) .

t J
~ .
-
,,- .. ' _. -. .
,,:.:.;-. ::: . ' . ' ~ ' . ':' ..
LECTURE NOTES
. on
STRABISYUS
by
...
FREDERIC! W. BROC!
i
1
A.
l. ORGANlSMIC LAWS THAT PERTAIN Ta VISUAL TRAINING
The purpose of visual training is ta bring about a better adjustment
of the individual ta his natural surroundings.
Therefore, training conditions should be made ta
natural surroundings as nearly as possible.
. B. There is an organismic tendency toward full use of existing
abili ties.
Question:
Answer:
Question:
Answer:
What, then, causes visual concessions?
Concessions occur when there is a lack of demand for
all existing abilities.
If there is a natural tendency ta make use of aIl
existing abilities, why do we need visual training?
Visual training if it is properly applied, makes à
demand for all existing abilities.
c. There is a natural tendency toward cOmpletion of a conternplated act
and ta accomplish it with the least expenditure of energy.
We are usually determined ta complete a task once we have
started. In visual training of the child things go weIl until the
given task is completed, but once it has been attained repetition
is not interesting. Renshaw says that if we get five minutes of
actual training per hour spent, we do weIl.
D. It is the nature of the posture which the nature of the
responses.
The above statement means this: while the eyes are in a
strabismic posture, the individual thinks strabismically, but the
minute his eyes are in a normal posture he ceases ta think
strabismically and thinks the way we do. 'The shift from strabismic
ta normal posture brings about a complete change in his interpretation.
This means that when he looks at a smaIl target with bath eyes
directly, he cannat think strabismically; he must think the way we
do. However, the shift from strabismic ta normaï posture cannat
be accomplishedwithout a change from wanting ta look at a given
fixation abject with one eye only ta wanting ta look at it with
bath eyes simultaneously.
Binocular interpretation does not have ta be taught! We
donlt have ta break down anomalous retinal correspondence in
order to establish normal retinal correspondence. Our sole
purpose in visual training is to posture an individual adequately,
and when that has been accamplished the rest comes easy.
1
2
We need contraIs. We need ta know when we have normal
posture and when we do note No training instrument 1s worthy
of i ts nalLe if i t does permit us te differentiate betiVeen iVhat
1s normal and what i5 note And no orthoptist i5 worthy of the
name if he cannot differentiate between a substitute performance
and a true performance. This i8 not a simple problem. It i5
not easy ta determine when a child trains in a constructive
way and when it perforrns ta sati5fy "minimum requirements".
Ta differentiate between purposeful and "lackadaiSical" performances
takes adequate controls. Unless we have such contraIs we cannat
hope ta mainta1n a high level of response.
Binocular posture is the ability ta ma1ntain Buch relative
eye positions in anticipation of a certain visual task that both
eyes directly fixate a single abject of special regard: Binocular
posture means, eBsentially, "looking at a single fixation abject
ri th bath eyes, at the srune time. 1/
Not all individuals who are adjusted ta their natural
environment depend on binocular posture. There are two other
:forma of osture around which an individual ma success:full
organize his seeing: a postur.e 'with one eye only,
or monocular posture, (b) mallltalmng separate Unes of direct
gaze for each eye, or strabismic posture.
Maintaining monocular'posture, means that only one eye
fixates the abject of special attention. Tge eye that looks at
the abject of regard is the eye that is used for the cortical
interpretation of that objecte The other eye is not used for
that purpose. The other eye maybe looking in an entirely
di:f:ferent direction. This eye may have, at the moment, a
perceptual purpose or i t may note The question nov{ arises, is
it used for any other purpose? If it has no other purpose, i3
kept in "cold storagef! so to speak, we have monocular posture,
for what the other eye is doing at the moment is of no interest
to the organisme
Maintaining separate lines of di:ect gaze for each ere, or
strabismic posture. In the sense deflned here, it does not
include aIl strabismics but is lirràted to those who are ambiocular
in their visual behavior. The term "aJJbiocular" describes a
condition where both eyes are used for separate and distinct
purposes. That is, they attend to different functions at the
sallE time. We find this posture in "anomàlous projection" of
alterating strabismics.
My investigations into the nature: of ambiocular vision have definitely
proved that these strabisrrUcs Can look in two directions at once and
interpret the macular images of bath eyes simultaneously.
1
1
1
If you play the piano with one hand, it does not prevent you
from playing someother chord with the other. If you cannot
coordinate both hands in this way, you may concentrate your whole
attention on the one task of playing the same tune with both
hands. It takes more skill to play different measures with each
hand than to play the same tune wi th both hands. The forzœr
ability illustrates the ambiocular strabismic, while the second
exemplifies normal binocular vision, and playing the piano with
one hand corresponds ta uniocular posture.
You may wri te "cat" ri th the right hand "hile writing cat
mirror-fashion with the left hand. This is easier of accomplish-
rœnt than wri ting the word cat wi th both hands in a left to
right direction. The latter-requires an entirely different
posturing rnechanism for the left hand than for the right, while
the former may be done with a single posturing effort for bath
hands. This may serve as a simile ta show why binc>cular posturing
is cortically less difficul t and requires lêS-sÛEntal effort than
stI'abismic posturing. Monocular posturing is stillless of an .
accomplishment, which may be the reason it ls frequently found
in the mentally deficient. In my own investigations l have
, never encountered a strongly integrated ambiocular percept in
very young children or in individuals of low intelligence. AlI
evidence points to the fact that strabismic posture is much
harder ta learn than binocular posture and ,that its acquisition
denotes a high achievement level, visually speaking. For the
same reason, once this posturing ability has been attained, the
individual is not readily willing to give it up in exchange for
binocular posture, unless the latter heightens hisaccuracy of
s p ~ t i a l orientation for exceptionally demanding tasks with which
he is being confronted and which cannot be solved while
maintaining strabismic posture.
The term "s trabismic posture", as above defined, represent' s
the sort of visu::!l behavior which l have variously called
"anomalous projection" (of the most accomplished order) or
"ambiocular vision". It is often referred to in ophthalmological
li terature as "anomalous retinal correspondence", IIvicarious
fovea
ll
, - terms wffich are usually promiscuously given to
essentially ambiocular and uniocular alternating postures.
Tt used ta be IllY ïrnplicit belief that we had to "break
down" anomalous projection prior to making any attempt to "building
up" normal projection. This seems no longer justifiable
because, s trictly speaking, you cannot "break down" learned
concepts. Yeu rnay suppress thern by presenting the individual
with new and different demands "hich require new learning. If
such learning is directed toward our eventual goal, the
undesirable, (from our point of view) patterns, may gradually
be replaced bv the more desirable patterns and may eventually
disappear from consciousness because of disuse.
When a binocular posturing attempt is made by an individual
ha ring strabismc or uniocular posture, the response v,'ill be
3
of poor quaIi ty, but, since i twill be bas ed on .a binocular field
structure it will be capable of interpreting retinal disparity
in ter ms ~ f depth variables; i.e., i t will have stereoscopie
qualities, provided stereoscopie demands are made.
Since stereoscopie demands require binocular posture, sueh
demands may serve as a. Ifspecial task" in an attenpt te elleit
binocular posture with the strabismic.
E. Varying perceptual demands may bring ab ou t varying postural sets.
1. ~ ~ individual, who i3 capable of binoeular posture
l
mal at
certain times maintain uniocular posture, if the latter
involves less effort and the visuai task can still be
eompleted. '
This is one of the most important tenets in visual
training. It raises rather interesting questions. Why
should an individual maintain accurate binocular posture
when he can complete the task to his entire satisfaction
with a less effortful posture? There is no organismic
reason. It ia therefore essential, in an effort ta improve
or establish binocular posturing ability, to present the
individual with the kind of task which requires for success-
fuI cornpletion exact binocular posture. An individu al ~ h o
habitually maintains uniocular posture can see no reason
why he should make a greater effort at'obtaining visual
data. whichcan 'be gaineçl without such addedeffort. Such
effort l'fould simply be an "added burden", added energy
expenditure, and without organismic purpose.
An individual who uses binocular posture can bring
two pointers tip to tip. This an individual who depends
on uniocular or strabismic posture simplycannot do, because
the task is above his accomplishment level. It is
important to kno\'{ that pointers may be used to f oree an
indi vidual to rna.intain binocul ar pos ture.
l may point out here that the use of pointers, theway
they are applied in flpointer training'! in the stereoscope,
does not fulfill the above requirements. This i5 so be-
cause the indi vidual who is capable of rapid al ternation
of fixation can achieve more accuratelz by far, if he
main tains alternate fixation than if he attempts binocular
fixation while he performs this task.
It is common practice today to use stereoscopie
photographs for binocular fusion training which contain a
vertical white line in a certain area of the total field
for the one eye, and a horizontal line in ~ ~ e corresponding
area of the total field of the other eye. This may be
permissible with individuals who are known ta possess weIl
integrated binocular field structures. However, it is
2.
J
,
1
î
1
F.
Th, ,
l
~
i
i
~ ab:
f
il
j th
J
th
1
ho
si
bi
ar
of
br
ir
cc
01
"1
f
f
1
1
1
1
1
F.
1
readily dernonstrable that the individual who has a
strabismic posture can interpret these photographs to
the entire satisfaction of the technician by alternate
fixation and, by doing so, the patient himself will be
of the oninion that he sees both pictures as one,
a perfect cross. He arrives at his
pretation via two consecutive impressions by the simple
expedient of "temporal fusion", even as we achieve
temporal fusion of successi<lre pictures when t..'1ey are
presented to us by means of a motion picture apparatus.
In fact the Keystone "moving picture" slides for the
Telebinocular are based on the same phenomenon. Such
controls are patently inadequate for differentiating
between binocular and strabismic posture, yet they are
presently allIDst the only 'ones on which any reliance
i3 being placed in vision training.
2. An individual habitually maintaining strabismic posture
may, for certain heightened perceptual demands, use
binocular posture if the latter is necessary for the
successful corrpletion of the task. That is something
we have not known, but it is nevertheless true. If
a task is difficult, the individual has two possibilities -
ignore it or reach high enough ta achieve it. The
diff:i,culty, of course, is to know what is "re'achable" and
-W:hat is 'note It holds true in aH training that it is
harmful to work above the individual's achievement level.
The individual who possesses binocular post1lring ability has a
higher achievement potenti21 than if he were lacking in that
ability.
The individu.<11 'Nho knows ho\'!' to posture binocularly can
therefore be confronted \Yi th a more difficul t visual task than
the individual who does not know how so ta posture. Again,
how high ail. indi vidual can reach visually has diagnostic
significance.
We can separate the individual who can and will posture
binocularly (no matter for ho\'{ short a time) under specifically
arranged conditions from the individual who is totally incapable
of binocular posture.
Centered corneal reflexes of a light which has been
brought ta the "crossing point" of the v'Îsual axes do not necessarily
indicate that fusable targets can be brought inta "retinal
correspondence" by adjusting aIl instrument ta the existing angle
of strabisrnus (amblyoscope, synoptascope, etc.)
Even in a push-up test, where there seerns good indication of
"binocular fixation" over sorne range, i t is nat possible to tell
5
6
whether an accurate or an inacurrate posture is being mairttained.
A rnuch lI'.ore accurate way of telling is to observe the individual t s
a.YiIlity·to achieve at certain tasks. For instance, if he is
capa.ble" of the extremely accurate spatial orientation which 1s
necessary ta s,uccessfully complete the Pointer test, we are
assured that he is capable of accurate binocular posturing ability.
This also means that, while he maintains such accurate posture,
he is capable of interpreting wi th satisfactory stereosc'opic
accuracy. If he does not achieve, it mean8 simply that we have
not been able ta provide the sort of test conditions which will
make him reach for the highest visu al achievement of which he i3
capable.
It i8 legitimate to come to conclusions by inference. If an
individual is left in an empty room ri th a piece of clean white
paper and a pencil, and he afterwards shOl'ls a written page and a
used pencil, i t is permissible ta infer that the indi vidual wrote
what i8 on the page. It is also possible to deduce with which
hand he wro te i t, if his handedness i8 known and copies of his
hand writing are available. If he attempts ta WTite with the non-
dominant hand, this will be readily apparent from'the nature of
his characters, because i t would be almost impossible for him ta
simulate wi th his non-dominant hand wri ting done wi th his other
hand. You could infer· these facts only because you had something
to compare. We know, for instance, that writing ri th the dominant
hand is far better integrated, more ballistic, than any writing
that may be attempted with a hand entirely new ta the task. We
also know that this skill is not easily transperable from one
hand ta the other.
How weIl an individual ls postured for a task is indicated by
the ease, the fluidity, with which the task is completed.
Normal binocular vision rlepends on binocular posture. The
two terms are actually interchangeable. We cannot separate binocular
vision from binocular posture nor can we separate binocular posture
from binocular vision.
G. Binocular posture makes possible the appreciation of the different
viewpoints of the two eyes looking at objects from different stations.
(a) the difference in the proximal stimulations received by
the two eres becauc'"' __ of their separated position in the s1.,111-is
organismicall;T . 'lY'tei =reted as depth variables in stereoscopie
perception.
(b) Accurate s tereosco ic abili t deoends on (1) maintenaTJ.ce
01 accurate binocular posture; 2 an organismic desire to achieve;
U) the ability of bath eles ta see clearly.
H. The specifie purpose of an visual training is' to bring about an
adequate binocular posture rrhich, in turn, guarantees the greatest
adeguacy of the 'Visual responses of which the individual is capable.
7
THE MEANING OF RETINAL CORRESPONDENCE AND RETINAL RIVALRY IN VISUAL PERCEPTION
From a. diagnostic point of vievi i t is important that we know how to
interpret retinal rivalry. Retinal rivalry is dependent on the existence
of corresponding retinal areas. Before we can discuss retinal rivalry
adequately, we must know more about the meaning of retinal correspondence •
. l. RETIN.AL CORRESPONDENCE
We come back to the fundamental concept of retinally corresponding
areas in the two eyes. l am prepared to say that in all cases the two
foveas are such corresponding retinal areas. Once this concep t i s ~
clearly established we shall have no further trouble with any of the
visual training concepts which will,be considered here.
A. Corresponding retinal areas are invariably equidistant and on the
Saffie side of the two foveas. No other areas are acceptable as
retinally corresponding areas. There are no "secondarily"
corresponding retinal areas - which are not geometrically
corresponding - not even in strabismic posture or in the so called
anomalous conditions. The two foveas are always retinally
corresponding. Let us be clear on this one thing: there are no
possible exceptions to retinal correspondence, as above defined.
AlI responses which make i t appear as if there were anomalously
corresponding retinal areas are artefacts which have a different
explanation. If we de fi ne retinal correspondence as fovea to
fovea correspondence, Our thinking :.;; ~ o m e s specifie and wç may
lay out clear programs for visual training - programs which are
not possible if we accept the theory of anomalous retinal
correspondence. Acceptance of the concept of abnormal retinal
correspondence, provides a very real reason why strabismus, which
exhibits this supposed forro of seeing, cannot be cured.
Let us assume that an area ten degrees off the fovea of one
eye, has become corresponding with the fovea area of the other
eye in a binocular field percept. How can we possibly change
such a relationship? When an individual once has acquired this
relationship he has no incentive whatever to give it up,
especially if he can also have full stereoscopie perception.
(Duke-EIder)
True, there are many indiviàuals maintaining eye positions,
which are within ten degrees of parallellism. Such individuals
may have a very low grade peripheral stereo-awareness but they
invariably show strong macular suppression. Vmen the suppression
is lifted, fovea to fovea corresponrlence is always immediately
apparent. These conditions will be discussed in greater detail
under the heading of !!Retinal Slip!!"
The concept of fovea ta fovea relationship in all binocular
8
sensory fields is vital when we seek to determine adequacy of binocular
posture. In accepting the presence of a binocular sensory !leld we
must assume the existence of fovea to fovea correspondence. How
else 'could we measure? If we use the phoria test of the Keystone .
Visual Survey Series for infinity, the position of the arrow in
relation ta the numerals which are yisible to the other eye cannot
be interpreted in terms of retinal positions unless favea to fovea
correspondence exists. When the arrow appears to point at the
numeral 9, we must be able to assume that the two eyes are in
exactly parallel position. If we could not make this assumption,
the phoria test would lose all meaning, because we would have
no means of determining the shift in retinal correspondence
which would be "normal'! for the particular indiviàual' and for none
other. We should have no measuring stick.
But measurements are possible. Under normal conditions, when
the arrow points to numbër 8 or number 7, it is possible to state
in mathematical terms how many degrees the eyes are out of
alignment. This we can do because the centers of both foveas are
the points of referenct:J from which a1l these calculations can be
made. Phoria measurements can be made as accurately as we can
measure the distance between two cities on a map, pravidedwe
knaw the exact scale of that map and are assured that it has
been drawn correctly. If the map were drawn by approximation
instead of by triangulation, these measurements could not be
interpreted. In order to determine the distance between two
cities, we put the points of the calipers in the center of the
two city areas and always use these same points ta make
comparisan between different cities on this map. Without such
specifie points of reference there can be no accurate interpretation
of the map. We could not, for instance, measure the length of
a table, if one end if i t were hidden from view. The center of
each fovea represents, in like manner, the unchanging point of
reference in ocular measurements of all kinds. If only one
foveal center were available, nomeasurements could be made.
This is an important consideration in amblyopia. In amblyopia
the center of one fovea may be necrotic, i.e., incapable of
conducting nerve to the brain. In an amblyopic eye
the blind area is apt ta include and surround the center of
one fovea because of a central scotoma. This means that the
individual cannat fixate along the primary axis. However, it is
this axis, and this axis alone, that reaches the retinal point
which must serve as the locus from which measurements are ta be
made. As long as we have the fixation point of the other eye,
we can draw a circle around the blind area of the amblyopie eye.
This circle is visible to the patient while its center i8 note
If it is possibill ta align the two eyes in su ch a way that the
circle is phenomenally centered around the fixation target of the
good eye, the center of the circle can be used as the second
point to which to apply our measuring stick.
Even in an eye a central coloborna, in which case there
is a large visible destruction of retinal tissue, we can present
this eye with a large enough circular target (a ring) to surround
the entire coloboma. This ring may be centered around a spot
source of light, which is visible ta the fixating eye only (the
light falling into the blind area of the defective eye). The
relative alignment of the two eyes can now be accurately
determined. By this method it is possible ta plot the scotomatous
area of the affected eye, but only because the relationship
between retinal areas of the two eyes is always the same (while
abinocular perceptual field is maintained).
B. Retina1ly corres ondin areas cannot exist where there ls no
binocular perceptual field as above defined. We know that a
sirnultaneous percept is possible in certain forms of strabismus
where the two eyes are not in normal alignment. In this case
the two foveas are never in permanent relationship to each other,
as Verhoeff has so ably demonstrated. The centers of the respective.
foveas can therefore not be used as a measuring-stick for binary
visual perceptions.
Two films, taken with the Saille camera, from the sarne point,
can be laid on top of each other sa that like images are superimposed
and a single clear print can be made thru the two films. On the
other hand, even if the prints are shawn separately each can be
interpreted accurately and independently of the other.
C. Ambiocular (strabismic) perception seems to be dependent on the
retention of two cortically separate sensory fields, which
obviates the need for retinal correspondence.
Experiments show that in s trabismic pos ture the cortical
images produced by the right and the left eye are separately
considered and that their closure into a single unitary percept
is obtained by a prQcess of abstraction (a frontal lobe process).
The strabismic learn to accept the right and left images of a
single object as belonging to that object, just as we can learn
to accept by the sarne process a mirrored abject as being part
and parcel of the ~ e a l object. The. two images are never fused,
as l have shown in my investigations relative to strabismic
seeing. It can be demonstrated that in these cases a binocular
sensory field does not exist, but rather two separate sensory
fields, one for each eye. For this reason an anomalous
horopter is never formed.
D. Difference between binocular and ambiocular sensory fields.
A binocular sensory field may be compared with two films being
laid on top of each other for inspection. Wnen variations in
photographs of ~ ~ object .(because of the different locations from
which the pictures have been taken) are superlmposed they may' be
9
i'
!
10
interpreted stereoscopie ally. A_ 'j)iIlocularsensory field percept
is neither a right nar a left percept bùt differs materially
from both. On the other hand, an ambiocular field percept
constitutes a summation of right and left percepts. In the
total field of the strabismic a certain area is foveally
perceived by one eye and another area is foveally perceived by
the other eye, resulting in two weIl defined areas of clear
vision in the total percept. Each clear area is seen exactly
as-the corresponding eye sees it.
The presence of a binocular sensory field doss not necessarily
mean that we have a single spatial percept. A single spatial
percept is possible only when binocular posture is available.
Suppose that we make binocular posture impossible
by the elevation of one eye above the other by means of a base
down prisme The fixation object can no longer reach corresponding
retinal areas and it is seen double. This means that even
though the binocular field persists, accurate binocular posture
cannot be maintained. It is evident that vre Imlst differentiate
between lIusuable" and· "non-usuable" binocular fields. Elimination
(by suppression) of an unusable binocular field i8 diffièûlt,
and- sortEtimes impossible with individuals who have fully matured
before the eyes were thrown out of alignment. The use of prisms
is definitely indicated when a non-usable binocular field can
thereby be· made usable. In a non-us able binocular field the
spatial concept is distorted because of the very existence of a
binocular field and accurate spatial orientation becomes
dependent on the resurrption of adequate binocular posture. Vlhen
that is not possible, total occlusion of one eye will give
temporary relief.
Suppose a binocular amblyope with 20/200 vision in both
eyes. How can we know whether he has a binocular field percept
or'not? When we put a six degree prism base down over one eye,
it is of diagnostic significance whether or not this prism
produces diplopia. If diplopia results and the two images can
be vertically aligned by addition of horizontal prism, it
indicates that the amblyope hact a usable binocular field prior
to the introduction of the vertical prisme On the other hand
if no diplopia is produced, we must assume that a binocular
field does not existe Establishment of a binocular sensory
field is desirable because it will heighten the visual
achievement level of the individual.
F. horia measurements throu h h to 6
over one eye indicates the existence of a
satisfac tory binocular field. When the responses to these tests
are uncertain, the existence of strongly established binocular
visual pe'rcept can be doubted. When phoria rneasurements cannot
j
i
1
1
j
l
1
f
a
!
1
j
1
1
made through the above amounts of prisms, it is questionable
ther a binocular field exists at all. When you cannat make
. ia measurernents easily and speedily, watch out! Be sure
.. ou are dealing ri th rœasurements and not wi th approximations •
.. that vertical diplopia may also be produced by base
down prism (over one eye) with an individual who has a strabismic
posture. But it usually takes more than six degrees to
produce diplopia. The can bring. the double
above each other, after a fashlon, but he Wlll usually glve
you a definite clue that his has b:en arrived.at by
abstraction rather than from retlnéü posi tJ.on. A patl.ent of
this type will almost invariably say "1 think that the two
images are now ab ove each other", or that "one seems to be to
one side and the other to the other side." It usually takes
several degrees or base-out or base-in prism before he is
aware of a lateral shirt between these two images. The
responses are always uncertain and sometirnes qui te unpredictable.
The strabismic usually (but not always) refers the right retinal
image as being to the right of the left retinaI, image, whether
he is an esotrope or an exotrope. lVhen double images produced
by vertical prisms are reported ta be in close proximity,
we know that the patient projects according ta his learned
strabismic habits. It is, then, of no further significance
whether he reports the one ta the right or ta the left of the
other. No effort should be made ta align them by the use of
lateral prisms Q The same true when an exotrope reports
uncrossed diplopia. Such diplopia is evidence of s trabismic
posture and time spent on "aligning" the two images will simply
be was ted.
In an effort ta differentiate between strabismic projection
and normal projection it i8 never advisable ta use mOre than U
ta 6 prism diopters of vertical prism. If the test remains
negati ve with that alllount placed firs t base down and then base
up over the same eye, the existence of a binocular field
percept mustbedoubted under these test conditions. The
nature and extent ofa binocular field structure will have to
be determined by other me ans • It is a red signal! The
ques tion nOV{ arises: Are we dealing wi th suppression or
strabismic seeing?
To differentiate between an 8J:1biocular and a monocular
field percept, it is advisable to use a stronger vertical
prism (ten p.d.) to determine Ivhetheror not diplopia Ca.ll be
experienced. When a four p.d. vertical prism produces
diplopia, we may conclude that total suppression did not cause
the prior lack of diplonia. Vie are then justified in assuming
that ambiocular field percept, adapted to the strabismus,
exists on the that an arrbiocular field percept
pertains a percept adapted to the strabismus.
The more vertical prism that is needed to produce a
11
- 12
sense of dip1opia, in a the less adapted he may be
deemed to be.
2. RETINAL RIVALRY
A. When the proximal stimuli, which reach corresponding perceptual
areas of the two eyes, emanate from difÎerent objects in space,
they unfusable and under certain conditions may rival with
each other for recognition.
B.
The above holds true on1y under certain conditions.
Retinal rivalry is lacking when oneeye is suppressed. But it
is not always possible to suppress totally all the stimuli that
reach the cortex via one eye. If suppression does not occur,
retinal rivalry results. This Jœans a shift of dominancy from
one eye to the other, neither eye being able to gain prolonged
complete control. Washburn èlaims that all binocular vision
is based on retinal rivalry and that without it there cannot
be any binocular vision.
The rules governing retinal rivalry and suppression have
been discussed elsewhere.
In a binocular field structure two unfusable macular stimulations
create field stresses which are ?pt to interfere with the
adeguacy of spatial
The retention of two unfusable macular images is, as a role,
unacceptable ta the organism. IVhen a binocular field structure
i8 present, retention of fusable macular images is of primary
importance to the organism. (This does not hold true for
peripheral irnagery). If tvro fus able macular images are not
maintained, one of these iWBges must be totally suppressed.
(This condition will be discussed under "Retinal Slip"). Vie
must main tain fusable macular images ta be comfortable, provided
we maintain a binocular field structure. .
c. If an individual finds it i ossible ta maintain e e ositions
that make fusion possible binocular posture , he will make a
determined effort ta suppress all proximal stimuli which reach
the less dominant eye, thus eliminating the field stresses
which interfere w2th the adeguacy of spatial organization.
That oecurs l'rhen like images carmot be maintained on the
respective maculas. Spatial adequacy cannat be maintained unless
one image is eliminated.
One wav to solve this problem is ta char1ge 3..11 inadequate
posture ta ,,-' adequate one, thus p:,oviding the two macu·:ae with
fusab1e images. If this is physical1y impossible, a determined
effort may be made to throw the two eyes into greater disalignme,nt,
50 that the non-macular image of the fixation object becomes so
poorly defined (because of its peripheral location in the turned
eye) that it can be easily suppressed.
D. The organismic tendeney ls always toward elimination of retinal
rivalrYt if it interfers with the c1earness and quality of the
ma.cul ar image.
Retinal rivar1y (particularly.in the macular areas) 18
the most troublesome attribute in a binocular field percept IVhen
binocular posture is lacking. It is of primary importance that
an individu al main tains a clear and unencumbered view of the
fixation object. If the macular stimulations of the turned eye
can be ignored, i.e., prevented from reaching conscious aware-
ness, the clearness and quality of the macular image of the
fixating eye are thereby greatly enhanced. Uniocular suppression
is therefore always practiced first in the màcula.r area of the
turned eye. It may be gradually extended ta the paramacular
areas and eventually may invade the peripheral areas as weIl.
However, ·sueh suppression never materially affects the capacUy
of the suppressing eye ta see clearly in a uniocular percept,
i.e., when the normally fixating eye isoccluded. ~ u l a r
SURpression is a process of adaptation to a new visual rèquirement
andhas to be learned.
E. The strengthening of retinal ri valry by visual training is
contraindicated with individuals who are incapable of binocular
posture.
This is a new concept but follows logica1ly from what
we have considered before. This concept is, at present,
frequently violated in visual training.
When a strabismic patient is incapable of binocular
posturing IVe have no right to attempt ta establish retinal
rivalry. It would interfer with his spatial adequacy. The
proponents of this procedure elaim that by developing retinal
rivalry the patient may "s traighten", or if he does not, he
may then be operated upon with a better chance for a binocular
pattern of seeing after operation. This used ta be my own
attitude toward the strabismics. However, l have found that
the individual who shOl'rs no incentive, under any conditions,
to posture binocularly prior ta the acquisition of a
binocular field percept, very rarely shows any rr.ore desire
to straighten his eyes after a binocular field percept has
been forced upon him. It is these individuals who develop
the dread fusion aversion which is knovm as horror fusionalis.
13
14

1
,
Today l feel it much more advisable and certainly mach
easier, bath for the patient and for the technician, not ta
is assured tbat the
patient can (under certain test candi tian) posture binocularly.
Where this assurance is lacking, l find it advisable ta have
the eyes straightened by operation, prior to any attempt on
part to establish a binocular field percept, and then ta
develop the latter by slow degrees.
The usual approach to strabismus is the establishment of
binocular seeing, even if this had to be done wi th the eyes in
strabisme posture. A binocular field structure is forced
upon the individual by means of instruments which ean be
adjusted to.the existing angle of strabismus. This normal
binocular.responses are being elicited with the eyes in a
strabismic posture in the hope that, once fusion has been
attained, it can be used to reduce, by gradual steps, the
existing angle of squint.
This procedure is no longer acceptable ta me. Instead,
l limit the. training for binocular field percepts ta the
particular situations where l have found that a patient has
')hown a desire posture. By doing this, l find
the patient learns to associate binocular seeing with
binocular posture and, what is more important,· ta reserve
binocular seeing ta those visual tasks for which he is willing
ta posture binocularly. When he returns ta strabisme
posture, he also returns ta strabismic seeing. This i3 the
orthoptic procedure which l am following successfully today
and which l am advocating for adaption by others.
Today, we are very careful, not ta develop binocular
field awareness in situations where it is not usable. We
fear that projection of binocular field awareness into
consciousness under such circumstances may result in its
rejection in good and bad situations alike.
This new'rr.ethod is applicable in cases of paresis where
concomitancy of rotations is at least in the areas
controlled by the paretic muscle (s). It is possible to
teach an individual to maintain stereoscopie awareness in
those areas of his surroundings where he can posture
binocularly and to let him rnaintain uniocular or strabisme
posture (and unioeular or strabismie thinking) in those
areas where binocular posture is not possible. The tlYO
modes of visionean eo-exist.
It is quite all right to assume that if we ma.\.ce a
strabismie suffieiently uneowJortable visually, he will
straighten his eyes. Frequcntly that is so, provided only
that he keep the eyes straight. Unless we have definite
evidenee to that effeet, l'Te have no right to follow out the above
F.
When the patient resents the establishment of binocular
f'el
d
proce8ses (usually for good and valid reasons, which
may not be able to recognize), and we nevertheless insist
establishing them, a conflict arises. Such conflicts are
. lost by the doctor. Many patients, whcJ show ability
to maintain straight eyes, feel that it is easier to maintain
a slightly esotropic or exotropic position when looking at
distant objects, although they are perfectly willing to maintain
binocul ar vision for close range. l u8ed to spend an immense
amount of time in an effort to change this situation and
occasionally suécocded in getting the patient to maintain
adequate binocular posture at far (at least while he was in
mv office), only to discover, that after the patient had been
discharged for a year or sa, he usually came back with slightly
strabismic posture at far, but maintained comfortable vision
with constant binocular fixation at near. Further, sueh
patients usually showed abHi ty to maintain binocular posture
at far for occasional heightened perceptual needs, whenever
such needs arase.
We have learned by hard experience that it does not pay
to establish certain visual patterns contrary to organismic
desires. The organism must be considered first and foremost.
Frequently its -needs are not expressed in a desire for straight
eyes. If the patient could have them as easily as he can wear
a new suit of clotbes, there would be no problems in strabismus.
But even the best-lcoking suit will not be worn long, if it
i8 uncomfortable. No man in his right senses would prefer ta
wear full dress clothes the year around, but he is willing,
for the sake of appearance, to wear them on occasion. Many
strabismics, who find it more confortable not to maintain
binoaular posture, will maintain it on special occasions.
They are usually and happy, until we try ta
convince thern that they should no longer continue in that
state.
It is, therefore, always inportant to raise the questions;
fils it of sufficient consequence for the patient to undergo the
visual training which l propose for him; to spend the time and
money; or aL1 l doing this simply because l.am a perfectionist?"
Binocular luster may be considered a forill of retinal rivalry.
Binocular luster, which is an incomplete color mixture,
resul ts when two corresponcting functional areas are stimulated
by different, undifferentiated colors. Let us suppose that we
keep one eye closed while we gaze with the other eye at a blank
green wall. When a pocket flashlight is held against the
closed lid, so that its beam of light is direc tel3: t0"t8.-:"d the
15
16
anteriar pole of the cornea, an even reddish glow pervades
the entire eye. We now have two areas of indifferentiated
coler = green in the open eye, reddish in the closed eye.
In ambiocular (strabismic) vision the patient will state
that he sees a green color with one eye and a red color
with the other eye. This is so because there apparently
is no color mixture in ambiocular vision. When a binocular
field percept is present, the green wall is seen as if tro:ù
a red glass. The wall may at times appear quite red anq at
other times quite green. Its color is apt ta vary betW€en
those two extremes. Under the most stable conditions the
perceived mixture may be an even reddish-green.
The resultant color is not deterrnined by the known
laws covering calor mixture. If we could inspect the
phenomenal wall by means of a microscope we might find that
it consisted of miscrosopic areas, which would show either
all green or all red, as would a KodachroIœ film which had
been exposed ta a red and green indifferentiated field. It
would also be possible ta determine that the mosaic of red
. and green would be constantly changing, green areas turning
red and vice versa. This ls the phenomenon of bino(:Ular
luster. Its presence is an indication of a binocular sensory
field. It also means that the other attributes of' binocular
vlslon, stereoscopie perception and rivalry, are
available under suitabJe conditions.
G. Testing the color-mixing ability of an individual in the
binocular luster test is a useful means of differentiating
between binocul::.r, rronocular" d.ud arnbiocular fiel'; structuring.
The first shows an incorrplete celor mixture; the second the
erceived color of one e e onl . the third tl'ro ad' acent
sometimes slightly overlapping areas of unmixed colors,
splitting the total stimulated areas in half.
This method of is eminently usable. The
only reason it i8 not universally applied is that we know so
little about its meaning. It is essential that we spend much
more time and thought on this problem; it will pay good
dividends. "r believe that retinal rivalry is destined to
become one of the most important visual training means of the
future. We haven't even begun to use it intelligently. l am
happy to know that retinal rivalry rates are being investigated
in routine optornetric procedures.
Measuring the retinal rivalry rate of parallel lines
running in opposite directions for alternate eyes - whether by
color separation (BSM technique) or by polarization (Renshaw's
tecbnique) - is of great importance and will result in a better
understanding of visual functions, as saon as a sufficient
number of tests are available ta compile statistics. There is
no reason why ratinal rivalry should not serve as a means of
determining the quality of binocular seeing. Further than that,
depending on how the patient reports seeing the linss, it is possible
to state '!{hether the patient has binocu13.r, ambiocular or uniocular
vision at the tilTe the test is made. It is well worth while
ta deterrni:18 the r esponses under varying posturing demands. . By
this method i t is possible to deterrIIÎ.ne the most desirable
objective visual conditions for binocular posture, l'rhere the latter
i5 not a constant factor in vision. It is for this reason that
in our own testing techniques reti:1al ri valry tests are a MUST
17
18
III. TI:1E MEANING OF "REALITY" IN VISUAL PERCEPTION
One rrust humanJJehavior into consideration when he deals with
people. It is ;:rLilly -inp-ôrta.'1t to listen to people and to try ta
inter!Jret wnàt they tell you. The reason is that what they tell you
èxpresses much more accurately what they.perceive than can be determined
by any objective test. After all, what they tell you is a summation of
what they perceive, even though it may be far from accurately reflecting
the proximal stimulations. AlI proximal stimulations which impinge
upon the eye go through a very rigorous sifting process. Sueh stimulation
are gross and disjointed and have to be shaped into soœething that i8
coherent and, ab ove all, something that makes sense. The product will
not be acceptable to the organism untilit does make sense. If I
observe something that is not reasonable, l do not want to admit it,
I am reluctant to admit that l saw something outside of rny common
experience. If l see a red bear in the park, even through l know that
there is no such animal, l shall be very hesitant in telling you what
l "thought" l saw, for fear that you might consider rœ an unreliable
ovserver. Sa l look twice and attempt to get a different view of the
peculiarly colored animal before l commit myself ta adrnitting seeing
the red bear. This means that only those things which are written
prior experience make up the reality of our visual percepts.
A. 1hings are not real because of their stability (or sirrplicity); they
are because of their realness.
This statement is apt to upset our present ideas regarding visual
functions. The human brain craves knovrledge, yet our thinking capaci ty
seems il1adequate to cornprehend corrplicated phenomena unless we break
them down into smaller 3ub-wholes. Ne cannot, i t appears, understand
a complex mechanism or organisrn unless we break it down in to its
various components and study each one separately. This analyzing
process has been considered hitherto the only acceptable scientific
procedure.
The breaking-down process seems to be admirably suited to
"simplify" our original problems. For instance, in the investigation
of matter scientists first dealt with macroscopic, then microscopie
particles which eventually were reduced to molecules, atoms and electrons.
There is but one difficulty with this proce33 - its i3 not reversible.
After we have all the pieces in greatest minutiae, we can no longer
relate them to the original problem at hand. This truism starts even now
to pervade all sciences, even medicine. The upswing of psycho-somatic
medicine provides illustration.
The holistic approach accepts as a fundamen tal tenet that the
w-hole is greater than the sum of i ts parts. A watch that keeps accurate
time differs greatly from a box filled with aIl the parts of a sirrQlar
watch. The accurate movement is not con tained in the wheels per se
but i3 the outcome of much For the sarre reason, a live human
being is an entirely different thing than a cadaver on the dissection
B.

