Strabismus, 18(2), 48–57, 2010

Copyright © 2010 Informa UK Ltd.

ISSN: 0927-3972 print/ 1744-5132 online
DOI: 10.3109/09273971003758412

Fusional Vergence Measures and Their

Significance in Clinical Assessment
Fiona J. Rowe, PhD, DBO
Directorate of Orthoptics and Vision Science, University of Liverpool, UK
Strabismus Downloaded from informahealthcare.com by The University of Manchester on 12/01/14

Abstract
Purpose: The aims of this study have been to evaluate differences between ranges in eso or exo
deviances and with varying target size.
Methods: Evaluation of sensory status in compensated deviations included measures of fusional
vergence (blur, break and recovery values) with randomization of target size and order of prism
base. Angle of deviation measures were assessed for each case.
Results: Twenty-two subjects, 7 esophoric and 15 exophoric, were recruited. Median prism fusional
vergence range at near fixation was 25BO to 10BI (central target); 35BO to 12BI (peripheral target).
At distance fixation median range was 16BO to 6BI (central); 25BO to 6BI (peripheral). Esophorics
For personal use only.

had a range shift towards the base out range. Exophorics had a shift towards the base in range.
Conclusions: Smaller positive fusional vergence values were obtained with small compared with
large target sizes. Additionally, esophoric subjects had a trend towards larger base out ranges while
exophoric subjects had a trend towards larger base in ranges.
Keywords:  fusion; vergence; strabismus; eso; exo

Introduction have varied, but generally the subjects measured have

Motor fusional vergences are the ability to maintain
binocular vision through a range of induced ver-
gence (often prism-induced) until a point is reached
where binocular vision is interrupted and the patient
commonly appreciates diplopia. Induced vergence
results in a “stress” situation for vergence and an
initial response is made by fast fusional vergence to
realign the visual axes following a retinal disparity
error message. Slow fusional responses then take
over to further adapt to the ocular position.1 Normal
and abnormal fast and/or slow vergence systems are
well reported in both asymptomatic and symptomatic
subjects.2-4
Data pertaining to the normal fusional vergence
range have been documented since 1948.5-16 The meth-
ods of measurement of normal fusional vergences
Received 17 August 2009; Revised 21 January 2010;
Accepted 27 January 2010
Correspondence: Dr Fiona Rowe, Division of Orthoptics, ­Thompson
Yates Building, University of Liverpool, Brownlow Hill, ­Liverpool
L69 3GB, UK. E-mail: rowef@liverpool.ac.uk
48
had small horizontal latent deviations of less than 10
prism diopters (PD) and ranges have been quoted
for either near or distance fixation. Other parameters
included method of prism fusion range measurement
(prism bars, loose prisms, or Risley prisms), ocular
dominance (prism before dominant or non-dominant
eye), and size of deviation.
On the basis of these studies the normal fusional
vergence range is generally quoted as 35 base-out
(BO: convergent range) to 16 base-in (BI: divergent
range) at near fixation and 20 BO to 8 BI at distance
fixation.17 However, there are considerable differences
reported in the various normative studies on fusional
vergence and in particular for positive fusional ver-
gence when measured with step fusion (prism bar).
The parameters that have been reported as not
impacting on fusional vergence include age and gen-
der.13 There is some controversy about the effect of
ocular dominance, as some studies show effect and
others do not.8,13,14 However, these studies also state
that where effects are seen, these do not constitute
clinically significant effect. Another confounder to

