Dichoptic and Monocular Visual Acuity in
Amblyopia
EILEEN E. BIRCH, REED M. JOST, LINDSEY A. HUDGINS, SARAH E. MORALE, MATTHEW DONOHOE, AND
KRISTA R. KELLY
• PURPOSE: Standard-of-care assessment for children
with amblyopia includes measuring amblyopic eye best-
corrected visual acuity (AE BCVA) with the fellow eye
occluded. By definition, this abolishes the interocular
suppression fundamental to amblyopia. Thus, measured
AE BCVA may not accurately represent that eye’s con-
tribution to natural binocular viewing. We compared di-
choptic and monocular AE BCVA and examined whether
any differences were associated with eye-hand coordina-
tion or reading speed.
• DESIGN: Cross-sectional study.
• METHODS: Dichoptic and monocular AE BCVA of
children aged 6-12 years (42 with amblyopia, 24 with
recovered normal AE BCVA, 30 control) were mea-
sured. Stereoacuity, suppression, eye-hand coordination,
and reading speed were also assessed.
• RESULTS: Overall, 81% of amblyopic children had
worse dichoptic than monocular AE BCVA (mean
difference=0.15±0.11 logMAR; P < .0001), and 71%
of children with recovered normal AE BCVA had worse
dichoptic than monocular AE BCVA (mean differ-
ence = 0.20±0.17 logMAR, P < .0001). Controls had
no significant difference. The difference between dichop-
tic and monocular AE BCVA was correlated with perfor-
mance in standardized aiming/catching (r = –0.48, 95%
CI –0.72, –0.14) and manual dexterity tasks (r = –0.37,
95% CI –0.62, –0.06), and with reading speed (r = –
0.38, 95% CI –0.65, –0.03).
• CONCLUSIONS: Dichoptic AE BCVA deficits were
worse than monocular AE BCVA deficits and were asso-
ciated with reduced stereoacuity and suppression, consis-
tent with the hypothesis that binocular dysfunction plays
a role. Further, impaired eye-hand coordination and slow
reading were associated with dichoptic, but not monocu-
lar, AE BCVA. Some children with amblyopia may ben-
efit from extra time for school tasks requiring eye-hand
Meeting Presentation: The data described in this manuscript
are from an oral presentation at the 2022 Annual Meeting of the Associ-
ation for Research in Vision and Ophthalmology (Denver, May 3, 2022).
Accepted for publication June 6, 2022.
From the Retina Foundation of the Southwest, Dallas, TX (E.E.B.,
R.M.J., L.A.H., S.E.M., M.D., K.R.K.), Department of Ophthalmology,
University of Texas Southwestern Medical Center, Dallas, Texas, USA
(E.E.B., K.R.K.)
Inquiries to Eileen E. Birch, Pediatric Vision Laboratory, Retina
Foundation of the Southwest, Dallas, Texas, USA.; e-mail:
ebirch@retinafoundation.org
0002-9394/$36.00 © 2022 ELSEVIER INC. ALL RIGHTS RESERVED.
https://doi.org/10.1016/j.ajo.2022.06.002
coordination or reading. (Am J Ophthalmol 2022;242:
209–214. © 2022 Elsevier Inc. All rights reserved.)
S
tandard-of-care assessment for children with
amblyopia includes measuring best-corrected monoc-
ular visual acuity (BCVA), with the nonviewing eye
occluded.1 Yet, by definition, interocular suppression is ab-
sent when visual input from the fellow eye is occluded. As
a result, the central suppression scotoma that is fundamen-
tal to amblyopia2-4 may have reduced impact on amblyopic
eye (AE) BCVA and the measured monocular AE BCVA
may not accurately represent AE function during natural
binocular viewing.
