VISION 

CATCHER: 

SENSORY
PHYSIOLOGY AND
PATHOLOGY 
Ospital ng Makati – Department of Ophthalmology
Rholter Dave M. Lee, MD
OUTLINE

• The physiology of normal binocular vison

THE
PHYSIOLOGY OF
NORMAL
BINOCULAR
VISION 
BINOCULAR SINGLE
VISION
• state of simultaneous vision achieved by coordinated
use of both eyes (motor fusion) so that separate
images arising in each eye (clear visual axis) are
appreciated as a single image (sensory fusion) by the
process of fusion. 
FUSION

• is the cortical unification of 2 images of an object, 1 from each eye, into a single percept. For retinal
images to be fused, they must be similar in size and shape. For fusion of macular images (central
fusion) to occur, there can be very little dissimilarity between the images in each eye, because of the
small receptive fields in the area near the fovea; otherwise, diplopia results. 
PEARL

• Adults with epiretinal membranes may experience

double vision because of foveal distortion. 
MOTOR
FUSION
MOTOR FUSION

• Motor fusion is a vergence movement that allows similar retinal images to be maintained on
corresponding retinal areas despite natural conditions (eg, heterophorias) or artificial causes that
induce disparities. For example, when a progressive base-out prism is intro- duced in front of both
eyes while a target is viewed, the retinal images move temporally over both retinas if the eyes
remain in fixed position. However, because of a response called fusional convergence (see Chapter
3), the eyes instead converge, repositioning so that similar retinal images are projected on
corresponding retinal areas. Measurement of fusional vergence amplitudes is discussed in Chapter
6. 
SENSORY FUSION

• Sensory fusion is based on the innate, orderly topographic relationship between the retinas and the
visual cortex, whereby images falling on corresponding (or nearly corresponding) retinal points in
the 2 eyes are combined to form a single visual percept. 
STEREOPSIS

• a binocular sensation of relative depth caused by horizontal disparity of retinal images. It is the highest
form of binocular cooperation. The region of points with binocu- lar disparities that result in stereopsis
is slightly wider than Panum’s area, so stereopsis is not simply a by-product of combining the disparate
images from a point into a single visual percept. The brain interprets nasal disparity between 2 similar
retinal images of an object in the midline as indicating that the object is farther away from the fixation
point, and temporal disparity as indicating that the object is nearer. Binasal or bitemporal images are
not a requirement for stereopsis; objects not in the midline in front of or behind the horopter also elicit
stereopsis, even though their images fall on the nasal retina in 1 eye and the temporal retina in the
other. Stereoacuity reaches a high level (60 seconds of arc) by approximately age 5–6 months. 
CLINICAL PEARL

• Stereopsis and depth perception are not synonymous. Monocular cues—which in- clude object
overlap, relative object size, highlights and shadows, motion parallax, and perspective—also
contribute to depth perception. Monocular patients can have excellent depth perception using these
cues. 
RETINAL CORRESPONDENCE

• term used when a viewed target stimulates paired retinal areas in an individual’s 2 eyes. 
• These retinal locations are said to be corresponding. 
• On the other hand, stimu- lation of noncorresponding or disparate retinal points results in the
sensation of 2 visual directions for the same target, or diplopia. 
NORMAL RETINAL
CORRESPONDENCE
• the foveae of the 2 eyes are corresponding points.
Retinal areas in each eye that are equidistant from the
right or left and above or below the fovea are also
corresponding points. 
• The locus of points in space that stimulate cor-
responding points in each retina is known as the
horopter. 
HOROPTER

• A space containing all object points that can be projected on corresponding retinal points at a given
fixation distance 
• Vieth-Muller Circle 
• Empirical Curve 
• Panum's area 
VIETH-MÜLLER
CIRCLE 

• A circle passing through the

center of rotation of the two
eyes and the fixation point 
• Formed by tracing
corresponding points that have
a regular horizontal distance
from the retina 
EMPIRICAL CURVE 

• Flatter than Vieth-Müller circle 

• Hering-Hillebrand deviation - deviation between the circle and the empirical curve 
• All points outside the curve are disparate and seen as double 
PANUM'S
AREA
• Narrow band around the
empirical curve 
• Objects stimulate disparate
retinal elements but produce
single vision 
• Narrow at fixation point
• Broad in periphery 
SENSORY ADAPTATIONS IN
STRABISMUS
SUPPRESSION 

• is the alteration of visual sensation that occurs when an eye’s retinal image is pre- vented from reaching
consciousness during binocular visual activity. 
• Physiologic suppression - the mechanism that prevents physiologic diplopia (diplopia elicited by objects
outside Panum’s area) from reaching consciousness. Pathologic suppression may develop because of
strabismic misalignment of the visual axes or other conditions resulting in discordant im- ages in each eye,
such as cataract or anisometropia. Such suppression can be regarded as an active binocular adaptation
within the immature visual system to avoid diplopia. If a patient with strabismus and normal retinal
correspondence (NRC) does not have diplopia, suppres- sion is present, provided the sensory pathways are
intact. In less obvious situations, several simple tests are available for clinical diagnosis of suppression (see
Chapter 6). 
CLASSIFICATION OF SUPPRESSION MAY BE
USEFUL FOR THE CLINICIAN: 
• Central suppression is the mechanism that keeps the foveal image of the deviating eye from
reaching consciousness, thereby preventing visual confusion. 
• Peripheral suppression eliminates diplopia by preventing awareness of the image that falls on the
peripheral retina in the deviating eye, which corresponds to the image falling on the fovea of the
fixating eye. When strabismus develops after visual maturation/in adults, peripheral suppression
does not develop, and the patient is thus unable to eliminate the peripheral second image without
closing or occluding the deviating eye. 
CLASSIFICATION OF SUPPRESSION MAY
BE USEFUL FOR THE CLINICIAN: 
• Nonalternating versus alternating. 
• Nonalternating: Suppression always causes the image from the dominant eye to be predominant over the
image from the deviating eye; this may lead to amblyopia. 
• Alternating: Suppression switches between the 2 eyes; amblyopia is less likely. 
CLASSIFICATION OF SUPPRESSION
MAY BE USEFUL FOR THE CLINICIAN: 
• Facultative: Present only when the eyes are deviated; absent in all other states. Patients with
intermittent exotropia, for instance, often experience suppression when the eyes are divergent but
may experience high-grade stereopsis when the eyes are straight. 
• Constant: Always present, whether the eyes are deviated or aligned. The suppres- sion scotoma in
the deviating eye may be either relative (permitting some visual sensation) or absolute (permitting
no perception of light). 
MANAGEMENT

• Therapy for suppression often includes the following: 

• proper refractive correction 
• amblyopia therapy using occlusion or pharmacologic treatment 
• alignment of the visual axes, to permit simultaneous stimulation of corresponding 
• retinal elements by the same object 
• Antisuppression orthoptic exercises may result in intractable diplopia and are not typically recommended.