lin
ow
e
table. True, it is a great deal easier to study the histological
features, the nerve paths, the individual cells, than it is to
analyse the behavior characteristics and the thoughts of the
live person.
Because of our limitations, as far as thinking power is
concerned, we are given ta The simpler a thing
is the better can we understand it, but the less it conforrn to
rei1ity. The use of atropin in eye examination is an example.
findings are the sole justification for its use.
Madigan, in an excellent paper, has recently shawn that the use of
atropin is of questionable benefit in static retinoscopy. However
the inhibition of accommodation rnakes it a great deal easier for
the physician ta "scope". It is this consideration, rather than
any other, which prevents this inadequate technique from becoming
extinct.
The reality of what we see does not depend on the complexity
of what we see. This is tremendously important. When we see
something farniliar, no matter how complex, i t 1s more rell to us
than a very simple but ambiguous forme We are capable of perceiving
a very complex, known, abject more rapidly than a simple nonsensical
outline. We can reproduce the former ID.1ch more accurately on paper
than we can reproduce the latter "simple" figure of unfamiliar .
shape.
B. Stereos co ic erce tion is more fundamental and more real than
"fIat" ,two-dimensional erce tion because the normal visual
surroundings are plastic or three-dimensional •
La\YS pertaining ta sensory perceptions are apt to apply ta
all sense organs. It is, therefore, weIl ta study the la\vs
pertaining ta sense other than vision and ta try ta
apply them ta the visual sense.
Inasmuch as our spatial surroundings form the medium which
serves as our milieu from birth, it is not reasonable that the three
dimensional quality of these surrounds should long escape the
organisme Why, then, should "fIat" seeing, or the seeing in a
single plane, precede the three-dimensional percept? Is it not
possible that we came to this belief because it appears ta
simplify our problems in understanding vision? The very fact
that we compare the visual organs with the man-made camera is
indicative that we try to reduce the imnensely complex neural
and cortical processes of seeing to the stat
1
1s of sonething which
i3 within our understanding.
Consider that the one-Gyed individual is capable of orientatinES
himself in a three-dimensional world. Such 2.:1 individu al v:oclj be
ver-y much aITIazed if you should tell him that hc''ô.c' ê'lastic
seeing. Koehler has shown that variable depth is :;':ll-:rent in
19
1
1:
1
·1,
20
certain uniocular sensory visual fields which have been exposed
to certain specifie figures. Many "fIat 11 figures, such as the
reversible staircase, geometric drawings of cubes, octagons,
etc., are pereeivedas three dimensional real objects even though
they are actually two dimensional projections. It seems
unreasonable to assume that perspective seeing ID.lst evolve from
flat seeing. Certainly, a great deal of experimental evidenee
seem3 to contradict such an assumption.
l like te illustrate later (under heading D) the
improb ab il it y of stereoscopie seeing being essentially a learn-ed
process - thru First, (Simultaneous perception) then Second
and finally Third Degree (stereoscopie) fus ion - by quoting the •
case of a small child who has been under IDlf observation since
infancy. The child has· been severely cross-eyed sinee birth and
never knew the rneaning of binocular posture prior ta a strabismus
operation.
C. Objective visual training situations should be based on reality
rather than on siIDElieity of design.
Provided the assumption, that stereoscopie V1Slon is more
fundalœntal than tlflat" VlSl.On, is true, how can we jus tif Y our
present visual training methods in regard to .strabismus?
Any training instrument that violates the reality of
perception violates a fundamental organismic principle and makes
it harder for the patient ta interpret through it. It is
important ta have instruments that reproduce reality as nearly as
pOssible in arder to make i t easy for the individual to interpret
the objective situation. If it is the intention to make it
difficult for an individual to interpret test conditions, the
above rule may be violated. But the testing and training must
be limi ted ta those individuals ..mose achievement level of
interpreting binocular phenomena is high. But if the training
setup is to create a situation that is simple and understandable,
i t must present s orrething which is real, in other words, something
which is wi thin the prior experience of the individual. This is
especia11y true when dealing with children. If it is possible,
through certain instrumentation, ta re-constitute sorrething which
the child knows, we are apt to get the response that we are seeking.
If we are to follow these principles it vall become necessary
to' alter our concept of what constitutes a suitable training
instrument. l'fe have given primacy ta training principles which
can no longer be adhered to in the light of the above discussion.
D. A new visual experience, when sufndentl y real, is apt to be
adequate at once; but it may gain added stabilit-r thru repetition.
According ta Goldstein, new vi su al experiences are not
------ ==----=-......................... -"""""B!_I_
..
arrived at by the slow and graduaI extension of prior experiencesj
rather, they appear suddenly as complete entities •

Here is the story of a small child which has been under mv
observation ever since she was barn. The child had a severe internal
strabismus from birth and consequently never had a chance ta acquire
binocular vision. One or the other eye was always turned so far in
ta the corner that you could hardly see it. At the age of about four
she started ta alternate fixation. This, in rny estimation, was a
critical period in the child's visual behavior because it might have
rueant the advent of ambiocular seeing, i.e., the emergence of the
turned eye from the suppression stage. The father was informed that,
should the child learn to interpret macularly from both eyes, it
would seriously interfere with a future binocular pattern of seeing,
were the eyes ta be straightened. The father agreed ta let the child
wear plana lenses with opaque nasal sections. About a third of each
Iesn was frosted, (AIs a see Chapter X, half ocluders) so that when
the child looked straight ahead wi th the right eye, the frosted
section of the left lens intercepted the direct line of gaze of the
(turned) left eye. Conversely, if she wanted ta look straight ahead
with her left eye she could do so with the result that the direct line
of gaze of the (turned) right eye was intercepted by the shield.
It may be argued that we did not by tbis means prevent the
formation of an retinal correspondence, because the contra-
ocular image of the fixated object was not erased. This objection is
valid only if it can be proved that anomalous retinal correspondence
can forme AlI experimental evidence argues asainst such an assumption.
Therefore, we did not worry about the secondaD
T
retinal image,of the
fixation abject, foroed on a widely peripheral retinal area of the
turned eye. Vie were concerned that macular images of tl'TO widely
separated abjects should not form, because the chiId, in aIl probability,
would le -'1't"n even tually t 0 interpret them c orrec tly in space, 1. e. ,
Iearn ta see ambiocularly.
The child wore the occluders until the parents were ready to
have the child operated on. No visual training was given before the
operation because we could elicit no binocular fixation attempt at
any range. The operation was successfully completed when the child
was seven years old. Two days after the bandages had been removed
the child came to IllY office. Her visual acuit-v was 2n;20 with either
eye and the eyes were cosmetically straight. She did not fixate
binocularly when an abject was brought to within arm's reach; rather,
the eyes retained parallelism (Iack of convergence). Because the
eyes were straight in distant gaze, an attempt was made at this first
visit to elicit a binocular visual response on a distant projection
screen (at 16 ft.). We reasoned that the attemot at elicitina a
• 0
binocular percept should be made because the ehilcl coulcl not have
Iearned a strabisme posture (looking with both eyes in two different
directions at once) but had alwavs dependecl on a uniocular posture
prior to operation.
Tests for retinal rivalry made on the cl istant screen stowed an
21
22
alternate percept, first one eye maintaining full control of the
screen and then the other. Very soon, however, indications of the
formation of a binocular sensory field were apparent and when the
Brock Ring Test (BSM 1, 2, 3) was made there was but a very short
period of "sideways motion" before the child exc1aimed that the ring
seemed to come toward her and to move back thru the screen.
Appropriate size changes were also perceived.
Immediate1y after the stereoscopie percept became evident, the
screen was filled with a cornplex stereoscopie scene, showing â water
buffalo partially immersed in water (BSM 16, 19). This scene was
selected because the child lives near a lake and is qui te familiar
ri th cows. The scene was the nearest approach to her habi tu al
surrounds that was available.
She looked at the screen for a little while and then al1 of a
sudden exclaimed - rrsay, daddy, that cow is reaU" This could only
mean that she had reconsti tuted a real cow thru stereoscopie ,clues
and that at first, she had seen it only as a picture on the screen.
If this were not so, the sudden exclamation of surprise and joy could
not be explained. That she saw the cow stereoscopically was
definitely proved by giving her a flash-light projector which threw a
baloon-shaped white onto the screen. This baloon, she p1aced
selectively on the particular objects in the three-dimensional
.fIe!'d'whîch happened to be in the sarne plane wi th the screene Inasmuch
as the BSM technique permitted me to move any given object into the
said plane, there was no possibility of her "guessing". This meant
,that she had accurate stereoscopie ability within half an hour after
she had "learned" binocular seeing.
Was i.t learned? How could she Iearn i t? And how did she know
what stereoscopie seeing rneant? Because that was what se'eing a !lreal"
cow Iœant to her. Why didn't she see rrflat?rr She had never had
binocular vision before. Since she recognized the stereoscopie
pic'ture of the cow as a rrreal
rr
cow, she IIDst have had an appreciation
of this reality prior ta the time that her percept was born.
The only new feature which was added to what she had already
experienced (in uniocular seeing throughout), was the opportunity to
reconstitute reality solely through stereoscopie clues.
It is about time that we abandoned the concept that one-eyed
seeing differs in any major particular from binocular seeing. AlI
that is added in binocular vis ion is apparently a finer depth
discrimination, and that primarily at close range. It is t rue that
,only through appreciation of retinal disparity can we reconstitute
'reality by means of stereoscopes or stereoscopie projection. That
is why the BSM equipment is sa valu able as a differentiating agent
between binocular, uniocular and strabismic seeing.
E. Reality of perception is only possible in adjusted behavior ..
lch
"
Renshaw says ttat nothing can happen unless the organism is
set to let it happen. This is a fundamental concept.
A persan who does not know what ta expect, or who is disturbed,
15 not in a position to give a clear account of what occurs. This
holds true in 311 phases of human behavior. Our psychopathie wards
are filled today with individuals of this type.
A very important factor in visual traininLis the setting up of
training situations which tend ta create stable visual conditions
aver as much af the total pereeptual field as possible.
The peripher31 portions of the visual field contribute largely
ta the maintenance of fusion in binocular vision (Halstead) and it
seems therefore unreasonable ta exclude sa large a section of the
peripheral binocular field in our training instruments.
One of the possible reason5 why narrow fields were designed
for visual training We felt that we could
simplify in two directions! (1) thât the sirnplest and least
'detailed forms were the easiest to fuse (2) we could reduce the
stimulated field area (and this was done in certain instances)
until only macular figures remained. Vllien such simplification has
been reached the objective visual situation has lost all semblance ta
reâlity and instead of being easy ta fuse, it has become difficult.
The "easy" way for the binocular processes ta function is in a
unified total field, something which has scarcely been trjed.
Our tendency in visual training should be to produce training
situations where larger and larger portions of the total binocular
field of an individual take part in the training. This will give
us a powerful means of staoilizing the macular functions. It is
these macular situations, which need our particular attention, because
they are the one which corne most readilyunder the inf1uence of the
patient's thought processes.
It should be noted that. mental attitudes frequently disrupt,
rather than enhance, the fusion processes. Peripheral responses
are much less influenced by undesirable attitudes on the part
of the patient.
The ract that uniocular ur alternate macular suppression is
the rnost common visual dysfunction would indicate that it is the
least difficult anomaly to achieve. We can hardly question that
suppression of this type is a learned process.
23
1
i!
J
I·... 1
il
li:!.1
h
2h
IV. SINGLE AWARENESS IN BINOCULAR VISION
Suppression is a normal phenomenon in all organismic behavior.
A. Suppression is not only a normal, but a necessary, function in binocular
vision, because all objects in three-dimensional space can not be on
corresponding fusional areas of the two eyes while binocular posture is
main tained.
There is no need ta speak of the significance of physiological
diplopia. The subject i8 adequately discussed in available literature.
We all know that if fixation is held at 30 ft. the horopter will form
there and that an object six feet from the observer will not be on
corresponding retinal areas. In order ta obtain fusion of this near-
er object fjxation would have to be altered sa that the two eyes would
converge at six feet. if the horopter is held at thirty
f'eet and an object is locatedsomewhere in the binocular field but not
in direct line og gaze, diplopia i8, as a rule, not experienced.
Diplopia i8 m08t likely to occur when the non-fixated object lies within
the triangle formed by the two visual axes and the interpupillary
distançe. In this position the non-fixated nearer object is brought
bnnon-fovealretinal areas equidistant and on opposite sides of the
respective foveas. Both images are then close enough to the foveas
to be qui te clearly intèrpreted. Because they are not fusable, a
sense of doubling readily obtains, provided attention is drawn to it.
Placing a pencil ten inches in front of the nose, while looking at a
distant abject straight ahead, i8 in fact a preferred method of teach-
ing an individual the awareness of physiological diplopia. If the
pencil is shifted a few inches ta the right or ta the left, the feeling
of "double" becorres le8s and less evident and saon ceases altogether.
x
Let X in the above represent the distant fixation abject and
Pl the location of the pencil where it is sean double most easily. It
is apparent that the retinal points Pl are equidistant an opposite sides
. B.
:ular
: ls
re.
m
t.hin
of the two maculae (M); When the pancil is intermediate ta the two
fixation axes, as when it occupies position Pl, both retinal images
are equally distinct and the organism is hard pressed ta decide which
of the two to suppress, if they both obtrude themselves to consciousness.
If the pencil i8 now rnoved ta a second position P2 ta the right of the
fixation axis of the right eye, the retinal points P2 are no longer
equistant from the respective maculas so that the image of the pencil
in P2 position is therefore easily suppressed, for the sake of single
vision.
It is likely that in normal occupations and in normal surroundings
anear object i3 more readily seen double when fixation is held at a
farther object located in the same general direction, than when the
reverse situation pertains, i.e., when a nearobject is fixated and
an object farther away obtrudes itself to consciousness.
When an individual has been made conscious of physiological
diplopia along the above lines, how doss this affect his spatial
adequacy at the time when he sees double? Suppose, he lights a
cigarette, while keeping his gaze at sorne farther distance, and that
he now sees two cigarettes. Will that·pose a question as to where to
hold the match? It seems reasonable that he would make a fusion
attempt before proceeding with the lighting of the cigarette. This
would !Dean that to light his cigarette, he would have to malee an
abstraction, i.e., he would have to think about how to do it, where
before he did it without giving it any thought. Could we say, then,
we has improved his spatial awareness? l believe the answer is, No.
; B. Fusion i8 not an essential fé1Ctor in "single" awareness of peripheral
ng abjects.
In normal binocular vlslon
J
as we have seen, the abjects which
do not have their images on retinally corresponding areas are still
perceived singly. Is such an abject seen in the direction where one
eye sees it and is it totally suppres3ed in the direction where the
other eye sees it? In other words, is the direction of such an abject
determined by a certain projection axis of one eye as if the other
eye had been totally occluded? The answer is, Na. The effective
projection axis i8 apt ta lie in a somewhat intermediate position
bétween the right and left projection axes. This mearrs that the lacality
of such a'1 object i8 still binocularly determined even though fusion
does not occur; Single awareness is then due ta a closure by a process
of abstraction.
, The above sort of closure without benefi t of fusion cm only
so long as the individual is not aware of diplopia. Diplopia forms an
lillperfect closure, even if the individual accepts the two images as
belonging to a single object in space. Even the consciousness of
d bl' .
ou lng does not necessarily prevent knowledge of the singleness of
It is important to rernember that this type of closure,
e lt elther complete or imperfect, is gained by and is,
25
,j!
l
'.'· '
!l'
il!
il
ii
il
i
'1
i'
!I
!i
'1
L
'i·
! '
"
; t
26
therefore, a frontal or pre-frontal lobe process. From the "adequacy"
point of view a total closure ls of course preferable to an incomplete
closure, yet we have been inclined to train individuals for incomplete
closure where we formerly had a complete closure.
-------- ~
-- -...........
,- -- '-......-
\ .-,' --- ----tJ. B
The above figure will illustrate the foregoing. If bath eyes
are fixating abject A at sorne distant point and a pencil P then is
aligned with a peripheral object B, it is placed in position as shown
in the figure. The position of the pencil does not agree with either
of the secondary fixation axes (broken lines) and projection occurs
from an intermediate point between the two eyes. When diplopia occurs,
the two pencils are sepn in positions indicated by the broken circles.
There is an organisrnic tendency to place the two phenomenal pencila
equidistant on either side of the abject with which the pencil is ta
be aligned. Only when one eye suppresses, 50 that the cortical image
is no longer of any use to the organism, will the pencil be placed in
direct line with the secondary axis of the other eye which reaches the
objecte In the latter case the object is less accurately localized;
in the former, better. When the pencil is seen singly, without benefit
of fusion, it is assumed that fusion attraction is still a factor in
bringing about the desired effect of thetwo retinal images forming a
single perceptual unit. It can be experimentally shown that, if
diplopia ls elicited, the two pencils appear much closer together t h ~ î
they should be, as deterrnined by their relative retinal positions.
It is assumed that fusion attraction furnlshes the necessary binocular
cue as to whether diplopiais-crossed or uncrossed 1. e., whether the
object is nearer or beyond the fixation plane.
A a..ridi tional experiment can be set up wi th the BSM slides No. l
and No. 2 (the red and the green ring) and the rabbit slide (BSM 20).
While fixation is held at the rabbit, the rings can be gradually
displaced sa that eventually fusion of rabbit and phenomenal ring can
no longer be maintained simultaneously. If fusion of the rabbit is
rnaintained, fusion of the rings i5 eventually broken. This is evident
when the color of the perceived ring changes from a mixed reddish-green
c.
cy"
ete
ete
t
c.
col
or
to green or red, or when two interlocking rings are seen, one
being green and the other red. It ispossible, to interpret partia1ly
interlocking rings, both perceived in crossed disparity, as beingdoser
, ta the observer than the rabbit on the screen. the. two rings
rlilappear mJre closely inte.rlocked when the color fil ters are worn tharJ.
'. when they are taken off. This indicates that a fusion attraction occured
wFdch ,even though incoDlJlete, was interpreted as depth variant between
rabbit and the two rings. On the other hand, if the phenomenally
perceived displacelIl€nt bet'l'leen the twa rings equals that of the actuaJ.
on the screen, bath rings are seen to lie in the
plane with the rabbit. It may be said, then, that fusion attraction)
even thou h it does not suffice for co lete closure (seeing an object
singly must be interpreted as depth variable. It is important that
we keep this in mind because it permits us to gross stereopercepts
.when the two eyes are not adequately postured for stereo-aceuracy. Many
strabismics, when we first see them, are capable of posturing accurately
enough for gross stereopsis. This becomes of importance in training.
Fusion attraction can only occur within certain limits of ratinaI
disparity.
It may be asked, "If closure i8 possible, where there can be no
fusion inthe strict sense of the term, why does this principle not hold
tr'Ue all the way ta strabismie dispari ty?1I
As previously reported, it has became apparent from aetual
observations that during incomplete fusion the depth variation between
the objects in question is measurably less than if fusion efforts were
lacking. These same experiments have shown, however, that if the ring
dispari ty becomes too grea t, both rings (as percei ved) suddenly "drop
back" to the plane of the screen and are then interpreted as a pair of
interlocking rings in a "fIat" percept.
Dr. Verhoeff told me sorne yearS ago that he learned through
practice to prevent fusion of stereograms ta such an extent that all
figures which are not exaetly alike (i.e., having stereoscopie qualities)
are seen double and fIat rather than single and three-dimensional. It
has been nv experience that many individu aIs are capable (and willing)
to inhibit stereoscopie fusion (prevent fusion attraction) and sorne, in
fact, will keep their eyes sufficiently off alignment ta prevent fusion
at all cost.
The above phenomenon is frequently eneountered with adul ts who
are subjected ta the Broek Ring test on a dis tant screer" Sa::... of i:-hem
Will not, at first, let the phenomenal ring come off the screen. They
prefer to see two rings in interloeked position. H:;wever, once this
inhibition is broken they rarely are capable of preventing stereo-
fUSlon in subsequent trials, unless they are psychopathie.
bb' In the Brock ring experirnents binocular fi' at:' or .; "': "t L l1e
ra lt, in other wards, the rabbi t is maintai ned as a,ir.gle fuseè object
27
in the center of the total binocular field. Within certain small
limits of disparity the rings may then be appreciated as fused and
being nearer or beyond the central target (the rabbit). If the ,
disparity i5 widened, there may be awareness of double-rings capable
of stimulatlng the fusi,on sense to such an exten t that they also are
seen either nearer or beyond the rabbit. This means that the
disparl ty is then beyond fusi on ab il it y but within fusion-attraction.
Finally, the rings may be brought te such widely disparate positions
that they are seen as interlocking rinEs in the plane of the rabbit.
Fusion attraction has then been In all three cases there is
one Comnlon factor: The central target is being maintained within
fusable limits. Anothp-r possibility may be encountered: An
individual may elect to r8tain the ring (s) fusable limits of
retinal dispari ty and let the rabbi t "double" when the dispari ty
between the two perceptual objects (ring and rabbit) becones too
great. In all instances, however, one of the two perceptual objects
i8 rnaintained on sufficiently .corresponcling retinal areas to rnake
fusion possible. This is not the case in strabisrnus where fixation
is maintained by one cye onlv. Here one end of the measuring stick
15 lacking indetermining dispari ty in terms of depth variable.
D. It 15 the to sUEpress diplopia in normal surroundings that
leads ta the most serious visual difficulties.
E.
That is something which needs to be remembered in strabismus
training. l am glad to have found a means of helping the strabismic
obtain binacular posture without having to teach him to see double
the,process. l reminded of this time anc again by patients whom
tauRht ta see double befarethey knew the true meaning of fusion.
patients found it very diffieult ta lose the sense of seeing
eVen though their remained straight. l know of a few who
or eight years of binocular seein::r still complain of
on small fixation abjects, although they show good peripheral
l-central fusion. These cases were as instances of
.. , r ru '
was th) Slonalis. It has been my belief for a long time that it
Toèa .. "':t candi tian which preven tedsuccessful completion of the cure.
l inclined to believe that it could have been prevented, had
strabistQ hen What l know now. The fact is that since l have trained
fusion attemptin; ta establish diplopia at the outset,
belie'le th has not been a serious problem. For this reason l
seein;;:" in \h training which tend. to produce "double.
unso-.:6ct. surroundlngs· of the patlent are to be consldered
t'"\ ....... a'
., - • -
nos !})'sSions are almost due to lack of adeouate binocular
a; "='1 ___ --:-__ -:-___ -:-: ______
" Qsually disappear nhen adequate binocular posture has
train in must be directed toward strengthenin
c'.(
;.s 3'" re.
"tll)
IJ
t-trJal visual acui ty may be caused by lack of direct
:n
'ed
fixation ability of the affected eye, the establishment of binocular
posture must bring about a better ability to fixate directly with
the subnormal eye and, bring about a heightening of visual
acuity. When a central scotoma is not the cause of low visual acuity,
such training always produces increased acuity of that eye.
F. Macular suppression does not create amblyopia-ex-anopsia.
It has frequently been assumed that if an eye is suppressed it
loses its ability to see clearly. This assumption appears no longer
to be true. Such an eye simply takes on other functlons which are
adaptations to the particular visual set. The retinal fibres never
ceaae being stimulated by the light impulses that reach it; proximal
stimuli will invariably reach the brain. In otherwords, the afferent
nerve paths remain open and active. How, then ean the perceptual
faculties of the amblyopie eye deteriorate? This question has to be
answered before we can intelligently eonsider the nature of amblyopia-
exanopsia. The only possible answer is that these undesirable impulses
are bloeked in the"brain in sueh a way that they eannot reach the level
of conscious awareness, and that this blocking may eventually result
in permanent inability to see clearly with the affected eye.
In uniocular amblyopia, where the amblyopie eye is not notieably
out of alignment, almost noriÏal peripheral awareness can freqently be
demonstrated to exist, but maeular awareness seems to be definitely
lacking. In sorne of the eyes where visual aeuity is below 6/200,
foveal stimulation of the affected eye, by a strong point source of
light, only produces the sensation of a "glow", the patient not being
aware of the light itself unless it is thrown on off-foveal retinal
areas of the eye. It can also be shown that when the lip,ht is not
seen directly, the pupillary reflex constriction to light stimulation
is also lacking, showing that the foveal retinal stimulation i5 being
blocked prior to the geniculate body, i.e., before it reaches the
cerebral cortex. In these instances the blocking is not on a cortical
level but i8 due to a lack of transrnissibility of these stimulations
from the fovea to the geniculate body. If the blocking occured in the
cortex, the pupillary reflex arc would be intact. This information has
been obtained through experimental evidence and should be indicative
that the anblyopia is due to destruction of foveal fibres rather than
to non-use.