In a large cohort of adults, including approximately 15%
with interocular acuity differences of 2 lines or more, binoc-
ular BCVA was predicted with good accuracy by the BCVA
of the better-seeing eye.5 Overall, there was modest binoc-
ular summation (0.02 logMAR [1 letter] better visual acu-
ity when tested binocularly than monocularly) when the
2 eyes had equivalent BCVA but no evidence of interoc-
ular inhibition (worse visual acuity when tested binocu-
larly than monocularly) when the BCVA of the 2 eyes
were dissimilar.5 Furthermore, the influence of visual acu-
ity on the performance of the everyday tasks of reading
and face recognition could be accounted for by monocular
acuity of the better-seeing eye.5 How then can we explain
the slow reading speed6-8 and impaired eye-hand coordina-
tion9-12 of children with amblyopia under normal binocu-
lar viewing conditions, when the adult model suggests that
normal better-eye BCVA should be sufficient for normal
function?5
Unlike adult-onset monocular visual impairment, which
is most often associated with degenerative changes within
anterior or posterior segment of the eye,13 amblyopia is a
neurodevelopmental disorder of the brain that arises as a re-
sult of binocularly discordant visual experience during the
first years of life.3 , 4 Although abnormal binocular experi-
ence produces the symptom of reduced AE BCVA, recent
evidence supports the hypothesis that interocular suppres-
sion is the primary cause of amblyopia; that is, amblyopia
is a disorder of binocular vision.3 , 4 , 14 , 15 Unlike adults with
monocular visual impairment, visual acuity of the better-
seeing eye of amblyopic children is not associated with per-
formance of reading and eye-hand coordination tasks under
natural binocular viewing conditions.7 , 8 , 16 Moreover, slow
209
 TABLE 1. Characteristics of Study Participants

Amblyopic (n=42) Recovered (n=24) Control (n=30)

Sex, female, n (%) 23 (46) 12 (50) 17 (57)

Age, y, mean (SD) and range 9.6 (1.7) 9.5 (1.5) 9.6 (1.8)
6.1-12.2 6.2-11.9 6.1-12.1
Race/ethnicity, n (%)
Non-Hispanic White 31 (74) 18 (75) 22 (73)
Hispanic White 6 (14) 0 (0) 6 (20)
Black/African American 1 (2) 2 (8) 0 (0)
Asian 2 (5) 2 (8) 0 (0)
Native American 0 (0) 1 (4) 0 (0)
More Than One 2 (5) 1 (4) 2 (7)
Amblyogenic factor, n (%) N/A
Anisometropia 20 (48) 7 (29)
Strabismus 9 (21) 12 (50)
Both 13 (31) 5 (21)
Preferred or lefta eye visual acuityb , logMAR, mean (SD) and range –0.02 (0.07) 0.00 (0.07) –0.02 (0.08)
–0.10 to 0.10 –0.10 to 0.10 –0.20 to 0.00
Nonpreferred or rightc eye visual acuityb , logMAR, mean (SD) and range 0.30 (0.09) 0.04 (0.07) –0.01 (0.08)
0.20-0.50 –0.10 to 0.10 –0.10 to 0.00
a
Left eye for control children.
b
Tested monocularly with E-ETDRS (ages 7-12 years) or ATS-HOTV (age 6 years) on an M&S Smart System.
c
Right eye for control children.

reading and impaired eye-hand coordination of amblyopic
children are not associated with AE BCVA but rather are
associated with deficits in binocular vision (reduced or nil
stereoacuity and peripheral or absent fusion).7 , 8 , 10
Given the significant disruption of binocular vision as-
sociated with amblyopia and suppression of the amblyopic
eye by the fellow eye, it is possible that amblyopic chil-
dren may show greater deficits in AE BCVA with natural
binocular viewing. The aim of this study was to compare di-
choptic and monocular AE BCVA in amblyopic children,
a paradigm that can better capture the impact of binocu-
lar function disruptions. In dichoptic presentation, a subset
of the optotypes on each line of the visual acuity chart are
viewed only by the right eye, some only by the left eye, and
some by both eyes. As a result, the effect of suppression of
the amblyopic eye by the fellow eye can be directly observed
as a reduction of visual acuity relative to monocular ambly-
opic eye visual acuity. A secondary goal was to determine
whether dichoptic AE BCVA was associated with perfor-
mance on everyday tasks of reading and eye-hand coordi-
nation with natural binocular viewing.