ocular dominance is the way in which it is assessed.
Ocular dominance relates to where we see ourselves in
space. However, some studies have used preferred eye
viewing as an indicator of ocular dominance13,14 when
in fact, this assessment is largely dependent on level
of acuity and thus does not always accurately indicate
ocular dominance. Measurement of fusional vergence
at near versus distance fixation also shows differences
in values and again, this is notable for positive fusional
vergence.5-9,13-16 There is no apparent information in the
literature regarding mid distance fusional vergence (ie,
3–meter distance). In view of changes in many testing
environments where long distance rooms are often
unavailable, there is a need to understand what dif-
Strabismus Downloaded from informahealthcare.com by The University of Manchester on 12/01/14
ferences are seen in fusional vergence at mid distances
in comparison with the traditional values noted at near
and distance fixation.
One aspect that does not appear to have been fully
addressed in the literature is the size of target that is
utilized when measuring fusional vergence. Many
studies state the type of target used.6,7,9,13,16 However,
these target sizes vary considerably from one study to
the next ranging from small, detailed targets (central
stimulus) to large targets (peripheral stimulus). This
For personal use only.
leads to the question as to whether target size may
influence the measurements obtained for fusional
vergence.
Type of deviation versus measured fusional ver-
gence does not receive much attention in the literature.
This may be because inclusion criteria for studies limits
the angle measurement to within ±10 prism dioptres.
One early study stated that greater amounts of exopho-
ria tend to accompany greater amounts of BI range and
the same applied to esophoria and BO ranges.5 That
study’s data on normal vergence ranges however did
not separate the deviation types. This raises the ques-
tion as to what differences can be seen when directly
comparing fusional vergence of eso deviations to those
of exo deviations.
The purpose of this prospective pilot study has been
to (1) measure fusional vergence for blur, break, and
recovery values to determine overall ranges with dif-
fering target sizes; (2) evaluate differences in fusional
vergence between esophoria and exophoria; and
(3) evaluate the fusional vergence values at a distance
of 3 meters for comparison with values obtained at
near and distance fixation.
Methods
The study design was that of a prospective cross sec-
tion pilot study. Subjects were recruited from a general
university population and were naive to the study
aims and measurements.
© 2010 Informa UK Ltd.
Significance of Fusion Measurements    49
Inclusion criteria included a best corrected visual
acuity of 6/6 Snellens or 0.0 logMAR in either eye,
refractive error within ± 5DS/±2DC, esophoria or
exophoria within ± 10 prism diopters (measured by
prism cover test at near and distance fixation) with no
decompensation to intermittent strabismus, full ocular
rotations, presence of fusional vergence and stereop-
sis (TNO response of 60 seconds or arc or better), and
visually asymptomatic.
Exclusion criteria included diagnosis other than
orthophoria, esophoria, or exophoria such as microtro-
pia, hyperphoria, and manifest strabismus. Individuals
with abnormal ocular motility other than physiological
V pattern were also excluded.
Each subject had a full orthoptic evaluation in an
emmetropic state (wearing habitual refractive correc-
tion, if required, to achieve inclusion criteria for visual
acuity). This included uniocular visual acuity (Snellens
or logMAR), cover test, ocular motility, retinal cor-
respondence (Bagolini glasses), stereoacuity (TNO),
fusional vergence, accommodation near point, and
prism cover test. Measures of fusional vergence were
undertaken by step prism fusion range using horizon-
tal (range 1 to 45 PD) and vertical (range 1 to 25 PD)
prism bars (Haag Streit, UK) including: blur, break
and recovery points to central (6/6:0.0 level), para-
foveal (6/9:0.2 level) and peripheral (6/60:1.0 level)
targets at near and distance fixation and at 3 meters.
The uncrowded target was a single Snellen letter and
the crowded target was a horizontal line of Snellen
letters. The order of testing for these measures was
randomized in terms of BI versus BO range first, near
versus distance fixation first, horizontal versus vertical
fusional vergence and choice of target. Previous studies
have shown some variation in measures according to
these variables.9,18-20 Thus, we sought to minimize order
effect plus fatigue effect by randomization. Measure-
ments of fusional vergence were undertaken during
one testing session with short breaks of 2 to 3 minutes
allowed between measures.
From this study, one group with esophoria and one
group with exophoria were gender and age matched
to form subgroups for comparison.
Statistical Analysis
As measurements taken with prism bars are not a
uniform step-wise assessment, non-parametric statis-
tical evaluation is often recommended to take median
values into consideration. In this study the fusional
vergence measures were assessed for goodness of fit
(Smirnov-Kolmogorov test) and for skewness. Results
were not found to be standardly distributed with a
skew of values to the lower prism strengths. Mean
 50    F. J. Rowe

values were consistently higher than median values
ranging from a 0.5 to 5.5 prism diopter difference.
Thus non-parametric analysis was undertaken using
Wilcoxon test for related measures and Mann-Whitney
test for independent measures. Bonferroni adjustment
was undertaken for multiple tests.
This research study adhered to the tenets of the Dec-
laration of Helsinki. Informed consent was obtained
from the subjects and the research was approved by
the Local Research Ethics Committee.
RESULTS
Strabismus Downloaded from informahealthcare.com by The University of Manchester on 12/01/14
23 years). Seven subjects had esophoria on cover test
and 15 had exophoria. The median prism cover test in
prism diopters (PD) was −1 PD (-8 to +10 PD) at near
fixation and 0 PD (−10 to +2 PD) at distance fixation
(Figure 1).
Varying Target Size
Table 1 shows the fusional vergence median and
ranges. The median horizontal prism fusion break
range at near fixation was BO 25 to BI 10 PD to a cen-
tral (6/6) target and BO 35 to BI 12 PD to a peripheral
(6/60) target. At distance fixation this was BO 16 to