29
: '
"
.'
30
v. RETINAL SLIP - A VISUAL CONCESSION
A. Art binocular posture results in retinal slip.
When binocular visual functions can be shown to exist while one
eye fixates a small fixation object,directly but the other eye is
slightly off corresponding position, then that eye has "slipped" away
from accurate binocular posture. This phenomenon is best described by
the term "retinal slip". It is a descriptive term, which may not be
any longer-in generaI use.
Peckham, many years ago, established experimentally that binocular
vision is not lost when the eyes are not accurately aligned on a single
object of regard. These findings gave the psychologists the basis for
their theory that retinal correspondence is not innately determined and
that it may vary considerably with different individuals and for
different visual demands. They have long since abandoned the concept of
point ta point relationship between the two eyes.
Du!ing retinal slip we may assume either that a new horopter,
which no longèr maintains correspondence between the centers of the two
Tovèae, has formed, or that the normal horopter is still present. In
the latter case it has been moved away from the plane of the fixation
abject, to a farther point in a slip toward convergence. The latter
assumption is more likely to be correct.
Personally, l have a variable condition of exophoria and retinal
slip toward exo. l often rnaintain a binocular pattern that is just
adequate ta maintain a peripheral binocular field structure but is no
longer capable of accurate stereo-perception, due ta a lack of macular
fusion. l have noticed when driving a car that suddenly l am aware of
two traffic lights (quite close if there is not any particular
need for keen visual discrimination. It is a simple matter to fuse
them, but this results in appreciable difference in the general appearance
of the landscape. It seems to me that l have this sensation of doubling
during "retinal slip" only because l have taught myself to be aware of
diplopia and because rqy eyes are aloost equally dominant. Most
individuals, who demonstrably have an exophoric slip, report that they
never see double. The fact that doubling occurs in my orrn case shows
that during phases of slip my,horopter lies considerably beyond
my gaze, (or normally behind the eyesJ,the eyes being in a somewhat
divergent position. The significant fact remains that l have never
seen the doubling of a cowl light of al1 oncoming car or of the tail
light of a car. must meal1 that accuracy of binocular posture
is maintaincod ;vI-: ;, . '.,r ne,::d for ;oncentrated attention arises. It
is also sigrnficÇ..nt ." '; a :<eyst.i1e Visual Survey test l show
at Cl. .::,.;1:1 Elodcrate esophoria at n8ar J and that rny
stereometrie accuracy is high. Only after prolonged total occ::'usion
of one eye does a'1 exophoria at far, which may reach considerable
proportions (beyol1d 10 prism diopters), become apparent.
While a retin.:i.l sllp prevails a high degreed stereoscopie acuity
B.
c
o
Vi
t
s
F
l
]
cannot be obtained. It is fortunate for my safety and for that of
,
other the road that l do not maintain a retinal slip
whenever visual demands require good binocular posture. As saon as
the eyes become alerted the retinal slip is irnmediately and in-
stinctively taken up.
Let us define ret:i,nal slip as a tropia position of very moderate
IIDSt not be collSused with conditions of excessive phorias
which may not be in evidence while binoeular posture is maintained.)
The essential difference between retinal slip and a tropia
. position is that in the former case the binocular pattern of seeing i3
përipherally maintaine<ii while in the latter case sueh a pattern is
lacking in all of the overlapping visual fields of the two eyes. The
one rnay be classed a tropia wi thin small limits of dis:gê-ri t:t while
tné other is usually atropîa-ûflarge dimensions"TâS" expressed in
prism diopters). Yetthe tropia is usually an extension of a prior
retinal slip. It is quite likely that, at least when the tropia
develops in later life, it is preeeded by a retinal slip. This holds
particularly true in exotropia at far, when a binocular pattern of
seeing is being rnaintained at near. Retinal slip may be considered
the stage between tropia and phoria cônd.:i.tions.
Retinal slip is possible only in uniocular suppression of the foveal
percept.
The extent of the suppression area depends on the arnount of the
retinal slip or vice versa. We may safely say that the suppression
area will include the foveal area of the suppressing eye and
will gradually extend into the periphery.
It used to be my belief that l eould not take up the retinal
slip unless awareneS8 of diplopia could first be produced. It has
become evident to me that this assurnption is not tenable. For one
reason, l frequently find IT\Yself seeing tIVO traffie lights for one
and the experience i5 not at all disturbing, in faet it is a rather
pleasant one. There seems ta be no organismie urge to pull the two
lights together. This observation agrees VQth that made by others
who show diplopia under experimental conditions. Secondly, it is
quite easy ta demonstrate that retinal slip is orten tmeen up by
patients who do not remember afterwards of having seen double prior
to the postural shift. Thirdly, the ease wi th which a maculai' image
can be suppressed has a direct bearing on vrhether or not retinal slip
oeeurs. This is in our setting up of objective training
si tua tians.
C. l%en suppression is lirni ted to foveal vision, 'a Gross stereoscopie
al'{areness is still in evidenee. That mearlS tnat stereoscopie
perception is not lost but orùy stereoscopie accuracy. For accurate
31
l'
i:
32
determination of depth variables the retinal slip has to be taken
up. The nature of the task, therefore, deterlllnes whether or not
accurate posture will be maintained.
The lack of understanding of these underlying principles has
been a source of a great deal of perplexity to many examining
practitioners. Frequently WB observe a high exotrope who, nevertheless,
shows adequate stereo-accuracy behind a stereoscope. Because, we may
not be able to observe the individual's eye positions, we fail to see
that for the special task which he cannat successfully perform with
the eyes in a tropia position, - he posture binocularly long enough to
perform it. By the time he looks out from behind the instrument be
again shows bis exotropia. It follows that, unless a desire can be
developed in this individual for maintenance of binocular posture
under less demanding conditions, his strabisll1Us cannot be "cured".
D. Periodic strabismus is an extension of retinal slip.
The only effective way to solve this problem, that l can see,
if to strengthen binocular posture in visual situations which correspond
withhis normal visual surrounds. It is for this reason that a
projection screen placed across the room is becoming so important in
Visual training. Pictures that recreate thru color separation or
polarization) visual situations similar ta the patient's normal
surrounds can be projected onto the screen. H ~ can then be taught to
posture binocularly instead of uniocularly in situations which are
transferrable to his normal surrounds. Until we train in normal
sUIToundings, we S,hall find that the periodic squinter may walk in
with one eye in a tropia position and th en proceed to main tain
binocular posture in all our training instruments. This will be true
regardless of his ability ta maintain fusion through lateral prism
which forces him ta over-converge. Duction exercises are, definitely,
not the answer in such cases.
The periodic strabismic chooses to have binocular'vision
whenever he wants it, but frequently, for bis own reasons, chooses
not to have it. That is why you dare not leave it up to an
individual's judgment whether or not he wants to keep bis eyes straight.
The only way to overcome these habits is ta strengthen binoeular
posture so that he no longer needs to make this choice. Until you do
that, the occasional squinter will invariably be seen with his eyes
turned at a time when he is not particularly interested in what is going
on. The minute he sits behind a training instrument he follows through
in great style. He gets an hourIs or half hour's workout and this can
be kept up for years without his ever getting heyonrl that stage.
E. In more extensive suppressions the suppressin2 eye rnay be turned to
a noticeable degree and stereoscopie ability will, then, no longer be
evidence.
F.
i
n
}
ss,
D
md
',te
ng
h
As with a periodic squinter the fusion processes become less
and less important to the individual, the central suppression extends
farther and farther into the peripheral field. This may bring about
an eventual shift from a habituaI binocular pas ture ta an habi tual
strabismic posture. He may eventually abanoon binocular vision
altogether, except for special occasions.
Nearly all strabismies have occasional moments when they
maintain binocular vision. The only reason this is not generally
known is that most 01 us have never taken the trouble to discover the
facto My whole training procedure no\'{ centers around the search for
the particular visual tasks ta which the strabisme l'espônds by an
effort ta find out under what conditions he will respond binocularly.
To visiting doctors it appears as if we spend an unreasonable amount
of time to obtain binocular posture (macùlar stereopsis). But tirne
thus spent invariably pays good dividends.
We find a point of attack, once binocular posture has been
obtained - under whatever conditions and at whatever range-that
eliminates the "breaking down
ll
process, which used to be a long
preliminary period of training before any attempt to elici t binocular
percepts was made. We are no longer concerned with breaking down
anomalous (strabismic) projection, provided we find a means of getting
to posture binocularly for even fractional periods. We
tackle the problern at the most logical position. This means that we
do not attempt ta get an initial binocular posture at infini ty position.
Parallelisrn is expeéted only at the end of training.
Marked retinal slips or actual intermittent tropias accur most
commonly in distant or during- mOr.1ents of inattention requiring
only lo\'{ postural demands.
Because vre found the above to be true, Strabismus training in
our office follows this general routine:
l) We find the position and visual task which will bring about
an attempt at binocular posture. Almost without exception this position
is found to be ,n thin easy arm
l
s reach of the patient, at distances
varying from four to twenty inches.
2) In order ta succeed in that attempt we see ta it that
the patient is confronted with a visual problern that requires
posture for adequate solution. We assume that the patient will make
an effort ta posture binocularly if he is presented with a problem
that cannat be solved while maintaining strabisrnic posture or by
alternate fixation.
J) Because fIat fusion targets do not require binocular posture
for their solutton we no longer consider the attainment of First or
Second degree fusion as an adequate criterion of a binocular field
structure. For this reason "flc. t" tarr;ets are seldom used in our
J3
i
,
1
office for strabismus training, nor for correction.of marked retinal
slips. From hard experience we have learned to reœmber that a11
strabismics who have fair visual acuity with either eye can look
alternately st targets presented to them in stereoscopes or other
training instruments and are capable of interpreting the total
situation in terms of bath, the right T1uS the 1eft, percepts. A
report of three dots in a row (BF Unit or a cross (0 series) is there-
fore not proof of binoeular posture. Additional evidence is necessary.
4) Indi viduals, on whom ne duction firidir.Lgs Ca..ï be made J are
not admitted ta stereoscopes for further tests. This is one of our
inviolable rules.
.
5) We do not consider the Keystone Visual Survey Test to be
a diagnostic test in Strabisnrus. This do es not rnean that a Keystone
Visual Survey test would fai1 to disqualify a strabismic in a.
general survey.' The individual might conceivably report "the dog above
the pig"; "the arrowunder the "three balls in vertical
alignment
ll
if he were a. clever alternator, but he could not rnaster the
stereometrie test and would be disqualified on that accaunt. On the
other hand, if we have no other information we cannot conclude frqrn
the Keystone Visual Survey above that the patient has any certain
type of strabisrnus. When the stereoscopie test is failed, we
imrnediately question all other tests of the visual survey as to their
validity.
6) We accept as a fact that a strabismic may gain information
from one eye and then the other, in temporal sequence, relative to
a given single area in Space (straight ahead) and that these impressions
may undergo a cortical closure. We have seen that sueh closure occurs
often ri thout the patient' s wishes. M:lst of these individuals seern
to be incapable of maintaining permanent fixation with one eye in
training instrument. Alternation of fixation seems for them to be
an entirely involuntary act.
G. T6 overcome retinaI slips,it is necessary to maKe perceptual
demands which require adegpate binocular postures for their
completion.
Skilled manipulations that require adequate binocular posture,
provide the requisite demands. Stereoscopie ability also furnished
this control.
Let us remember that cortical closure of temporally successive
events i8 a common oecurenee. We see in it moving pictures, in
successive fixations while reading. In other l'TOrds, i t is not a
of strabismies only. 'The abili ty to differentiate between
fusion a.r1d closure at a higher cortical level is one of the essentiàl
con troIs in testing s trabismies.
H. An individual does not depend on conseious awareness of physiological
diplopia ta regain adequate binocular posture. In faet, such awareness
may have an inhibitory effect on the resumption of binocular posture.
VI. AMBLYOPIA - A PERMANENT VISUAL DISABILITY
Amblyopia is the result of destruction (or congential lack)
nerve bundles in one or both eyes. This i8 my definition.
types of subnor mal vis ion will be defined 1 ater.
of foveal
Other
In unioeular or binocular amblyopia the eyes may be in an adeguate
binoeular posture, whieh means that they are in such alignment "i th
each other that stereoscopie clues are most effective under the
existing condition. The individual i9 then capable of the most
suffieient responses whieh are possible to the partially disabled
organisme
Stereopsis is the appreciation of the differenees between right
and left visual images as depth variations. Sinee stereopsis is the
product of the different viewpoints of the two eyes when looking at
objects in space, a single eye cannot have stereoscopie qualities.
This does not mean that a single eye may not have three-dimensional
appreciation of space.
In good binocular posture, regardless of central retinal
defeets, the achievement potential of an individual has been reached.
The visual responses will be adequatewithin the achievement level of
the partially disables organisme
If we define amblyopia in the above manner, and good binoeUlar
posture is in evidenee, the patient's existing amblyopia represents
close to the maxinnm possible visual acui ty.
It must be said, however, that such ideal postures rarely exist
with amblyopie patients. There is a strong organismic tendeney to
center attention on the better eye while the poorer eye is proportionally
pushed into the background. By pushing into the background is meant
a shift of awareness toward the better eye so that eventually most of
the conseiously perceived phenomena are related to the visual
impressions received via the better eye. The local signs from
amblyopie eye affect the total interpretations less and less and may
eventually cease entirely. Thus, the posture of the amblyopie eye
becomes of less and less importance. Such over-dominancy of the
better eye may be corrected through visual training.
l t is, therefore s important for us to know whether a person has
a good, fair or poor binocular posture in amblyopia, particularly in
unioeular amblyopia, in an effort to de termine how the cyclopean
eye has been shifted tmv-ard the better eye. mere are rneans to test
it. We can tell almost instantly whether a person has shifted his
cyclopean eye toward the better eye, by employing a cardboard with a
central hole about an inch in dia@eter. The patient if
he is a uniocular amblyope) looks at a sti'ong light sorne ten feet away
and above eye level. He holds the cardboard, which contains the
central round opening, .. ri th bath hands, at arms length, in such a way
3S
1 1
1
i
'l'
, 1
that he sees the hole in the cardboarddirectly below the light which
he fixates. He is not to lower his gaze to de termine the position of
the opening but to judge it while he is at the light. He is
then instructed to bring the cardboard straight upward in a sloW'
siVeeping motion until he "can see the light thru the hole." Inasmuch
as the cardboard is then betiVeen the patient and the light, the hole
produces a brilliantly lighted area On the patient. It is important
to observe where this area is located imrnediately after the cardboard
has been brought "straight Up" and before the patient can look at the
light thru the holé. It is also important to observe what lateral '
adjustment is made by the patient if he finds that he cannot see the
light in his first approximation.
Ca) If the lighted disc is seen center to the forehead,
a Iœdially located cyclopean eye can be assumed to €xist. In that case
the cardboard occludes the distant light from either eye and the patient
is forced to make a secondary lateral adjustment toward the dominant
eye.
Cb) If the lighted disc is placed 50 that the one eye is very
close to the la teral edge (ri th the medial edge extending well pas t the
ridge of the nose) the cyclopean eye has shifted markedly toward the
eye which is inclosed in the light keg, but a binocular pattern is still
strongly in evidence.
(c) If the lighted disc is brought straight up 50 that one eye i8
exactly center ta the keg, then dominancy of this eye is complete and
the existence of an effective binacular field structure may be seriously
questianed and will certainly needta be investigated.
Why is it that, in weIl balanced binocular field,behaviar the
hale in the cardboard is placed in such a position that, when it is
brought straight up, it conceals the light from either eye? Let us
that the hole has been brought directly in line with the vi su al
axis of the right eye. The center of the hale then lies directly below
the light as seen by the right eye but it will be markedly to the right
(and below) of the light as seen by the left eye. The local signs from
the right eye will indicate "the light is directly below this eye" while
the local signs of the left eye will indicate Il the light is decidedly
ta the right and below the light". The total percept, if botheyes were
equally important to the organism, can therefore not be "the hale is
direc tly below my (both) eyes.
11
On the other hand, if the hale is
bcought into the central vertical plane of the head, the hole as it
appears to the right eye is a bit ta the left while as seen by the other
so that the total percept of the hole being directly below the more
distant light is perfectly reasonable and logical.
In ambl, oDia the e es ma be in an inade uate binocular osture
so that stereoscopie clues are just barely utilizable. oar posture
interferes with the maxilffilm response of l'ihich the individual is capable.
Poor posture means that the related retinal images are so far
disparate that the fusion attraction between them i8 just barely
utilizable, which results in lessened ability to peform certain
demanding visual tasks. If binocular posture is 50 poor that the
macular images from single objects in space can no longer be fused,
it means that the individual must learn to suppress the image from
amblyopie eye, but it does not necessarily mean that peripheral
fu.sionIrnlst also be totally abandoned. T'here are many non-strabismic
who main tain such poor binocular posture (at least for
non-demanding that total suppression of the contra-ocular
image of the fixated object is the ruIe, although they main tain
binocular field awareness para-centrally and peripherally. While
sueh poor posture obtains, the eyes remain cosIDetically straight but
·large retinal slips are eommon and stereoscopie accuracy is nil on
stereometrie tests.
37
Stereoscopie accuracy is determined by macular imageryj it
cannot be determined on any other retinal areas. Stereoscopie perception,
on the other hand, is dependent only on the existence of a binocular
field. If a binocular field i8 lacking in direct line of gaze, bècause
cfa central scotoma, this does not affect the peripheral stereoscopie
unless the binocular field percept has also been abandoned.
Such an individual remains permanently incapable of stereoscopie
even though his peripheral depth clues may be normal.
Stereoscopie ability can he measured quantitatively and
qualitatively. Qualitatively, it measures the smallest possible retinal
disparity which is diseernible as depth variation; quantitatively, the
stereoscopie range. The latter is expressed by the distances beyond
and nearer than the horopter in which single binocular awareness can be
maintained. This range i8 peripherally determi.ned because in direct
gaze the stereoscopie ra..'1ge is most limi ted. While stereoscopie accuraey
is determined with small and sharply defined targets, the stereoscopie
range is deterrnined with large and not necessarily weIl defined targets,
preferably rings.
It may be assumed that an individual who can pass a stereometrie
test also is capable peripheral stereoscopie awareness, at least l have
ne ver come across an individu al who hari macular stereo-awareness and
lacked peripheral stereopsis. The reverse is not true.
Peripheral stereoscopie awareness is quite frequently found in
individuals who do not show any lœasurabls. stereo-accuracy even though
both eyes are visually capable of normal resolution.
It is quite possible that macular and peripheral stereo perception
may be functions .of two entirely different cortical processes. This
ls in line wi th the opinion of Halstead vrho clailIE that IIcentral vision
in man is projected to the striate cortex of the occipital lobes while
peripheral vision is mediated by the cortex of the lateral surfaces of
these structures
lf
(Brain a..'1d Intelligence, Dec. 1947; pg. )3).
Halstead' s investigations have shown also that "peripheral vision
ordinarily has little direct re1ationship to consciousness or awareness
li
1
li
1:
1.1 i,
il
1
"l" , 1
: 1
l
t
His f ar-reaching investi
6
ations have lead him to the conc;Lusion that
the peripheral portions of the visual field have a steadying effect
on the binocular field structure and that they thus contribute to the '
maintenance of binocular visual functions at a high operational level
because they integrate vernier postural adjustments. (pg. 54)
In amblyopia the eyes may be inmonocular or in strabismic posture,
when fusion attraction can no longer occur. Stereoscopie vision is then
absent B..l'ld Daual adeguacy i8 at its lowest.
The term "fusion" needs sorne explanation. We normallythink of
fusion as the "superimposition of fusible images on corresponding
areas, producing a single perceptual image of heightened discriminative
quali ties." Many investigators doubt whether the closure - making one
out of two - ever occurs in the cortex of the occipital lobes. Sorne
investigators believe thatthis closure occurs in the frontal lobes, at
high-level consciousness. Be that as i t may, i t seems that the field
stresses bécome less and less potent when retinal dispari ty betweenrigh,
, and left-eyed seeing is increased. This may be likened ta the magnetic
fields produced by twa magnets. When they are held close tagether ,the
magne tic force is considerable and tends to close the gapbetween them;
but as they are held fartherand fartherapart, this force, which effec
"closure", becomes weaker' and eventually reachesthe, vanishing point.
Also no matter how strong the magnetic attraction between two magnets
may be, their pulling together ( c losure) c an b e preven ted by applying
equal but oppositely directed pressure (pulling them apart). It seems
weIl established experimentally that fusion can be inhibited ta a marked
degree (in exchange for diplopia) at leastin the macular areas andthat,
this blocking is a frontal lobe process. '
The psychologists and physiologists also speak of visu al fusion in
the sense of fusion of teffiporally successive images. In fact, such
temporal fusio,n is accepted as being' existènt in all sense modali ties.
Halsteadspeaks oi a critical fusion faculty as the t e ~ o r a l resolving
power' of the visual system a'1d measures i t by determining the flash
'rate of an intermittent soUrce of light which just eliminated flicker.
This closure,according to Halstead's findings, is due to central
(cerebral) processes rather thanto peripheral (retinal) processes.
Single a.wareI1essin 'a binocular' fieldprocess is, of course,
a des1I-able feature. To teach an individu al to be consciously aware
of physiological diplopia i5 paramount to inhibi ting su ch single
awareness. To be conséious of physiological diplopia means seeing
abjects in a state of unreali ty. Thid does not seem ta be in the best
intérest of the individual' s spatial awareness. By developing an
excessive amount (or any amount for that matter). of awareness of
physiolagical diplopia, vre prevent! the "closure" of retinal figures
which belong ta single objects in space - a closlirl! which should occur"
before these figures emerge into consciousness.
The term fusion is arnbiguous when applied ta the various forros
of closure which we have Just discussed. Yet, at present we do not

hen
3.t
ic
n' ,
t91
l

lat
.n
39
differentiate between the processes. This accounts for many
of the misconceptions that are prevalent in optometrical and ophthalmolagical
literature relative to the meaning of fusion. It becomes, therefore,
of paramount importance that testing methods which make an absolute
possible between the various forms of closure in two eyed
be deYised. This is particularly important because aIl three
processes can co-exist in one and the sarne individual.
The organismic desire is to achieve closure, i.e., to see aIl
objects in space singly even though these objects are usually sa situated
that onlv a comoarativelv few cano at any one time
j
be brought on
. ;etinally normal binocular vision it is
organismically important that the macular images are fus able since other-
wise stereo-accuracy i5 last. Yet, ather abjects in the sarne visual
surrourids may be projected to such ridely disparate retinal areas that
they cannot be fused at the lowest cortical level and have ta be brought
ta single awareness by a closure process an a higher cortical level.
It,can then be readily demonstrated that projection still occurs from the
cyclopean eye. For instance, if a peripherally perceived 'object at
twenty feet, say a lamp shade, serves as the abject of indirect fixation,
while the gaze is held on an object situated sorne six feet to the right
of it, we may hold a pencil at arms length so as to point directly at
the shade. If we then close the eyes alternately we are likely to
discoverthat the pencil is not in direct line with either eye and the
center of the shade. Yet, individuals who have not trained themselves
to observe physiological diplopia will never be conscioûs of two pencils.
The sane principle, of course, is operative in the ctorninancy test
where a cardboard with central round opening is used to determinE
position of the cyclopean center. Very few individuals are of
two openings in the cardboard. These are confronted with a choice as to
which of the two they should align or whether both should be equally
disaligned. Such a choice, of course, requires abstraction and becomes,
therefore, a frontal lobe process. Hm'fever, in absence of physiological
diplopia, it seems that this choice is made subconsciously, even though
it must still be thought of as a frontal lobe process.
There c an be no question tha t the awareness of diplopia in terferes
with adequate spatial orientation as regards the abject in question. A
strabismic who "sees double
lf
out on the street is in potential danger.
Vlhen he meets up ri th a situation which requires an irnmediate response
(escape), he will have no titre to organize around these double images.
The decision he makes may be the wrong one. On the other hand, the
individual who maintains single awareness of both the near and the far
object may have a less accurate (retinal) percept (at least those who
teach physiological diplopia will say sa) but he certainly behaves as
if he had the more accurate spatial percept.
For the above reason it seems best ne ver to develop a'fiareness of
physiological diplopia on purpose. In our own training procedures we
absolutely prevent its appearance, if it is at all pcs3ible. The only
situations in which feel that we can make use of physiological diplopia
La
in training are those where it is not directly transferable ta the normal
Visu81 surroundings. For instance, in posture training we produce
diplopia, which cannat be carried into normal surroundings. In
convergence training we use a string which i8 stretched from a distant
wall attachment to the nose. These si are highly artificial and
are notlikely to find counterparts in -riormal visuà1surroundings.
Because we have the means today of training a strabismic te normal
binocular function without the internediate step of diplopia, we are in
the happy position of letting the strabismic maintain an adequate spatial
awareness while this shift frOID strabismie to binocu1ar posture is being
made.
The above considerations brine us to an entire1y different concept
of the value of diplopia training in strabisIIlls. Further discussion will
have to be postponed.
Coming back to our tenet mat in roonocular and in strabismie posture
stereoscopie vision is who1ly 1acking, we can now restate it by saying that
in uniocular and strabismie posture a c10sure ean no longer occur except
at the highest cortical 1eve1s (frontal lobe).
Uniocular posture be maintained in alternate V1Slon. How may
we speak of closure in uniocular posture? Here the c10sure concerns
the temporal fusion (as in movie projection) of right and 1eft alternate
postures. When such closure is obtained the individual will be entire1y
unaware of how he arrived at the final interpretation of his visual
surrounds.
Inasmuch as stereoscopie range seems ta be definite1y limited ta
retinal disparity within fusion attraction, it cannot exist when the eyes
are markedly out of alignment. It>under such conditions a binocular
sensory field can be assumed to exist only if patient cornplains that he
sees everything double (as in paralytic strabismic of recent onset).
Conversely, when it can be shawn that when an individual possesses good
stereoscopie discrimination under certain test conditions, it may be
assumed that during the particular visual task his eyes were in perfect
alignment with each other.
c. The purpose of visual training in aroblyopia is to teach the individual
adeguate binocular posture by strengthening bis binocular field percept
and by gradually increasing the demands on his perceptual abilities.
The best training approach is ta increase, gradually, the demands
made on the visual of the patient, as expressed by his
perceptual cr rmnipulatory competency. This means that he rrrust be
confronted wi th visual probleI:lS which ca..n.not be solved unless he postures·
better than he is l'font. If such heightened ability has once been
attair.ed, i t can be achie7ed again and again and eventually become the
habi tual pattern.
Phorias are expressions of inadequa te postures. Pos ture training

el
v:
e;
[n
l
Lal
19
ûl
;e
.y
-es
s
es
.
is actually the simplE:st sort of phoria traini ng and is exceptionally
effec ti ve in changing phori2.s.
ilhen i t i3 found tha;:. adeouate [OsturA is maintained in amblyopia,
visual training can i t.tle te> t!"n ty of the
bi nOC1Üé'.r vision
-- -
hl
h2
VII. . SUBNORMAL VISION IN UNIOCULAR STRABISMJS
If l define AMBLYOPIA as an incurable condition, it becomes
necessary to describe the type of subnormal vision found in uniocular
strabismus that responds to visual training. There are many cases of
uniocular amblyopia on record where an eye has been brought from finger
count ta usable vision and in certain cases even to normal acuity. How
can we account for this visual improverrent?
Before this matter can be satisfactorily discusses 'iVe ITllst define
what the term STRABISMUS rneans and what is meant by UNIOCULAR strabisrmls,
in particular.
A. STRABISMUS may be said to be the condition where a sin le fixation ob"ect.
?of smail dimensions can be brought into direct.line of gaze of
eye at a time.
If the fixation abject is a houseat twenty feet, the lines of
gaze of both eyes will be likely to intercept different parts of this
but a single window can not be looked at with the right and left eye,
except by alternate fixation.
B. ?eoplewho have one good eye and a subnormal eye will tend toward
uniocular strabismus because it is easy for them to suppress the macular
images of the subnormal eye.
On the other hand, individuals who have two equally good eyes cannot
maintain suppression so well as the amblyope and tend to evolve gradually
from suppression ta the arganisnUcally much ITDre acceptable use of the t'If 0
eyes as independent visual organs, integrated without the benefit of
füsion.
/'
c. Uniocular strabismus represents the type of where one l'lye
eventually loses the ability of direct fixation, sa on occlusion
of the dominant eye, the indi vidual is no longer capable of bringing .
the object of direct regard onto the macula of the turned eye.
To illustrate what l mean, let me tell of a farnily of strabismics.
The father, a physician. is a uniocular strabismic and aIl his sons are
strabismics. Sorne are alternators, the rest are unioculars. One of the
uniocular strabismics, on examination, was incapable of direct' fixation
ri th the habitually turned eye when the good eye l'fas occluded. He kept
the eye turned in the habitual squinting position. This individu al was
subjected ta tests with the Stimulator which l described in the
Jur.e 5th issue of the Optornetric Weekly (19h7). The method used was to
align the test letter l'rith the direct Une ·of gaze of the turned eye.
Visual acui ty was found ta be 20/40. Vihen the good eye was norr ocèluded
the patient turned the other eye away from the test letter, which he
had been able ta recognize, with the result that he no lonEer could see
this 1etter. His effective visual acuity came up very rapidly and final1y
reached 20/30. Gan this be claased as amb1yopia-ex-anopsia? I think
note In this particular case the squniting eye was amblyopie only to
the extent of visual reduction to 20/30 , the other eye being 20/15. With
direct fixation assured, the 1ack of normal visual acuity may be
considered arnblyopia.
becomes ex-anopsic is not the vision of the turned eye
but the fixation ability. If l should wear for years a strap which wou1d
prevent my left upper arm from being brought above a horizontal positions
the arm would not atrophy because there would be a sufficient number of
of movements to keep it active. Yet, l might in tirne lose the incentive
to raise the arm straight up even when the strap was removed. I should
have to learn to manipu1ate this arm in a normal manner in or der to becorne
proficient in the coordinated use of both hands above the head.
When a strabismic has been entirely uniocular for years, the turned
eye is never caIIed upon te fixate any abject of special regard directIy,
because this has become the sole function of the other eye. Why, then,
should it be surprising that the ability for direct fixation may no
longer be present? The Iaek of direct fixation, in turn, results in
subnormal vision. With sueh individuals the turned eye remains in its
habituaI strabismic position when the habituaIIy straight eye is being
occluded. 18 it any wonder the off-rnacular acuity of the strabismic
eye is very Iow when resolution of the object of direct regard is attempted
with the dominant eye totally occluded?
Law visual acuity, due to lack of ability for direct fixation, readily
responds ta visual training, when such training brings about direct
fixation of the object of regard by the strahismic eye provided that
the foveal area of such an eye has not been darnaged by prior in jury or
or disease.
El the time an eye has lost direct fixation ability it has assumed a
position of some importance in the total visual behavior of the individual,
but onlv in the direction of the turne In that direction the individual
nON sees more clearly when bath eyes are open than when the squinting
eye is occluded. This constitutes an adaptation ta the existing strabismus,
an adjustment shift that may lead eventually ta arnbiocular vision.
Building visual acuity of the strabismic eye by prolonged total occlusion
of the norrnally dominant eye, without the simultaneous establishment of
an ability for binocular posture, may have the undesirable result of
speeding the strabismic on his \Vay ta arnbiocular seeing.
If the above propositions are correct, the following is also true!
1eaching the uniocular s trabismic binocular posture, au tomatically raises
the visual acuity of the turned eye.
43
·1
1
1
1
41'
A.
B.
VIII. STRAI3ISMUS
In strabismus, a single fixation abject can be brought into direct line
of gaze of .only one eye. Therefore, the adeguacy with which this abject
is seen depends on the organismie ability ta suppress conflicting
sensations that reach the macula of the other eye, i.e., it depends on
the organismie ability to prevent a binoeular field percept.
When bath eyes look simultaneously at a single (small) object
in space, al though a binocular field perceptexists, sarre other abject is
. apt ta be projected to the macula of the non-dominant eye. Thisobject
sets up rivalrv sensations ri th the first one. The image of the second
object must be suppressed for the sake of a clear and unhampered view of

The sufficiency of the spatial concept of the uniocular strabismic
is measured byhis abili ty to retain selecti vely the abject of rlirect
,!'êgardinits -t;of.alitY. às-the centrâl figure of his total pèrcept. His
abiÜ.ty ta maintain spatial awareness depends directly on hm'i weIl hé
the macular image of the turned eye from interfering wi th the
macular image of the straight eye.
The prevention of a binocular field percept can be attained in two ways
by:
1. Maintainin
a
an essential field b Iœans of
suppression
If the strabismie has not learned to dissociate his
eyes, he must, for the sake of correct spatial interpretation,
suppress the macular image of the non-dominant eye. If
he cannot do this, int81erable retinal rivalry results.
'l'rue suppression squint is rare because it represents a
transition period to more effective strabismic seeing. The
organism is apparently not willing to shelve an eye because
it can no longer cooperate in normal fashion with the other
aye. This holjs true especially when the strabismus has
developed in infancy or chilrlhood. But even when the
condi tion develops in fully matured indi viduals sorne adapt-
ations, which delegate sorne useful purpose to the turned
eye, are possible. Here the concession squint turns into a
more or less adapted strabi;qnrus, where the turned eye takes
over visual functions not normal to binocular seeing.
A suporession squint remains a "concession" squint sa
long as ilothing ne·,y is learned toward arl adaptation to ambiocul
seeing. A trJe suppression squint pushes that which is not
desirable into the background. We all have a tendeilcy ta do
that, but not ta the same degree. The squinter simply has
more undesirable visual experiences ta push aside. He learns
!ct
is
an
ar
to do this by totally suppressing the vision of one
eye. This eye, then, no longer has any use except in
the monocular field where the other eye does not see.
Such a situation is not acceptable to the organism
for long. If the suppressed eye is capable of good
vision along the direct line of gaze, the organism usually
finds means ta draw out all the capabilities of a turned
eye. This causes no undue interference with what the
straight eye wants to see. However, the process of re-
adaptation is a very slow one.
2. Maintaining separate fields for right and left eyed
seeine, as evidenced in the ambiocular vision of the
adapted alternating strabismic, who the
visual impressions receiverl via the two eyes by a "thinking
Erocess" devoid of true fusion.
It has already been stated that there is an organismic
tendency toward full use of all existing abilities. This
holds just as true for visual as for other human behavior.
It is a fundamental principle that no matter hON handicapped
a persan is he will try ta develop all remaining abilities.
An individual with an artificial leg is prevented from
moving about in the manner and with the ease formerly
experienced. Yet, he will learn to coardinate the
artificial leg with his good one. He may even learn to
perform sorne special feats that cannat be accorrplished by
an individual l'rho hasn't an artificial leg. l'here are, of
course, individuals who do not care ta recover the full
use of their faculties after a calamity has befallen them,
but they can no longer to be classed as following norJœl
behavior patterns.
In respect to vlSlon, while SOIœ semblance of the
old habits of seeing can be retained, no matter how poor
or inefficient they are, the subject will not nearly
as decided an effort ta learn a shift to an entirely new
performance. That is, the individual who can main tain a
binocular pattern of seeing at near, though not as far, is
not likely to acquire a highly developed seeing.
How is it possible to the ability ta maintain separate perceptual
fields for the right and the left eye?
Tnis is one of the problems that will interest us for a long time
ta come. FroIil visual training arlgle it is importa.l1t only to remember
that ambiocular vision acts as if separate sensory fiel::is for the t1VO
eyes exist. We can infer only from wnat these strabis mies report that
they "think" separately wi th ei ther eye, and that closure of the single
unitary percept is more nearly allied with the closure of the teII90ral
45
,1
:1
Ii
i:: J
. :1 I.i
'Ii!
il,l:
! 1; i
1: '
n
,
ii
l
1
sequence of events, as previously diseussed.
It has been weIl established experimentally, that the alternation
of right and left percepts, is not always a closure of temporal
The ambioeular strabisme, in sorne manner, acquires the
é3,]JUi ty to interpret directlyhis visual space in' two directions at
sametime, in accordance with the respective lines of gaze. These two
macular impressions are ineorporated into a unified ambioeular percept
by what is most likely a frontal lobe, a thinking process. Sinee there
1s no birlûcul ar field,.therecan he no fusion attraction between right
and left images belongingto the same objects in space. Because there
no fusion attraction there can be no stereoscopie awareness, even of the
lowest quality.
If one eyeis turned off position 50 far that a binocular pattern
of seeing be maintained, how does the organism come te terms
with sueh problem? Several adaptations are possible •
.
1. Thefua:ividual may make a strong atternpt ta straighten his
eyes by an effort of will •
. If a head inj
1
1ry:.causes a child' 5 eyes to begin to
cross, he will make every effort to prevent the strabisIIDS.
Even though by a considerable effort of will he manages
to keep .them parallismçannot be
main occ asionally relax ând
then the cro3secl· appearance. The
child may organize around a particular head p03ition which
permits him to main tain straight eyes with the least effort.
2. The macular image of ,the turned eye maybe suppressed in
the manner alrèady discussed
J
if of binocular
vision becomes tao much of a mental burden.
The individu al maintains uniocular posture during suppress
and sees the world from the straight eye, that eye becoming
the locus of reference for all visual projection. 'l'he
cyclopean (binocular) projection i8 discarded. If a pencH
now is placed between the individual and the fixated object,
the pencil ia placed on the fixation axis of the straight
eye. This is a subtle but important change which paves the ,
way for the learning of a ambiocular seeing.
3. Dissociation between right and left brain centers may occur
through the constant maintenance of uniocular posture, the
cortical disjunction resul tin;;; in dissociation of the sens0.Œ
fields of t'he two e'res •
.
The ret
1
1rn ta separate sensory fielrls may be considered
a regression ta earlier mode of seeing, phylogenetically
Ls
speaking (Verhoeff), inaslIDch as the binoeular sensory
field represents the highest development in the
evolutionary scale.
The shift from separate sensory fields ta a
binocular sensory field is not a gradual transition, but
an acquisition of something entirely new. Shifts of
this type are weIl known in all phases of evolution.
They are not extensions but mutations. It ls essential
ta remember this, because it has a direct bearing on our
approach ta visual training of the strabismic.
The formerly suppressed eye can funetion organismically on
a different basis, if the dissociation between the two eyes
becomes conplete. l t can act as an auxiliary information
center, capable of spatial information because
its line of direct gaze has a different direction than
that of the other eye. The heightened acuity, which i8
available in the direction of the turned eye, rnay become
a desirable feature in the total visual percept and may
eventually be incorporated in the total spatial percept,
but on strictly new terms - separativeness of right and
left visual fields.
When a strabismic has learned ta see ambiocularly, he is not
prevented from forming a binocular field structure if the opportunity
arises.
Nhen, due to sorre fortuitous circumstance, conciitions are
such that a strabismic c?n maintain binocular posture for a certain
visual task, he do SO-and then return to his amhiocular seeing.
In other words, a strabismie who has learned to interpret from both
eyes in a strabismic posture may still organize his seeing around a
binocular sensory field percept, if he has the opportunity and the
desire. He may, allegorically speaking, leave the door between
the two rooms open, entering one or the other at will; but he can
never be in both at once. The fact that such an individual usually
has the ehoiee of both foros of seeing 1s not generally known. Yet,
it is the most important single factor in considering ways and means
of recondi tioning the- squinter to normal visual habits.
Returning to our allegory of going from one room to another
when the shift is made froD strabismic posture to binocular posture,
the conditions existing in these two rooms must be c'o[lsidered ta
be entirely different. Suppose, for instance, that one room is
occupied by people speaking English only and the other by people
speaking only German. The individual who vran.ts to be at home in
bath roorus will have ta have knowledge of German as 'l'feIl as of
English. If he is not equally fluent in the two he
will naturally prefer to rew2in in the room where the language
47
,1
l,
l,
"
Il
1
1
48
w:l. th '/l'hich he is most familiar 1.8 spoken and will enter the other
room only on occasions.
We find such a situation frequently occuring in visual
training - that the strabismic converses 'with us thru the open door,
so to speak. This is a substitute performance, because the shift
from one form of seeing to the other has not actually, but only
seemingly, occured. lAlch of the present day "training" if os this
nature. It behooves us to devise contraIs tu prevent sueh occurences.
Let us f0110w this allegory a bit farther. l WÇl.S barn and
raised in Switzerland. My mother' s tangue i8 German. If l had
stayed in Switzerland, German would still be-my preferred language.
Because l came to America at the age of 21 and have resided here ever
since, l have spoken English longer than German and now prefer
English to German. This state of affairs was, however, long in coming.
The only reason l have acquired a preference for English is that l
have practically ceased to use German, except for short periods when
l meet up with someone who can not speak English but knows German, or
for the purpose of reading a German book.
rhe most difficult phase of the transition was that from
in German to thinking in English, partieularly when mathematical
problems were eoneerned. It was mueh easier to caleulate mentally
in German and report the resul t in English than to conplete the whole
mathematical probelm (silently) in English. It took a tremendous
effort of will for me ta make a total shift from German dominated
thinking to English, but if tests were made today, only traces of
formed way of thinking would be found. Many foreign barn never learn
ta make this transition, no matter how long they remain in America.
For the cure of a strabisme a similar transi tian has ta be
made. A complete transition is not neeessary for the habitual
rraintenance of binocular posture. However, sueh an individual may
occasionally (or frequently) return to strabismie behavior, simply
because of his preference for it. Even if this state of affairs i8
far preferable to constant strabismie posture, it does not constitute
a cure.
,Just as individual who is inherently left handed can be taught
ta learn to use his right hand for writing and ta essentially
right handed thru constant praetice, sa can we teach a person ta
maintain habitually a non-preferred visual posture.
It is my belief that no individual is inherently strabismie
and that strabisrnic posture is al .... 'ays a learned adaptation. When an
individu al has learned strabismie seeing, it is neVér because of his
preference for it, but due to necessity. It is r·lpful, at least,
ta make this assumption in our consideration of strabismus. We no
longer have ta fear the possible lack of a faculty or fusion
desire in our patient. Yfe may concentrate on finding the underlying
causes of the strabiswus.
E,
We are now ready tolay down certain postulates and restrictions
in regard ta the fully adapted strabismic as a basis for our training
and testing program.
The ambiocular (fully adapted) strabismie ean maintain direct
fixation on two spatially separated abjects, if they lie on the
direct lines of gaze. Ambioeular vision means the abilitv to see in
two at once. This deseribes the aehievement level of
the fully adapted strabismie.
A good deal of experimental evidenee has been accumulated to
prove that bimacular interpretation ean be aecomplished within
l/lOOth of àseeond. This indicates that we are not dealing with
tenporal sequence, but wi th a silllll taneous process. The only
difference between the ambiocular strabismic and themternating
strabismic is that the alternating squinter attempts closure of
visual events (seeing alternately with one eye and then with the
other) that follow each other in temporal sequence, while the
ambiocular strabismie ob tains a single unified percept of two
spatially separated fixation targets (one belonging to the right eye,
the other to the left eye) at a simultaneous glanee.
The ambiocular strabismic has certain charaèteristies.
1. He is usually not aware of the fact that he shifts eyes,
when he al ternately fixa tes a single objeet in space.
Vihen the ambioeular strabisme is confronted with a
situation where there is but one target to draw his attention, he
is apt to fixate it alternately, just as an habitual alternator does.
The visual impressions gained by alternate fixations are eortically
summated ta form a continuous unitary impression. In this sense,
his behavior does not differ frOID the alternating strabismic, who
has not to the point where he can sirnultaneously fixate
two objects in space.
2. The strabismic has as little awareness of the temporal
sequence of alternate right and left fixation as one normally has
of the temporal sequence of the "fixation jumps" that occur in the
process of reading. This, again, agrees with what the alternator,
who is not a fullY,adapted ambiocular strabismic, mayaccomplish.
From the above it is apparent that the fully adapted
ambiocular strabismic has simply extended the learned accornplishments
of the less corrrpletely adapted al ternator ta include si mul taneous
fixation of two spatially separated objects. The alternator would
have to interpret these abjects in temporal sequence.
Ambiocular vision, which depends on s,trabismic posture, gives way
ta normal binocular DOS ture when the individu al makes a binocular
EOsturing effort to fixate a single object in his normal surroundings.
49
50
lt. is the effort. tLat zuarantees his ability to do it. It is
the posturinc eff(Jrt that matters, we do not have ta
the patier:t 1 s ability to interpret a binocular posturing
effort.
The above postul3.tes have been throuc
b
studies,
thr our.
h
expEJri rr.entation, thrC\11f:h cl inic:ll oos erva tiens. If we
these postulates, he'.': does that affec:. our approach te the
problem of s trabislTJu:c? l;Jese ques tions are considered herewi th.
IX. VISUAL TRAINING IN STRABISMUS
The purpose of visual training in al1 forms of strabismus is (a) to
elicit an effort at binocular osture under s ecific test conditions,
b to extend this adually over ever widening retinal areas
in the individual' s normal surroundings c to maintain i t over more
and more extended periods.
The laid down abOYé can be follûwed explicitly and include
all forms of strabismus, the suppressor, the amblyope, the alternator
and the ambiocular. They all point in a straight direction teward the
goal. The main purpose for all is the establishment of binocular
posturing ability. It becomes, therefore, apparent that we can follow
a single pro gram of visual training for aIl of them.
l spent many years teaching how to differentiate between the
various types of strabismus, because different training procedures had
to be applied te the different individuals. As recently as a year ago
l still was of the opinion that the ambiocular strabismie had to be
"broken down" before a new pattern of seeing could be developèd. This
beliei is still an accepted principle in clinics.
It has always been throught that the ambiocular strabismic and the
individual who posseses normal visual functiàns represented opposite
poles of specialized achievements and that the ambïocular individual
individual had to be sboved by slow degrees toward the distant goal
of normal binocular vision. If we think of the arnbiocular strabismic
as being at one end of a long path and the normal individual at the
other end, according to old way of thinking, the distance between them
has to be shortened one step at a time until they meet. Today we
know that the distance can be covered in a single step.
It was not until l had experimented with the BSM technique, using ,
an intermediate screen, that this realization was forced upon me in
a rather spectacular fashion. The story has been told before but it
bears repeating.
An exceedingly intelligent girl in her teens, an alternate
exotrope, came to office sorne months ago, not to have her eyes
straightened but because she needed new glasses. It became
that she did not know how to look at any object with both eyes
simul taneously. At the tirœ l l'ras interested in ambiocular phenomena
and it was not difficult to interest her in becoming a subject for rny
studies.
We set up the testing procedure described in detail in rny
article on Binocular Vision in Strabisrrus under the heading l1]kasuring
the Speed of Bi-Macular Perception. Il (FrederickYi. Brock: Binocular
Vision in Strabismus Part 2, Relationship between the two fovea in
strabismus, Optometric Weekly J 19L5-46). Two letters were projected
onto two squares which had been drawn on a translucent screen. The
51
patient was placed in front of this screen in such a way that the
right axis of gaze intercepted one square, while the left axis of
gaze intercepted the other square. Interchangeable letters were
flashed onta these squares. The letters were read off without
error at a hundredth of a second. This ability identi:ied her as
an accornplished ambiocular squinter.
It occured to me that this in di vi dual would be a good sub,ject
on whom to test the validity of lTlf belief that reti!1al dispari t;)r
.... 1,,<'30::: wn,,1 r1 nnt. hA available for the interDretation deDth variations
was' decided to project the
rabbit and rings (BSM 20-1-2) between the squares with the rabbit in
the center of the total field. The green and red rings surrounded
the rabbit and were initially brought to exact superirnposition.· The
physical set up between the above is shown in the below figure.
L