METHODS
Children aged 6-12 years diagnosed with hyperopic or astig-
matic anisometropia ≥1 diopter (D) or strabismus were re-
ferred to the Retina Foundation by pediatric ophthalmol-
ogists in the Dallas–Fort Worth area for participation in
this cross-sectional study. These included children who had
amblyopia with AE BCVA of 0.2 to 0.5 logMAR (20/32-
60; n = 42) and children with a history of amblyopia who
had recovered normal visual acuity with treatment (≤0.1
logMAR; 20/25 or better in each eye; n = 24). Ambly-
opia was defined as an interocular difference in visual acu-
ity ≥0.2 logMAR (≥2 lines), with fellow eye BCVA ≤0.1
logMAR (20/25 or better) tested with the electronic ET-
DRS (E-ETDRS) protocol17 for children aged 7-12 years
(n = 61) or the Amblyopia Treatment Study HOTV (ATS-
HOTV) protocol18 , 19 for children aged 6 years (n = 5) us-
ing an M&S Smart System (M&S Technologies).17 , 19
Age-similar control children (n = 30) with age-normal
visual acuity and stereoacuity, and no history of vision dis-
orders, were also enrolled. All children were tested with
their habitual spectacle correction, which was confirmed by
medical record review. No child enrolled in the study was
born preterm (<37 weeks’ gestational age) or had coexist-
ing ocular or systemic disease, congenital infections or mal-
formations, or developmental delay. Medical records were
obtained from referring ophthalmologists to extract diag-
nosis, current refractive correction, and current alignment.
Strabismic children were initially diagnosed with esotropia,
but were aligned with surgery or spectacle correction to or-
thotropia or an intermittent strabismus ≤8 pd at the time
of their participation.
The research protocol observed the tenets of the Decla-
ration of Helsinki, was approved by the Institutional Re-
view Board of the University of Texas Southwestern Med-
ical Center, and conformed to the requirements of the

210 AMERICAN JOURNAL OF OPHTHALMOLOGY OCTOBER 2022

United States Health Insurance Portability and Account-
ability Act. Informed consent was obtained from a parent
and assent was obtained from children aged ≥10 years.
• DICHOPTIC AND MONOCULAR VISUAL ACUITY: Di-
choptic visual acuity testing of the amblyopic eye was con-
ducted with an Optec 2000 Vision Tester (Stereo Optical
Inc) set in the FAR mode (simulating a 6-m test distance),
which presents Sloan letters (for children aged 7-12 years)
or numbers (for children aged 6 years) as the optotypes. The
Optec 2000 Vision Tester has a built-in baffle assembly to
segregate optotypes to the left eye, right eye, or both eyes
without crossover or unwanted reflective light. For ambly-
opic children, testing began with 0.55-logMAR size letters
viewed dichoptically. The leftmost 4 optotypes were pre-
sented only to the left eye, the middle 4 optotypes were pre-
sented to both eyes, and the rightmost 4 optotypes were pre-
sented only to the right eye. If the child missed 2 or more of
the optotypes with the amblyopic eye, the child failed that
level. If the 0.55-logMAR level (20/70) was passed, testing
proceeded with progressively smaller optotype sizes of 0.4,
0.3, and 0.2 logMAR.
Dichoptic AE BCVA was recorded as the smallest level
passed or, if unable to pass even the largest optotype (0.55
logMAR), the result was recorded as “unable.” Once di-
choptic testing was complete, monocular visual acuity test-
ing of the amblyopic eye was conducted with the Optec
2000 Vision Tester using the same protocol. For children
with anisometropia or strabismus who had recovered nor-
mal visual acuity, the same protocol was followed for di-
choptic and monocular testing of the formerly amblyopic
eye. Right eyes of all control children were tested with the
0.2-logMAR optotype with both dichoptic and monocular
viewing conditions.
• BINOCULAR VISION: Stereoacuity was assessed using
the Randot Preschool Stereoacuity and Stereo Butterfly
Tests.20 , 21 Stereoacuity data were converted to log arcsec
for analyses if measurable (range available: 1.3-2.9 log ar-
sec) or assigned a nominal value of 4.0 log arcsec if nil. Sup-
pression was assessed using the Worth 4 Dot (W4D) test at
33 cm and at 3 m.1 Depth of suppression was assessed us-
ing a computerized dichoptic eye chart that determines the
nonpreferred eye–preferred eye contrast ratio (ie, balance
point) at which the child can overcome interocular sup-
pression and report letters presented to each eye with equal
likelihood (Contrast Balance Index).15 , 22
• VISUOMOTOR FUNCTION: Amblyopic children also par-
ticipated in 3 visuomotor tasks: reading, manual dexterity,
and ball skills. All visuomotor tasks were conducted with
natural binocular viewing, and the child wore their habit-
ual optical correction.