Twenty-two subjects were recruited; 7 males and 15 BI 6 PD to a central target and BO 25 to BI 6 PD to a

females. The mean age was 20 years (range was 19 to peripheral target.

A Near fixation

3
Number of subjects
For personal use only.

0
−8 −6 −4 −2 −1 2 4 6 10
Near fixation angle of deviation

B Distance fixation

5
Number of subjects

0
−10 −6 −4 −2 −1 0 1 2
Distance fixation angle of deviation

FIGURE 1  Distribution of angles of deviation.

Strabismus
 Significance of Fusion Measurements    51

TABLE 1  Fusional vergence values are provided for the overall group including BO and BI ranges according to target size (central,
parafoveal, and peripheral) and for blur, break, and recovery points. The amplitudes (BO and BI ranges combined) are provided for
central and peripheral target sizes
NEAR Base out Base in
Target size Central Parafoveal Peripheral Central Parafoveal Peripheral
Blur 25[P]=0.002 25[P]=0.002 35 10[NS] 10[NS] 11
Break 25[P]=0.006 27.5[P]=0.002 35 10[NS] 10[NS] 12
Recovery 20[P]=0.007 22.5[P]=0.003 30 8[NS] 8[NS] 10
Amplitude of break point: 42.5 central; 50 peripheral
Vertical: Base down 5 to base up 4 PD
The p values relate to non-parametric assessment of fusional vergence measures with either a central or parafoveal target in
comparison with the measures obtained with a peripheral target (Wilcoxon test). NS denotes non-significant results

DISTANCE Base out Base in

Strabismus Downloaded from informahealthcare.com by The University of Manchester on 12/01/14

Target size Central Parafoveal Peripheral Central Parafoveal Peripheral

Blur 16[P]=0.029 16[P]=0.029 25 6[NS] 6[NS] 6
Break 16[NS] 17[NS] 25 6[NS] 6[NS] 6
Recovery 12[P]=0.036 14[NS] 16 4[NS] 4[NS] 4
Amplitude of break point: 28 central; 30 peripheral
Vertical: Base down 4 to base up 3 PD
The p values relate to non-parametric assessment of fusional vergence measures with either a central or parafoveal target in
comparison with the measures obtained with a peripheral target (Wilcoxon test). NS denotes non-significant results

MID 3m Base out Base in

Target size Central Peripheral Central Peripheral
Blur 18 25 6 8
For personal use only.

Break 20 25 6 8
Recovery 15 16 4 6

When comparing fusional vergence measures
obtained with different sized targets at near and dis-
tance fixation there was no significant difference in the
measures obtained for many BI ranges using varying
target sizes at the same testing difference. There was
a significant difference when comparing BI values at
near and at distance fixation distance using a central
target size (p = 0.0001) and using a peripheral target
size (p = 0.0001): Wilcoxon. However for BO ranges, a
significantly higher measure was obtained when using
a peripheral target in comparison to a central or para-
foveal sized target at near fixation, p = 0.003 (Wilcoxon).
Additionally, there was a significant difference between
BO values from near to distance fixation with both a
central target size (p = 0.004) and peripheral target size
(p = 0.0001): Wilcoxon.
Values at 3 Meters
The median prism fusion break range at mid fixation
was BO 18 to BI 6 PD to a central target and BO 25
to BI 8PD to a peripheral target. A significant differ-
ence existed for comparison of near BO values to mid
distance values with varying target sizes (p = 0.007 for
central stimulus and p = 0.0001 for peripheral stimu-
lus: Wilcoxon) but not for distance fixation versus mid
distance. There was also a significant difference com-
paring BI values at near fixation to those at mid dis-
tance (p = 0.0001 central stimulus; p = 0.003 peripheral
stimulus: Wilcoxon) but with little difference between
measures for distance fixation and mid distance.
Esophoria Versus Exophoria Values
From the overall group of 22 subjects, 7 subjects with
esophoria and 7 subjects with exophoria were taken to
form age and gender matched groups (4 females and
3 males in each group). The median angle of deviation
was 2 PD (2 to 10 PD) at near fixation and 1 PD (0 to 2
PD) at distance for esophoric subjects and -2 PD (-1 to
-8 PD) at near fixation and -1 PD (0 to 6 PD) at distance
for exophoric subjects.
Table 2 shows the fusional vergence median and
ranges for esophoria subjects. The median prism hori-
zontal fusion break range at near fixation was BO 30 to
BI 10 PD to a central (6/6) target and BO 40 to BI 12 PD
to a peripheral (6/60) target. At distance fixation this
was BO 25 to BI 6 PD to both central and peripheral
targets.
When comparing fusional vergence measures
obtained with different sized targets at near and dis-
tance fixation there was no significant difference in

