VT Works

By definition, binocularity is the ability to achieve function with two eyes at the same time, which is often measured in three or four degrees of fusion, depending on the respective visual model.  First degree fusion consists of simultaneous perception with the ability to overlap, or “fuse” dissimilar targets.  As an aside, some visual models refer to simultaneous perception as it’s own skill set thus creating the aforementioned fourth bar for measurement. Second degree fusion is the fusion of two similar targets, with corresponding contours, which do not offer depth.  Third degree fusion is the ability to derive three dimensional depth (or stereopsis) by way fusion of two targets similar contours, yet the disparity to make stereopsis possible.

Good binocularity will generally coincide with good spatial awareness.  The patient needs to gain the concept of where they are in space in relation to the object of regard.  In our therapy room, we use these concepts with both strabismic and non-strabismic patients; however, the main goal is to achieve clear and single vision because we are always working to better integrate and build degrees of freedom between the vergence system and the accommodative system.

We will usually begin working binocularity in second and third degree fusion, if there is no strabismus or amblyopia.  When using third degree fusion targets, we pay particular attention to accommodative vergence, (i.e. aperture rule, lifesaver card, eccentric circles), and when using second degree fusion targets, we strive for flexibility and stability with less emphasis on accommodation (i.e. Brock String, MFBF activities like Red/Green Mazes.)

Vectograms, which can be one of the strongest and most successful activities utilized in Vision Therapy, are an example of a technique used to improve binocularity.  Without much in the way of isolated accommodative demand, this target allows for work more specifically on the convergence and divergence ranges on a gross peripheral basis, allows the patient to experience feeling tone with the different postures, allows for an initial localization attempt, and provides an opportunity for parallax.  The Quoits also do not offer much in the way of a central, or focal, target which helps build strong peripheral fusion.  This is important because we can have the patient gaze in the middle of the rope circles while learning how to rely on their periphery to appreciate the changes in size and depth, or SILO.  SILO (smaller in, larger out) occurs when a patient is asked to maintain fusion as the vergence demand is increased or decreased, and a perceptual change is experienced.  SILO appreciation is important because it demonstrates the patient’s ability to trust the input they are receiving from their visual system, without interjecting logic of real life experiences since in real life objects increase in size as they become closer, and vice versa when objects get farther away.  From there, we will move in the second round of vectograms with a new target, the Clown.  With more detail and more central stimulus, the Clown offers the patient the opportunity to integrate the detail oriented central vision with the depth perceptive peripheral vision which will assist binocularity, and ultimately with the improvement of the patient’s depth perception.  The Spirangle allows for more work in spatial localization and degrees of freedom between accommodation and vergence.  Chicago Skyline target works degrees of freedom even more.

An increase in demand to build degrees of freedom between accommodation and vergence is working with what is commonly referred to as BOP and BIM (BOP = Base Out Plus /  BIM = Base In Minus), and is reflected in the AC/A testing done during an exam.  We can either introduce +/- lens flippers or introduce BI/BO prism flippers to drive the two systems in opposite fashion, stimulate one while relaxing the other.

BOP increases the demand as follows:

• A base out vectogram target requires the patient to converge on the target to keep it single and clear.  Since plus lenses relax the accommodative system, first vergence will reflexively relax, but then to maintain a single target, it must actively converge.  Conversely, if BI prism is introduced to a vectogram set for BO, it further stimulates more convergence to keep the target single while asking the accommodative system to relax to keep the target single on the plane of regard.

BIM increases the demand as follows:

• A base in vectogram target requires the patient to diverge the target to keep it single and clear.  .  Since minus lenses stimulate the accommodative system, first vergence will reflexively be stimulated to converge, but then to maintain a single target, it must actively diverge. Conversely, if BO prism is introduced while looking at a vectogram set for BI, it further relaxes the vergence system to keep the target single while asking the accommodative system to stimulate to kept the target single on the plane of regard.

We also will use the vectograms for jump vergences by setting one set of cards in the Base In posture and the other in a Base Out posture.  The goal of these jump vergences is for the patient to understand the feeling tone of switching back and forth.  The patient is then asked to use the feeling tone information to make the jump from one target to another more efficient and precise. As with all vergence tasks in therapy, accommodation is reflexively responsive to the change in positioning, thereby allowing the image to remain single and clear.

Whether working at a near distance or placing vectograms on a window to work more in real space, we will have patient walk closer and farther while maintaining a single and clear image.  This “tromboning” action furthers the patient’s ability to appreciate SILO, increases the flexibility in accommodative vergence as the patient travels closer and further from the plane of regard, as well as assists the patient with learning to appreciate the changes in real space which ultimately sets the stage for these new skills to transfer into their real world.   Other methods we will use to increase the demand, or load, an activity will be by adding auditory interference, increasing the stress level with unnecessary and unneeded visual stimulation that the patient must ignore, or at the highest level as the patient to multi-task while performing the activity at hand.

Since peripheral vision is directly responsible for answering the “where am I” and the “where is it” questions, or depth perception equation, as modeled by Dr. A.M Skeffington, stimulating and expanding a patient’s peripheral awareness is a crucial step in the process of successfully achieving solid binocularity.  In order to achieve good binocularity and appreciate stereopsis by way of third degree fusion, a person must be able to understand the relative distance between themselves and the object, or objects, they are looking at.  Appreciating the spatial difference between the “where am I” and the “where is it” is the backbone of appreciating depth, which is the ultimate goal in working with patients suffering from a general binocular dysfunction.

One common misconception seems to be with respect to the interchangeability of the terms depth perception and stereopsis. Although similar in that they both refer to a person’s ability to appreciate depth, they represent two very different abilities. Human beings process the ability to appreciate monocular depth cues (See Chart Above) which allow depth perception with only one eye open. While the argument can be made that monocular depth processing is not as informative as its binocular counterpart, we need to understand the difference. Stereopsis, which by the way has Greek roots which when translated mean “solid appearance”, refers to the measurement of one’s perception of depth and understanding of a three dimensional target when viewed with a normal developing binocular visual system. (Tip of the Cap to Wiki for the Assist). So by definition, depth perception is achievable monocularly and binocularly, while stereopsis remains truly a binocular phenomenon. When administering Vision Therapy, it’s important to remain mindful of the difference.

Lastly, I would be remiss if I didn’t mention once again the importance of peripheral awareness to this entire process. Since humans do not walk around looking through drinking straws, and instead have a vast amount of visual information peripherally available, it’s important to remember how much of a binding factor central-peripheral integration is to achieving three dimensional viewing. The information is there for our collection, and it’s important we help our patients understand the most effective way to integrate and benefit from it.

Cheers!