\
\
\
b
/
1
6
While the right eye looked
into square (R), the left
eye was directed toward
square (L). The patient
reported that" she saw the
letters in both squares and
that she also saw the rabbi t
and surrounding ring. The
ring appeared to her to be
half red, half green, as i5
customary in ambiocular
vision.
When the rings were
motivated, one to the right,
the other to the left, the
patient stated at once that
she was aware of a single
ring which seelIEd te move to
the rieht and the left, but did not appear ta leave the screen. She
thoueht of the ring as being squashed and pulled into a barrel shape,
and yet it seerned to remain perfectly round. Suddenly, she reported
that her appreciation of the objective situation had changed and that
now the ring seeffi?d ta come closer toward her and at other tirnes
appeared ta recede to a position beyond the rabbit. A shrinking and
swelling of the perceived ring also becarne apparent.
This was a distinct shock to me. At the tirne she reported these
changes I was attending to the instrument and was on the opposite side
of the screen froID the patient. Cansequently, l could nat wa teh her
eyes while she reparted. Vlhen I realized the significance af her
answer I felt as if ten years af study had came ta naught. My whole
structure, so labariausly built up aver these many years, seemed ta
tumble. l had hardly the strength to change ray lacatian ta 'rie\'/' the
patient. It was bath a decided surprise and relief ta find th1.t her
eyes no langer seerned in their farmer exatrapic pasi tian but appeared
B.
C.
to be directed to the centel' of the screen. My questioI( ''Where are
yaii Tôoklng7
f1
-seemed ta come as a surprise to her, because after a
moments hesitation she exclaimed rather dazedly that she felt she
was lookjng at the rabbit rather than the two letters.
It was but a very short period of time befare the girl learned
ta maintain binacular posture bath at the intermediate screen and the
near-vie?rer. She progressed very rapidly in her acquisition of normal
binocular vision.
This was the first indication which l had that posture determines
the nature of the visual responses: If an individuar-p6s tures bin-
ocularly he thinks binoGularly; if he postures strabismically, he
thinks as a strabismic must, if he wants to maintain an adequate
spatial percept. To me, this was, of course, the beginning of a new
line of reason1.ng regarding what an ambiocular patient can do, when
proper test and training conditions are provided. '
l have followed this lead since and found it applicable in most
strabisme probleIlli3.
l have found it desirable ta attempt ta obtain a binocular
posture with aIl strabismies right at the outset of training. When
this can be done the training procedure is tremendously shortened.
B. In convergent strabismus the setting up of training situations at
the crossing point of the visual axes by setting the training
instruments to the existing angle of squint permits the patient ta
maintain his habitual strabismic posture. This'is the most unlikely
position where a binocular field percept can be developed.
C. In divergent strabismus, the placement of the target at the angle of
deviation, either by adjustment 0: the instrument or by prism prevents
a binocular posturing effort &'1d therefore inhibits the formation of
a binocular field percept.
Alignment of the eyes of a divergent squinter on a single
distant abject by means of prism is simply another method of bringing
a fusable object on his two axes of gaze while he raintai;,s an habituaI
s trabismic pos ture. This procedure has a tendency vo inhibit a
binocular field percept because of the existinc; strabismic post.'êTe.
As a matter of fact, when the above procedure is fol10wed it is
frequently found that the strabismie "runs awayll fror!! the impossible
situation either by increasing his t u ~ n or reducing it just enaugh
ta prevent the Iike retinal images from forming on the respective
maculae. He may report that he S2es tr.c objects at 'Nidely different
points in his total field. He instinctively fee}, L,hat the objective
si tua tion has no meanirg, .;. e., l,rla 1:, il L armot be ir: l:-erpreterl to his
satisfaction.
53
-=-
54
1) 1bst divergent strabismics find it easier ta posture
binocularly at near than at far. Many of them maintain
occasion.].l binocular posture at near long after they
abandoned binocular seeing at far.
The abject that is close enough to the person ta
be manipulated can be handled more satisfactorily while
binocular posture is maintained. Threading a needle or
using a screw driver becornes easier when the two eyes
posture for the task. Greater compétence of manipulation,
which appears ta be the main purpose of binocular vision,
justified the development of this exeeedingly complicated
visual process.
2) The first binocular posturing efforts are, therefore, apt
succeed at close range when demangs are
kept beyond the achievernen level in uniocular or
ambiocular
Thisfollovrs the reasoning we have been expounding
in our whole approach ta visual training. It is fundamentally
sound and will pay dividends if followed explicitly.
Let is assume that we have a strabismic who has a
30 degree exotropia. This individual is persuaded to
undergo an operation in whieh the surgeon pulls the tvro
eyes straight by shortening the ligaments of the two
internal recti. The question l would Iike ta raise is,
'n,'fas the posture of this individual ehanged from Cl.
strabisrnie posture to a binocul2r posture by the operation?"
We may consider this ques tian from a differen t angle.
Suppose, instead of the operation, the patient had been
supplied with sufficient base in prism ta bring the two
eyes ta an effective paraIIeIism, we should have accomplished
essentially what the surgeon did. Again, had we placed
the individual before an amblyoscope and had adjusted the
instrument to the 30 degree exotropia, the resultant
objective situation woulrl not have differed from either of
the
Vie all l think, that the strabismic retains in
both these cases, his strabiscric posture. It must, therefore,
also be assumed that thru operation no shift to binocular
posture occurs.màt sa many of these operated individuals
with straight eyes see double after operation, attests to
of this assucption.
This undoubtedly, is the reason '.my i t is custorra..ry
in stréibismus operations not ta atterrpt to bring the two eyes
in to exact parallelism, unless no estéiblishm€nt of binocular
visual habits (after operation) i8 conternplated. Usually
a near-straight position is found to be more satisfactory.
l'hepatTènt can then, by effort of will, bring about a
posture, if he 50 desires.
When the eyes of a strabismic are fully straightened,
there is apt to occur a more or lesS-Violent reaction ta
new status. The patient will make a decided effort
to escape this new visual sensation by moving his eyes
away from "there". If his eyes were fully straight before
he makes this effort, any voluntayy shift in the relative
eye positions is necessarily aNay from the position where
a binocular pattern can forme In other words, any
shift will be away from the very posture he should maintain.
But if theCyes are not ful],y straightened by operation a
snift of posture away from the original position mày go
eTfber way. The chances are equal that i t may be in the
direction where a binocular field percept may become
possible. The patient may suddenly realize that with a
moderate effort he can now direct his eyes toward binocular
posture, which is then apt ta forme He learns ta see
binocularly by making the effort. Take away the need for
effort, you take away the oècasion to learn.
Let us remember that adjusting an instrument, or using
prism to conpensate for the habituaI turn, is_natsynonymaus
ri th establishing binocular pos ture. Unless an individu al
wants to look at the same object with both eyes directly,
he i3 not for it, even though he may
be made to look in that direction.
The question arises, How can we tell when an individual
postures binocularly? Few strabismics know how to posture
properly, and certainly not on their first attempt. It i8
fortunate that we do not have to have perfeet binocular
posture ta obtain stereoscopie vision, provided we do not
desire stereoscopic aecuraey. He have seen that fusion
attraction can oeeur ri th the eyes in considerable dis-
alignment (possibly as mueh as 10 prism diopters of lateral
disparity). c'llils makes visual trainine a great deal easier.
'Ne should help the strabisme in his effort at binoeular
posture. When it is not within his to posture at 12
inches, it may be possible for him ta d') so at 8 inches.
It is, then, our dut y t') see ta it that he gets a chance to
attemp t i t at the closer range. Our job is to bring the
target close enough for the patient ta posture the way we
want to. This is our main problem. It is also our
responsibility ta present him ffith an objective visual
sit1Jation that does not require accuréltl':: posture for it3
successful élccomplishment.
55
S6
D. The more realistic the objective situation is, which confronts the
strabismic, the easier it will be for him ta respond adeouately
when he makes a binocular posturing attempt.
A septum in an instrument, which divides right and left eye
seeing, has a tendency to foster separate field percepts (where the
latter have previously existed) and is contraindicated in the early
training of the strabismic. This is importânt te remember.
Ignorance of this rule has caused a great deal of confusion amongst
eye specialis-ts and technicians
\Vhere a binocular field percept already exists the stereoscope
is the instrument of choice. The use of the stereoscope should,
however, be limi ted so long as regression to s trabimic posture is to
be feared. Even after full stereoscopie perception can be demonstrated
to exist by the B3M or Vectograph techniques, an individual who has
not been trained in the stereoscope may not be able to interpret
through it and may revert to alternation in preference to binocular
posture. We must be constantly on the watch that l're do not present
him with objective situations which he can more easily
assocîate with hisstrabismic posture than with his newly acquired
binocula.r posture. Interpretation through a stereoscope is a
special skill.
The strabismic should be trained as as possible 'in the
open', in other words, under conditions tbat approxima te his normal
surroundings. BSM (anaglyphs) and Vectograph methods of training
seem to be the least artificial approaches for the training of
stereoscopie perception.
Binocular rotations, under strict supervlslon, given bv having
the p.t.ient observe a candIe or smaU lighted bulb, are a MUST in
strabismus training. Gare must be taken that the corne al reflections
are weIl centered in the two pupils.
My favari te method of "touching pencils" is another excellent
means of creating demands on visual skills that can only be met in
binocQlar seeing. This rnethod lends itself excellently to home
training.
E. Shrinking the perceptual field to exclude peripheral awareness is
éL'1 unsound procedure, especially in amblyopia and strabismus, be-
cause a peripheral binocular field structure has a effect
on the macular visual processes.
Only by inclusion of the periphery can the eyes be steadied
sufficiently to permit of gross stereo-awareness. l have already
mentioned Halstead's recognition of the importance of peripheral
perception as in aid to fusion (Brain and Intelligence, p. )4).
In case of paralysis specifie the establishment of
a binoeular field percept in only certain areas in the total
perceptual field is not contradicated, provided the individual is
Eeroitted ta retain his ability ta suppress the undesirable
"seeondary in the_ areas of his total fiek where he finds
i t irrpossible ta m.untain binocular posture (beeause of the
existing paralysis.)
Training ean be given for the purpose of effecting more
adequate visual behavior in paralytic strabismus, where coneomi taney
of .oeular rotations is known to be lacking.
As reeently as a year ago l spent a great deal of time teaching
how to differentiate between concortltant and non-concomitant ocular
rotations so that they would learn ta differentiate non-trianable
and trainable cases. The ,non-concomitants were the non-trainables.
This still holds true for the doctor who insists that a sense
of diplopia is perequisite ta normal visual functions (stereoscopie
vision). Only after we have learned ta establish binoeular posture
without ereating-a-5ense of double vision, when the eyes are not
straight, may we atternpt to help the paralytic squinter ta become
more efficient visually. The improvement will of neeessity be
limited to those areas in the individual' s surrounds where he can
learnto maintain binoeular posture.
As a matter of fact, sorne individuals will exhibit sterèoscopie
ability and binocular in certain directions and show a
tropia position (without seeing double) in other directions, before
they come ta us for eye eare. In such cases it would be a disfavor
to "improve" the si tua tian by teaching thern diplopia in the areas
where binocular posture cannet be obtained.
The establishment of binocular osture at near (in both eso- and
exotropia is desirable, even though such posturing is not possible
at infintiy. Binocular posture at near tends to keep the eyes
cosrœtically straight and rais es the ac hievement level of
manipulatory tasks.
Organismica11y, the important causat.i ve factor in binoculotr
vision is the dernand for space manipula.tion. This is not, hmrever,
the 'importan t consideration, as far as the patient' s rlshes are
coneerned. The individual who has never had stereoscopie vision
does not miss it except on certain occasions. He is primarily
concerned with the fact that his eyes cosmetically look different
from those of the people around hirn. He cornes ta you for relief
from the disfiguring turn of his eyes. That to him (or his parents)
is the important consideration. If vre can straighten the eyes to
cosruetically acceptable proportions, have accomplished a great deal.
This is of course tre surgeon's arguoent who often hopes that
57
1
!
1
1
1
1
1
1
j
!I
1
'1
'1
1
58
the strabismic will go on seeing alternately after operation, as
long as he keeps the eyes cosmetically straight. There is only
one objection to this policy. If fusion does not develop when
the eyes are quite straight, one eye loses its ability(to look
into a different direction) and the individual, without knowing
it, will graduaJ.ly grope for an inclusion of the IIditched
ll
eye in
his total spatial percept. There are only two ways in which this
can be done:
a) He may fall into a binocular of seeing by learning
binocular posture often ta the pleasant surprise of the
. surgeon or
b) He may turn the non-fixating eye sa that it can assume a
position of sorne organismiè importance - where it can
observe (directly) a different object in space than does
the fixating eye. This opens the way ta a return of
ambiocular seeing, which is the second way of establishing
a stable relationship between the two eyes. Unfortunately,
once the turning away from parallelism has begun, there
is no way of telling how far i t rill progress. We can
control the situation only through the establishment of
a binocular pattern of seeing.
H. Any individual who can be taught to posture binocularly will be able
ta interpret according ta normal binocular vision.
This is somewhat in opposition to conventional thinking. It is
generally assumed that the chance for normal binocular vision after
operation is greatly enhanced by developing the fusion faculty prior
to operation. This is logical assumption but it has a dangerously
weak spot. Eow do we knmr that binocular posture will be desirable,
or even possible, after operation? l have seen sorne of own
patients undergostrabismus operations, after l had built up what
l thought to be a strong urge for fusion by placing fusible tar[;ets
at the angle· of strabismus. Several of these patients shol'ied after
operation a total inability (or what l now believe was a total lack
of desire fbr binocular posture) to fuse. As a result they developed
a fusion aversion and a sense of diplopia which continued through
the years although their eyes were in sufficiently straight position
for normal binocular vision to function. had created a binocular
sensory field th.t became a burden and an annoyance ta the operated.
strabismic. Today, l know that if l had waited to establish a
binocular field until after the operation, my chances in all cases
of strabisrrus where no binoculélr posture can be obtained prior to
operation woulà have been better. By following this procedure we
have avoiàed horror fusionalis none of our patients is troubled
with an a'1noying sense of seeing double.
Questions and Answers.
Question 1: Why is strabismus prevalent in certain families and not
in other s?
Answer: The prevalence of central scotomata in certain families seems
to be one of the reasons. Until l'le know how many scotomatous conditions
are due to lack of development of the macular nerve bundles, ta birth
injuries, to septic diseases or abnormalities in the formation of the
orbital cavities (which create a greater susceptibility for scotomata
in certain individuals) this question be &iswered with any degree
of accuracy. It is quite possible that the study of brain functions
by means of measuring brain waves may throw some light on the cortical
involvements which tend toward the development of divergent and
strabismus in cases where no physical abnormalities are
demonstrable.
Retrobulbar neuritis is one of the known factors in the development
of central scotamata. Whether the location of the central nerve bundles
(reaching the macula) on the temporal si de of the optic nerve imffiediately
behind the eye rnakes them more accessible to taxic involvement ls a
question which is still debated. Apparently these nerve bundles are
most susceptible ta permanent in jury in cases of optic neuritis. There
may also be an inheritance factor.
Question 2: Is it advisable ta start training at the crossing point in
esotropia?
Answer: This is the one point where training should not be started.
The place to "coai:
1l
a binocular field is alV'rays sorne distance beyond the
érossing point. Let us assume that by bringing a light toward the
eyes until the reflexes are &entered on both corneas, the crossing
point is found to be at three and a half inches. When the patient makes
no effort to fixate the light binocularly at that distance, he should
attempt it at five inches. It is this effort that is apt to bring
about the shift from strabismic to binocular seeing. The establishment
of rudimentary binocular field processes depends on the effort whieh
the patient makes to posture binocularly. the target is placed
at theccrossing point, we not only do not invite a binocular pesturing
effort, but actually prevent it from occuring. On the ether hand,
if the abject is brought beyond this point, the patient feels that he
has "done something" \'l'hen he is able ta look at the target ri th both
eyes (as he has been instrueted ta do). It is this effort ta lido
something" ",mch is capable of changing his concept of what he sees.
He has been forced ta enter the other room instead of talking thru the
door.
Question 3: HOIT do \'re knol'r l'rhether or not ... patient will respond te
training?
Answer: If Ci!. patient cann.ot De braugnt to the necessary posturing
59
60
effort, the chances of establishing a binocular sensory field are
slim. The only question i8 how far fram the cros8ing point should the
original atternpt at binocular posture be made.
The push-up test can furnish the desired information. Increases
in the convergence of the strabismic eye, when the light is brought
closer, is frequently noted. This overconvergence stops at a certain
point and both eyes suddenly fixate the light. Let us asSUl'œ that Othis
oeeurs at 3 1/2 incbes. The retinoscope light should then be brought
still nearer to the patient's nose in orderto observe whether bath eyes
will follow ttclight in or whether the strabismic eye now assumes a
position of under convergence. When the latter is the case we have
no right to assurœ that the individu al had shown a :--inocular posture
at 3 1/2 inches. If, on the other hand, both eyes follow the light in
to two inches before an apparent break occurs, the light i8 drawn
slowly avray from the nase and careful watch iS kept as to when the two
eyes abandon direct fixation. This may happen at 4 1/2 inches or at
10 inches. In the former case we should likely attempt binocular
posture initially at five inches, while in the latter case at 12 inches,
approaching the target closer only when the initial attempt proved a
failure.
Question 4: What use has the amblyoscope in strabisl!D.ls training?
Answer: The amblyoscope has a defini te pl a.ce ::"n visuaJ. training of the
strabismic. However certain restrictions should be ob8erved te prevent
the violation of the rules just For instance, it is
important to remember that it is not permissible (ta our way of thinking)
to aijust a synoptoscope or amblyoscope ta the existing angle of squint
for an initial eff0rt at establishing a binocular field percept. To
try to establish a binocular pattern, in an individual who ls permitted
to maintain his habitual strabismic posture, simply means that you
elect to fight against odds that you don't have to take. Besides, if
you succeed, how will you induce him to change to normal posture?
When, on the other hand, you determine the existing angle of squint
to be 35 degrees, and you attempt to establish with the instrument
at 25 degrees, your chances of success are greatly enhanced. However,
even this does not constitute an advisable procedure. What the
individual learns in the amblyoscope set-up cannat easily be transferred
into his normal surroundings. When a stereo-percept can be established
at nine or ten inches with the BSM technique the individu al can apply
what he has learned (or rather experienced) in his normal surroundings
when an abject is brought to this distance in front of him. To see
that this happens is a part of the training program.
Question 5: If rre achieve binocular vision in a former strabismic, with-
out teaching him diplopia, can l'fe aften'iards ta.tce phorias
ductions as we do with non-strabismics?
Ansner: This ia an important question and the answer is NO. The reason
i5 that when making duction or phoria tests, the patient can still
revert to his strabismic thinking. Rather than see double, he will
simp1y revert and report one target. In duction tests
he Will not be conscious of the breakpoint and the only was.< we can
de termine i twill be by his gbserving a lateral motion of the fixation
target, indicating that binocular seeing hact been abandoned. It
will be very difficult to de termine a recovery point. The chances are
that he will not again recover a binocular pattern of seeing, unless
he is permitted to reorganize his binocular pattern outside of the
phoropter. As a matter of fact, only if larn assured that the patient
can maintain a binocular pattern at all times and without undue
discomfort, do l consider that diplopia training may be given as a
safeguard against occasional lapses into the former tropia position.
Care has to be taken that as saon as a comp1aint of annoying
diplopia i5 made diplopia training is immediately abandoned, at
least for the time being. Also, before diplopia training is
undertaken (as a final step) it has ta be ascertained that fusion
can be maintained in all portions of the field.
61
62
APPENDIX
A. Notes on testing the pre-school child.
This afternoon l ta sh01f you how you can haneile a t'irO and
a hill year old child to get the maxirnlm information. We had a very gOGd
subject for the demonstration. The doctor whom l approached rOI' the
selection of a little patient did not want ta suggest her because she is
so very bashful and shy. l him that 'Iras the very child l wanted.
It seemed all very easy the way we "ent about it, but the child would
have been a Yery difficul t patient in the ordinary office routine.
You aIl watched me get a glimpse at the child's two foveas by playing
the game of the two of us peepïng into the ophthalmoscope from opposite
ends, ta see what was inside. This, of course, came after the delightful
past time of "blowing out the candle." You noticed that as saon as the
child blew at the exposed ophthalmoscope bulb (the "candle")' l sritched
it off, regardless of hOir mch l ha.ted ta do it at the lllJment because l
was observing her for indications of binocular fixation (push-up test).
After a while, l managed to tell her to wait with the IIblowing out"
until l told her to blow. In that way l could observe rotations and
saccadic fixations at will.
When l was ready for the fundus examination l turned the light on
inslde the ophthalmoscope and from a distance directed the instrument in
such a way that she could see the light. Then came the "game". "Do you
see how l look inside this hole?" "Wou Id you like ta look in from the
other side?" It was as easy as that. Once she did look inside, the
macula was in clear view. l did not go for the disc, but by finding
tœ macula centered in my 1igh t l:eg l knew that she had direct fixation
abi1ity with either eye and that she could not be very amblyopie. An
arr,blyopic eye usual1y wavers and may not show the macula at all when the
game is played. If a child refuses ta pldy the game, don't ever force
yourself on the child.
l would never set a child up on a refraction chair without making
it difficult for him. l raise the chair up high and put an additional
cushion on top of it and then am apt to say: "1 bet you can't get up
there by yourself - ri thou t having Mother help you!" The usual
answer is: "1 bet l can!" And up he goes! But you have to give him
a better incentive to climb the chair tban to have his eyes examined.
That is as unpleasant a prospect ta a child as is the dentist' s
appointment.
The child has, by now, become accustomened to two different lights.
l show him that l have still another one. "Look, can you se.e the light
while l riggle it like this?" It is j then, not very difficul t ta get
him to look at the little red dog, which serves as my dynamic target.
The lit tle red dag has still a smaller black squirrel underneath. "Did
you ever see su ch a very red dog? 'r'Inat is he jumping over?f1 By the
time the child has made up his mino how to the scoping is done.
B.
!WO things are, of course, important in all examinations: occular
motility and the fundus pieture. Refraction cornes third. Once the child
has permitted you ta look into his eyes, refraetion should not pose too
mueh of a problem.
l never put a trial frame on a small child. If l need a lens, the
big problem is how ta get itin front of the child's eyes. As a rule,
the minute you start holding something very close ta his eyes he starts
ta get seared. ~
For the purpose of refraeting ehildren, l always use the standard
old-fashioned trial case with the bi-concave and bi-convex lenses. l
hold a lens up about midway between the child and myself and mve i t
63
around. Soon the child wonders what l see through it and makes an effort
to look through it also. T h a ~ is the time ta bring the lens, by slow
degrees, nearer and nearer ta his eyes. The difficult task is aceomplished.
A good refractionist can estirnate a cylindrical correction quite elosely
withQut the use of cylindrical lenses. If l can get within a diopter of
an accurate scoping, th.at i5 all l need at the moment.
It may be stated right here that we are very much in need of a
suitable subjective test to determine within reasonable accuracy the visual
acuity in a pre-school child from two years up. It i8 a difficult
problem but by no mean8 insurmountable.
Notes on occlusion of a pre-school child.
In order to make monocular tests for visual acuity or to prevent
alternation of fixation during the difficult task of scoping, it is
necessary to occlude one of the child's eyes. May l counsel you right
here that you should never attempt to ocelude a small ehild's eye your-
self, at least not the first tirne. It is mueh better ta let the child
occlude his own eye by keeping his hand in front of it or to let the
mother hold her hand cupped in front of the eye which is ta be occluded.
This does not permit you to place a trial frame in front of the child
and that is just as weIl, because a frame would be apt to evoke a
eatastrophic reaction. It is mueh better for the examiner ta hold a
trial lens in front of the child's seeing eye and to be ready to with-
draw it the minute he notices any sign of anxiety developing.
We had a little girl here this afternoon - the one l used to
demonstrate haw ta approach a pre-school child in an effort to get the
most information·with the least arnount of unpleasant reaction. You
noticed that l played with the little girl while a3sembling rny data.
The parents came to the clinic, not to let rny play with the shy little
girl but ta arrive at sorne decision regarding her strabismie condition.
After l had finished the mother wanted me ta advise her as what she
should do about the strabismus. As you may weIl imagine, it takes more
than one short visit to assemble sufficient data ta give a valid
opinion, but we were able ta ascertain that the little girl is an
alternating strabismie and shows no marked tendencies toward binocular
6h
posture. She seems te be weil on the way ambiocular vision. What
can we do about it?
Because of lack of sufficient information let us make a few
assumptions. Let us assume that the child had come to your office and
you had gone through the first session in sorne such manner as you saw me.
Let us suppose that, on the third visit you had been able to find
indications of binocular fixation ability at very close range. Having
gathered this it not seem advisable, to MY way ef
'thinking, to order prolQnged total occlusion of one of the other eye
or alternate occlusion on alternate days because, by doing sa yeu might
destroy the binocular pattern of seeing. In this case it would be more
advisable toorder partial occlusion of both eyes which l shaIl describe
shortly - to prevent the developrnent of ambiocular seeing.
First let us discuss other questions which might leas us to
occlusion. Suppose the lit tle ëhild in question had shown unilateral
strabismus and that turned eye showed little inclination to follow a
light or ta turn directly toward a fixation abject. It vw'ould, then,
become necessary to occlude the good eye ta determine the usability
of the squinting eye. Vfuen such a situation arises with a pre-school
child it is never advisable ta occlude the good eye except for fractional
periods until an estimate of the usable vision of the turned eye can be
made. When total prolonged occlusion of the good eye is necessary we
usually proceed as follows:
The mother is instrueted to take the ehild home and tell him the
next lOOrning that one eye has to be closed up· because i t rrlooks bad."
The mother then proceeds ta acclude the turned eye rather than the good
one by fastening a cellUbid shield over it with cellophane or adhesive.
The ehild i8 not apt to resent having his turned eye occluded after he
gets over the first shoek of having a Ifbandage
lf
• By the occlusion of
the bad eye he is in no way handicapped visually and usuallyis quite
willing ta leave the occluder on for a quite a spell. As SODn as it it
becomes evident that the child is irritable beeause of the occluder,
orders are ta remove it for the rest of the day. This procedure ls
followed daily until the child tolerates the occluder for a whole day.
Only then begins the process of occlusion of the good eye, at first
for very short periods. Specifie orders are given that the child i5
not ta be let out of sight while the occluder is on the good eye and
the every effort must be made ta entertain the child and ta coax it
to E!3r while the occluder is in place. Under no circumstances must
the occluder ever he used as a means of punishment for nad behavior,
or for bad behavior during occlusion. It is only after it has been
ascertained that the occlusion of the good eyehas no bact effects on
the child's behavior and ability ta get around that the occluder may
be left on the good eye for days at a time. If the child shows
indications of inadequate vision when the good eye is totally occluded,
it becomes ta attempt to improve the visual deficiency. Law
Vision may be due to lack of fixation ability of the Irabandoned eye
lf
or ta a central seoto8a.
r
c.
C. Notes on training the pre-school child.
In our own procedure this child would be brought to the office
at least trice a week for Tlplay". Carefully supervised "games", sueh as
tracing the bunny (BSM 20) as projected through a ruby filter onto the
intermediate screen, would be played. The child would wear red and green
filters, the green one over the good eye. Thus the bunny could not be
seen by the good eye and the cpild would have no feeling of occlusion of
that eye. Other games are - playing with marbles, picking up small
pellets, or stringing beads with the good eye tot
al
1y occluded.
We usually advise parents to buy the child two identical coloring
books with bsld outline drawings. The chi Id is allowed to color in one
book with the good eye, followed by an attempt te celor the same page
in the other book with the good eye occluded. In this way it is often
possible to establish a desire in the child to do as weIl with one eye
as with other, without causing resentment in the child that the speèific
task has always ta be done ri th the "bad" eye "hen he knows that he
could do the task sa much better with the other eye.
When it is possible by such methods to bring about satisfactory
fixation of the forrnerly turned eye, it is permissible ta alternate total
occlusion of the good eye with a day when bath eyes are allowed to remain
open. This gives the child a chance ta develop binacular pasturing
ability, if that it within his achievernent level. It is not permissible
to maintain bath eyes unoccluded for very prolonged periods, if after a
month of two there are no indications that binocular posturing oceurs.
Keeping both eyes permanently i ~ the race is simply to invite the
emergence of an ambiocular mode of seeing (associated with alternation),
which will complicate the original problem rather than simplify it.
Case Report. The follo?Qng story was given as a background - At
the age of three the child' s eyes become partially turned. The mother
became perturbed and brought the child to a local medical practitioner.
The latter furnished the inforID3.tion that the refractive condition was
approxirnately plus 2.00 OU and that she had 20/20 vision with each eye.
The doctor ordered occlusion of one eye when the child was three years
old. The child now is nine, sa that occlusion was begun six year aga.
Every six months the child was brought to the doctor's office but
apparèntly nothingwas done except ta take the occluder off one eye and
place over the other eye. This procedure was carried on for six years,
sa that, as of today, the child has had every minute of her waking hours
one eye or the other totally occluded. Now this is what her parents
report: - Year by year the occluded eye turned in farther and farther so
that today the child has a tremendous convergent souint with one eye
almost lost from vie',,,- when the occluder i8 removed, On examining the
patient l recomr.ended removal of the occluder. W h ~ r r the mother agreed,
the child broke into a terrible fit. She became completely hysterical
at the thought of the occluder being removed from her glasses - for
tte first time in six years. It was an insurmountable problem for her
ta face. Because of her violent reaction the matter l'fas dropped
65
66
immediately. After a few more visits, acceptance was gradually
obtained, as psychologically she accepted the new situation. There
is the background of that story.
Has this child been able to develop a binocular posture? The
is that binocular posturing has been inhibi ted for the last
six years. On the other hand, occlusion has not permitted her ta
develop an ambiocular (strabismie) posture, and in that sense the
procedure was justified.
The fact that the eye turned more after occlusion is not an
isolated case. We have recently had several reports in the ophthalmo-
logical literature of similar occurences, which questioned the
advisability of total occlusion for this very reason. The report went
on to say that in several instances, where occlusion was cm'ried out
because of amblyopia associated with straight eyes, they had strabismus
to deal with after occlusion therapy. Actuallysome parents sued the
doctors responsible for the occlusion because of the resultant strabisrnus.
It is therefore quite true that total occlusion has its drawbacks.
1 do not agree to total occlusion of one eye for any extended
periode It is not an acceptable procedure in my way of thinking. If
total occlusion brings about a better fixation, the better fixation
can be brought about more directly by visual training. So why not
train? Total occlusion certainly cannat build a binocular pos ture,
because it destroysany possibili ty of an occasional at.teIq)t at
binocular posture from becoJring effective. These factors have to be
considered in occlusion therapy.
On the other hand, subnormal VlSlon in uniocular strabismus fre-
quently improves under total occlusion, the patient becoming an
alternator. In such cases occlusion therapy is acceptable until direct
fixation ability has been established. Then a different kind of
occlusion should be started.
The second kind of occlusion is the one we want to consider now.
D. Notes on the use of HALF
If we take the total occluder off the li ttle patient, she will
have no incentive to binocular posture. Also, if total uniocular
occlusion is abandoned, the visual impressions that enter via the turned
eye will have ta be cortically "suppressed:1 or interpreted according to
the relative eye positions. Inasmuch as this patient is sa very
strabismic, interpretation will folloN strabismic laws, in other words,
seeing (strabismic posture) will eventually evolve, unless
prevented.
c..:uestion: Could ambiocular posture be prevented bv occludine one
eye the first day, the other eye second not occluding either
eye the third day, so that the child might "fall into" binocular fixation
at least at near?
Answer: In rny oplnlon this procedure would n0t effectively prevent
the advent of ambiocular posture. By alternate occlusion each eye wauld
be forced ta take over the visual functians of the ather (occluded) eye.
The third day there would result a rivalry between two eyes as to which
should take the lead and which should be suppressed. It is quite likely
that this procedure would hasten strabismic posture rather t ~ a n prevent
i ts accurence.
It seems ta me that the answer ta the problem i3 - put on half-
occluders on both eyes for a prolonged periad. This is best done by
frosting the nasal areas of both spectacle lenses 50 that, an gazing
,straight ahead the whole pupil clears the frosted area (see figure).
This method can, of course, only be applied in marked convergent
strabismv.s, because i t would not be safe to occlude the temporal fields
in divergent strabismus (one eye cannot take over where the other eye
does not see) they are not overlapping fields.
RI"HT Cyr STf?A\GHT
AREA
From the figure i t is eviden t that, when the one eye looks "out"
the direct line of gaze of the other eye is directed under the occluder.
A macular image cannot form in that eye so long as it is turned. If
both eyes can c l e ~ ~ the occluder, the eyes are cosmetically straight
and a binocular pattern of seeing is possible, provided the strabismic
wants i t.
67
J
'J
1
-j
1

1
l. ORGANlSMIC LAWS THAT PERTAIN Ta VISUAL TRAINING

A.