© 2010 Informa UK Ltd.

 52    F. J. Rowe

TABLE 2  Fusional vergence values are provided for the eso group including BO and BI ranges according to target size (central,
parafoveal, and peripheral) and for blur, break, and recovery points. The amplitudes (BO and BI ranges combined) are provided for
central and peripheral target sizes
NEAR Base out Base in
Target size Central Parafoveal Peripheral Central Parafoveal Peripheral
Blur 30[P]=0.042 25[NS] 40 10[NS] 8[NS] 12
Break 30[P]=0.042 30[P]=0.043 40 10[NS] 10[NS] 12
Recovery 20[P]=0.039 25[P]=0.043 30 8[NS] 8[NS] 10
Amplitude of break point: 42 central; 52 peripheral
Vertical: Base down 5 to base up 3 PD
The p values relate to non-parametric assessment of fusional vergence measures with either a central or parafoveal target in
comparison with the measures obtained with a peripheral target (Wilcoxon test). NS denotes non-significant results

DISTANCE Base out Base in

Strabismus Downloaded from informahealthcare.com by The University of Manchester on 12/01/14

Target size Central Parafoveal Peripheral Central Parafoveal Peripheral

Blur 25[NS] 25[NS] 25 6[NS] 6[NS] 6
Break 25[NS] 25[NS] 25 6[NS] 6[NS] 6
Recovery 20[NS] 20[NS] 20 2[NS] 4[NS] 4
Amplitude of break point: 29 central; 33 peripheral
Vertical: Base down 4 to base up 3 PD
The p values relate to non-parametric assessment of fusional vergence measures with either a central or parafoveal target in
comparison with the measures obtained with a peripheral target (Wilcoxon test). NS denotes non-significant results

TABLE 3  Fusional vergence values are provided for the exo group including BO and BI ranges according to target size (central,
For personal use only.

parafoveal, and peripheral) and for blur, break, and recovery points. The amplitudes (BO and BI ranges combined) are provided for
central and peripheral target sizes
NEAR Base out Base in
Target size Central Parafoveal Peripheral Central Parafoveal Peripheral
Blur 20[P]=0.016 25[NS] 35 10[NS] 10[NS] 10
Break 25[P]=0.018 25[P]=0.046 35 10[NS] 10[NS] 14
Recovery 18[P]=0.028 16[P]=0.046 30 8[NS] 8[NS] 10
Amplitude of break point: 35 central; 49 peripheral
Vertical: Base down 5 to base up 4.5 PD
The p values relate to non-parametric assessment of fusional vergence measures with either a central or parafoveal target in
comparison with the measures obtained with a peripheral target (Wilcoxon test). NS denotes non-significant results

DISTANCE Base out Base in

Target size Central Parafoveal Peripheral Central Parafoveal Peripheral
Blur 14[NS] 12[NS] 16 8[NS] 8[NS] 8
Break 14[NS] 12[NS] 16 8[NS] 8[NS] 8
Recovery 10[NS] 10[NS] 12 6[NS] 6[NS] 6
Amplitude of break point: 28 central; 28 peripheral
Vertical: Base down 3 to base up 3 PD
The p values relate to non-parametric assessment of fusional vergence measures with either a central or parafoveal target in
comparison with the measures obtained with a peripheral target (Wilcoxon test). NS denotes non-significant results