Reading speed7 , 8 (words per minute) was measured us-
ing the ReadAlyzer, an infrared eye movement recording
system mounted in goggles worn over the child’s habitual
VOL. 242 DICHOPTIC AND MONOCULAR VISUAL ACUITY IN AMBLYOPIA
optical correction. The child sat at a comfortable, habitual
reading distance (35-40 cm) and silently read paragraphs
of text that averaged 12 lines and 100 words per para-
graph. After practice with a grade level 1 paragraph, the
child was asked to read a grade-appropriate paragraph. Ten
yes/no comprehension questions followed. Recordings were
acceptable if comprehension was ≥80% and tracking relia-
bility was ≥70%.
Motor skills10 were assessed with the Manual Dexterity
and Aiming/Catching scales of the Movement Assessment
Battery for Children-2 (MABC-2), a standardized test used
to identify children with delay or impairment in motor de-
velopment.23 To compare a child’s motor proficiency with
published age-matched normative data,23 raw scores from
the MABC-2 were converted into standardized scale scores
for Manual Dexterity and Aiming/Catching.
• STATISTICAL ANALYSES: For statistical analyses, tests
scored as “unable” to pass even with the largest optotype
size (0.55 logMAR) were arbitrarily assigned a score of
0.60 logMAR. Dichoptic AE BCVA of amblyopic and non-
amblyopic children with strabismus or anisometropia were
compared to the results from monocular AE BCVA with
paired t tests. Associations between dichoptic AE BCVA
and binocular vision and visuomotor function were evalu-
ated with Spearman rank correlations.
RESULTS
Characteristics of the participants are summarized in
Table 1. Overall, 53% of participants were female, 73%
were of non-Hispanic White race/ethnicity, and the mean
(±SD) age was 9.6±1.7 years.
Dichoptic and monocular AE BCVA are shown in
Figure 1. Overall, 34 of 42 (81%) amblyopic children had
worse AE BCVA with dichoptic testing compared with
monocular testing, with 16 (38%) scoring 2 to 4 lines bet-
ter monocularly than dichoptically. The mean (±SD) dif-
ference between monocular and dichoptic AE BCVA was
0.15 ± 0.11 logMAR (t41 = 8.49, P < .0001).
Similar results were obtained when AE BCVA tested
monocularly with E-ETDRS or ATS-HOTV was compared
with dichoptic testing, with 39 of 42 (93%) amblyopic chil-
dren having better AE BCVA with monocular than dichop-
tic testing (Figure 2). The mean (±SD) difference between
monocular and dichoptic AE BCVA was 0.20±0.12 log-
MAR (t41 = 11.09, P < .0001). No significant difference
was found between AE BCVA measured by standard meth-
ods (ATS-HOTV or E-ETDRS on an EVA system) vs AE
BCVA measured on the Optec 2000 (–0.03 ± 0.10 log-
MAR: t41 = 1.94, P = .06).
In contrast to the amblyopic children, all of the 30 con-
trol children were able to pass the 0.2-logMAR optotype
level on both the dichoptic and monocular tests, that is, no
211
FIGURE 1. Dichoptic and monocular amblyopic eye best-
corrected visual acuity in amblyopic children with ani-
sometropia or strabismus. All testing used the Optec 2000 Vi-
sion Tester. The diagonal line illustrates perfect agreement.
FIGURE 2. Dichoptic and monocular amblyopic eye best-
corrected visual acuity in amblyopic children with ani-
sometropia or strabismus. Dichoptic testing used the Optec
2000 Vision Tester and standard monocular testing was com-
pleted using single surrounded optotypes on an LCD display.