The purpose of visual training is ta bring about a better adjustment of the individual ta his natural surroundings. Therefore, training conditions should be made ta natural surroundings as nearly as possible.
sim~late

. B.

There is an organismic tendency toward full use of existing abili ties. Question: Answer: Question: Answer: What, then, causes visual concessions? Concessions occur when there is a lack of demand for all existing abilities. If there is a natural tendency ta make use of aIl existing abilities, why do we need visual training? Visual training i f it is properly applied, makes à demand for all existing abilities.

c.

There is a natural tendency toward cOmpletion of a conternplated act and ta accomplish it with the least expenditure of energy. We are usually determined ta complete a task once we have started. In visual training of the child things go weIl until the given task is completed, but once it has been attained repetition is not interesting. Renshaw says that if we get five minutes of actual training per hour spent, we do weIl.

D.

It is the nature of the posture which responses.

deterw~nes

the nature of the

The above statement means this: while the eyes are in a strabismic posture, the individual thinks strabismically, but the minute his eyes are in a normal posture he ceases ta think strabismically and thinks the way we do. 'The shift from strabismic ta normal posture brings about a complete change in his interpretation. This means that when he looks at a smaIl target with bath eyes directly, he cannat think strabismically; he must think the way we do. However, the shift from strabismic ta normaï posture cannat be accomplishedwithout a change from wanting ta look at a given fixation abject with one eye only ta wanting ta look at it with bath eyes simultaneously. Binocular interpretation does not have ta be taught! We donlt have ta break down anomalous retinal correspondence in order to establish normal retinal correspondence. Our sole purpose in visual training is to posture an individual adequately, and when that has been accamplished the rest comes easy.

i

1

2

We need contraIs. We need ta know when we have normal posture and when we do note No training instrument 1s worthy of i ts nalLe if i t does permit us te differentiate betiVeen iVhat 1s normal and what i5 note And no orthoptist i5 worthy of the name if he cannot differentiate between a substitute performance and a true performance. This i8 not a simple problem. It i5 not easy ta determine when a child trains in a constructive way and when it si~ly perforrns ta sati5fy "minimum requirements". Ta differentiate between purposeful and "lackadaiSical" performances takes adequate controls. Unless we have such contraIs we cannat hope ta mainta1n a high level of response. Binocular posture is the ability ta ma1ntain Buch relative eye positions in anticipation of a certain visual task that both eyes directly fixate a single abject of special regard: Binocular posture means, eBsentially, "looking at a single fixation abject ri th bath eyes, at the srune time. 1/ Not all individuals who are adjusted ta their natural environment depend on binocular posture. There are two other :forma of osture around which an individual ma success:full organize his seeing: a m~n~n~ng postur.e 'with one eye only, or monocular posture, (b) mallltalmng separate Unes of direct gaze for each eye, or strabismic posture. Maintaining monocular'posture, means that only one eye fixates the abject of special attention. Tge eye that looks at the abject of regard is the eye that is used for the cortical interpretation of that objecte The other eye is not used for that purpose. The other eye maybe looking in an entirely di:f:ferent direction. This eye may have, at the moment, a perceptual purpose or i t may note The question nov{ arises, is it used for any other purpose? If it has no other purpose, i3 kept in "cold storagef! so to speak, we have monocular posture, for what the other eye is doing at the moment is of no interest to the organisme Maintaining separate lines of di:ect gaze for each ere, or strabismic posture. In the sense deflned here, it does not include aIl strabismics but is lirràted to those who are ambiocular in their visual behavior. The term "aJJbiocular" describes a condition where both eyes are used for separate and distinct purposes. That is, they attend to different functions at the sallE time. We find this posture in "anomàlous projection" of alterating strabismics. My investigations into the nature: of ambiocular vision have definitely proved that these strabisrrUcs Can look in two directions at once and interpret the macular images of bath eyes simultaneously.

The term " s trabismic posture". which may be the reason it ls frequently found in the mentally deficient.3 If you play the piano with one hand.that its acquisition denotes a high achievement level. The latter-requires an entirely different posturing rnechanism for the left hand than for the right. may gradually be replaced bv the more desirable patterns and may eventually disappear from consciousness because of disuse.terms wffich are usually promiscuously given to essentially ambiocular and uniocular alternating postures. the undesirable. . It is often referred to in ophthalmological li terature as "anomalous retinal correspondence". never encountered a strongly integrated ambiocular percept in very young children or in individuals of low intelligence. This seems no longer justifiable because. IIvicarious fovea ll . In my own investigations l have . s trictly speaking. Yeu rnay suppress thern by presenting the individual with new and different demands "hich require new learning. once this posturing ability has been attained. When a binocular posturing attempt is made by an individual ha ring strabismc or uniocular posture. accomplishment. This is easier of accomplishrœnt than wri ting the word cat wi th both hands in a left to right direction. unless the latter heightens hisaccuracy of sp~tial orientation for exceptionally demanding tasks with which he is being confronted and which cannot be solved while maintaining strabismic posture.'ill be 1 1 1 . you cannot "break down" learned concepts. (from our point of view) patterns. Tt used ta be IllY ïrnplicit belief that we had to "break down" anomalous projection prior to making any attempt to "building up" normal projection. This may serve as a simile ta show why binc>cular posturing is cortically less difficul t and requires lêS-sÛEntal effort than stI'abismic posturing. visually speaking. The forzœr ability illustrates the ambiocular strabismic. the response v. AlI evidence points to the fact that strabismic posture is much harder ta learn than binocular posture and . the individual is not readily willing to give it up in exchange for binocular posture. while the second exemplifies normal binocular vision. It takes more skill to play different measures with each hand than to play the same tune wi th both hands. For the same reason. Monocular posturing is stillless of an . You may wri te "cat" ri th the right hand "hile writing cat mirror-fashion with the left hand. represent' s the sort of visu::!l behavior which l have variously called "anomalous projection" (of the most accomplished order) or "ambiocular vision". it does not prevent you from playing someother chord with the other. If you cannot coordinate both hands in this way. as above defined. you may concentrate your whole attention on the one task of playing the same tune with both hands. If such learning is directed toward our eventual goal. and playing the piano with one hand corresponds ta uniocular posture. while the former may be done with a single posturing effort for bath hands.

This an individual who depends on uniocular or strabismic posture simplycannot do. theway they are applied in flpointer training'! in the stereoscope. if the latter involves less effort and the visuai task can still be eompleted. An individu al ~ho habitually maintains uniocular posture can see no reason why he should make a greater effort at'obtaining visual data. However.of poor quaIi ty. It ia therefore essential. i t will have stereoscopie qualities. J . l may point out here that the use of pointers.. l F. ' ~~ This is one of the most important tenets in visual training. E. individual. 1. Ifspecial task" in an attenpt te elleit binocular posture with the strabismic. sueh demands may serve as a. i. provided stereoscopie demands are made. since i twill be bas ed on . who i3 capable of binoeular posture l mal at certain times maintain uniocular posture. An individual who uses binocular posture can bring two pointers tip to tip. 1 î 1 . does not fulfill the above requirements. This may be permissible with individuals who are known ta possess weIl integrated binocular field structures.e. added energy expenditure. if he main tains alternate fixation than i f he attempts binocular fixation while he performs this task. Such effort l'fould simply be an "added burden". It is important to kno\'{ that pointers may be used to f oree an indi vidual to rna. Why should an individual maintain accurate binocular posture when he can complete the task to his entire satisfaction with a less effortful posture? There is no organismic reason.intain binocul ar pos ture. Th j J 1 il f ~ i i ~ ab th th h s b a o It is common practice today to use stereoscopie photographs for binocular fusion training which contain a vertical white line in a certain area of the total field for the one eye. This i5 so because the indi vidual who is capable of rapid al ternation of fixation can achieve more accuratelz by far. in an effort ta improve or establish binocular posturing ability. and a horizontal line in ~~e corresponding area of the total field of the other eye. to present the individual with the kind of task which requires for successfuI cornpletion exact binocular posture. Since stereoscopie demands require binocular posture. it is b .a binocular field structure it will be capable of interpreting retinal disparity in ter ms ~f depth variables. whichcan 'be gaineçl without such addedeffort. Varying perceptual demands may bring ab ou t varying postural sets. 2. but. It raises rather interesting questions. because the task is above his accomplishment level. and without organismic purpose.

by doing so. The diff:i. synoptascope. Again.) Even in a push-up test. The individu. is to know what is "re'achable" and -W:hat is 'note It holds true in aH training that it is harmful to work above the individual's achievement level. We can separate the individual who can and will posture binocularly (no matter for ho\'{ short a time) under specifically arranged conditions from the individual who is totally incapable of binocular posture.. That is something we have not known. of course. Such controls are patently inadequate for differentiating between binocular and strabismic posture. i t is nat possible to tell 1 . F. yet they are presently allIDst the only 'ones on which any reliance i3 being placed in vision training. He arrives at his in~er­ pretation via two consecutive impressions by the simple expedient of "temporal fusion". where there seerns good indication of "binocular fixation" over sorne range.'1ey are presented to us by means of a motion picture apparatus. but it is nevertheless true. even as we achieve temporal fusion of successi<lre pictures when t. the patient himself will be of the oninion that he sees both pictures as one. An individual habitually maintaining strabismic posture may. 5 1 1 1 2. Centered corneal reflexes of a light which has been brought ta the "crossing point" of the v'Îsual axes do not necessarily indicate that fusable targets can be brought inta "retinal correspondence" by adjusting aIl instrument ta the existing angle of strabisrnus (amblyoscope. indi vidual can reach visually has diagnostic significance. The individual who possesses binocular post1lring ability has a higher achievement potenti21 than i f he were lacking in that ability. containi~g a perfect cross. how high ail. for certain heightened perceptual demands. use binocular posture if the latter is necessary for the successful corrpletion of the task.culty.f 1 1 f readily dernonstrable that the individual who has a strabismic posture can interpret these photographs to the entire satisfaction of the technician by alternate fixation and. If a task is difficult. the individual has two possibilities ignore it or reach high enough ta achieve it. etc. In fact the Keystone "moving picture" slides for the Telebinocular are based on the same phenomenon.<11 'Nho knows ho\'!' to posture binocularly can therefore be confronted \Yi th a more difficul t visual task than the individual who does not know how so ta posture.

while he maintains such accurate posture. H. For instance. if he is capa. The specifie purpose of an visual training is' to bring about an adequate binocular posture rrhich. A rnuch lI'. 2 an organismic desire to achieve. Binocular posture makes possible the appreciation of the different viewpoints of the two eyes looking at objects from different stations. for instance. i t is permissible ta infer that the indi vidual wrote what i8 on the page. The two terms are actually interchangeable.6 whether an accurate or an inacurrate posture is being mairttained. We cannot separate binocular vision from binocular posture nor can we separate binocular posture from binocular vision. in turn. G.ce 01 accurate binocular posture.T . with which the task is completed. (a) the difference in the proximal stimulations received by the two eres becauc'"' __of their separated position in the s1. If an individual is left in an empty room ri th a piece of clean white paper and a pencil. we are assured that he is capable of accurate binocular posturing ability. the fluidity. and he afterwards shOl'ls a written page and a used pencil. if his handedness i8 known and copies of his hand writing are available. because i t would be almost impossible for him ta simulate wi th his non-dominant hand wri ting done wi th his other hand. (b) Accurate s tereosco ic abili t deoends on (1) maintenaTJ. he is capable of interpreting wi th satisfactory stereosc'opic accuracy. that writing ri th the dominant hand is far better integrated. than any writing that may be attempted with a hand entirely new ta the task. We also know that this skill is not easily transperable from one hand ta the other. Normal binocular vision rlepends on binocular posture. If he attempts ta WTite with the nondominant hand. 'lY'tei =reted as depth variables in stereoscopie perception. . more ballistic. If he does not achieve.ore accurate way of telling is to observe the individual t s a. It i8 legitimate to come to conclusions by inference. This also means that. How weIl an individual ls postured for a task is indicated by the ease. You could infer· these facts only because you had something to compare.ble" of the extremely accurate spatial orientation which 1s necessary ta s.uccessfully complete the Pointer test. this will be readily apparent from'the nature of his characters.111-is organismicall. It is also possible to deduce with which hand he wro te i t. U) the ability of bath eles ta see clearly.YiIlity·to achieve at certain tasks.. We know. it mean8 simply that we have not been able ta provide the sort of test conditions which will make him reach for the highest visu al achievement of which he i3 capable. guarantees the greatest adeguacy of the 'Visual responses of which the individual is capable.

provides a very real reason why strabismus. cannot be cured. Retinal rivalry is dependent on the existence of corresponding retinal areas. ~omes specifie and wç may lay out clear programs for visual training . we must know more about the meaning of retinal correspondence • .7 THE MEANING OF RETINAL CORRESPONDENCE AND RETINAL RIVALRY IN VISUAL PERCEPTION From a. Let us be clear on this one thing: there are no possible exceptions to retinal correspondence. Let us assume that an area ten degrees off the fovea of one eye. Corresponding retinal areas are invariably equidistant and on the Saffie side of the two foveas. There are no "secondarily" corresponding retinal areas . which exhibits this supposed forro of seeing. there are many indiviàuals maintaining eye positions. l. especially if he can also have full stereoscopie perception.programs which are not possible if we accept the theory of anomalous retinal correspondence. Acceptance of the concept of abnormal retinal correspondence. Vmen the suppression is lifted. RETIN. How can we possibly change such a relationship? When an individual once has acquired this relationship he has no incentive whatever to give it up. A.AL CORRESPONDENCE We come back to the fundamental concept of retinally corresponding areas in the two eyes. fovea to fovea corresponrlence is always immediately apparent.not even in strabismic posture or in the so called anomalous conditions. AlI responses which make i t appear as if there were anomalously corresponding retinal areas are artefacts which have a different explanation. The two foveas are always retinally corresponding. Our thinking :. Such individuals may have a very low grade peripheral stereo-awareness but they invariably show strong macular suppression. These conditions will be discussed in greater detail under the heading of !!Retinal Slip!!" The concept of fovea ta fovea relationship in all binocular . Before we can discuss retinal rivalry adequately. No other areas are acceptable as retinally corresponding areas. which are within ten degrees of parallellism. as above defined. If we de fi ne retinal correspondence as fovea to fovea correspondence..be considered here. Once this concep t is~ clearly established we shall have no further trouble with any of the visual training concepts which will.. diagnostic point of vievi i t is important that we know how to interpret retinal rivalry. l am prepared to say that in all cases the two foveas are such corresponding retinal areas. (Duke-EIder) True.which are not geometrically corresponding . has become corresponding with the fovea area of the other eye in a binocular field percept.

This we can do because the centers of both foveas are the points of referenct:J from which a1l these calculations can be made.. Under normal conditions. it is this axis. Visual Survey Series for infinity. the phoria test would lose all meaning. When the arrow appears to point at the numeral 9. when the arrow points to numbër 8 or number 7. that reaches the retinal point which must serve as the locus from which measurements are ta be made. If only one foveal center were available. pravidedwe knaw the exact scale of that map and are assured that it has been drawn correctly. the position of the arrow in relation ta the numerals which are yisible to the other eye cannot be interpreted in terms of retinal positions unless favea to fovea correspondence exists. it is possible to state in mathematical terms how many degrees the eyes are out of alignment. In an amblyopic eye the blind area is apt ta include and surround the center of one fovea because of a central scotoma. As long as we have the fixation point of the other eye. This circle is visible to the patient while its center i8 note If it is possibill ta align the two eyes in su ch a way that the circle is phenomenally centered around the fixation target of the good eye. This is an important consideration in amblyopia.8 sensory fields is vital when we seek to determine adequacy of binocular posture. If we could not make this assumption. In amblyopia the center of one fovea may be necrotic. we put the points of the calipers in the center of the two city areas and always use these same points ta make comparisan between different cities on this map. nomeasurements could be made. The center of each fovea represents. If the map were drawn by approximation instead of by triangulation. How else 'could we measure? If we use the phoria test of the Keystone . Without such specifie points of reference there can be no accurate interpretation of the map. We should have no measuring stick. the center of the circle can be used as the second point to which to apply our measuring stick. because we would have no means of determining the shift in retinal correspondence which would be "normal'! for the particular indiviàual' and for none other. in like manner. for instance. But measurements are possible. However. We could not. measure the length of a table. we must be able to assume that the two eyes are in exactly parallel position. Phoria measurements can be made as accurately as we can measure the distance between two cities on a map.e. we can draw a circle around the blind area of the amblyopie eye. if one end i f i t were hidden from view. This means that the individual cannat fixate along the primary axis. Even in an eye ~nth a central coloborna. in which case there . the unchanging point of reference in ocular measurements of all kinds. i. these measurements could not be interpreted. and this axis alone. incapable of conducting nerve irr~ulses to the brain. In order to determine the distance between two cities. In accepting the presence of a binocular sensory !leld we must assume the existence of fovea to fovea correspondence.

C. Wnen variations in photographs of ~~ object . Two films. as Verhoeff has so ably demonstrated. By this method it is possible ta plot the scotomatous area of the affected eye. In this case the two foveas are never in permanent relationship to each other. but only because the relationship between retinal areas of the two eyes is always the same (while abinocular perceptual field is maintained). one for each eye. The. foveas can therefore not be used as a measuring-stick for binary visual perceptions. Difference between binocular and ambiocular sensory fields. we can present this eye with a large enough circular target (a ring) to surround the entire coloboma. On the other hand. B. which obviates the need for retinal correspondence. The relative alignment of the two eyes can now be accurately determined. It can be demonstrated that in these cases a binocular sensory field does not exist. We know that a sirnultaneous percept is possible in certain forms of strabismus where the two eyes are not in normal alignment. can be laid on top of each other sa that like images are superimposed and a single clear print can be made thru the two films. For this reason an anomalous horopter is never formed. from the sarne point. This ring may be centered around a spot source of light. A binocular sensory field may be compared with two films being laid on top of each other for inspection. but rather two separate sensory fields. Retina1ly corres ondin areas cannot exist where there ls no binocular perceptual field as above defined.9 is a large visible destruction of retinal tissue. taken with the Saille camera. which is visible ta the fixating eye only (the light falling into the blind area of the defective eye). two images are never fused.(because of the different locations from which the pictures have been taken) are superlmposed they may' be . just as we can learn to accept by the sarne process a mirrored abject as being part and parcel of the ~eal object. The centers of the respective. Ambiocular (strabismic) perception seems to be dependent on the retention of two cortically separate sensory fields. D. Experiments show that in s trabismic pos ture the cortical images produced by the right and the left eye are separately considered and that their closure into a single unitary percept is obtained by a prQcess of abstraction (a frontal lobe process). as l have shown in my investigations relative to strabismic seeing. even i f the prints are shawn separately each can be interpreted accurately and independently of the other. The strabismic learn to accept the right and left images of a single object as belonging to that object.

an ambiocular field percept constitutes a summation of right and left percepts. resulting in two weIl defined areas of clear vision in the total percept. j i 1 1 j l 1 ! a f 1 F. and. A_ 'j)iIlocularsensory field percept is neither a right nar a left percept bùt differs materially from both. ~. total occlusion of one eye will give temporary relief. it is of diagnostic significance whether or not this prism produces diplopia. The presence of a binocular sensory field doss not necessarily mean that we have a single spatial percept. Suppose that we make binocular posture te~orarily impossible by the elevation of one eye above the other by means of a base down prisme The fixation object can no longer reach corresponding retinal areas and it is seen double. In a non-us able binocular field the spatial concept is distorted because of the very existence of a binocular field and accurate spatial orientation becomes dependent on the resurrption of adequate binocular posture.10 ! i' interpreted stereoscopie ally. horia measurements throu h h to 6 over one eye indicates the existence of a satisfac tory binocular field. How can we know whether he has a binocular field percept or'not? When we put a six degree prism base down over one eye. it indicates that the amblyope hact a usable binocular field prior to the introduction of the vertical prisme On the other hand if no diplopia is produced. Suppose a binocular amblyope with 20/200 vision in both eyes. accurate binocular posture cannot be maintained. we must assume that a binocular field does not existe Establishment of a binocular sensory field is desirable because it will heighten the visual achievement level of the individual. On the other hand.sortEtimes impossible with individuals who have fully matured before the eyes were thrown out of alignment. When the responses to these tests are uncertain. A single spatial percept is possible only when binocular posture is available. When phoria rneasurements cannot . If diplopia results and the two images can be vertically aligned by addition of horizontal prism. The use of prisms is definitely indicated when a non-usable binocular field can thereby be· made usable. Vlhen that is not possible. It is evident that vre Imlst differentiate between lIusuable" and· "non-usuable" binocular fields. Each clear area is seen exactly as-the corresponding eye sees it. the existence of strongly established binocular visual pe'rcept can be doubted. In the total field of the strabismic a certain area is foveally perceived by one eye and another area is foveally perceived by the other eye. Elimination (by suppression) of an unusable binocular field i8 diffièûlt. This means that even though the binocular field persists.

ent of this type will almost invariably say "1 think that the two images are now ab ove each other".on. vertical prism produces diplopia. we may conclude that total suppression did not cause the prior lack of diplonia. When a four p. The nature and extent ofa binocular field structure will have to be determined by other me ans • It is a red signal! The ques tion nOV{ arises: Are we dealing wi th suppression or strabismic seeing? To differentiate between an 8J:1biocular and a monocular field percept. then. the existence of a binocular field percept mustbedoubted under these test conditions. whether he is an esotrope or an exotrope. ou are dealing ri th rœasurements and not wi th approximations • .d. exists on the assu~tion that an arrbiocular field percept pertains a percept adapted to the strabismus. it is questionable ther a binocular field exists at all. of no further significance whether he reports the one ta the right or ta the left of the other. the double i~ages above each other. It is. image. The more vertical prism that is needed to produce a . we know that the patient projects according ta his learned strabismic habits. When you cannat make . adapted to the strabismus. or that "one seems to be to one side and the other to the other side. No effort should be made ta align them by the use of lateral prisms The same hol~s true when an exotrope reports uncrossed diplopia.at by abstraction rather than from retlnéü posi tJ. it is advisable to use a stronger vertical prism (ten p.~ ambiocular field percept. watch out! Be sure .11 made through the above amounts of prisms. Vie are then justified in assuming that a.. but he Wlll usually glve you a definite clue that his per~ept has b:en arrived.ll be experienced. ia measurernents easily and speedily. A patl. The strabismic usually (but not always) refers the right retinal image as being to the right of the left retinaI.) to determine Ivhetheror not diplopia Ca." It usually takes several degrees or base-out or base-in prism before he is aware of a lateral shirt between these two images. But it usually takes more than six degrees to produce diplopia. The strabis~c can bring. Such diplopia is evidence of s trabismic posture and time spent on "aligning" the two images will simply be was ted.d. after a fashlon. Q j 1 1 In an effort ta differentiate between strabismic projection and normal projection it i8 never advisable ta use mOre than U ta 6 prism diopters of vertical prism. lVhen double images produced by vertical prisms are reported ta be in close proximity. If the test remains negati ve with that alllount placed firs t base down and then base up over the same eye.. ~emember that vertical diplopia may also be produced by base down prism (over one eye) with an individual who has a strabismic posture. The responses are always uncertain and sometirnes qui te unpredictable.

thus eliminating the field stresses which interfere w2th the adeguacy of spatial organization. RETINAL RIVALRY ~trabismic. neither eye being able to gain prolonged complete control.11 inadequate posture ta . retinal rivalry results. Spatial adequacy cannat be maintained unless one image is eliminated. one of these iWBges must be totally suppressed. they ar~ unfusable and under certain conditions may rival with each other for recognition. This Jœans a shift of dominancy from one eye to the other. retention of fusable macular images is of primary importance to the organism. The rules governing retinal rivalry and suppression have been discussed elsewhere... thus p:.. which reach corresponding perceptual areas of the two eyes. c. The retention of two unfusable macular images is. Washburn èlaims that all binocular vision is based on retinal rivalry and that without it there cannot be any binocular vision. the less adapted he may be When the proximal stimuli. (This condition will be discussed under "Retinal Slip").12 sense of dip1opia. If tvro fus able macular images are not maintained. (This does not hold true for peripheral irnagery).-' adequate one.oviding the two macu·:ae with . IVhen a binocular field structure i8 present. One wav to solve this problem is ta char1ge 3. . Retinal rivalry is lacking when oneeye is suppressed. provided we maintain a binocular field structure. emanate from difÎerent objects in space. In a binocular field structure two unfusable macular stimulations create field stresses which are ?pt to interfere with the adeguacy of spatial orientàt~on. But it is not always possible to suppress totally all the stimuli that reach the cortex via one eye. If suppression does not occur. as a role. The above holds true on1y under certain conditions. 2. If an individual finds it i ossible ta maintain e e ositions that make fusion possible binocular posture . A. B. in a deemed to be. That oecurs l'rhen like images carmot be maintained on the respective maculas. he will make a determined effort ta suppress all proximal stimuli which reach the less dominant eye. unacceptable ta the organism. Vie must main tain fusable macular images ta be comfortable.

It is these individuals who develop the dread fusion aversion which is knovm as horror fusionalis.r area of the turned eye. However. he may then be operated upon with a better chance for a binocular pattern of seeing after operation. a determined effort may be made to throw the two eyes into greater disalignme. This used ta be my own attitude toward the strabismics. It may be gradually extended ta the paramacular areas and eventually may invade the peripheral areas as weIl.e. ·sueh suppression never materially affects the capacUy of the suppressing eye ta see clearly in a uniocular percept. under any conditions. to posture binocularly prior ta the acquisition of a binocular field percept. very rarely shows any rr. When a strabismic patient is incapable of binocular posturing IVe have no right to attempt ta establish retinal rivalry. It is of primary importance that an individu al main tains a clear and unencumbered view of the fixation object. at present. or if he does not. 50 that the non-macular image of the fixation object becomes so poorly defined (because of its peripheral location in the turned eye) that it can be easily suppressed. Retinal rivar1y (particularly.13 fusab1e images.nt. l have found that the individual who shOl'rs no incentive.. when the normally fixating eye isoccluded. The strengthening of retinal ri valry by visual training is contraindicated with individuals who are incapable of binocular posture. The organismic tendeney ls always toward elimination of retinal rivalrYt if it interfers with the c1earness and quality of the ma. ~ular SURpression is a process of adaptation to a new visual rèquirement andhas to be learned.. frequently violated in visual training. The proponents of this procedure elaim that by developing retinal rivalry the patient may "s traighten". D. Uniocular suppression is therefore always practiced first in the màcula. the clearness and quality of the macular image of the fixating eye are thereby greatly enhanced. This concept is.ore desire to straighten his eyes after a binocular field percept has been forced upon him. If this is physical1y impossible. i.e. i. prevented from reaching conscious awareness. . However. If the macular stimulations of the turned eye can be ignored. It would interfer with his spatial adequacy.cul ar image.in the macular areas) 18 the most troublesome attribute in a binocular field percept IVhen binocular posture is lacking. This is a new concept but follows logica1ly from what we have considered before. E.

at least in the areas controlled by the paretic muscle (s).§Jina. A binocular field structure is forced upon the individual by means of instruments which ean be adjusted to. By doing this. Where this assurance is lacking. The tlYO modes of visionean eo-exist. This i3 the orthoptic procedure which l am following successfully today and which l am advocating for adaption by others. Today. training for binocular field percepts ta the particular situations where l have found that a patient has ')hown a desire for'~inocular posture. he will straighten his eyes.\. not ta develop binocular field awareness in situations where it is not usable. l find ~hat the patient learns to associate binocular seeing with binocular posture and. When he returns ta strabisme posture. ~ . what is more important. This procedure is no longer acceptable ta me. bath for the patient and for the technician.responses are being elicited with the eyes in a strabismic posture in the hope that.the existing angle of strabismus. the existing angle of squint. This new'rr. even if this had to be done wi th the eyes in strabisme posture. provided only that he ~ keep the eyes straight. Frequcntly that is so.14 Today l feel it much more advisable and certainly mach easier. once fusion has been attained. It is quite all right to assume that if we ma. he also returns ta strabismic seeing.· ta reserve binocular seeing ta those visual tasks for which he is willing ta posture binocularly. Instead. The usual approach to strabismus is the establishment of binocular seeing. by gradual steps. Unless we have definite evidenee to that effeet. and then ta develop the latter by slow degrees. This normal binocular.ethod is applicable in cases of paresis where concomitancy of rotations is lackin~.Lr-i_y_é!lIT l1ntil~_hedoct_or is assured tbat the patient can (under certain test candi tian) posture binocularly. We fear that projection of binocular field awareness into consciousness under such circumstances may result in its rejection in good and bad situations alike. It is possible to teach an individual to maintain stereoscopie awareness in those areas of his surroundings where he can posture binocularly and to let him rnaintain uniocular or strabisme posture (and unioeular or strabismie thinking) in those areas where binocular posture is not possible. l limit the. l find it advisable ta have the eyes straightened by operation. we are very careful. it can be used to reduce. l'Te have no right to follow out the above 1 . not ta deYê~~J·.ce a strabismie suffieiently uneowJortable visually. prior to any attempt on ~ part to establish a binocular field percept.

When a pocket flashlight is held against the closed lid. feel that it is easier to maintain a slightly esotropic or exotropic position when looking at distant objects.-:"d the . But even the best-lcoking suit will not be worn long. for the sake of appearance. which ~ may not be able to recognize). They are usually ~ontented and happy. resul ts when two corresponcting functional areas are stimulated by different. Binocular luster. will maintain it on special occasions. ~~·ua1lY lost by the doctor. Frequently its -needs are not expressed in a desire for straight eyes. although they are perfectly willing to maintain binocul ar vision for close range. to wear them on occasion. a conflict arises. if it i8 uncomfortable. and we nevertheless insist w~ establishing them. but he is willing.15 When the patient resents the establishment of binocular f'el d proce8ses (usually for good and valid reasons. always inportant to raise the questions. to spend the time and money.am a perfectionist?" F. therefore. undifferentiated colors. but maintained comfortable vision with constant binocular fixation at near. fils it of sufficient consequence for the patient to undergo the visual training which l propose for him. It is. which is an incomplete color mixture. that after the patient had been discharged for a year or sa. We have learned by hard experience that it does not pay to establish certain visual patterns contrary to organismic desires. or aL1 l doing this simply because l. Let us suppose that we keep one eye closed while we gaze with the other eye at a blank green wall. Further. whcJ show ability to maintain straight eyes. l u8ed to spend an immense amount of time in an effort to change this situation and occasionally suécocded in getting the patient to maintain adequate binocular posture at far (at least while he was in mv office). sueh patients usually showed abHi ty to maintain binocular posture at far for occasional heightened perceptual needs. until we try ta convince thern that they should no longer continue in that state. only to discover. Many patients. The organism must be considered first and foremost. Such conflicts are . so that its beam of light is direc tel3: t0"t8. No man in his right senses would prefer ta wear full dress clothes the year around. If the patient could have them as easily as he can wear a new suit of clotbes. who find it more confortable not to maintain binoaular posture. there would be no problems in strabismus. he usually came back with slightly strabismic posture at far. Binocular luster may be considered a forill of retinal rivalry. Many strabismics. whenever such needs arase.

Its presence is an indication of a binocular sensory field.r. G.ud arnbiocular fiel'. the third tl'ro ad' acent sometimes slightly overlapping areas of unmixed colors. The only reason it i8 not universally applied is that we know so little about its meaning. the second the erceived color of one e e onl . Under the most stable conditions the perceived mixture may be an even reddish-green. Testing the color-mixing ability of an individual in the binocular luster test is a useful means of differentiating between binocul::. structuring. There is . stereoscopie perception and retin~l rivalry. splitting the total stimulated areas in half. as saon as a sufficient number of tests are available ta compile statistics. This is so because there apparently is no color mixture in ambiocular vision. which would show either all green or all red. This ls the phenomenon of bino(:Ular luster. If we could inspect the phenomenal wall by means of a microscope we might find that it consisted of miscrosopic areas.whether by color separation (BSM technique) or by polarization (Renshaw's tecbnique) . The resultant color is not deterrnined by the known laws covering calor mixture. Measuring the retinal rivalry rate of parallel lines running in opposite directions for alternate eyes .16 anteriar pole of the cornea. rronocular" d. Its color is apt ta vary betW€en those two extremes.is of great importance and will result in a better understanding of visual functions. The wall may at times appear quite red anq at other times quite green. l am happy to know that retinal rivalry rates are being investigated in routine optornetric procedures. It would also be possible ta determine that the mosaic of red . When a binocular field percept is present. the green wall is seen as if tro:ù a red glass. "r believe that retinal rivalry is destined to become one of the most important visual training means of the future. In ambiocular (strabismic) vision the patient will state that he sees a green color with one eye and a red color with the other eye. it will pay good dividends. as would a KodachroIœ film which had been exposed ta a red and green indifferentiated field. and green would be constantly changing. are available under suitabJe conditions. This method of dif~'erentiation is eminently usable. an even reddish glow pervades the entire eye. It also means that the other attributes of' binocular vlslon. green areas turning red and vice versa. The first shows an incorrplete celor mixture. We now have two areas of indifferentiated coler = green in the open eye. We haven't even begun to use it intelligently. reddish in the closed eye. It is essential that we spend much more time and thought on this problem.