the measures obtained for BI ranges. However for BO
ranges, a higher measure was obtained when using a
peripheral target in comparison with a central or para-
foveal sized target for near fixation only, p = 0.039 to
p = 0.043 (Wilcoxon). These higher measures were not
found to be significant after Bonferroni correction.
Table 3 shows the fusional vergence median and
ranges for the exophoria group. The median prism
horizontal fusion break range at near fixation was BO
25 to BI 10 PD to a central (6/6) target and BO 35 to BI
14 PD to a peripheral (6/60) target. At distance fixation
this was BO 14 to BI 8 PD to a central target and BO 16
to BI 8 PD to a peripheral target.
When comparing fusional vergence measures
obtained with different sized targets at near and dis-
tance fixation there was no significant difference in
the measures obtained for BI ranges. However for BO
ranges, a higher measure was obtained when using a
peripheral target in comparison to a central or para-
foveal sized target for near fixation only, p = 0.016 to

Strabismus
 Significance of Fusion Measurements    53

p = 0.046 (Wilcoxon). Again, these higher measures
were not found to be significant after Bonferroni cor-
rection.
Figures 2 and 3 detail the prism fusion range at near
and distance fixation to central and peripheral targets
for the overall group plus the separate esophoria and
exophoria groups. A shift towards the base-out range
in seen in the esophoria group while a shift towards the
base-in range is seen in the exophoria group. However,
this shift was not found to be statistically significant.
DISCUSSION
Strabismus Downloaded from informahealthcare.com by The University of Manchester on 12/01/14
to BI 6 using a central target and BO 25 to BI 8 using
a peripheral target. These were comparable to the
distance ranges. Three-meter distance is not a routine
clinical assessment distance for fusional vergence
ranges. However where room constraints allow a
3-meter testing distance only, it is feasible to use these
vergence ranges for comparison.
A limitation of this study was the small number
of subjects recruited. However, the study was under-
taken under repeatable and consistent environment
conditions using naive subjects. All measurements
were taken by the same examiner (FR). Measure-
ments were taken of fusional vergence responses in
a randomized order to take into consideration both

The normal horizontal vergence range for all normal
subjects in this study was BO 25 to BI 10 using a central
target and BO 35 to BI 12 using a peripheral target at
near fixation. At distance the normal vergence range
was BO 16 to BI 6 using a central target and BO 25
to BI 6 using a peripheral target. The normal vertical
vergence range was BD 5 to BU 4 for near fixation and
BD 4 to BU 3 at distance fixation.
Additionally, horizontal vergence ranges were
measured at 3-meter distance. The ranges were BO 18
For personal use only.
fatigue and practice effects. A larger-scale study is
recommended to evaluate further the differences
found in fusional vergence values in esophoria ver-
sus exophoria and taking into account varying fixa-
tion distances and target sizes.
Table 4 outlines the step prism bar fusional ver-
gence values reported in the literature against the
values obtained in this current study. Scobee and
Green measured prism fusion vergence at both near
(28 BO to 20 BI) and distance fixation (19 BO to 7 BI)

A
A
PFR: Distance fixation (central stimulus)
PFR: Near fixation (central stimulus) 50
45 45
50 45 40
45
40 30
35 25 25
30 30
25 25 20
20 16 14
12 10
10 10 10 6 6 10
PD 0 PD 0 −4
−1 −4
−10 −6 −6 −6 −10 −6 −6 −8
−10 −10 −10
−20 −14 −20 −20 −12 −20
−30 −30
-30 −30
−40 Overall Eso Exo
Overall Eso Exo
B
B

PFR: Distance fixation (peripheral stimulus)

PFR: Near fixation (peripheral stimulus)

50 50
45 45 45 45 45
40 40
35 40 35 35
30 30
25
20 20 22
14 14 16 16
10 10 10
PD 0 PD 6 6
−6 −6 −6 0 −4 −4 −4
−10
−12 −12 −14 −10 −6 −6 −8
−20
−30 −20 −8 −20
−30 −30 −20
−40 −30
Overall Eso Exo Overall Eso Exo

FIGURE 2  Prism fusion range at near fixation for overall FIGURE 3  Prism fusion range at distance fixation for over-
normal range, eso and exo ranges. all normal range, eso, and exo ranges.

© 2010 Informa UK Ltd.

 Strabismus Downloaded from informahealthcare.com by The University of Manchester on 12/01/14
For personal use only.