The diagonal line illustrates perfect agreement.
difference in performance under the 2 conditions. Some-
what surprisingly, 17 (71%) of the children who had re-
covered normal vision with amblyopia treatment had better
AE BCVA with monocular testing compared with dichop-
tic testing, with 14 (58%) scoring 2 to 4 lines better monoc-
ularly than dichoptically (Figure 3). The mean (±SD) dif-
ference between monocular and dichoptic AE BCVA was
0.20±0.17 logMAR (t23 = 5.62, P < .0001).
212 AMERICAN JOURNAL OF OPHTHALMOLOGY
FIGURE 3. Dichoptic and monocular best-corrected visual
acuity of the formerly amblyopic eye in children who had re-
covered normal visual acuity with amblyopia treatment. The
diagonal line illustrates perfect agreement.
• BINOCULAR VISION: Dichoptic AE BCVA was moder-
ately correlated with stereoacuity (r = 0.52, 95% CI 0.26,
0.71; P = .0004) and the contrast balance index (r = 0.52,
95% CI 0.26, 0.71; P = .0004). Monocular AE BCVA was
only weakly correlated with stereoacuity (r = 0.35, 95%
CI 0.05, 0.59; P = .02) and the contrast balance index
(r = 0.38, 95% CI 0.09, 0.62; P = .02).
• MOTOR SKILLS: Dichoptic AE BCVA was strongly corre-
lated with performance on the aiming and catching tasks of
the MABC-2 (Table 2). We were unable to observe an as-
sociation between monocular AE BCVA and performance
of either set of motor skills tasks of the MABC-2. The dif-
ference between dichoptic and monocular AE BCVA was
moderately correlated with performance on the aiming and
catching tasks and weakly correlated with performance on
the Manual Dexterity tasks (Table 2).
• READING: The difference between dichoptic and
monocular AE BCVA was weakly correlated with reading
speed (Table 2). We were unable to observe an associa-
tion between binocular BCVA or monocular BCVA and
reading speed.
DISCUSSION
We found greater deficits in dichoptic AE BCVA than
when measured with monocular occlusion of the fellow eye.
The results in Figure 1 demonstrate that AE BCVA mea-
sured with dichoptic viewing could not be easily predicted
OCTOBER 2022

TABLE 2. Monocular and Dichoptic Visual Acuity, Motor
Skills, and Reading
r P 95% CI
Monocular AE VA
Manual dexterity 0.26 .15 –0.10, 0.55
Aiming and catching 0.35 .10 –0.53, 0.28
Reading speed 0.17 .41 –0.52, 0.23
Dichoptic AE VA
Manual dexterity 0.15 .41 –0.47, 0.21
Aiming and catching 0.65 .0 0 08 –0.84, –0.32
Reading speed –0.34 .09 –0.62, 0.05
Dichoptic/Monocular Difference
Manual dexterity –0.38 .03 –0.62, –0.06
Aiming and catching –0.48 <.0 0 01 –0.72, –0.14
Reading speed –0.38 .03 –0.65, –0.03
AE = amblyopic eye, VA = visual acuity.
Boldface indicates significance (P < .05).
from AE BCVA as typically measured with monocular oc-
clusion. Dichoptic AE BCVA was moderately correlated
with stereoacuity and the Contrast Balance Index of sup-
pression.
Taken together, these results suggest that the dichoptic
task better captured the binocular deficits present in am-
blyopia than standard visual acuity testing. Interocular sup-
pression may have interfered with the child’s ability to iden-
tify the set of optotypes presented to the amblyopic eye dur-
ing dichoptic testing but not during monocular testing. Un-
expectedly, the discrepancy between AE BCVA measured
dichoptically vs monocularly was also observed in a cohort
of children who had recovered normal visual acuity with
amblyopia treatment. Many children who recover normal
visual acuity with amblyopia treatment do not recover nor-
mal binocular vision.4 , 24 Persistent binocular dysfunction,
including interocular suppression, may underlie poorer di-
choptic than monocular AE BCVA.
Previous reports demonstrate that neither performance
of eye-hand coordination tasks nor reading speed are cor-
related with monocular AE BCVA.7 , 8 , 10 However, the re-
sults presented here suggest that AE BCVA measured with
monocular occlusion may not accurately represent its func-
tion during natural binocular viewing. In contrast to pre-
vious reports, we found that AE BCVA measured with di-
choptic viewing was associated with performance on eye-
hand coordination tasks and reading speed.