17 no reason why ratinal rivalry should not serve as a means of determining the quality of binocular seeing. l'rhere the latter i5 not a constant factor in vision.r. . Further than that. depending on how the patient reports seeing the linss. By this method i t is possible to deterrIIÎ.ne the most desirable objective visual conditions for binocular posture. It is for this reason that in our own testing techniques reti:1al ri valry tests are a MUST . It is well worth while ta deterrni:18 the r esponses under varying posturing demands. it is possible to state '!{hether the patient has binocu13. ambiocular or uniocular vision at the tilTe the test is made.

Ne cannot. A watch that keeps accurate time differs greatly from a box filled with aIl the parts of a sirrQlar watch. i t appears. If I observe something that is not reasonable. After all. The reason is that what they tell you èxpresses much more accurately what they.perceive than can be determined by any objective test. This truism starts even now to pervade all sciences. The holistic approach accepts as a fundamen tal tenet that the w-hole is greater than the sum of i ts parts. Sueh stimulation are gross and disjointed and have to be shaped into soœething that i8 coherent and. something that makes sense. we can no longer relate them to the original problem at hand. After we have all the pieces in greatest minutiae. for fear that you might consider rœ an unreliable ovserver. .18 III. The upswing of psycho-somatic medicine provides a~ illustration. The human brain craves knovrledge. For instance. TI:1E MEANING OF "REALITY" IN VISUAL PERCEPTION One rrust tak~ humanJJehavior into consideration when he deals with people. It is . This statement is apt to upset our present ideas regarding visual functions. This analyzing process has been considered hitherto the only acceptable scientific procedure. then microscopie particles which eventually were reduced to molecules. AlI proximal stimulations which impinge upon the eye go through a very rigorous sifting process. understand a complex mechanism or organisrn unless we break it down in to its various components and study each one separately. a live human being is an entirely different thing than a cadaver on the dissection B.its i3 not reversible. yet our thinking capaci ty seems il1adequate to cornprehend corrplicated phenomena unless we break them down into smaller 3ub-wholes. even though it may be far from accurately reflecting the proximal stimulations. Sa l look twice and attempt to get a different view of the peculiarly colored animal before l commit myself ta adrnitting seeing the red bear. If l see a red bear in the park. ab ove all. l shall be very hesitant in telling you what l "thought" l saw.'1t to listen to people and to try ta inter!Jret wnàt they tell you. The product will not be acceptable to the organism untilit does make sense. I am reluctant to admit that l saw something outside of rny common experience. There is but one difficulty with this proce33 . even medicine. in the investigation of matter scientists first dealt with macroscopic.:rLilly -inp-ôrta. The accurate movement is not con tained in the wheels per se but i3 the outcome of much pl~~~ing. This means that only those things which are written w~thin prior experience make up the reality of our visual percepts. A. l do not want to admit it. even through l know that there is no such animal. The breaking-down process seems to be admirably suited to "simplify" our original problems. what they tell you is a summation of what they perceive. they are ~table because of their realness. 1hings are not real because of their stability (or sirrplicity). For the sarre reason. atoms and electrons.

as far as thinking power is concerned. or the seeing in a single plane. La\YS all sense organs. Because of our limitations. When we see something farniliar. It is this consideration. therefore. abject more rapidly than a simple nonsensical outline.c' ~. the nerve paths. it is a great deal easier to study the histological features. i t 1s more rell to us than a very simple but ambiguous forme We are capable of perceiving a very complex. Koehler has shown that variable depth is :.1ch more accurately on paper than we can reproduce the latter "simple" figure of unfamiliar . no matter how complex. has recently shawn that the use of atropin is of questionable benefit in static retinoscopy. Stereos co ic erce tion is more fundamental and more real than "fIat" . Consider that the one-Gyed individual is capable of orientatinES himself in a three-dimensional world. However the inhibition of accommodation rnakes it a great deal easier for the physician ta "scope".two-dimensional erce tion because the normal visual surroundings are plastic or three-dimensional • pertaining ta sensory perceptions are apt to apply ta It is. but the less it conforrn to rei1ity. The simpler a thing is the better can we understand it. The use of atropin in eye examination is an example. known. We can reproduce the former ID. precede the three-dimensional percept? Is it not possible that we came to this belief because it appears ta simplify our problems in understanding vision? The very fact that we compare the visual organs with the man-made camera is indicative that we try to reduce the imnensely complex neural and cortical processes of seeing to the stat11s of sonething which i3 within our understanding. rather than any other. ~ion lin B.19 table. weIl ta study the la\vs pertaining ta sense ~odalities other than vision and ta try ta apply them ta the visual sense. we are given ta ~yer~simplification.':ll-:rent in e . in an excellent paper. it is not reasonable that the three dimensional quality of these surrounds should long escape the organisme Why.:1 individu al v:oclj be ver-y much aITIazed if you should tell him that hc''ô. Such 2. This is tremendously important. True. Madigan. than it is to analyse the behavior characteristics and the thoughts of the live person. then. The reality of what we see does not depend on the complexity of what we see. which prevents this inadequate technique from becoming extinct. should "fIat" seeing. the individual cells. ow Inasmuch as our spatial surroundings form the medium which serves as our milieu from birth. ê'lastic seeing. shape. Impr~ed'static findings are the sole justification for its use.

It is important ta have instruments that reproduce reality as nearly as pOssible in arder to make i t easy for the individual to interpret the objective situation. It seems unreasonable to assume that perspective seeing ID. how can we jus tif Y our present visual training methods in regard to .mose achievement level of interpreting binocular phenomena is high. Many "fIat 11 figures. A new visual experience. But if the training setup is to create a situation that is simple and understandable. when sufndentl y real. we are apt to get the response that we are seeking.lst evolve from flat seeing. through certain instrumentation. D.. the above rule may be violated. If we are to follow these principles it vall become necessary to' alter our concept of what constitutes a suitable training instrument. is apt to be adequate at once. something which is wi thin the prior experience of the individual. in other words.On. such as the reversible staircase. Objective visual training situations should be based on reality rather than on siIDElieity of design. etc. According ta Goldstein. geometric drawings of cubes. (Simultaneous perception) then Second (f~at) and finally Third Degree (stereoscopie) fus ion . . l ~hould like te illustrate later (under heading D) the improb ab i l ity of stereoscopie seeing being essentially a learn-ed process .thru First. C. l'fe have given primacy ta training principles which can no longer be adhered to in the light of the above discussion. Certainly.by quoting the • case of a small child who has been under IDlf observation since infancy. If it is possible. octagons. ta re-constitute sorrething which the child knows. This is especia11y true when dealing with children.20 certain uniocular sensory visual fields which have been exposed to certain specifie figures. is true. are pereeivedas three dimensional real objects even though they are actually two dimensional projections..strabismus? Any training instrument that violates the reality of perception violates a fundamental organismic principle and makes it harder for the patient ta interpret through it. But the testing and training must be limi ted ta those individuals . i t must present s orrething which is real. new vi su al experiences are not 1 1: 1 ·1. The child has· been severely cross-eyed sinee birth and never knew the rneaning of binocular posture prior ta a strabismus operation. that stereoscopie V1Slon is more fundalœntal than tlflat" VlSl. a great deal of experimental evidenee seem3 to contradict such an assumption. Provided the assumption. but it may gain added stabilit-r thru repetition. If it is the intention to make it difficult for an individual to interpret test conditions.

. . One or the other eye was always turned so far in ta the corner that you could hardly see it..20 with either eye and the eyes were cosmetically straight. we did not worry about the secondaDT retinal image. foroed on a widely peripheral retinal area of the turned eye.e........ was a critical period in the child's visual behavior because it might have rueant the advent of ambiocular seeing. the eyes retained parallelism (Iack of convergence). The father agreed ta let the child wear plana lenses with opaque nasal sections. because the contraocular image of the fixated object was not erased. Because the eyes were straight in distant gaze.. because the chiId. rather.. (AIs a see Chapter X...------ --~-- ==----=-. Conversely. Vie were concerned that macular images of tl'TO widely separated abjects should not form.... were the eyes ta be straightened.. e. they appear suddenly as complete entities • • Here is the story of a small child which has been under mv observation ever since she was barn... the frosted section of the left lens intercepted the direct line of gaze of the (turned) left eye. Her visual acuit-v was 2n. if she wanted ta look straight ahead with her left eye she could do so with the result that the direct line of gaze of the (turned) right eye was intercepted by the shield. The father was informed that. The child wore the occluders until the parents were ready to have the child operated on. Iearn ta see ambiocularly. It may be argued that we did not by tbis means prevent the formation of an ~omalous retinal correspondence.. i...). the emergence of the turned eye from the suppression stage. We reasoned that the attemot at elicitin a a binocular percept should be made because the ehilcl coulcl not have Iearned a strabisme posture (looking with both eyes in two different directions at once) but had alwavs dependecl on a uniocular posture prior to operation. half ocluders) so that when the child looked straight ahead wi th the right eye.. ~~~ 21 arrived at by the slow and graduaI extension of prior experiencesj rather. Therefore. No visual training was given before the operation because we could elicit no binocular fixation attempt at any range. She did not fixate binocularly when an abject was brought to within arm's reach. Two days after the bandages had been removed the child came to IllY office. would le -'1't"n even tually t 0 interpret them c orrec tly in space.of the fixation abject. This. in rny estimation. should the child learn to interpret macularly from both eyes. • 0 Tests for retinal rivalry made on the cl istant screen stowed an . 1. an attempt was made at this first visit to elicit a binocular visual response on a distant projection screen (at 16 ft.. About a third of each Iesn was frosted. The child had a severe internal strabismus from birth and consequently never had a chance ta acquire binocular vision.. -"""""B!_I_ . The operation was successfully completed when the child was seven years old.. At the age of about four she started ta alternate fixation. it would seriously interfere with a future binocular pattern of seeing. This objection is valid only if it can be proved that anomalous retinal correspondence can forme AlI experimental evidence argues asainst such an assumption. in aIl probability.

Very soon. Was i. . she had seen it only as a picture on the screen. If this were not so. the screen was filled with a cornplex stereoscopie scene. showing â water buffalo partially immersed in water (BSM 16. and that primarily at close range.. Reality of perception is only possible in adjusted behavior . The scene was the nearest approach to her habi tu al surrounds that was available. Immediate1y after the stereoscopie percept became evident. It is t rue that . that cow is reaU" This could only mean that she had reconsti tuted a real cow thru stereoscopie . the sudden exclamation of surprise and joy could not be explained. 2. This baloon.22 alternate percept.only through appreciation of retinal disparity can we reconstitute 'reality by means of stereoscopes or stereoscopie projection. 19). This scene was selected because the child lives near a lake and is qui te familiar ri th cows. daddy.clues and that at first. Appropriate size changes were also perceived. there was no possibility of her "guessing". Since she recognized the stereoscopie pic'ture of the cow as a rrreal rr cow.that she had accurate stereoscopie ability within half an hour after she had "learned" binocular seeing. E. Why didn't she see rrflat?rr She had never had binocular vision before.rrs ay . she IIDst have had an appreciation of this reality prior ta the time that her ~inocular percept was born. first one eye maintaining full control of the screen and then the other. That she saw the cow stereoscopically was definitely proved by giving her a flash-light projector which threw a baloon-shaped white fi~e onto the screen. That is why the BSM equipment is sa valu able as a differentiating agent between binocular. however. was the opportunity to reconstitute reality solely through stereoscopie clues. indications of the formation of a binocular sensory field were apparent and when the Brock Ring Test (BSM 1. she p1aced selectively on the particular objects in the three-dimensional . This meant . It is about time that we abandoned the concept that one-eyed seeing differs in any major particular from binocular seeing. 3) was made there was but a very short period of "sideways motion" before the child exc1aimed that the ring seemed to come toward her and to move back thru the screen. uniocular and strabismic seeing.t learned? How could she Iearn i t? And how did she know what stereoscopie seeing rneant? Because that was what se'eing a !lreal" cow Iœant to her. AlI that is added in binocular vis ion is apparently a finer depth discrimination. The only new feature which was added to what she had already experienced (in uniocular seeing throughout). She looked at the screen for a little while and then al1 of a sudden exclaimed .fIe!'d'whîch happened to be in the sarne plane wi th the screen e Inasmuch as the BSM technique permitted me to move any given object into the said plane.

Our tendency in visual training should be to produce training situations where larger and larger portions of the total binocular field of an individual take part in the training. It should be noted that. because they are the one which corne most readilyunder the inf1uence of the patient's thought processes. The peripher31 portions of the visual field contribute largely ta the maintenance of fusion in binocular vision (Halstead) and it seems therefore unreasonable ta exclude sa large a section of the peripheral binocular field in our training instruments. One of the possible reason5 why narrow fields were designed for visual training was~implification. something which has scarcely been trjed. It is these macular situations. This will give us a powerful means of staoilizing the macular functions. or who is disturbed. We felt that we could simplify in two directions! (1) thât the sirnplest and least 'detailed forms were the easiest to fuse (2) we could reduce the stimulated field area (and this was done in certain instances) until only macular figures remained. Our psychopathie wards are filled today with individuals of this type. 15 not in a position to give a clear account of what occurs. lch " . We can hardly question that suppression of this type is a learned process. Peripheral responses are much less influenced by undesirable attitudes on the part of the patient. A persan who does not know what ta expect. mental attitudes frequently disrupt. This is a fundamental concept. the fusion processes.23 Renshaw says ttat nothing can happen unless the organism is set to let it happen. rather than enhance. it has become difficult. Vllien such simplification has been reached the objective visual situation has lost all semblance ta reâlity and instead of being easy ta fuse. The "easy" way for the binocular processes ta function is in a unified total field. This holds true in 311 phases of human behavior. The ract that uniocular ur alternate macular suppression is the rnost common visual dysfunction would indicate that it is the least difficult anomaly to achieve. A very important factor in visual traininLis the setting up of training situations which tend ta create stable visual conditions aver as much af the total pereeptual field as possible. which need our particular attention.

1 . If the pencil is shifted a few inches ta the right or ta the left. but a necessary. Placing a pencil ten inches in front of the nose. In this position the non-fixated nearer object is brought bnnon-fovealretinal areas equidistant and on opposite sides of the respective foveas. Both images are then close enough to the foveas to be qui te clearly intèrpreted. if the horopter is held at thirty f'eet and an object is locatedsomewhere in the binocular field but not in direct line og gaze. There is no need ta speak of the significance of physiological diplopia. not experienced. In order ta obtain fusion of this nearer object fjxation would have to be altered sa that the two eyes would converge at six feet. . as a rule. A. The subject i8 adequately discussed in available literature. 1 il Let X in the above fi~Jre represent the distant fixation abject and Pl the location of the pencil where it is sean double most easily. SINGLE AWARENESS IN BINOCULAR VISION Suppression is a normal phenomenon in all organismic behavior.. because all objects in three-dimensional space can not be on corresponding fusional areas of the two eyes while binocular posture is main tained. NeY~I''theless. diplopia i8. Because they are not fusable. while looking at a distant abject straight ahead. the horopter will form there and that an object six feet from the observer will not be on corresponding retinal areas. B. i8 in fact a preferred method of teaching an individual the awareness of physiological diplopia. a sense of doubling readily obtains. x 1 i! I·. provided attention is drawn to it. We all know that if fixation is held at 30 ft. the feeling of "double" becorres le8s and less evident and saon ceases altogether.. Suppression is not only a normal. It is apparent that the retinal points Pl are equidistant an opposite sides J h li:!. Diplopia i8 m08t likely to occur when the non-fixated object lies within the triangle formed by the two visual axes and the interpupillary distançe.2h IV. function in binocular vision.

When an individual has been made conscious of physiological diplopia along the above lines. how doss this affect his spatial adequacy at the time when he sees double? Suppose. i. :ular : ls re. we has improved his spatial awareness? l believe the answer is. he would have to think about how to do it. It is important to rernember that this type of closure. even if the individual accepts the two images as belonging to a single object in space. Na. ~Xlst . and that he now sees two cigarettes. is gained by ab3tr~ction and is. This mearrs that the lacality of such a'1 object i8 still binocularly determined even though fusion does not occur. then. the retinal points P2 are no longer equistant from the respective maculas so that the image of the pencil in P2 position is therefore easily suppressed. as when it occupies position Pl. ou lng does not necessarily prevent knowledge of the singleness of ~he. he lights a cigarette. is the direction of such an abject determined by a certain projection axis of one eye as if the other eye had been totally occluded? The answer is. Single awareness is then due ta a closure by a process of abstraction. i. When the pancil is intermediate ta the two fixation axes. This would !Dean that to light his cigarette. if they both obtrude themselves to consciousness. No. . If the pencil i8 now rnoved ta a second position P2 ta the right of the fixation axis of the right eye. for the sake of single vision. m t.e. It is likely that in normal occupations and in normal surroundings anear object i3 more readily seen double when fixation is held at a farther object located in the same general direction. In normal binocular vlslon J as we have seen. The effective projection axis i8 apt ta lie in a somewhat intermediate position bétween the right and left projection axes. than when the reverse situation pertains. Diplopia forms an lillperfect closure.Obj~ct..25 of the two maculae (M). where before he did it without giving it any thought. B. e lt elther complete or imperfect. Will that·pose a question as to where to hold the match? It seems reasonable that he would make a fusion attempt before proceeding with the lighting of the cigarette. both retinal images are equally distinct and the organism is hard pressed ta decide which of the two to suppress. when a nearobject is fixated and an object farther away obtrudes itself to consciousness. Could we say.. Is such an abject seen in the direction where one eye sees it and is it totally suppres3ed in the direction where the other eye sees it? In other words. Even the consciousness of d bl' . . while keeping his gaze at sorne farther distance. The above sort of closure without benefi t of fusion cm only so long as the individual is not aware of diplopia.hin ng Fusion i8 not an essential fé1Ctor in "single" awareness of peripheral abjects.e. the abjects which do not have their images on retinally corresponding areas are still perceived singly. he would have to malee an abstraction.

.-. it is assumed that fusion attraction is still a factor in bringing about the desired effect of thetwo retinal images forming a single perceptual unit.. as deterrnined by their relative retinal positions.. If fusion of the rabbit is rnaintained. without benefit of fusion. fusion of the rings i5 eventually broken... -.'-. While fixation is held at the rabbit. 2 (the red and the green ring) and the rabbit slide (BSM 20)... There is an organisrnic tendency to place the two phenomenal pencila equidistant on either side of the abject with which the pencil is ta be aligned. When the pencil is seen singly. l and No. 50 that the cortical image is no longer of any use to the organism.j! iiil il i '1 !i !I i' L 'i· '1 -------.ridi tional experiment can be set up wi th the BSM slides No. If bath eyes are fixating abject A at sorne distant point and a pencil P then is aligned with a peripheral object B. The above figure will illustrate the foregoing.26 therefore. it is placed in position as shown in the figure.B ----tJ..-. yet we have been inclined to train individuals for incomplete closure where we formerly had a complete closure. will the pencil be placed in direct line with the secondary axis of the other eye which reaches the objecte In the latter case the object is less accurately localized.. The position of the pencil does not agree with either of the secondary fixation axes (broken lines) and projection occurs from an intermediate point between the two eyes....'· l '!l'' il! . e. It can be experimentally shown that. whether the object is nearer or beyond the fixation plane.. better..' ~ --. c. the two pencils appear much closer together th~î they should be. the two pencils are sepn in positions indicated by the broken circles. . A a. if diplopia ls elicited. !' " t . a frontal or pre-frontal lobe process. the rings can be gradually displaced sa that eventually fusion of rabbit and phenomenal ring can no longer be maintained simultaneously. Only when one eye suppresses. in the former. From the "adequacy" point of view a total closure ls of course preferable to an incomplete closure.. When diplopia occurs... This is evident when the color of the perceived ring changes from a mixed reddish-green . It is assumed that fusion attraction furnlshes the necessary binocular cue as to whether diplopiais-crossed or uncrossed 1..-\..

in fact. in other wards. It may be asked. The above phenomenon is frequently eneountered with adul ts who are subjected ta the Broek Ring test on a dis tant screer" Sa::. bath rings are seen to lie in the ~ plane with the rabbit.when the two eyes are not adequately postured for stereo-aceuracy. Verhoeff told me sorne yearS ago that he learned through practice to prevent fusion of stereograms ta such an extent that all figures which are not exaetly alike (i.. ta the observer than the rabbit on the screen. two rings rlilappear mJre closely inte.e. both perceived in crossed disparity.. then.. disPfac~ment on the screen. that fusion attraction) even thou h it does not suffice for co lete closure (seeing an object singly must be interpreted as depth variable.rlocked when the color fil ters are worn tharJ. '. They prefer to see two rings in interloeked position. where there can be no fusion inthe strict sense of the term. "t Ll1e lt. that if the ring dispari ty becomes too grea t. or when two interlocking rings are seen. It is important that we keep this in mind because it permits us to elici~y gross stereopercepts . one being green and the other red. These same experiments have shown. of i:-hem Will not..ir. It ispossible. as beingdoser .wever. when they are taken off.gle fuseè object .27 cy" ete ete col or to green or red. It may be said. to interpret partia1ly interlocking rings. "': h~J'. why does this principle not hold tr'Ue all the way ta strabismie dispari ty?1I As previously reported. if the phenomenally perceived displacelIl€nt bet'l'leen the twa rings equals that of the actuaJ. ra bb' In the Brock ring experirnents binocular fi' at:' or . t Dr. both rings (as percei ved) suddenly "drop back" to the plane of the screen and are then interpreted as a pair of interlocking rings in a "fIat" percept. Fusion attraction can only occur within certain limits of ratinaI disparity. let the phenomenal ring come off the screen. will keep their eyes sufficiently off alignment ta prevent fusion at all cost. the rabbi t is maintai ned as a. Many strabismics. "If closure i8 possible.en~al inhibition is broken they rarely are capable of preventing stereofUSlon in subsequent trials. having stereoscopie qualities) are seen double and fIat rather than single and three-dimensional. unless they are psychopathie. the. are capable of posturing accurately enough for gross stereopsis. when we first see them. This indicates that a fusion attraction occured wFdch . it has became apparent from aetual observations that during incomplete fusion the depth variation between the objects in question is measurably less than if fusion efforts were lacking. however. once this rr. On the other hand. This becomes of importance in training. at first. was interpreted as depth variant between rabbit and the two rings.even though incoDlJlete. It has been nv experience that many individu aIs are capable (and willing) to inhibit stereoscopie fusion (prevent fusion attraction) and sorne. Ho~ver. H:. c.

<1~:1 Qsually disappear nhen adequate binocular posture has . ~ne~e patients found it very diffieult ta lose the sense of seeing _~~ ~e eVen though their ey~s remained straight. there may be awareness of double-rings capable of stimulatlng the fusi. r ru ' was th) Slonalis.. The fact is that since l have trained fusion ~v~s ~ithout attemptin.'~..:. For this reason l seein. had strabistQ hen What l know now.:. a. .process. unso-. to produce "double. .. Finally.• ~'I~'""nos t. This means that the disparl ty is then beyond fusi on ab i l i ty but within fusion-attraction....:" in \h ~sua~ training met~ads which tend.s 3'" re. Here one end of the measuring stick 15 lacking indetermining dispari ty in terms of depth variable. In all three cases there is one Comnlon factor: The central target is being maintained within fusable limits.. one of the two perceptual objects i8 rnaintained on sufficiently . Fusion attraction has then been brok~n. !})'sSions are almost _--:-_ _-:-_ _ _-:-:______ binocular "='1 _ _ due to lack of adeouate :--~ " r~. It has been my belief for a long time that it Toèa ..~r .:--=-_~ o:~J~~ar~Visual train in c'. This is not the case in strabisrnus where fixation is maintained by one cye onlv.. candi tian which preven tedsuccessful completion of the cure.( . however. If the .......:..on sense to such an exten t that they also are seen either nearer or beyond the rabbit. "tll) must be directed toward strengthenin IJ t-trJal visual acui ty may be caused by lack of direct . belie'le th r~lon has not been a serious problem. D. It 15 the ~nability to sUEpress diplopia in normal surroundings that leads ta the most serious visual difficulties.c--:~ ~. In all instances... l kn~wn ~~ inclined to believe that it could have been prevented..... a' .:.:~...in the center of the total binocular field.. That is something which needs to be remembered in strabismus training. Within certain small limits of disparity the rings may then be appreciated as fused and being nearer or beyond the central target (the rabbit).e. These cases were cl~sed as instances of .corresponcling retinal areas to rnake fusion possible... l am glad to have found a means of helping the strabismic ~a obtain binacular posture without having to teach him to see double ~n the.~even or eight years of binocular seein::r still complain of an~ ~~~~ on small fixation abjects.~~t'''' ~ '-. Anothp-r possibility may be encountered: An individual may elect to r8tain the ring (s) ~~thin fusable limits of retinal dispari ty and let the rabbi t "double" when the dispari ty between the two perceptual objects (ring and rabbit) becones too great.:.. disparity i5 widened. although they show good peripheral ho~r~o l-central fusion.:6ct. ta establish diplopia at the outset. l know of a few who ~ . the rings may be brought te such widely disparate positions that they are seen as interlocking rinEs in the plane of the rabbit. l ~ reminded of this time anc again by patients whom ~ tauRht ta see double befarethey knew the true meaning of fusion. ~}lal surroundlngs· of the patlent are to be consldered "':t E. t'"\ .

• 29 fixation ability of the affected eye. by a strong point source of light.e. bring about a heightening of visual acuity. only produces the sensation of a "glow". It has frequently been assumed that if an eye is suppressed it loses its ability to see clearly. but maeular awareness seems to be definitely lacking. Macular suppression does not create amblyopia-ex-anopsia. the afferent nerve paths remain open and active. the pupillary reflex constriction to light stimulation is also lacking. It can also be shown that when the lip. In these instances the blocking is not on a cortical level but i8 due to a lack of transrnissibility of these stimulations from the fovea to the geniculate body. In uniocular amblyopia.ht is not seen directly. :n 'ed . In sorne of the eyes where visual aeuity is below 6/200. If the blocking occured in the cortex. F. In otherwords. p~rforce. proximal stimuli will invariably reach the brain. the patient not being aware of the light itself unless it is thrown on off-foveal retinal areas of the eye. This information has been obtained through experimental evidence and should be indicative that the anblyopia is due to destruction of foveal fibres rather than to non-use. The retinal fibres never ceaae being stimulated by the light impulses that reach it. foveal stimulation of the affected eye. When a central scotoma is not the cause of low visual acuity. the pupillary reflex arc would be intact. showing that the foveal retinal stimulation i5 being blocked prior to the geniculate body. the establishment of binocular posture must bring about a better ability to fixate directly with the subnormal eye and. such training always produces increased acuity of that eye. Such an eye simply takes on other functlons which are adaptations to the particular visual set. almost noriÏal peripheral awareness can freqently be demonstrated to exist.. i. where the amblyopie eye is not notieably out of alignment. and that this blocking may eventually result in permanent inability to see clearly with the affected eye. How. before it reaches the cerebral cortex. then ean the perceptual faculties of the amblyopie eye deteriorate? This question has to be answered before we can intelligently eonsider the nature of amblyopiaexanopsia. This assumption appears no longer to be true. The only possible answer is that these undesirable impulses are bloeked in the"brain in sueh a way that they eannot reach the level of conscious awareness.

Peckham. Most individuals.. which no longèr maintains correspondence between the centers of the two Tovèae. It seems to me that l have this sensation of doubling during "retinal slip" only because l have taught myself to be aware of diplopia and because rqy eyes are aloost equally dominant. Only after prolonged total occ::'usion of one eye does a'1 exophoria at far. The latter assumption is more likely to be correct.. . In the latter case it has been moved away from the plane of the fixation abject. become apparent. This phenomenon is best described by the term "retinal slip".~is must meal1 that accuracy of binocular posture is maintaincod .l sllp prevails a high degreed stereoscopie acuity F l ] .::d for .. Personally.::. The fact that doubling occurs in my orrn case shows that during phases of ret~nal slip my. established experimentally that binocular vision is not lost when the eyes are not accurately aligned on a single object of regard. .r ~\'e ne. l have a variable condition of exophoria and retinal slip toward exo.: ' 30 c o v.' " B. which may reach considerable proportions (beyol1d 10 prism diopters).. report that they never see double.:i. (or normally behind the eyesJ. a :<eyst. Art in~lequate RETINAL SLIP . They have long since abandoned the concept of point ta point relationship between the two eyes. or that the normal horopter is still present. but this results in appreciable difference in the general appearance of the landscape. These findings gave the psychologists the basis for their theory that retinal correspondence is not innately determined and that it may vary considerably with different individuals and for different visual demands.directly but the other eye is slightly off corresponding position. which may not be ~ any longer-in generaI use." '.vI-: . who demonstrably have an exophoric slip. due ta a lack of macular fusion. l have noticed when driving a car that suddenly l am aware of two traffic lights (quite close together~ if there is not any particular need for keen visual discrimination. to a farther point in a slip toward convergence. many years ago. It is also sigrnficÇ. '. t s When binocular visual functions can be shown to exist while one eye fixates a small fixation object. A.nt ~ .oncentrated attention arises. While a retin.A VISUAL CONCESSION Vi binocular posture results in retinal slip.. then that eye has "slipped" away from accurate binocular posture. has formed.1:1 Elodcrate esophoria at n8ar J and that rny stereometrie accuracy is high.i1e Visual Survey test l show ort~ophoria at Cl.the eyes being in a somewhat divergent position. Du!ing retinal slip we may assume either that a new horopter. The significant fact remains that l have never seen the doubling of a cowl light of al1 oncoming car or of the tail light of a car. It is a descriptive term. It is a simple matter to fuse them. T.horopter lies considerably beyond my gaze. l often rnaintain a binocular pattern that is just adequate ta maintain a peripheral binocular field structure but is no longer capable of accurate stereo-perception. .

This is import~~t in our setting up of objective training si tua tians. As saon as the eyes become alerted the retinal slip is irnmediately and instinctively taken up. l%en suppression is lirni ted to foveal vision. We may safely say that the suppression area will al~ays include the foveal area of the suppressing eye and will gradually extend into the periphery. It has become evident to me that this assurnption is not tenable. The extent of the suppression area depends on the arnount of the retinal slip or vice versa.31 cannot be obtained. when a binocular pattern of seeing is being rnaintained at near._.nal slip as a tropia position of very moderate which may not be in evidence while binoeular posture is maintained. This observation agrees VQth that made by others who show diplopia under experimental conditions. Thirdly. That mearlS tnat stereoscopie perception is not lost but orùy stereoscopie accuracy.-~----- é3.l1lQ~!1:t-=---(Thls· IIDSt not be collSused with conditions of excessive phorias Let us define ret:i. . l frequently find IT\Yself seeing tIVO traffie lights for one and the experience i5 not at all disturbing. 'a Gross stereoscopie al'{areness is still in evidenee. it is preeeded by a retinal slip. the ease wi th which a maculai' image can be suppressed has a direct bearing on vrhether or not retinal slip oeeurs. It used to be my belief that l eould not take up the retinal slip unless awareneS8 of diplopia could first be produced. in faet it is a rather pleasant one. It is quite likely that. at least when the tropia develops in later life.:i. Retinal slip is possible only in uniocular suppression of the foveal percept. C. It is fortunate for my safety and for that of other motorîsts~on the road that l do not maintain a retinal slip whenever visual demands require good binocular posture. The one rnay be classed a tropia wi thin small limits of dis:gê-ri t:t while tné other is usually atropîa-ûflarge dimensions"TâS" expressed in prism diopters). Retinal slip may be considered the stage between tropia and phoria cônd. position is that in the former case the binocular pattern of seeing i3 përipherally maintaine<ii while in the latter case sueh a pattern is lacking in all of the overlapping visual fields of the two eyes.-. Yetthe tropia is usually an extension of a prior retinal slip. For accurate . Secondly. :~.---_. it is quite easy ta demonstrate that retinal slip is orten tmeen up by patients who do not remember afterwards of having seen double prior to the postural shift. There seems ta be no organismie urge to pull the two lights together.) The essential difference between retinal slip and a tropia . This holds particularly true in exotropia at far.tions. For one reason.