54    F. J. Rowe

Table 4  Comparison of fusional vergence with varying target size

Rowe Scobee & Green Tait Wesson Rosenbaum et al Narbheram & Firth Antona et al
2009 1948 1949 1982 1995 1997 2008
6/6 target size Unknown target 1.4° target size at Parafoveal 6/6 target size 0.8 target size
size near target size
6/12 target size at
distance
Near Distance Near Distance Near Distance Near Distance Near Distance Near Distance
25 BO– 16 BO– 28 BO– 19 B– 19 BO– 11 BO– 27 BO– 57 BO– 33 BO– 28.91 BO– 23.25 BO–
10 BI 6 BI 20 BI O7 BI 13 BI 7 BI 8 BI 18.5 BI 9.7 BI 12.14 BI 8.63 BI
6/36 and 6/60 target 6/30 target size
size
Near Distance Near Distance
35 BO– 25 BO– 30 BO–
12 BI 6 BI 12 BI

Strabismus

but with unknown target size.5 The near and distance
ranges are midway between the ranges for this study
for central and peripheral target sizes. One possible
explanation is the use of a parafoveal target size. Tait
measured prism fusion vergence with a 6/30 periph-
eral target at distance fixation and obtained an average
range of 18/30 BO to 10/12 BI.6 This is comparable
with the range in this study with a similar target size.
In this study prism fusion range was measured with
a 6/36 sized target as well as a 6/60 target and found
both target sizes gave the same measures as detailed
in Table 1.
Wesson et al. used a 1.4° target at near fixation and
a 6/12 target at distance fixation and reported fusional
Strabismus Downloaded from informahealthcare.com by The University of Manchester on 12/01/14
vergence of 19 BO to 13 BI for near and 11 BO to 7
BI for distance.13 The distance values in particular are
not that dissimilar to those found in our study with
smaller target sizes. Rosenfield et al.. documented a
range of 27 BO to 8 BI using a parafoveal target at
distance fixation.9 In 1997, Narbheram and Firth used
a central target at both near (57 BO to 18.5 BI) and
distance fixation (33 BO to 9.7 BI).7 Their BO range
was particularly high, which may relate to the subjects
used in the study (orthoptic undergraduate students).
For personal use only.
The convergence range can be improved with long-
term adaptation14,21 and this is likely to have influ-
enced and enhanced the results of their study. Hainey
et al. used a peripheral target at distance fixation but
placed before the dominant and non-dominant eye.8
They found a slightly increased BO range when placed
before the non-dominant eye but results were gener-
ally comparable with our distance peripheral target
range. A more recent study in 2008 utilized a 0.8 deci-
mal letter size and reported fusional vergence values
of 28.91 BO to 12.14 BI for near fixation and 23.25 BO
to 8.63 BI for distance fixation.16 The BI values are very
similar to those reported in the literature for similar
target sizes. The positive fusional vergence is slightly
larger, however, for distance fixation and more com-
parable to that of peripheral sized target values.
It would appear from the current study and much
of the literature that the early prism fusional vergence
values from 1948 generally remain consistent across
various studies. Where there are some discrepancies,
these undoubtedly relate to varying methodology
across studies, namely biased/unbiased subjects,
underlying angle of deviation, target size, prisms
placed before one or both eyes, and placement of prism
(prentice versus frontal plane). In addition the time
allowed to fixate the target, use of dominant or non-
dominant eye, and order of testing (BO before or after
BI range) will impact on fusional vergence measures
and typically these factors are specified in individual
studies. This study allowed 2 seconds per prism: too
little, and the subject has insufficient time to fixate the
© 2010 Informa UK Ltd.
Significance of Fusion Measurements    55
target and overcome the prism effect; too much, and
the results can be overestimated.
Target size appears to impact on the extent of
fusional vergence values obtained and particularly
for positive fusional vergence. This finding warrants
further study in a larger study series. Amplitudes
of fusional vergence depend on the amount of fus-
ible material in the subject’s field of view. Therefore
the greater the amount of fusible material, the larger
the amplitudes.21 This is not surprising considering
the size of the fusible stimulus plus accommodative
convergence will play a greater role in fusional con-
vergence at near than at distance fixation. There was
a far greater difference in target size results for exo-
phoria compared to esophoria, which would suggest
that exophoric subjects make far use of accommoda-
tive convergence in the control of their underlying
deviation.
From a clinical viewpoint, certain aspects can
be controlled. It is evident that the order of testing
can impact on fusion vergence. The BO range in
particular can produce vergence/prism adaptation
resulting in a transient fusional after-effect.18 This
response may not have worn off by the time the BI
range is subsequently measured.19 The result is that
the fusional vergence range is biased in the direc-
tion of the first measure. The authors recommend an
order of testing such as BO, base-up, BI, and base-
down. For many patients it should be the procedure
adopted to prevent vergence adaptation. However
where the deviation is known, i.e., eso or exo, a fur-
ther recommendation is that the compensating range
for the heterophoria should be measured first as it is
this range that determines the quality of control for
the deviation, e.g., BO range for an exo deviation.
This would ensure that the critical vergence range is
assessed first without introducing bias from a pre-
ceding vergence measure.9,18-20
In addition to testing the critical range first the
true vergence range for horizontal deviations is of
importance. Scobee and Green reported their ranges