This result differs from previous reports that adults’ per-
formance of everyday tasks, including reading, was associ-
ated with the visual acuity of the better-seeing eye.5 All
of our participants had normal visual acuity in the better-
seeing eye (by eligibility criteria) and, thus, based on the
adult data would be expected to have normal reading speed
and motor skills.5 That is, although the influence of vi-
sual acuity on the performance of everyday tasks can be ac-
counted for by monocular acuity of the better-seeing eye in
adults,5 the slow reading speed and impaired eye-hand co-
ordination of children with amblyopia under normal binoc-
ular viewing conditions cannot.
Most school accommodations for vision disability apply
only to children with reduced visual acuity of the better-
seeing eye, a bar that neither the amblyopic child nor a
child who has recovered normal visual acuity with ambly-
opia treatment can meet (see, eg, definitions provided by
the US National Eye [https://www.nei.nih.gov/learn-
about- eye- health/outreach- campaigns- and- resources/eye-
health- data- and- statistics/all- vision- impairment- data- and-
statistics] and the US Centers for Disease Control and Pre-
vention [https://www.cdc.gov/visionhealth/risk/burden.
htm]).
As a result, children with amblyopia or a history of am-
blyopia treatment most often are not considered for ac-
commodations and modifications for their impaired eye-
hand coordination and slow reading speed. Motor skills
and reading speed are fundamental to cognitive develop-
ment and academic achievement, and poor performance
can affect the child’s self-perception.11 , 12 Simple accommo-
dations (eg, extra time) to help students with amblyopia or
a history of amblyopia with recovery of normal visual acuity
succeed in their daily school tasks, and improve their per-
formance on the timed, standardized tests that are critical
for promotion and admission.
Strengths of this study include inclusion of a large and
diverse group of amblyopic children, children who had re-
covered from amblyopia with treatment, and controls and
use of standardized, objective protocols and test materials
for assessment of visual acuity, binocular vision, and vi-
suomotor function. One limitation of this study was that
we only included children with ≤0.5 logMAR AE BCVA
(20/60 or better). This limitation was in place because the
Optec 2000 was not capable of presenting at least 4 letters
to each eye and 4 to both eyes for larger optotypes. It is pos-
sible that children with worse AE BCVA might not have
the same pattern of visual deficits or associations with vi-
suomotor task performance as the children included in this
study.
A second potential limitation of the study was that there
was no randomization of test order. All children completed
standard monocular visual acuity testing of each eye with
the ATS-HOTV or E-ETDRS protocol on the EVA system
first, dichoptic testing of the amblyopic or right eye with the
Optec 2000 and, lastly, monocular testing of the amblyopic
or right eye with the Optec 2000. The excellent agreement
between AE BCVA measured during the initial monocu-
lar test and during the final Optec 2000 test suggests that
there was little learning or fatigue effect on the measure-
ment of monocular acuity. Moreover, the finding that am-
blyopic children were able to pass additional lines during
monocular testing with the Optec 2000 that were not vis-
ible to them when viewed dichoptically is consistent with
a lack of an effect of prior dichoptic testing on monocular
acuity results.

VOL. 242 DICHOPTIC AND MONOCULAR VISUAL ACUITY IN AMBLYOPIA 213

Funding/Support: This project was supported by grants from the National Eye Institute: EY022313 (E.E.B., principal investigator [PI]) and EY028224
(K.R.K., PI). Financial Disclosures: The authors indicate no financial support or conflicts of interest. All authors attest that they meet the current ICMJE
criteria for authorship. Author Contributions: Conceptualization: E.E.B., K.R.K.; Methodology: E.E.B., R.M.J., K.R.K.; Formal analysis: E.E.B., K.R.K.;
Data curation: E.E.B., R.M.J., L.A.H., S.E.M., M.D.; Investigation: R.M.J., L.A.H., S.E.M., M.D.; Writing—original draft: E.E.B.; Writing—review and
editing: R.M.J., L.A.H., S.E.M., M.D., K.R.K.; Funding acquisition: E.E.B.
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