Frequently WB observe a high exotrope who. chooses not to have it. we S.32 determination of depth variables the retinal slip has to be taken up. It is for this reason that a projection screen placed across the room is becoming so important in Visual training. E. . Until you do that. no longer be evidence. definitely. It follows that. The nature of the task. that l can see.hall find that the periodic squinter may walk in with one eye in a tropia position and th en proceed to main tain binocular posture in all our training instruments. In more extensive suppressions the suppressin2 eye rnay be turned to a noticeable degree and stereoscopie ability will. Duction exercises are. Because. The minute he sits behind a training instrument he follows through in great style. Pictures that recreate thru color separation or polarization) visual situations similar ta the patient's normal surrounds can be projected onto the screen. for bis own reasons.he posture binocularly long enough to perform it. not the answer in such cases. unless a desire can be developed in this individual for maintenance of binocular posture under less demanding conditions. D. his strabisll1Us cannot be "cured". i n } l' i: F. nevertheless. H~ can then be taught to posture binocularly instead of uniocularly in situations which are transferrable to his normal surrounds. The only effective way to solve this problem. if to strengthen binocular posture in visual situations which correspond withhis normal visual surrounds. He gets an hourIs or half hour's workout and this can be kept up for years without his ever getting heyonrl that stage. This will be true regardless of his ability ta maintain fusion through lateral prism which forces him ta over-converge. The only way to overcome these habits is ta strengthen binoeular posture so that he no longer needs to make this choice. Periodic strabismus is an extension of retinal slip. we fail to see that for the special task which he cannat successfully perform with the eyes in a tropia position. By the time he looks out from behind the instrument be again shows bis exotropia. the occasional squinter will invariably be seen with his eyes turned at a time when he is not particularly interested in what is going on. then. Until we train in normal sUIToundings. deterlllnes whether or not accurate posture will be maintained. we may not be able to observe the individual's eye positions. but frequently. shows adequate stereo-accuracy behind a stereoscope. The lack of understanding of these underlying principles has been a source of a great deal of perplexity to many examining practitioners. The periodic strabismic chooses to have binocular'vision whenever he wants it. That is why you dare not leave it up to an individual's judgment whether or not he wants to keep bis eyes straight. therefore. .

ss. To visiting doctors it appears as if we spend an unreasonable amount of time to obtain binocular posture (macùlar stereopsis). The only reason this is not generally known is that most 01 us have never taken the trouble to discover the facto My whole training procedure no\'{ centers around the search for the particular visual tasks ta which the strabisme l'espônds by an effort ta find out under what conditions he will respond binocularly. We find a point of attack. once binocular posture has been obtained . This means that we do not attempt ta get an initial binocular posture at infini ty position. Strabismus training in our office follows this general routine: l) We find the position and visual task which will bring about an attempt at binocular posture. Almost without exception this position is found to be . the central suppression extends farther and farther into the peripheral field.under whatever conditions and at whatever range-that eliminates the "breaking down ll process. Parallelisrn is expeéted only at the end of training.h~patient to posture binocularly for even fractional periods.mOr. This may bring about an eventual shift from a habituaI binocular pas ture ta an habi tual strabismic posture. Nearly all strabismies have occasional moments when they maintain binocular vision. But tirne thus spent invariably pays good dividends. which used to be a long preliminary period of training before any attempt to elici t binocular percepts was made. provided we find a means of getting }. Marked retinal slips or actual intermittent tropias accur most commonly in distant gaz~ or during. We assume that the patient will make an effort ta posture binocularly if he is presented with a problem that cannat be solved while maintaining strabisrnic posture or by alternate fixation. For this reason "flc. t" tarr.te ng h . J) Because fIat fusion targets do not require binocular posture for their solutton we no longer consider the attainment of First or Second degree fusion as an adequate criterion of a binocular field structure. We tackle the problern at the most logical position.ets are seldom used in our D md i .1ents of inattention requiring only lo\'{ postural demands. 1 '.n thin easy arm l s reach of the patient. except for special occasions. He may eventually abanoon binocular vision altogether. Because vre found the above to be true. at distances varying from four to twenty inches. We are no longer concerned with breaking down anomalous (strabismic) projection. 2) In order ta succeed in that attempt we see ta it that the patient is confronted with a visual problern that requires binoc~lar posture for adequate solution.J3 As with a periodic squinter the fusion processes become less and less important to the individual.

but he could not rnaster the stereometrie test and would be disqualified on that accaunt. We see in it moving pictures. Let us remember that cortical closure of temporally successive events i8 a common oecurenee. provide the requisite demands. if we have no other information we cannot conclude frqrn the Keystone Visual Survey above that the patient has any certain type of strabisrnus. When the stereoscopie test is failed. From hard experience we have learned to reœmber that a11 strabismics who have fair visual acuity with either eye can look alternately st targets presented to them in stereoscopes or other training instruments and are capable of interpreting the total situation in terms of bath.it is necessary to maKe perceptual demands which require adegpate binocular postures for their completion. T6 overcome retinaI slips. nor for correction. Additional evidence is necessary. G. This is one of our inviolable rules. .office for strabismus training.ï be made J are not admitted ta stereoscopes for further tests. 'The abili ty to differentiate between fusion a. On the other hand. H. Alternation of fixation seems for them to be an entirely involuntary act. M:lst of these individuals seern to be incapable of maintaining permanent fixation with one eye in training instrument.' The individual might conceivably report "the dog above the pig". Stereoscopie ability also furnished this control. we imrnediately question all other tests of the visual survey as to their validity. on whom ne duction firidir. such awareness may have an inhibitory effect on the resumption of binocular posture. Skilled manipulations that require adequate binocular posture. percepts. in successive fixations while reading. 5) We do not consider the Keystone Visual Survey Test to be a diagnostic test in Strabisnrus.. in temporal sequence.r1d closure at a higher cortical level is one of the essentiàl con troIs in testing s trabismies. In faet.Lgs Ca. general survey. This do es not rnean that a Keystone Visual Survey test would fai1 to disqualify a strabismic in a. In other l'TOrds. 4) Indi viduals. the right T1uS the 1eft. We have seen that sueh closure occurs often ri thout the patient' s wishes. i t is not a prer~ative of strabismies only.of marked retinal slips. "the arrowunder nine"~ the "three balls in vertical alignment ll i f he were clever alternator. 6) We accept as a fact that a strabismic may gain information from one eye and then the other. a. An individual does not depend on conseious awareness of physiological diplopia ta regain adequate binocular posture. relative to a given single area in Space (straight ahead) and that these impressions may undergo a cortical closure. A report of three dots in a row (BF Unit or a cross (0 series) is therefore not proof of binoeular posture. .

fair or poor binocular posture in amblyopia. in an effort to de termine how f~r the cyclopean eye has been shifted tmv-ard the better eye. therefore s important for us to know whether a person has a good. by employing a cardboard with a central hole about an inch in dia@eter. particularly in unioeular amblyopia. The patient (~specially if he is a uniocular amblyope) looks at a sti'ong light sorne ten feet away and above eye level. and good binoeUlar posture is in evidenee.3S VI. It must be said. at arms length. The visual responses will be adequatewithin the achievement level of the partially disables organisme If we define amblyopia in the above manner.ri th bath hands. This i8 my definition. however. Such over-dominancy of the better eye may be corrected through visual training. He holds the cardboard. l t is. The individual i9 then capable of the most suffieient responses whieh are possible to the partially disabled organisme Stereopsis is the appreciation of the differenees between right Sinee stereopsis is the product of the different viewpoints of the two eyes when looking at objects in space. The local signs from amblyopie eye affect the total interpretations less and less and may eventually cease entirely. the patient's existing amblyopia represents close to the maxinnm possible visual acui ty. There is a strong organismic tendeney to center attention on the better eye while the poorer eye is proportionally pushed into the background.A PERMANENT VISUAL DISABILITY Amblyopia is the result of destruction (or congential lack) of foveal nerve bundles in one or both eyes. a single eye cannot have stereoscopie qualities. Other types of subnor mal vis ion will be defined 1 ater. whieh means that they are in such alignment "i th each other that stereoscopie clues are most effective under the existing condition. We can tell almost instantly whether a person has shifted his cyclopean eye toward the better eye. the posture of the amblyopie eye becomes of less and less importance. By pushing into the background is meant a shift of awareness toward the better eye so that eventually most of the conseiously perceived phenomena are related to the visual impressions received via the better eye. and left visual images as depth variations. regardless of central retinal defeets. . AMBLYOPIA . which contains the central round opening.. In good binocular posture. Thus. mere are rneans to test it. that such ideal postures rarely exist with amblyopie patients. in such a way . This does not mean that a single eye may not have three-dimensional appreciation of space. the achievement potential of an individual has been reached. In unioeular or binocular amblyopia the eyes may be in an adeguate binoeular posture.

The total percept. i f the hale is bcought into the central vertical plane of the head. He is then instructed to bring the cardboard straight upward in a sloW' siVeeping motion until he "can see the light thru the hole. The center of the hale then lies directly below the light as seen by the right eye but i t will be markedly to the right (and below) of the light as seen by the left eye. Cb) If the lighted disc is placed 50 that the one eye is very close to the la teral edge (ri th the medial edge extending well pas t the ridge of the nose) the cyclopean eye has shifted markedly toward the eye which is inclosed in the light keg. the hole as i t appears to the right eye is a bit ta the left while as seen by the other so that the total percept of the hole being directly below the more distant light is perfectly reasonable and logical. It is also important to observe what lateral ' adjustment is made by the patient if he finds that he cannot see the light in his first approximation. In that case the cardboard occludes the distant light from either eye and the patient is forced to make a secondary lateral adjustment toward the dominant eye. the hole produces a brilliantly lighted area On the patient. then dominancy of this eye is complete and the existence of an effective binacular field structure may be seriously questianed and will certainly needta be investigated. i f botheyes were equally important to the organism.that he sees the hole in the cardboarddirectly below the light which he fixates. in weIl balanced binocular field. it conceals the light from either eye? Let us su~pose that the hole has been brought directly in line with the vi su al axis of the right eye." Inasmuch as the cardboard is then betiVeen the patient and the light. Poor posture means that the related retinal images are so far 1 1 1 i 'l' . but a binocular pattern is still strongly in evidence. 11 On the other hand. In ambl. It is important to observe where this area is located imrnediately after the cardboard has been brought "straight Up" and before the patient can look at the light thru the holé.behaviar the hale in the cardboard is placed in such a position that. can therefore not be "the hale is direc tly below my (both) eyes. when it is brought straight up. 1 . Ca) If the lighted disc is seen center to the patient~s forehead. (c) If the lighted disc is brought straight up 50 that one eye i8 exactly center ta the keg. a Iœdially located cyclopean eye can be assumed to €xist. Why is it that. The local signs from the right eye will indicate "the light is directly below this eye" while the local signs of the left eye will indicate Il the light is decidedly ta the right and below the light". oar posture interferes with the maxilffilm response of l'ihich the individual is capable. oDia the e es ma be in an inade uate binocular osture so that stereoscopie clues are just barely utilizable. He is not to lower his gaze to de termine the position of the opening but to judge it while he is ~ooking at the light.

of two entirely different cortical processes. the stereoscopie range is deterrnined with large and not necessarily weIl defined targets.. which results in lessened ability to peform certain demanding visual tasks. Such an individual remains permanently incapable of stereoscopie accurao~ even though his peripheral depth clues may be normal. the stereoscopie range.'1d Intelligence. If a binocular field i8 lacking in direct line of gaze. but it does not necessarily mean that peripheral fu. This range i8 peripherally determi. Peripheral stereoscopie awareness is quite frequently found in individuals who do not show any lœasurabls. Stereoscopie accuracy is determined by macular imageryj it cannot be determined on any other retinal areas. this does not affect the peripheral stereoscopie abili~ unless the binocular field percept has also been abandoned. at least l have ne ver come across an individu al who hari macular stereo-awareness and lacked peripheral stereopsis. preferably rings. it measures the smallest possible retinal disparity which is diseernible as depth variation. The latter is expressed by the distances beyond and nearer than the horopter in which single binocular awareness can be maintained. 1947. If binocular posture is 50 poor that the macular images from single objects in space can no longer be fused.'1ge is most limi ted. it means that the individual must learn to suppress the image from th~ amblyopie eye. It is quite possible that macular and peripheral stereo perception may be functions .. While sueh poor posture obtains. pg. Stereoscopie ability can he measured quantitatively and qualitatively. on the other hand.sionIrnlst also be totally abandoned. Stereoscopie perception. quantitatively. )3). The reverse is not true. It may be assumed that an individual who can pass a stereometrie test also is capable peripheral stereoscopie awareness. is dependent only on the existence of a binocular field. Dec. Qualitatively. While stereoscopie accuraey is determined with small and sharply defined targets. the eyes remain cosIDetically straight but ·large retinal slips are eommon and stereoscopie accuracy is nil on stereometrie tests. stereo-accuracy even though both eyes are visually capable of normal resolution. bècause cfa central scotoma.ned because in direct gaze the stereoscopie ra. although they main tain binocular field awareness para-centrally and peripherally. This ls in line wi th the opinion of Halstead vrho clailIE that IIcentral vision in man is projected to the striate cortex of the occipital lobes while peripheral vision is mediated by the cortex of the lateral surfaces of these structures lf (Brain a.37 disparate that the fusion attraction between them i8 just barely utilizable. Halstead' s investigations have shown also that "peripheral vision ordinarily has little direct re1ationship to consciousness or awareness li . T'here are many non-strabismic i~dlviduals who main tain such poor binocular posture (at least for non-demanding ~asks) that total suppression of the contra-ocular image of the fixated object is the ruIe.

l'ld Daual adeguacy i8 at its lowest. By developing an excessive amount (or any amount for that matter). this blocking is a frontal lobe process. This closure.n is accepted as being' existènt in all sense modali ties. . 54) li 1: 1. at high-level consciousness. which effec "closure". l t The term fusion is arnbiguous when applied ta the various forros of closure which we have Just discussed.wareI1essin 'a binocular' fieldprocess is.His f ar-reaching investi6 ations have lead him to the conc. ' The psychologists and physiologists also speak of visu al fusion in the sense of fusion of teffiporally successive images. vre prevent! the "closure" of retinal figures which belong ta single objects in space . We normallythink of fusion as the "superimposition of fusible images on corresponding areas. To teach an individu al to be consciously aware of physiological diplopia i5 paramount to inhibi ting su ch single awareness. Halsteadspeaks oi a critical fusion faculty as the te~oral resolving power' of the visual system a'1d measures i t by determining the flash 'rate of an intermittent soUrce of light which just eliminated flicker. (pg. To be conséious of physiological diplopia means seeing abjects in a state of unreali ty. when fusion attraction can no longer occur. of course. producing a single perceptual image of heightened discriminative quali ties. a des1I-able feature.according to Halstead's findings.. In fact.ever occurs in the cortex of the occipital lobes. is due to central (cerebral) processes rather thanto peripheral (retinal) processes. It seems weIl established experimentally that fusion can be inhibited ta a marked degree (in exchange for diplopia) at leastin the macular areas andthat. il 1 . of awareness of physiolagical diplopia. such temporal fusio.a closlirl! which should occur" before these figures emerge into consciousness. and left-eyed seeing is increased. 1 "l" : 1 The term "fusion" needs sorne explanation. Also no matter how strong the magnetic attraction between two magnets may be. Thid does not seem ta be in the best intérest of the individual' s spatial awareness. becomes weaker' and eventually reachesthe.Lusion that the peripheral portions of the visual field have a steadying effect on the binocular field structure and that they thus contribute to the ' maintenance of binocular visual functions at a high operational level because they integrate vernier postural adjustments.the magne tic force is considerable and tends to close the gapbetween them. but as they are held fartherand fartherapart. Stereoscopie vision is then absent B. vanishing point.1 1 In amblyopia the eyes may be inmonocular or in strabismic posture." Many investigators doubt whether the closure . Yet. Be that as i t may. this force. This may be likened ta the magnetic fields produced by twa magnets.making one out of two . Sorne investigators believe thatthis closure occurs in the frontal lobes. their pulling together ( c losure) c an b e preven ted by applying equal but oppositely directed pressure (pulling them apart). i t seems that the field stresses bécome less and less potent when retinal dispari ty betweenrigh. Single a. When they are held close tagether . i. at present we do not .

requires abstraction and becomes. serves as the abject of indirect fixation. while the gaze is held on an object situated sorne six feet to the right of it. therefore.n The sane principle. In our own training procedures we absolutely prevent its appearance. say a lamp shade. Very few individuals are conSC~0US of two openings in the cardboard. even though it must still be thought of as a frontal lobe process. I~ normal binocular vision it is organismically important that the macular images are fus able since otherwise stereo-accuracy i5 last. he will have no titre to organize around these double images. ~. the individual who maintains single awareness of both the near and the far object may have a less accurate (retinal) percept (at least those who teach physiological diplopia will say sa) but he certainly behaves as if he had the more accurate spatial percept. It. Yet. If we then close the eyes alternately we are likely to discoverthat the pencil is not in direct line with either eye and the center of the shade. Yet. we may hold a pencil at arms length so as to point directly at the shade. It becomes. of paramount importance that testing methods which make an absolute dj5f~r~ntiatian possible between the various forms of closure in two eyed ~sion be deYised. This is particularly important because aIl three processes can co-exist in one and the sarne individual. a frontal lobe process. A strabismic who "sees double lf out on the street is in potential danger. These are confronted with a choice as to which of the two they should align or whether both should be equally disaligned. The only situations in which feel that we can make use of physiological diplopia . of course. There c an be no question tha t the awareness of diplopia in terferes with adequate spatial orientation as regards the abject in question.can then be readily demonstrated that projection still occurs from the cyclopean eye.t ic . if a peripherally perceived 'object at twenty feet.39 differentiate between the vaJ:"i~us processes. hen 3. in absence of physiological diplopia.e. Such a choice. The decision he makes may be the wrong one. On the other hand. ather abjects in the sarne visual surrourids may be projected to such ridely disparate retinal areas that they cannot be fused at the lowest cortical level and have ta be brought ta single awareness by a closure process an a higher cortical level. For instance. . n' ~c t91 The organismic desire is to achieve closure..etinally corre~ponding ~éas. j l ~ed lat . individuals who have not trained themselves to observe physiological diplopia will never be conscioûs of two pencils. therefore. Vlhen he meets up ri th a situation which requires an irnmediate response (escape). to see aIl objects in space singly even though these objects are usually sa situated that onlv a comoarativelv few cano at any one time be brought on . if it is at all pcs3ible. is operative in the ctorninancy test where a cardboard with central round opening is used to determinE th~ position of the cyclopean center. Hm'fever. i. For the above reason it seems best ne ver to develop a'fiareness of physiological diplopia on purpose. of course. This accounts for many of the misconceptions that are prevalent in optometrical and ophthalmolagical literature relative to the meaning of fusion. it seems that this choice is made subconsciously.

the demands made on the visual perfor~~ce of the patient. Pos ture training . it cannot exist when the eyes are markedly out of alignment. c. gradually.not be solved unless he postures· better than he is l'font. How may we speak of closure in uniocular posture? Here the c10sure concerns the temporal fusion (as in movie projection) of right and 1eft alternate postures. Coming back to our tenet mat in roonocular and in strabismie posture stereoscopie vision is who1ly 1acking. we are in the happy position of letting the strabismic maintain an adequate spatial awareness while this shift frOID strabismie to binocu1ar posture is being made. we can now restate it by saying that in uniocular and strabismie posture a c10sure ean no longer occur except at the highest cortical 1eve1s (frontal lobe). It>under such conditions a binocular sensory field can be assumed to exist only if patient cornplains that he sees everything double (as in paralytic strabismic of recent onset). as expressed by his perceptual cr rmnipulatory competency. When such closure is obtained the individual will be entire1y unaware of how he arrived at the final interpretation of his visual surrounds. These si tuati~ns are highly artificial and are notlikely to find counterparts in -riormal visuà1surroundings. In convergence training we use a string which i8 stretched from a distant wall attachment to the nose. Inasmuch as stereoscopie range seems ta be definite1y limited ta retinal disparity within fusion attraction. which cannat be carried into normal surroundings. The above considerations brine us to an entire1y different concept of the value of diplopia training in strabisIIlls. This means that he rrrust be confronted wi th visual probleI:lS which ca. The best training approach is ta increase. For instance. Conversely. Further discussion will have to be postponed. when it can be shawn that when an individual possesses good stereoscopie discrimination under certain test conditions.La in training are those where it is not directly transferable ta the normal Visu81 surroundings. The purpose of visual training in aroblyopia is to teach the individual adeguate binocular posture by strengthening bis binocular field percept and by gradually increasing the demands on his perceptual abilities. Phorias are expressions of inadequa te postures.n. Uniocular posture m~ be maintained in alternate V1Slon. it may be assumed that during the particular visual task his eyes were in perfect alignment with each other. Because we have the means today of training a strabismic te normal binocular function without the internediate step of diplopia. If such heightened ability has once been attair. i t can be achie7ed again and again and eventually become the habi tual pattern.ed.. in posture training we produce v~rtical diplopia.

tle te> _~eith t!"n tb. adeouate [OsturA is maintained in amblyopia.s. visual training can accc~]is~) i t. is actually the simplE:st sort of phoria traini ng and is exceptionally effec ti ve in changing undesirabl~ phori2. [n ilhen i t i3 found tha.'p(1:1ses.hl .- ---~ l Lal 19 ûl .y -es s es .:.e .e~}i ty of the ~xistinr: bi nOC1Üé'.r vision rf'~. ~~---~------ -.

in particular. B. ?of smail dimensions can be brought into direct. the lines of gaze of both eyes will be likely to intercept different parts of this but a single window can not be looked at with the right and left eye. One of the uniocular strabismics. integrated without the benefit of füsion. is a uniocular strabismic and aIl his sons are strabismics. the rest are unioculars. individuals who have two equally good eyes cannot maintain suppression so well as the amblyope and tend to evolve gradually from suppression ta the arganisnUcally much ITDre acceptable use of the t'If 0 eyes as independent visual organs. /' Uniocular strabismus eventually loses the of the dominant eye. Sorne are alternators. except by alternate fixation. There are many cases of uniocular amblyopia on record where an eye has been brought from finger count ta usable vision and in certain cases even to normal acuity. The method used was to align the test letter l'rith the direct Une ·of gaze of the turned eye. sa th~~~ on occlusion the indi vidual is no longer capable of bringing . To illustrate what l mean. on examination.h2 VII. Visual acui ty was found ta be 20/40. SUBNORMAL VISION IN UNIOCULAR STRABISMJS If l define AMBLYOPIA as an incurable condition. c. which he had been able ta recognize. The father.e 5th issue of the Optornetric Weekly (19h7). . was incapable of direct' fixation ri th the habitually turned eye when the good eye l'fas occluded. it becomes necessary to describe the type of subnormal vision found in uniocular strabismus that responds to visual training. with the result that he no lonEer could see .line of gaze of eye at a time. This individu al was subjected ta tests with the J~cula Stimulator which l described in the Jur. regard onto the macula of the turned eye. the object of direct represents the type of s~int where one l'lye ability of direct fixation. If the fixation abject is a houseat twenty feet. He kept the eye turned in the habitual squinting position. How can we account for this visual improverrent? Before this matter can be satisfactorily discusses 'iVe ITllst define what the term STRABISMUS rneans and what is meant by UNIOCULAR strabisrmls. A. STRABISMUS may be said to be the condition where a sin le fixation ob"ect. ?eoplewho have one good eye and a subnormal eye will tend toward uniocular strabismus because it is easy for them to suppress the macular images of the subnormal eye. let me tell of a farnily of strabismics. a physician. On the other hand. Vihen the good eye was norr ocèluded the patient turned the other eye away from the test letter.

Why. without the simultaneous establishment of an ability for binocular posture. :mLa~_really becomes ex-anopsic is not the vision of the turned eye but the fixation ability. may have the undesirable result of speeding the strabismic on his \Vay ta arnbiocular seeing. . the following is also true! 1eaching the uniocular s trabismic binocular posture. With direct fixation assured. Building visual acuity of the strabismic eye by prolonged total occlusion of the norrnally dominant eye. readily responds ta visual training. the 1ack of normal visual acuity may be considered arnblyopia. because this has become the sole function of the other eye. I should have to learn to manipu1ate this arm in a normal manner in or der to becorne proficient in the coordinated use of both hands above the head. the turned eye is never caIIed upon te fixate any abject of special regard directIy. due to lack of ability for direct fixation. With sueh individuals the turned eye remains in its habituaI strabismic position when the habituaIIy straight eye is being occluded. Gan this be claased as amb1yopia-ex-anopsia? I think note In this particular case the squniting eye was amblyopie only to the extent of visual reduction to 20/3 0 . His effective visual acuity came up very rapidly and final1y reached 20/30. Yet. au tomatically raises the visual acuity of the turned eye. This constitutes an adaptation ta the existing strabismus. when such training brings about direct fixation of the object of regard by the strahismic eye provided that the foveal area of such an eye has not been darnaged by prior in jury or or disease. If the above propositions are correct. but onlv in the direction of the turne In that direction the individual nON sees more clearly when bath eyes are open than when the squinting eye is occluded. should it be surprising that the ability for direct fixation may no longer be present? The Iaek of direct fixation. in turn.43 this 1etter. then. When a strabismic has been entirely uniocular for years. 18 it any wonder the off-rnacular acuity of the strabismic eye is very Iow when resolution of the object of direct regard is attempted with the dominant eye totally occluded? Law visual acuity. an adjustment shift that may lead eventually ta arnbiocular vision. El the time an eye has lost direct fixation ability it has assumed a position of some importance in the total visual behavior of the individual. If l should wear for years a strap which wou1d prevent my left upper arm from being brought above a horizontal positions the arm would not atrophy because there would be a sufficient number of of movements to keep it active. the other eye being 20/15. l might in tirne lose the incentive to raise the arm straight up even when the strap was removed. results in subnormal vision.

i. A suporession squint remains a "concession" squint sa long as ilothing ne·. His abiÜ. When bath eyes c~~~ot look simultaneously at a single (small) object in space. sarre other abject is . The squinter simply has more undesirable visual experiences ta push aside.41' VIII.e. Maintainin a an essential suppression field b Iœans of ·1 1 1 1 If the strabismie has not learned to dissociate his eyes. If he cannot do this.ty ta maintain spatial awareness depends directly on hm'i weIl hé p:r~y~nt the macular image of the turned eye from interfering wi th the macular image of the straight eye. but not ta the same degree.y is learned toward arl adaptation to ambiocul seeing.alitY.. Thisobject sets up rivalrv sensations ri th the first one. are possible. But even when the condi tion develops in fully matured indi viduals sorne adaptations. We all have a tendeilcy ta do that. STRAI3ISMUS A. A trJe suppression squint pushes that which is not desirable into the background. às-the centrâl figure of his total pèrcept.qnrus. The prevention of a binocular field percept can be attained in two ways by: 1. Therefore. suppress the macular image of the non-dominant eye. al though a binocular field perceptexists. apt ta be projected to the macula of the non-dominant eye.only one eye. B. This holjs true especially when the strabismus has developed in infancy or chilrlhood. The image of the second object must be suppressed for the sake of a clear and unhampered view of thefiI's~. int81erable retinal rivalry results.!'êgardinits -t.of. he must. where the turned eye takes over visual functions not normal to binocular seeing. for the sake of correct spatial interpretation. it depends on the organismie ability to prevent a binoeular field percept. The organism is apparently not willing to shelve an eye because it can no longer cooperate in normal fashion with the other aye. which delegate sorne useful purpose to the turned eye. Here the concession squint turns into a more or less adapted strabi. The sufficiency of the spatial concept of the uniocular strabismic is measured byhis abili ty to retain selecti vely the abject of rlirect . the adeguacy with which this abject is seen depends on the organismie ability ta suppress conflicting sensations that reach the macula of the other eye. 'l'rue suppression squint is rare because it represents a transition period to more effective strabismic seeing. He learns . In strabismus. a single fixation abject can be brought into direct line of gaze of .

no matter how poor or inefficient they are.~e visual training arlgle it is importa. That is. the subject will not ma~e nearly as decided an effort ta learn a shift to an entirely new performance. who seemi~--rèJL. He may even learn to perform sorne special feats that cannat be accorrplished by an individual l'rho hasn't an artificial leg. the individual who can main tain a binocular pattern of seeing at near.45 to do this by totally suppressing the vision of one eye. It is a fundamental principle that no matter hON handicapped a persan is he will try ta develop all remaining abilities. of course.ites the visual impressions receiverl via the two eyes by a "thinking Erocess" devoid of true fusion. while SOIœ semblance of the old habits of seeing can be retained. though not as far. Yet. then. This causes no undue interference with what the straight eye wants to see. If the suppressed eye is capable of good vision along the direct line of gaze.l1t only to remember that ambiocular vision acts as if separate sensory fiel::is for the t1VO eyes exist. individuals who do not care ta recover the full use of their faculties after a calamity has befallen them. This holds just as true for visual as for other human behavior. l'here are. Such a situation is not acceptable to the organism for long. In respect to vlSlon. he will learn to coardinate the artificial leg with his good one. the process of readaptation is a very slow one. We can infer only from wnat these strabis mies report that they "think" separately wi th ei ther eye. This eye. is not likely to acquire a highly developed a~)iocular seeing. the organism usually finds means ta draw out all the capabilities of a turned eye. as evidenced in the ambiocular vision of the ar Tnis is one of the problems that will interest us for a long time FroIil t. . an It has already been stated that there is an organismic tendency toward full use of all existing abilities. no longer has any use except in the monocular field where the other eye does not see. but they can no longer to be classed as following norJœl behavior patterns. An individual with an artificial leg is prevented from moving about in the manner and with the ease formerly experienced. How is it possible to ac~~ire the ability ta maintain separate perceptual fields for the right and the left eye? !ct is seeine. 2. and that closure of the single unitary percept is more nearly allied with the closure of the teII90ral ta come. Maintaining separate fields for right and left eyed adapted alternating strabismic. However.

in dissociation of the sens0. 3. phylogenetically . If a head inj 11ry:. the pencil ia placed on the fixation axis of the straight eye.l: i:: J . If a pencH now is placed between the individual and the fixated object. in accordance with the respective lines of gaze. Even though by a considerable effort of will he manages to keep .. If one eyeis turned off position 50 far that a binocular pattern of seeing ~annot be maintained.J. The ret11rn ta separate sensory fielrls may be considered a regression ta a~ earlier mode of seeing.ight.them str.i cross. Dissociation between right and left brain centers may occur through the constant maintenance of uniocular posture. The ambioeular strabisme. Because there no fusion attraction there can be no stereoscopie awareness. The child may organize around a particular head p03ition which permits him to main tain straight eyes with the least effort..~- i l 1 1. This is a subtle but important change which paves the . These two macular impressions are ineorporated into a unified ambioeular percept by what is most likely a frontal lobe.Œ fields of t'he two e'res • . The individu al maintains uniocular posture during suppress and sees the world from the straight eye. the cortical disjunction resul tin.sequence of events.. Sinee there 1s no birlûcul ar field. way for the learning of a ambiocular seeing.:_~()sFlikely parallismçannot be main tainedindefinitely~':~~. n .therecan he no fusion attraction between right and left images belongingto the same objects in space.]JUi ty to interpret directlyhis visual space in' two directions at sametime.the turned eye maybe suppressed in the manner alrèady discussed J if rna~nten~îce of binocular vision becomes tao much of a mental burden. he will make every effort to prevent the strabisIIDS. The macular image of . ' i 2. il. even of the lowest quality. that eye becoming the locus of reference for all visual projection. that the alternation of right and left percepts. a thinking process.causes a child' 5 eyes to begin to . 'l'he cyclopean (binocular) projection i8 discarded..Heniist occ asionally relax ând then the èyesassumeatê~orary cro3secl· appearance. acquires the é3.1 :1 1: ! 1. is not always a closure of temporal sequence~_.'::.'~. as previously diseussed. It has been weIl established experimentally. Ii :1 ~ 'Ii! I. Thefua:ividual may make a strong atternpt ta straighten his eyes by an effort of will • . in sorne manner. how does the organism come te terms with sueh problem? Several adaptations are possible • .

Suppose. The heightened acuity. rnay become a desirable feature in the total visual percept and may eventually be incorporated in the total spatial percept. which i8 available in the direction of the turned eye. When a strabismic has learned ta see ambiocularly. Shifts of this type are weIl known in all phases of evolution. They are not extensions but mutations. because it has a direct bearing on our approach ta visual training of the strabismic. The fact that such an individual usually has the ehoiee of both foros of seeing 1s not generally known. entering one or the other at will. he will naturally prefer to rew2in in the room where the language Ls . he m~ do SO-and then return to his amhiocular seeing.separativeness of right and left visual fields. In other words. capable of supplJ~ng spatial information because its line of direct gaze has a different direction than that of the other eye. allegorically speaking. He may. if he has the opportunity and the desire. Returning to our allegory of going from one room to another when the shift is made froD strabismic posture to binocular posture. leave the door between the two rooms open. It ls essential ta remember this. but an acquisition of something entirely new. The formerly suppressed eye can funetion organismically on a different basis. l t can act as an auxiliary information center.ts to be at home in bath roorus will have ta have knowledge of German as 'l'feIl as of English. due to sorre fortuitous circumstance. The individual who vran. if the dissociation between the two eyes becomes conplete. Yet. conciitions are such that a strabismic c?n maintain binocular posture for a certain visual task. The shift from separate sensory fields ta a binocular sensory field is not a gradual transition.squinter to normal visual habits. Nhen. for instance. but on strictly new terms .47 speaking (Verhoeff). that one room is occupied by people speaking English only and the other by people speaking only German. a strabismie who has learned to interpret from both eyes in a strabismic posture may still organize his seeing around a binocular sensory field percept. it is the most important single factor in considering ways and means of recondi tioning the. the conditions existing in these two rooms must be c'o[lsidered ta be entirely different. If he is not equally fluent in the two la~guages. he is not prevented from forming a binocular field structure i f the opportunity arises. but he can never be in both at once. inaslIDch as the binoeular sensory field represents the highest development in the evolutionary scale.

l.1 We find such a situation frequently occuring in visual training . at least. Many foreign barn never learn ta make this transition. but due to necessity. occured. long in coming. th '/l'hich he is most familiar 1. A complete transition is not neeessary for the habitual rraintenance of binocular posture.. Let us f0110w this allegory a bit farther. ta make this assumption in our consideration of strabismus. However. because the shift from one form of seeing to the other has not actually. sa can we teach a person ta maintain habitually a non-preferred visual posture. .8 spoken and will enter the other room only on ~pecia1 occasions. " Il 1 1 . except for short periods when l meet up with someone who can not speak English but knows German. partieularly when mathematical problems were eoneerned. or for the purpose of reading a German book. For the cure of a strabisme a similar transi tian has ta be made.'ays a learned adaptation. it is neVér because of his preference for it.S barn and raised in Switzerland. Because l came to America at the age of 21 and have resided here ever since. lAlch of the present day "training" i f os this nature. in German to thinking in English. sueh an individual may occasionally (or frequently) return to strabismie behavior. My mother' s tangue i8 German. When an individu al has learned strabismie seeing. . no matter how long they remain in America.. This is a substitute performance. l WÇl. l.48 w:l. It behooves us to devise contraIs tu prevent sueh occurences. however. It is r·lpful.that the strabismic converses 'with us thru the open door. simply because of his preference for it. German would still be-my preferred language. so to speak. The only reason l have acquired a preference for English is that l have practically ceased to use German. but only seemingly.. rhe most difficult phase of the transition was that from thinkiner~ E. It is my belief that no individual is inherently strabismie and that strabisrnic posture is al . but if tests were made today. l have spoken English longer than German and now prefer English to German. It was mueh easier to caleulate mentally in German and report the resul t in English than to conplete the whole mathematical probelm (silently) in English. It took a tremendous effort of will for me ta make a total shift from German dominated thinking to English. it does not constitute a cure. If l had stayed in Switzerland. Even if this state of affairs i8 far preferable to constant strabismie posture.Just as individual who is inherently left handed can be taught ta learn to use his right hand for writing and ta beeo~ essentially right handed thru constant praetice. only traces of ~ formed way of thinking would be found. Yfe may concentrate on finding the underlying causes of the strabiswus. We no longer have ta fear the possible lack of a fus~on faculty or fusion desire in our patient. This state of affairs was.

. the other to the left eye) at a simultaneous glanee. 1. if they lie on the direct lines of gaze. A good deal of experimental evidenee has been accumulated to prove that bimacular interpretation ean be aecomplished within l/lOOth of àseeond. when he al ternately fixa tes a single objeet in space. mayaccomplish. The visual impressions gained by alternate fixations are eortically summated ta form a continuous unitary impression. The strabismic has as little awareness of the temporal sequence of alternate right and left fixation as one normally has of the temporal sequence of the "fixation jumps" that occur in the process of reading. while the ambiocular strabismie ob tains a single unified percept of two spatially separated fixation targets (one belonging to the right eye. He is usually not aware of the fact that he shifts eyes. agrees with what the alternator. who has not progre~sed to the point where he can sirnultaneously fixate two objects in space. The only difference between the ambiocular strabismic and themternating strabismic is that the alternating squinter attempts closure of visual events (seeing alternately with one eye and then with the other) that follow each other in temporal sequence.trabismic posture. Ambiocular vision. The ambiocular strabismic has certain charaèteristies. gives way ta normal binocular DOS ture when the individu al makes a binocular EOsturing effort to fixate a single object in his normal surroundings. just as an habitual alternator does. From the above it is apparent that the fully adapted ambiocular strabismic has simply extended the learned accornplishments of the less corrrpletely adapted al ternator ta include si mul taneous fixation of two spatially separated objects. his behavior does not differ frOID the alternating strabismic. The alternator would have to interpret these abjects in temporal sequence. This. which depends on s.adapted ambiocular strabismic. This indicates that we are not dealing with tenporal sequence.49 We are now ready tolay down certain postulates and restrictions in regard ta the fully adapted strabismic as a basis for our training and testing program. again. This deseribes the aehievement level of the fully adapted strabismie. In this sense. Ambioeular vision means the abilitv to see in two dir~r!tions at once. The ambiocular (fully adapted) strabismie ean maintain direct fixation on two spatially separated abjects. who is not a fullY. but wi th a silllll taneous process. he is apt to fixate it alternately. 2. Vihen the ambioeular strabisme is confronted with a situation where there is but one target to draw his attention.

we do not have ta qùt.50 lt. the posturinc eff(Jrt that matters.entation.Jese ques tions are considered herewi th.': does that affec:. .'~tion the patier:t 1 s ability to interpret a binocular posturing effort. our approach te the problem of s trabislTJu:c? l. tLat zuarantees his ability to do it.fore. thr our. he'. h expEJri rr. It is th~rf.tes have been ~stablished throuc b studies. is the effort. If we acce~t these postulates. thrC\11f:h cl inic:ll oos erva tiens. The above postul3.