of fusional vergence.5 At a near testing distance they
found the amount of exo deviation to be significantly
correlated with the prism divergence break point and
commented that greater amounts of exo deviation
accompanied greater amounts of prism divergence
while greater amounts of eso deviation accompanied
lower amounts of prism divergence. This was also
seen at distance testing with greater measurements at
distance fixation having greater prism vergence at near
fixation.
The current study found a clear difference between
fusional vergence for eso versus exo deviations with
a greater BO range for esos and greater BI range for
exos. Amplitudes were also compared and found to
 56    F. J. Rowe
be skewed according to the type of deviation present.
There appears to be a skewed vergence range with eso-
phoria having a bias towards the convergent range and
exophorias having a bias towards the divergent range.
The differences found in this study did not reach sig-
nificance, which may reflect the small numbers in each
group and the variance across groups. This warrants
further investigation in a larger cohort of esophoric
versus exophoric subjects.
It is proposed that these findings have potential
clinical significance. Patients who have small angle
latent deviations with fusional vergence measures fall-
ing within these normal ranges are considered most
likely to be asymptomatic with regard to control of the
Strabismus Downloaded from informahealthcare.com by The University of Manchester on 12/01/14
heterophoria.6 Clinically however we often see patients
with poor fusional vergences who are asymptomatic
or patients with normal fusional vergences who are
symptomatic.15,22 In addition it is also evident that eso
deviations can have different vergence responses to
exo deviations.
Numerous parameters contribute to the success or
failure of treatment for eso and exo deviations. For
example, refractive error, presence or absence of sen-
sory and motor binocular function, angle of deviation,
For personal use only.
and level of visual acuity. Binocular function is of par-
ticular importance and specifically the motor fusional
vergences. It is important to fully assess binocular
vision in symptomatic patients22 despite the presence
of apparently normal fusional vergence values. Atten-
tion must be paid to the target size being used to obtain
the fusional vergence values so that accurate compari-
son of vergence measures can be made to the angle of
deviation, particularly when considering the extent of
binocular control of the deviation.
This information is important when considering
what values are being used when determining the
patient’s use of fusional vergence in control of the
patient’s angle of deviation. It is recommended that
the patient fixate a target of size commensurate with
his or her visual acuity when measuring their angle of
deviation. The same target size should then be used
when measuring fusional vergence. Subsequently like
with like can be compared. If not, erroneous interpreta-
tion of ability to control a deviation may occur.
In addition, it may be important to take angle
of deviation into consideration when considering
whether fusional vergence measures are normal for
the individual. Considering so much of the literature
relates binocular outcome success as to within +/− 10
prism diopters of ortho it is imperative that we ques-
tion our outcome measures for future studies for those
deviations with binocular potential.
Scobee and Green stated that patients with large
esophoria and poor BI range would be symptomat-
ic.5 They recommended that the aim should be to
attain deviations at 6 m within +/−5 prism diopters
and at 1/3 m within 10 prism diopters of exophoria
and 4 prism diopters of esophoria to have comfort-
able binocular control. Tait discussed this fact in his
paper, stating that subjects use about one quarter to
one third of their vergence amplitude to control their
deviation successfully.6 Criteria exist that can aid the
prediction of angle of deviation with presence/absence
of symptoms. Sheard’s criteria have been reported to
be a good discriminatory tool with exo deviations
whereas eso deviations were better predicted by a
variant of Percival’s criteria or degree of deviation
measurement.23,24
CONCLUSIONS
The results of this study demonstrate that the differ-
ences between fusional vergence values reported in
the literature appear less when target size is taken
into consideration indicating a potential influence of
central versus peripheral stimulus on fusional ampli-
tude. Subjects with eso deviations show larger BO and
smaller BI vergences than exo deviations although a
study with a larger sample size is required to confirm
whether this shift is of statistical significance.
ACKNOWLEDGMENT
Declaration of Interest:  No funding was allocated to
this paper. The author reports no conflicts of interest.
The author alone is responsible for the content and
writing of the article.
REFERENCES
1. Schor CM. The relationship between fusional vergence eye
movements and fixation disparity. Vision Res. 1979;19:1359–
1367.
2. Carter DB. Fixation disparity and heterophoria following
prolonged wearing of prisms. Am J Optom Arch Am Acad
Optom. 1965;42:141–151.
3. Pickwell LD, Kurtz BH. Lateral short-term prism adaptation
in clinical evaluation. Ophthalmic Physiol Opt. 1986;6:67–73.
4. North RV, Henson DB. The effect of orthoptic treatment
upon the vergence adaptation mechanism. Optom Vis Sci.
1992;69:294–299.
5. Scobee RG, Green EL. Relationships between lateral hetero-
phoria, prism vergence and the near point of convergence.
Am J Ophthalmol. 1948;31:427−441.
6. Tait EF. Fusional vergence. Am J Ophthalmol. 1949; 32:
1223−1230.
7. Narbheram J, Firth AY. Prism fusion range: blur point, break
point and recovery point. Br Orthopt J. 1997;54:2−6.
Strabismus

