers between
red and green Normal. (White light flickers
due to colour rivalry)
Three green, two red - Acquired strabismus/
diplopia
- Red on right, green on left Uncrossed
diplopia = Esotropia
- Red on left, green on right Crossed
diplopia = Exotropia

Three green light Right eye suppression

Two red light Left eye suppression
Two red lights alternating with three green
lights Alternate Suppression
Patients with large scotomas (more than six
degrees) will suppress both the distance and near
Worth four dots.
Patients with the monofixational syndrome
have a small central suppression scotoma (less
than six degrees) and peripheral fusion. They will
therefore fuse the near Worth four dots which
subtend six degrees because the dots fall outside
the scotoma, but suppress the distance worth four
dots as the dots fall within the scotoma.

Bagolini Striate Glasses

Principle
The eyes are minimally dissociated by perpendicular
striations.
Apparatus
- Bagolini Striated lenses are clear lens with linear
scratches on each lens that produce a streak of
light at 90 degrees to the striation.
- Point source of light
Method
One lens is placed over each eye with the striations
oriented obliquely at 45 and 135 degrees. A point
source of light is shined at 6 meters and 33 cm.
Results

Indicating binocular single vision. This may be

normal with no manifest squint and normal retinal
correspondence or abnormal with manifest squint
and abnomal retinal correspondance.
A central gap seen in one line is caused by a
small central suppression area which is found in
some very small angle squints.
Indicates manifest squint (esodeviation).
Indicates manifest squint (exodeviation). Indicates
suppression of image seen by squinting eye.

Tests for Stereoacuity

Stereoacuity tests present an image to each
eye that is similar except that the images are
horizontally displaced; so they stimulate slightly
non-corresponding points, thus producing
stereoscopic perception. The amount of horizontal
separation of the two images is measured as an
angle in seconds of arc and is referred to as the
image disparity.
The smallest angle of image disparity that can
produce a stereoscopic percept is the measurement
of stereoacuity. Disparities between 40 and 50
seconds of arc indicate central or bifoveal fusion,
while stereoacuity between 80 and 3000 seconds
represent peripheral fusion.
There are two types of stereoscopic tests:
Contour stereopsis test Involves actual
horizontal separation of the targets presented
to each eye (with polarized or red-green
glassed) such that mono-ocular clues to depth
are present at lower stereoacuity levels. Eg.
Titmus test.
Random dot stereopsis Circumvents the
problem of mono-ocular clues by embedding
the stereofigure in a background of random
dots. Eg. TNO test, Lang stereo test.

AECS Illumination

TNO Test
The Netherlands Organization for Applied
Specific Research Test.
Materials
- Red Green Goggles
- Seven plates of various shapes (square dots and
crosses) created by computer generated random
dots printed in red and green complimentary
colours.
Method
Patient wears the red - green goggles and views
all the plates in sequence at a distance of 40 cm
and reports the shapes seen. The plates contain
both visible features which can be seen with and
without spectacles as well as hidden shapes which
are only apparent when the spectacles are worn
and stereopsis is present.
Advantages
- Quick estimation of stereopsis
- Determination of level of stereoscopic vision
from 480 to 15 seconds of arc.
- True measurement of stereoacuity than Titmus
test as there are no mono-ocular clues
- Can be performed on children older than
4 years

References
1. Bishop P: Vertical disparity, egocentric distance and stereoscopic depth constancy: A new interpretation.
Proc R Soc Lond B Biol Sci 237: 1289, 1989
2. Blake R, Fox R: The psychophysical inquiry into binocular summation. Perspect Psychophysiol 14:161,
1973.
3. Jones RK, Lee DN: Why two eyes are better than one: The two views of binocular vision. J Exp Psychol
Hum Percept. Perform 7:30, 1981.
4. Shimojo S, Bauer JA Jr, OConnell KM, et al: Pre-stereoptic binocular vision in infants, Vision Res
26:501, 1986
5. Guriazda J, Bauer JAJ, Held R: Binocular fusion in infants: Correlation of stereoptic and fusion-rivalry
discrimination, JPOS 26:128, 1989
6. Gunter K. von Noorden: Binocular Vision and Ocular Motility, Theory and Management of strabismus,
Sixth edition; Chptr 2.

Vol. XIII, No.2, April - June 2013

7. Feingold M, Bossert W: Normal values for selected physical parameters: an aid to syndrome delineation, in
Bergsman D, ed: Birth defects: vol 10, New York, The national foundation/ March of dimes, 1974
8. Hoyt; C. S. , Nickel, B.L.,and Bilson F, Ophthalmological examination of the infant: developmental
aspect, Surv. Ophthalmol 26.177,1982
9. Wiesel TN, Hubel DH: Effects of Visual Deprivation on Morphology and physiology of cells in the cats
lateral geniculate body. J Neurophysiol 26:978-993, 1963.
10. Garey LJ, Fisken RA, Powell TPA: Effects of experimental deafferentaion on cells in the cats lateral
geniculate body. Brain Res 52:363-369, 1973.
11. Hubel, D.H., and Wiesel TN,: Receptive Field of single neurons in the cats striate cortex, J Physiol.
148:574, 1959.
12. Hubel, D.H., and Wiesel TN: Stereoscopic vision in macaque monkey, cells sensitive to binocular depth in
area 18 of the macaque monkey cortex, Nature 225:41, 1970.
13. Barlow, H. B., Blakemore, C., and Pettigrew, J.D.: The normal mechanisms of binocular depth
discrimination, J. Physiol. (Lond). 193:327, 1967.
14. Hubel, D.H., and Wiesel TN: Binocular Interaction in striate cortex of kittens reared with artificial
squint, J. Neurophysiol. 28: 1041, 1965.
15. Hubel, D.H., and Wiesel TN: The period of susceptibility to the physiological effects of unilateral eye
closure in kittens, J. Physiol. (Lond.) 206:419, 1970.
16. Verhoeff, F. H.: A new theory of binocular vision, Arch. Ophthalmol. 13:152, 1935.
17. Duanne, A.: Projection and double vision: some new viewpoints, Arch. Ophthalmol. 54:233, 1925.
18. Linksz, A.: Physiology of the Eye. In vision, vol. 2, New York, 1952, Grune and Stratton, Inc.
19. Khurana A. K.: Theory and Practise of Squint and Orthoptics; first edition:4;61-89.
20. Burin, H: Sensorial retinal relationship in concomitant strabismus. Tr Am Ophth Soc. 43:373, 1945.
21. Bielschowsky, A: Lectures on motor anomalies. Hanover, 1940, Dartmauth college Publication.
22. Veith G. A.U.: Ueber die Richtung der Augen, Ann Phys 48: 233-251, 1818.
23. Muller J: vom Gesichtsinn. In Handbuch der Physiologie des Menschen fur Vorlesungun. Coblenz,
Holscher, 1840.
24. Kenneth Wright.W: Pediatric Ophthalmology and Strabismus, ed 95: 11, 163.