Relationship between the two fovea in strabismus. It has always been throught that the ambiocular strabismic and the individual who posseses normal visual functiàns represented opposite poles of specialized achievements and that the ambïocular individual individual had to be sboved by slow degrees toward the distant goal of normal binocular vision. according to old way of thinking. The main purpose for all is the establishment of binocular posturing ability. The story has been told before but it bears repeating. the distance between them has to be shortened one step at a time until they meet. because different training procedures had to be applied te the different individuals. using . Brock: Binocular Vision in Strabismus Part 2. They all point in a straight direction teward the goal. It was not until l had experimented with the BSM technique. We set up the testing procedure described in detail in rny article on Binocular Vision in Strabisrrus under the heading l1]kasuring the Speed of Bi-Macular Perception. VISUAL TRAINING IN STRABISMUS The purpose of visual training in al1 forms of strabismus is (a) to elicit an effort at binocular osture under s ecific test conditions. The ~ùles laid down abOYé can be follûwed explicitly and include all forms of strabismus. Il (FrederickYi. The . came to ~ office sorne months ago. It became apparen~ that she did not know how to look at any object with both eyes simul taneously. As recently as a year ago l still was of the opinion that the ambiocular strabismie had to be "broken down" before a new pattern of seeing could be developèd. apparent that we can follow a single pro gram of visual training for aIl of them. therefore. b to extend this adually over ever widening retinal areas in the individual' s normal surroundings c to maintain i t over more and more extended periods. an alternate exotrope. the suppressor. that this realization was forced upon me in a rather spectacular fashion. Today we know that the distance can be covered in a single step. Two letters were projected onto two squares which had been drawn on a translucent screen. This beliei is still an accepted principle in most~trabismic clinics. An exceedingly intelligent girl in her teens. the alternator and the ambiocular. At the tirœ l l'ras interested in ambiocular phenomena and it was not difficult to interest her in becoming a subject for rny studies. not to have her eyes straightened but because she needed new glasses. l spent many years teaching how to differentiate between the various types of strabismus. If we think of the arnbiocular strabismic as being at one end of a long path and the normal individual at the other end. Optometric Weekly J 19L5-46). It becomes. the amblyope. an intermediate screen.51 IX.

she reported that her appreciation of the objective situation had changed and that now the ring seeffi?d ta come closer toward her and at other tirnes appeared ta recede to a position beyond the rabbit. so labariausly built up aver these many years. She thoueht of the ring as being squashed and pulled into a barrel shape.1 r1 nnt.. L ~ \ \ When the rings were motivated... as i5 customary in ambiocular vision. A shrinking and swelling of the perceived ring also becarne apparent. The green and red rings surrounded the rabbit and were initially brought to exact superirnposition. the patient stated at once that she was aware of a single ring which seelIEd te move to the rieht and the left. half green. \ b 6 1 / B. but did not appear ta leave the screen. Interchangeable letters were flashed onta these squares.ject on whom to test the validity of lTlf belief that reti!1al dispari t. 1.<'30::: wn..~C~d-bY th~ B~o. the other to the left. hA available for the interDretation deDth variations .kRing-~thod~-It was' decided to project the rabbit and rings (BSM 20-1-2) between the squares with the rabbit in the center of the total field. one to the right. The patient reported that" she saw the letters in both squares and that she also saw the rabbi t and surrounding ring.· The physical set up between the above is shown in the below figure.... This was a distinct shock to me. While the right eye looked into square (R).patient was placed in front of this screen in such a way that the right axis of gaze intercepted one square. The ring appeared to her to be half red. The letters were read off without error at a hundredth of a second. l could nat wa teh her eyes while she reparted. while the left axis of gaze intercepted the other square. Suddenly. This ability identi:ied her as an accornplished ambiocular squinter.)r . Vlhen I realized the significance af her answer I felt as if ten years af study had came ta naught. It occured to me that this in di vi dual would be a good sub. and yet it seerned to remain perfectly round.t her eyes no langer seerned in their farmer exatrapic pasi tian but appeared . l had hardly the strength to change ray lacatian ta 'rie\'/' the patient. the left eye was directed toward square (L). My whole structure. seemed ta tumble. It was bath a decided surprise and relief ta find th1. At the tirne she reported these changes I was attending to the instrument and was on the opposite side of the screen froID the patient. Cansequently. C.

53
to be directed to the centel' of the screen. My questioI( ''Where are yaii Tôoklng7 f1 -seemed ta come as a surprise to her, because after a moments hesitation she exclaimed rather dazedly that she felt she was lookjng at the rabbit rather than the two letters. It was but a very short period of time befare the girl learned ta maintain binacular posture bath at the intermediate screen and the near-vie?rer. She progressed very rapidly in her acquisition of normal binocular vision. This was the first indication which l had that posture determines the nature of the visual responses: If an individuar-p6s tures binocularly he thinks binoGularly; if he postures strabismically, he thinks as a strabismic must, if he wants to maintain an adequate spatial percept. To me, this was, of course, the beginning of a new line of reason1.ng regarding what an ambiocular patient can do, when proper test and training conditions are provided. ' l have followed this lead since and found it applicable in most strabisme probleIlli3. l have found it desirable ta attempt ta obtain a binocular posture with aIl strabismies right at the outset of training. When this can be done the training procedure is tremendously shortened. B. In convergent strabismus the setting up of training situations at the crossing point of the visual axes by setting the training instruments to the existing angle of squint permits the patient ta maintain his habitual strabismic posture. This'is the most unlikely position where a binocular field percept can be developed. In divergent strabismus, the placement of the target at the angle of deviation, either by adjustment 0: the instrument or by prism prevents a binocular posturing effort &'1d therefore inhibits the formation of a binocular field percept. Alignment of the eyes of a divergent squinter on a single distant abject by means of prism is simply another method of bringing a fusable object on his two axes of gaze while he raintai;,s an habituaI s trabismic pos ture. This procedure has a tendency vo inhibit a binocular field percept because of the existinc; strabismic post.'êTe. As a matter of fact, when the above procedure is fol10wed it is frequently found that the strabismie "runs awayll fror!! the impossible situation either by increasing his tu~n or reducing it just enaugh ta prevent the Iike retinal images from forming on the respective maculae. He may report that he S2es tr.c objects at 'Nidely different points in his total field. He instinctively fee}, L,hat the objective si tua tion has no meanirg, .;. l,rla 1:, i l L armot be ir: l:-erpreterl to his satisfaction.

C.

e.,

-=-

54
1) 1bst divergent strabismics find it easier ta posture binocularly at near than at far. Many of them maintain occasion.].l binocular posture at near long after they ha~e abandoned binocular seeing at far. The abject that is close enough to the person ta be manipulated can be handled more satisfactorily while binocular posture is maintained. Threading a needle or using a screw driver becornes easier when the two eyes posture for the task. Greater compétence of manipulation, which appears ta be the main purpose of binocular vision, justified the development of this exeeedingly complicated visual process. 2) The first binocular posturing efforts are, therefore, apt ~ succeed at close range when ~erceptual demangs are kept beyond the hiK~_est achievernen ~ level in uniocular or ambiocular 'p_o~.
in our whole approach ta visual training.

Thisfollovrs the reasoning we have been expounding It is fundamentally sound and will pay dividends if followed explicitly.

Let is assume that we have a strabismic who has a 30 degree exotropia. This individual is persuaded to undergo an operation in whieh the surgeon pulls the tvro eyes straight by shortening the ligaments of the two internal recti. The question l would Iike ta raise is, 'n,'fas the posture of this individual ehanged from Cl. strabisrnie posture to a binocul2r posture by the operation?" We may consider this ques tian from a differen t angle. Suppose, instead of the operation, the patient had been supplied with sufficient base in prism ta bring the two eyes ta an effective paraIIeIism, we should have accomplished essentially what the surgeon did. Again, had we placed the individual before an amblyoscope and had adjusted the instrument to the 30 degree exotropia, the resultant objective situation woulrl not have differed from either of the above~ Vie all ~ayee, l think, that the strabismic retains in both these cases, his strabiscric posture. It must, therefore, also be assumed that thru operation no shift to binocular posture occurs.màt sa many of these operated individuals with straight eyes see double after operation, attests to t~~th of this assucption. This undoubtedly, is the reason '.my i t is custorra..ry in stréibismus operations not ta atterrpt to bring the two eyes in to exact parallelism, unless no estéiblishm€nt of binocular

55
visual habits (after operation) i8 conternplated. Usually a near-straight position is found to be more satisfactory. l'hepatTènt can then, by effort of will, bring about a binocul~ posture, if he 50 desires. When the eyes of a strabismic are fully straightened, there is apt to occur a more or lesS-Violent reaction ta th~s new status. The patient will make a decided effort to escape this new visual sensation by moving his eyes away from "there". If his eyes were fully straight before he makes this effort, any voluntayy shift in the relative eye positions is necessarily aNay from the position where a binocular fi~ld pattern can forme In other words, any shift will be away from the very posture he should maintain. But if theCyes are not ful],y straightened by operation a snift of posture away from the original position mày go eTfber way. The chances are equal that i t may be in the direction where a binocular field percept may become possible. The patient may suddenly realize that with a moderate effort he can now direct his eyes toward binocular posture, which is then apt ta forme He learns ta see binocularly by making the effort. Take away the need for effort, you take away the oècasion to learn. Let us remember that adjusting an instrument, or using prism to conpensate for the habituaI turn, is_natsynonymaus ri th establishing binocular pos ture. Unless an individu al wants to look at the same object with both eyes directly, he i3 not posturin~binocularly for it, even though he may be made to look in that direction. The question arises, How can we tell when an individual postures binocularly? Few strabismics know how to posture properly, and certainly not on their first attempt. It i8 fortunate that we do not have to have perfeet binocular posture ta obtain stereoscopie vision, provided we do not desire stereoscopic aecuraey. He have seen that fusion attraction can oeeur ri th the eyes in considerable disalignment (possibly as mueh as 10 prism diopters of lateral disparity). c'llils makes visual trainine a great deal easier. 'Ne should help the strabisme in his effort at binoeular posture. When it is not within his po~er to posture at 12 inches, it may be possible for him ta d') so at 8 inches. It is, then, our dut y t') see ta it that he gets a chance to attemp t i t at the closer range. Our job is to bring the target close enough for the patient ta posture the way we want to. This is our main problem. It is also our responsibility ta present him ffith an objective visual sit1Jation that does not require accuréltl':: posture for it3 successful élccomplishment.

l have already mentioned Halstead's recognition of the importance of peripheral perception as in aid to fusion (Brain and Intelligence. p. the easier it will be for him ta respond adeouately when he makes a binocular posturing attempt. The strabismic should be trained as ~lch as possible 'in the open'. BSM (anaglyphs) and Vectograph methods of training seem to be the least artificial approaches for the training of stereoscopie perception. are a MUST in strabismus training. \Vhere a binocular field percept already exists the stereoscope is the instrument of choice. has a tendency to foster separate field percepts (where the latter have previously existed) and is contraindicated in the early training of the strabismic.S6 D. Binocular rotations. in other words. given bv having the p. We must be constantly on the watch that l're do not present him with objective trainin~ situations which he can more easily assocîate with hisstrabismic posture than with his newly acquired binocula.ient observe a candIe or smaU lighted bulb. Gare must be taken that the corne al reflections are weIl centered in the two pupils. Ignorance of this rule has caused a great deal of confusion amongst eye specialis-ts and technicians ~like.t. My favari te method of "touching pencils" is another excellent means of creating demands on visual skills that can only be met in binocQlar seeing. however. The use of the stereoscope should. under conditions tbat approxima te his normal surroundings. The more realistic the objective situation is. )4). . A septum in an instrument. which confronts the strabismic. Even after full stereoscopie perception can be demonstrated to exist by the B3M or Vectograph techniques. under strict supervlslon. an individual who has not been trained in the stereoscope may not be able to interpret through it and may revert to alternation in preference to binocular posture. especially in amblyopia and strabismus. which divides right and left eye seeing. Interpretation through a stereoscope is a special skill. This is importânt te remember. be limi ted so long as regression to s trabimic posture is to be feared. Shrinking the perceptual field to exclude peripheral awareness is éL'1 unsound procedure.r posture. E. Only by inclusion of the periphery can the eyes be steadied sufficiently to permit of gross stereo-awareness. because a peripheral binocular field structure has a steadyin~ effect on the macular visual processes. This rnethod lends itself excellently to home training.

even though such posturing is not possible at infintiy. The improvement will of neeessity be limited to those areas in the individual' s surrounds where he can learnto maintain binoeular posture. the 'importan t consideration. before they come ta us for eye eare. Only after we have learned ta establish binoeular posture without ereating-a-5ense of double vision.tion. He cornes ta you for relief from the disfiguring turn of his eyes. That to him (or his parents) is the important consideration. ~e have accomplished a great deal. The establishment of binocular osture at near (in both eso. As a matter of fact.untain binocular posture (beeause of the existing paralysis. The individual who has never had stereoscopie vision does not miss it except on certain occasions. This still holds true for the doctor who insists that a sense of diplopia is perequisite ta normal visual functions (stereoscopie vision).and exotropia is desirable. provided the individual is Eeroitted ta retain his ability ta suppress the undesirable "seeondary im~ in the_ areas of his total fiek where he finds i t irrpossible ta m. This is not. This is of course tre surgeon's arguoent who often hopes that .i ve factor in binoculotr vision is the dernand for space manipula. If vre can straighten the eyes to cosruetically acceptable proportions. In such cases it would be a disfavor to "improve" the si tua tian by teaching thern diplopia in the areas where binocular posture cannet be obtained. where coneomi taney of . the important causat. hmrever.oeular rotations is known to be lacking. He is primarily concerned with the fact that his eyes cosmetically look different from those of the people around hirn. may we atternpt to help the paralytic squinter ta become more efficient visually. Binocular posture at near tends to keep the eyes cosrœtically straight and rais es the ac hievement level of manipulatory tasks. as far as the patient' s rlshes are coneerned.57 In case of paralysis o~ specifie ey~ ~lscles. Organismica11y. As reeently as a year ago l spent a great deal of time teaching how to differentiate between concortltant and non-concomitant ocular rotations so that they would learn ta differentiate non-trianable and trainable cases. the establishment of a binoeular field percept in only certain areas in the total perceptual field is not contradicated. The . sorne individuals will exhibit sterèoscopie ability and binocular fixatio~ in certain directions and show a tropia position (without seeing double) in other directions. when the eyes are not straight.) Training ean be given for the purpose of effecting more adequate visual behavior in paralytic strabismus.non-concomitants were the non-trainables.

or even possible. This is somewhat in opposition to conventional thinking. surgeon or He may turn the non-fixating eye sa that it can assume a position of sorne organismiè importance . If fusion does not develop when the eyes are quite straight. There is only one objection to this policy.ets at the angle· of strabismus. . which is the second way of establishing a stable relationship between the two eyes. It is generally assumed that the chance for normal binocular vision after operation is greatly enhanced by developing the fusion faculty prior to operation. my chances in all cases of strabisrrus where no binoculélr posture can be obtained prior to operation woulà have been better. 1 ! 1 1 1 1 1 !I j 1 1 b) '1 '1 1 H. once the turning away from parallelism has begun. strabismic. This is logical assumption but it has a dangerously weak spot. As a result they developed a fusion aversion and a sense of diplopia which continued through the years although their eyes were in sufficiently straight position for normal binocular vision to function. This opens the way ta a return of ambiocular seeing.where it can observe (directly) a different object in space than does the fixating eye. We can control the situation only through the establishment of a binocular pattern of seeing. Several of these patients shol'ied after operation a total inability (or what l now believe was a total lack of desire fbr binocular posture) to fuse. after l had built up what l thought to be a strong urge for fusion by placing fusible tar[. there is no way of telling how far i t rill progress.58 the strabismic will go on seeing alternately after operation.ly grope for an inclusion of the IIditched ll eye in his total spatial percept. Eow do we knmr that binocular posture will be desirable. Unfortunately. will graduaJ. one eye loses its ability(to look into a different direction) and the individual. l know that if l had waited to establish a binocular field until after the operation. after operation? l have seen sorne of ~r own patients undergostrabismus operations. without knowing it. There are only two ways in which this can be done: a) He may fall into a binocular pa~~ern of seeing by learning binocular posture often ta the pleasant surprise of the . Today. as long as he keeps the eyes cosmetically straight. \~e had created a binocular sensory field th.t became a burden and an annoyance ta the operated. Any individual who can be taught to posture binocularly will be able ta interpret according ta normal binocular vision. By following this procedure we have avoiàed horror fusionalis ~nd none of our patients is troubled with an a'1noying sense of seeing double.

59 Questions and Answers. ta birth injuries. He has been forced ta enter the other room instead of talking thru the door. It is this effort ta lido something" ". ~hen the target is placed at theccrossing point. if the abject is brought beyond this point. the crossing point is found to be at three and a half inches. Until l'le know how many scotomatous conditions are due to lack of development of the macular nerve bundles. HOIT do \'re knol'r l'rhether or not . the patient feels that he has "done something" \'l'hen he is able ta look at the target ri th both eyes (as he has been instrueted ta do). Whether the location of the central nerve bundles (reaching the macula) on the temporal si de of the optic nerve imffiediately behind the eye rnakes them more accessible to taxic involvement ls a question which is still debated.. Question 1: Why is strabismus prevalent in certain families and not in other s? Answer: The prevalence of central scotomata in certain families seems to be one of the reasons. On the ether hand. The establishment of rudimentary binocular field processes depends on the effort whieh the patient makes to posture binocularly.ot De braugnt to mù~ the necessary posturing . Apparently these nerve bundles are most susceptible ta permanent in jury in cases of optic neuritis. When the patient makes no effort to fixate the light binocularly at that distance. patient will respond te training? patient cann. Let us assume that by bringing a light toward the eyes until the reflexes are &entered on both corneas. Retrobulbar neuritis is one of the known factors in the development of central scotamata.mch is capable of changing his concept of what he sees. It is quite possible that the study of brain functions by means of measuring brain waves may throw some light on the cortical involvements which tend toward the development of divergent and conv~rgent strabismus in cases where no physical abnormalities are demonstrable. Question 2: Is it advisable ta start training at the crossing point in esotropia? Answer: This is the one point where training should not be started. he should attempt it at five inches. It is this effort that is apt to bring about the shift from strabismic to binocular seeing. Question 3: Answer: If Ci!. There may also be an inheritance factor. to septic diseases or abnormalities in the formation of the orbital cavities (which create a greater susceptibility for scotomata in certain individuals) this question C~-illût be &iswered with any degree of accuracy. but ~e actually prevent it from occuring. The place to "coai:1l a binocular field is alV'rays sorne distance beyond the érossing point.. we not only do not invite a binocular pesturing effort.

The only question i8 how far fram the cros8ing point should the original atternpt at binocular posture be made. If. Increases in the convergence of the strabismic eye. how will you induce him to change to normal posture? When. For instance.tce phorias &~d ductions as we do with non-strabismics? NO. However. In the former case we should likely attempt binocular posture initially at five inches. the chances of establishing a binocular sensory field are slim. Besides. Question 5: If rre achieve binocular vision in a former strabismic. without teaching him diplopia. you determine the existing angle of squint to be 35 degrees. The retinoscope light should then be brought still nearer to the patient's nose in orderto observe whether bath eyes will follow ttclight in or whether the strabismic eye now assumes a position of under convergence.ce ::"n visuaJ.60 effort. when the light is brought closer. This may happen at 4 1/2 inches or at 10 inches. This overconvergence stops at a certain point and both eyes suddenly fixate the light. approaching the target closer only when the initial attempt proved a failure. your chances of success are greatly enhanced. To try to establish a binocular pattern. The push-up test can furnish the desired information. simply means that you elect to fight against odds that you don't have to take. in an individual who ls permitted to maintain his habitual strabismic posture. is frequently noted. When a stereo-percept can be established at nine or ten inches with the BSM technique the individu al can apply what he has learned (or rather experienced) in his normal surroundings when an abject is brought to this distance in front of him.ls training? Answer: The amblyoscope has a defini te pl a. Ansner: This ia an important question and the answer is The reaso n . on the other hand. if you succeed. However certain restrictions should be ob8erved te prevent the violation of the rules just disc~s5ed. What the individual learns in the amblyoscope set-up cannat easily be transferred into his normal surroundings. To see that this happens is a part of the training program. When the latter is the case we have no right to assurœ that the individu al had shown a :--inocular posture at 3 1/2 inches. on the other hand. Let us asSUl'œ that Othis oeeurs at 3 1/2 incbes. and you attempt to establish fusio~ with the instrument at 25 degrees. training of the strabismic. the light i8 drawn slowly avray from the nase and careful watch iS kept as to when the two eyes abandon direct fixation. Question 4: What use has the amblyoscope in strabisl!D. it is important to remember that it is not permissible (ta our way of thinking) to aijust a synoptoscope or amblyoscope ta the existing angle of squint for an initial eff0rt at establishing a binocular field percept. even this does not constitute an advisable procedure. both eyes follow the light in to two inches before an apparent break occurs. while in the latter case at 12 inches. can l'fe aften'iards ta.

The chances are that he will not again recover a binocular pattern of seeing. do l consider that diplopia training may be given as a safeguard against occasional lapses into the former tropia position. Care has to be taken that as saon as a comp1aint of annoying diplopia i5 made diplopia training is immediately abandoned. Rather than see double. before diplopia training is undertaken (as a final step) it has ta be ascertained that fusion can be maintained in all portions of the field. indicating that binocular seeing hact been abandoned. the patient can still revert to his strabismic thinking. he will simp1y revert and report ~_eeing9n1y one target. at least for the time being. It will be very difficult to de termine a recovery point. In duction tests he Will not be conscious of the breakpoint and the only was. . only i f larn assured that the patient can maintain a binocular pattern at all times and without undue discomfort. unless he is permitted to reorganize his binocular pattern outside of the phoropter.61 i5 that when making duction or phoria tests. Also. As a matter of fact.< we can de termine i twill be by his gbserving a lateral motion of the fixation target.

l would never set a child up on a refraction chair without making it difficult for him. The lit tle red dag has still a smaller black squirrel underneath. regardless of hOir mch l ha.blyopic eye usual1y wavers and may not show the macula at all when the game is played.62 APPENDIX A. After a while. We had a very gOGd subject for the demonstration." You noticed that as saon as the child blew at the exposed ophthalmoscope bulb (the "candle")' l sritched it off. but the child would have been a Yery difficul t patient in the ordinary office routine. In that way l could observe rotations and saccadic fixations at will. . "Do you see how l look inside this hole?" "Wou Id you like ta look in from the other side?" It was as easy as that. ta see what was inside. When l was ready for the fundus examination l turned the light on inslde the ophthalmoscope and from a distance directed the instrument in such a way that she could see the light. but by finding tœ macula centered in my 1igh t l:eg l knew that she had direct fixation abi1ity with either eye and that she could not be very amblyopie. Once she did look inside. This afternoon l atte~ted ta sh01f you how you can haneile a t'irO and a hill year old child to get the maxirnlm information. l assur~d him that 'Iras the very child l wanted.ri thou t having Mother help you!" The usual answer is: "1 bet l can!" And up he goes! But you have to give him a better incentive to climb the chair tban to have his eyes examined. "Look. j B. If a child refuses ta pldy the game. An arr. by now. of course. Then came the "game". don't ever force yourself on the child. "Did you ever see su ch a very red dog? 'r'Inat is he jumping over?f1 By the time the child has made up his mino how to ~~swer the scoping is done. This. not very difficul t ta get him to look at the little red dog. which serves as my dynamic target. came after the delightful past time of "blowing out the candle. the macula was in clear view. can you se. That is as unpleasant a prospect ta a child as is the dentist' s appointment. The child has. l did not go for the disc.e the light while l riggle i t like this?" It is then. The doctor whom l approached rOI' the selection of a little patient did not want ta suggest her because she is so very bashful and shy. It seemed all very easy the way we "ent about it.ted ta do it at the lllJment because l was observing her for indications of binocular fixation (push-up test). l show him that l have still another one. become accustomened to two different lights. l managed to tell her to wait with the IIblowing out" until l told her to blow. l raise the chair up high and put an additional cushion on top of it and then am apt to say: "1 bet you can't get up there by yourself . Notes on testing the pre-school child. You aIl watched me get a glimpse at the child's two foveas by playing the game of the two of us peepïng into the ophthalmoscope from opposite ends.

refraetion should not pose too mueh of a problem. of course. A good refractionist can estirnate a cylindrical correction quite elosely withQut the use of cylindrical lenses. l never put a trial frame on a small child. Refraction cornes third. The difficult task is aceomplished. This does not permit you to place a trial frame in front of the child and that is just as weIl. If l need a lens. It is mueh better for the examiner ta hold a trial lens in front of the child's seeing eye and to be ready to withdraw it the minute he notices any sign of anxiety developing. because a frame would be apt to evoke a eatastrophic reaction. th. it takes more than one short visit to assemble sufficient data ta give a valid opinion. ~ For the purpose of refraeting ehildren. l always use the standard old-fashioned trial case with the bi-concave and bi-convex lenses. May l counsel you right here that you should never attempt to ocelude a small ehild's eye yourself. the big problem is how ta get itin front of the child's eyes. If l can get within a diopter of an accurate scoping. In order to make monocular tests for visual acuity or to prevent alternation of fixation during the difficult task of scoping. Soon the child wonders what l see through it and makes an effort to look through it also. After l had finished the mother wanted me ta advise her as what she should do about the strabismus. Tha~ is the time ta bring the lens. l hold a lens up about midway between the child and myself and mve i t around.at i5 all l need at the moment. at least not the first tirne. Once the child has permitted you ta look into his eyes. but we were able ta ascertain that the little girl is an alternating strabismie and shows no marked tendencies toward binocular . As a rule. by slow degrees. You noticed that l played with the little girl while a3sembling rny data. it is necessary to occlude one of the child's eyes. nearer and nearer ta his eyes. the minute you start holding something very close ta his eyes he starts ta get seared.63 !WO things are. It is mueh better ta let the child occlude his own eye by keeping his hand in front of it or to let the mother hold her hand cupped in front of the eye which is ta be occluded. Notes on occlusion of a pre-school child. We had a little girl here this afternoon . not to let rny play with the shy little girl but ta arrive at sorne decision regarding her strabismie condition. It i8 a difficult problem but by no mean8 insurmountable. As you may weIl imagine. The parents came to the clinic. It may be stated right here that we are very much in need of a suitable subjective test to determine within reasonable accuracy the visual acuity in a pre-school child from two years up.the one l used to demonstrate haw ta approach a pre-school child in an effort to get the most information·with the least arnount of unpleasant reaction. important in all examinations: occular motility and the fundus pieture.

it becomes necess~-y ta attempt to improve the visual deficiency. to MY way ef 'thinking. by doing sa yeu might destroy the binocular pattern of seeing. Because of lack of sufficient information let us make a few assumptions. on the third visit you had been able to find indications of binocular fixation ability at very close range. to order prolQnged total occlusion of one of the other eye or alternate occlusion on alternate days because. It vw'ould. As SODn as it it becomes evident that the child is irritable beeause of the occluder. It is only after it has been ascertained that the occlusion of the good eyehas no bact effects on the child's behavior and ability ta get around that the occluder may be left on the good eye for days at a time. In this case it would be more advisable toorder partial occlusion of both eyes which l shaIl describe shortly . First let us discuss other questions which might leas us to occlusion. become necessary to occlude the good eye ta determine the usability of the squinting eye. Let us assume that the child had come to your office and you had gone through the first session in sorne such manner as you saw me. then.6h posture." The mother then proceeds ta acclude the turned eye rather than the good one by fastening a cellUbid shield over it with cellophane or adhesive. can we do about it? What c. Under no circumstances must the occluder ever he used as a means of punishment for nad behavior. Law Vision may be due to lack of fixation ability of the Irabandoned eye lf or ta a central seoto8a. orders are ta remove it for the rest of the day. Suppose the lit tle ëhild in question had shown unilateral strabismus and that turned eye showed little inclination to follow a light or ta turn directly toward a fixation abject. Specifie orders are given that the child i5 not ta be let out of sight while the occluder is on the good eye and the every effort must be made ta entertain the child and ta coax it to E!3r while the occluder is in place. This procedure ls followed daily until the child tolerates the occluder for a whole day. The ehild i8 not apt to resent having his turned eye occluded after he gets over the first shoek of having a Ifbandage lf • By the occlusion of the bad eye he is in no way handicapped visually and usuallyis quite willing ta leave the occluder on for a quite a spell. at first for very short periods. Having gathered this ir~orIT~ticn it ~outd not seem advisable.to prevent the developrnent of ambiocular seeing. Let us suppose that. When total prolonged occlusion of the good eye is necessary we usually proceed as follows: The mother is instrueted to take the ehild home and tell him the next lOOrning that one eye has to be closed up· because i t rrlooks bad. She seems te be weil on the way ambiocular vision. If the child shows indications of inadequate vision when the good eye is totally occluded. r . Vfuen such a situation arises with a pre-school child it is never advisable ta occlude the good eye except for fractional periods until an estimate of the usable vision of the turned eye can be made. or for bad behavior during occlusion. Only then begins the process of occlusion of the good eye.

as of today. or stringing beads with the good eye tot al 1y occluded. It was an insurmountable problem for her ta face. The follo?Qng story was given as a background . i f after a month of two there are no indications that binocular posturing oceurs. the green one over the good eye. The child would wear red and green filters. On examining the patient l recomr. Keeping both eyes permanently i~ the race is simply to invite the emergence of an ambiocular mode of seeing (associated with alternation). She became completely hysterical at the thought of the occluder being removed from her glasses . It is not permissible to maintain bath eyes unoccluded for very prolonged periods. if that it within his achievernent level. We usually advise parents to buy the child two identical coloring books with bsld outline drawings. sueh as tracing the bunny (BSM 20) as projected through a ruby filter onto the intermediate screen.. This procedure was carried on for six years. In this way it is often possible to establish a desire in the child to do as weIl with one eye as with other.At the age of three the child' s eyes become partially turned.ended removal of the occluder. Wh~rr the mother agreed. followed by an attempt te celor the same page in the other book with the good eye occluded.Year by year the occluded eye turned in farther and farther so that today the child has a tremendous convergent souint with one eye almost lost from vie'. When it is possible by such methods to bring about satisfactory fixation of the forrnerly turned eye. The doctor ordered occlusion of one eye when the child was three years old. the child has had every minute of her waking hours one eye or the other totally occluded.. In our own procedure this child would be brought to the office at least trice a week for Tlplay". Case Report. would be played. sa that. Carefully supervised "games". The latter furnished the inforID3. it is permissible ta alternate total occlusion of the good eye with a day when bath eyes are allowed to remain open. without causing resentment in the child that the speèific task has always ta be done ri th the "bad" eye "hen he knows that he could do the task sa much better with the other eye. Thus the bunny could not be seen by the good eye and the cpild would have no feeling of occlusion of that eye. Because of her violent reaction the matter l'fas dropped . picking up small pellets. Every six months the child was brought to the doctor's office but apparèntly nothingwas done except ta take the occluder off one eye and place over the other eye.65 C.. The mother became perturbed and brought the child to a local medical practitioner.tion that the refractive condition was approxirnately plus 2.00 OU and that she had 20/20 vision with each eye. Other games are .playing with marbles. Now this is what her parents report: . the child broke into a terrible fit. which will complicate the original problem rather than simplify it. The chi Id is allowed to color in one book with the good eye. Notes on training the pre-school child.when the occluder i8 removed. The child now is nine.for tte first time in six years. This gives the child a chance ta develop binacular pasturing ability. sa that occlusion was begun six year aga.

On the other hand.. In such cases occlusion therapy is acceptable until direct fixation ability has been established. It is therefore quite true that total occlusion has its drawbacks. ans\~er The fact that the eye turned more after occlusion is not an isolated case. The second kind of occlusion is the one we want to consider now.:uestion: Could ambiocular posture be prevented bv occludine one eye the first day. Notes on the use of HALF OCCLUD~nS If we take the total occluder off the l i ttle patient. the visual impressions that enter via the turned eye will have ta be cortically "suppressed:1 or interpreted according to the relative eye positions. the other eye th~ second d~y ~~d not occluding either eye the third day. Then a different kind of occlusion should be started. in other words. as psychologically she accepted the new situation. and in that sense the procedure was justified. unless prevented. if total uniocular occlusion is abandoned. Has this child been able to develop a binocular posture? The is that binocular posturing has been inhibi ted for the last six years. because i t destroysany possibili ty of an occasional at. There is the background of that story. Actuallysome parents sued the doctors responsible for the occlusion because of the resultant strabisrnus. where occlusion was cm'ried out because of amblyopia associated with straight eyes. they had strabismus to deal with after occlusion therapy. We have recently had several reports in the ophthalmological literature of similar occurences. Also. h~r acceptance was gradually obtained. subnormal VlSlon in uniocular strabismus frequently improves under total occlusion. the patient becoming an alternator. interpretation will folloN strabismic laws. the better fixation can be brought about more directly by visual training. she will have no incentive to binocular posture. After a few more visits. ~~biocular seeing (strabismic posture) will eventually evolve. The report went on to say that in several instances. so that the child might "fall into" binocular fixation at least at near? . On the other hand. occlusion has not permitted her ta develop an ambiocular (strabismie) posture. 1 do not agree to total occlusion of one eye for any extended periode It is not an acceptable procedure in my way of thinking. which questioned the advisability of total occlusion for this very reason. If total occlusion brings about a better fixation. D.teIq)t at binocular posture from becoJring effective. These factors have to be considered in occlusion therapy.66 immediately. So why not train? Total occlusion certainly cannat build a binocular pos ture. Inasmuch as this patient is sa very strabismic. c.

This method can. The third day there would result a rivalry between two eyes as to which should take the lead and which should be suppressed. This is best done by frosting the nasal areas of both spectacle lenses 50 that. RI"HT Cyr STf?A\GHT AREA 'J From the figure i t is eviden t that. -j J 1 1 .s. provided the strabismic wants i t.put on halfoccluders on both eyes for a prolonged periad. because i t would not be safe to occlude the temporal fields in divergent strabismus (one eye cannot take over where the other eye does not see) they are not overlapping fields.straight ahead the whole pupil clears the frosted area (see figure). an gazing . A macular image cannot form in that eye so long as it is turned.67 Answer: In rny oplnlon this procedure would n0t effectively prevent the advent of ambiocular posture. when the one eye looks "out" the direct line of gaze of the other eye is directed under the occluder. the eyes are cosmetically straight and a binocular pattern of seeing is possible. It is quite likely that this procedure would hasten strabismic posture rather t~an prevent i ts accurence. By alternate occlusion each eye wauld be forced ta take over the visual functians of the ather (occluded) eye. of course. If both eyes can cle~~ the occluder. It seems ta me that the answer ta the problem i3 . only be applied in marked convergent strabismv.

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer: Get 4 months of Scribd and The New York Times for just $1.87 per week!

Master Your Semester with a Special Offer from Scribd & The New York Times