8. Hainey J, Cleary M, Wright L. Does ocular dominance
influence the clinical measurement of fusional amplitude?
Br Orthopt J. 1999;56:72−76.
9. Rosenfield M, Ciuffreda KJ, Ong E, Super S. Vergence
adaptation and the order of clinical vergence range testing.
Optom Vis Sci. 1995;72:219−223.
10. Jimenez R, Perez MA, Garcia JA, Gonzalez MD. Statisti-
cal normal values of visual parameters that characterize
binocular function in children. Ophthalmic Physiol Opt.
2004;24:528−542.
11. Sethi B, North RV. Vergence adaptive changes with
varying magnitudes of prism induced disparities and
fusional amplitudes. Am J Optom Physiol Opt. 1987;6:
151−156.
12. Carter DB. Effects of prolonged wearing of prisms. Am J
Optom Physiol Opt. 1963;40:265−273.
Strabismus Downloaded from informahealthcare.com by The University of Manchester on 12/01/14
13. Wesson MD. Normalization of prism bar vergences. Am J
Optom Physiol Opt. 1982;59:628−634.
14. Wesson MD, Amos JF. Norms for hand-held rotary prism
vergences. Am J Optom Physiol Opt. 1985;62:88−94.
15. Scheiman M, Herzberg H, Frantz K, Margolies M. A norma-
tive study of step vergence in elementary school children.
J Am Optom Assoc. 1989;60:276−280.
16. Antona B, Barrio A, Barra F, Gonzalez E, Sanchez I.
Repeatability and agreement in the measurement of
For personal use only.
© 2010 Informa UK Ltd.
Significance of Fusion Measurements    57
horizontal fusional vergences. Ophthalmic Physiol Opt.
2008;28:475−491.
17. Von Noorden GK, Campos EC. Binocular vision and ocular
motility. Theory and Management of Strabismus. 6th edition.
Mosby, 2002.
18. Sethi B. Vergence adaptation: a review. Documenta Ophthal-
mologica. 1986;63:247−263.
19. Morgan MW. The clinical aspects of accommodation
and convergence. Am J Optom Arch Am Acad Optom.
1944;21:301−313.
20. Tuff LC, Firth AY, Griffiths HJ. Prism vergence measure-
ments following adaptation to a base out prism. Br Orthopt
J. 2000;57:42−44.
21. Goldstein JH, Hornblass A, Clahane AC. Effect of peripheral
vision on the binocular relationship: a further study. Am J
Ophthalmol. 1968;66:86.
22. Gall R, Wick B. The symptomatic patient with normal pho-
rias at distance and near: what tests detect a binocular vision
problem? Optometry. 2003;74:309.
23. Sheedy JE, Saladin JJ. Association of symptoms with mea-
sures of oculomotor deficiencies. Am J Optom Physiol Opt.
1978;55:670−676.
24. Sheedy JE, Saladin JJ. Phoria, vergence and fixation dis-
parity in oculomotor problems. Am J Optom Physiol Opt.
1977;54:474−478.