1. Fusional vergence

2. Maddox components of vergence
Tonic
Fusional
Accommodative
Proximal

3. Maddox’s thoughts 4 components are independent Additive
a given vergence movement can be decomposed into components which are added together to produce the full movement
If any one component is insufficient, pts. will have nearpoint complaints
asthenopia

4. Specifying the amount of vergence
Three basic units of measurement
Angular (°)
Prism diopters (∆)
Meter angles

5. Angular
Take distance from target and pd in identical units of measurement
Divide pd in half
Take inverse tangent of 0.5 pd/distance
Double that to get the full angle
d (m) R R’
pd (cm)

6. Prism diopters most commonly used clinical measure of vergence angle
1∆ (prism diopter) is the tangential deviation of 1 linear centimeter at 1 meter’s distance
For ø ≤ 10 deg., tan ø=ø and ∆ = p/d
a viewing distance of .4 m( 40 cm) with p = 6 cm (60 mm), the eyes must converge 15∆ (6/.4).

7. Meter angle
The meter angle is the amount of vergence required for both eyes to look at an object at 1m distance
1 meter angle = 1/d (in m)
1 meter angle = 1∆/p.d.

8. Proximal Vergence Maddox called this component “psychic” vergence
the amount of vergence produced by the awareness of a near object
In the optometric exam, the phoroptor is a near object that can contribute to a vergence posture.

9. Tonic Vergence
difference between the anatomical position of rest and the physiological position of rest
anatomical position of rest is that which the eyes assume in deep anesthesia, coma, or death
divergent

10. Physiological position of rest
orientation of the two eyes in the absence of any stimulus to fusion
identical to the distance phoria if the eyes are emmetropic or properly refracted

11. Distance phoria
A patient is said to be orthophoric if he/she has no distance phoria.
If there is a heterophoria, its direction shows whether tonic vergence is excessive or insufficient
If exophoric (eyes divergent), tonic vergence is probably insufficient.
If esophoric (eyes convergent), tonic vergence is probably excessive.

12. Distance phoria
phoria = position of the two eyes is the position of the visual axes relative to one another when all stimuli to binocular fusion have been eliminated.
“dissociating” the two eyes
assumes that the person is emmetropic or properly corrected

13. Qualifers
If there are visual stimuli for fusion, the position of the eyes will be determined by both fusional vergence and tonic vergence.
If the test target is nearer than about 6 m, accommodative vergence will also be present.

14. Dissociating the two eyes
two ways
by covering one eye, as in the cover test
by placing a dissociating prism in front of one eye and a measuring prism in front of the other
use a value of vertical dissociating prism that is too great to be overcome by fusional vergence in front of one eye (e.g., 7-8∆).

15. Exophoria
target
perception
Through dissociating prism
Measuring prism

16. Distance phoria
If alignment occurs at 0 ∆, the patient is orthophoric.
If alignment requires base-in prism, the patient is exophoric.
If alignment requires base-out prism, the patient is esophoric.

17. Distance phoria
Distance phoria measurements assume the target is located at 6 m or greater.
Tonic vergence is a significant determiner of the distance phoria.
Other factors contributing to distance phorias
the position of the eye in the orbit
the length of the EOM
the positions of the insertions of the EOM.

18. Fusional vergence also known as disparity vergence
operates to reduce retinal disparity
To see an object singly, the image of the fixated object must falls on corresponding points on the two retinas

19. Corresponding retinal points
Definition: points on the two retinas which, when stimulated, give rise to perception of identical visual direction
Fusional vergence movements take place to eliminate noncorresponding retinal stimulation or retinal disparity
fusional vergence prevents diplopia

20. Eliciting fusional vergence
place a prism in front of one eye
The eye will move (fusional vergence movement) to prevent diplopia.
uncover a covered eye elicits a fusional vergence movement
The eye will move from the phoria position to obtain single binocular vision.

21. Clinical determination of fusional vergence
Ideally, introduce a small amount of horizontal prism, in equal amounts, before the two eyes
Inward movements are positive and outward movements are negative
base-out prism induces positive fusional vergence (convergence)
base-in prism induces negative fusional vergence (divergence)

22. Clinical tests at both distance and near (40 cm.)
using 20/20 letters as the test target
patient is asked to report if the letters blur or become double
note prism powers where blur (if it occurs) and where doubling (break) are reported
then reduce prism until the target is seen singly (recovery)--and note that value

23. Negative fusional vergence at distance
At optical infinity: base-in prism is added equally before the two eyes as the patient views 20/20 letters
What does the blur indicate? Is a blur finding expected in this case? Why or why not?
What does the break represent?
What does recovery mean?

24. Negative fusional vergence at distance
Blur indicates the limits of negative fusional vergence
now accommodative vergence is called on the supplement fusional vergence
in this case, we have to diverge so we would have to relax accommodation
Should we be able to relax accommodation at 6 m?

25. Negative fusional vergence at distance
Break indicates that the total ability of the eyes to diverge to avoid diplopia has been reached.
The eyes return to the phoria position at break.
Recovery indicates that a negative fusional vergence movement has been made to again obtain single binocular vision.

26. Positive fusional vergence at distance
adds base-out prism equally before the two eyes while the patient focuses on the test target (20/20 letters)
patient again reports blur, break and recovery.
Should we have a blur finding here?

27. Positive fusional vergence
Blur -- limits of fusional vergence
accommodative vergence is being called on to supplement fusional; we should be able to accommodate at distance
Break -- limits of accommodative vergence (if there is blur
Recovery occurs after the eyes have converged (positive fusional vergence movement).

28. Negative and positive fusional vergence at near
same tests but performed at 40 cm
expects blur for base-in vergence
focusing on a target at 40 cm demands 2.5D of accommodation (D=1/.4m)
accommodation is relaxed to supplement negative fusional vergence

29. Expected values for fusional vergence
from Morgan (and Bachman)
At optical infinity
Base-in x/7/4
Base-out 9/19/10
At 40 cm
Base-in 13/21/13
Base-out 17/21/11

30. Why? Test base in before base out? Test distance before near?
There are aftereffects of prism testing
Effects of base in are less than those of base out
Effects at distance are less than those at near
Start where the aftereffects are least for most accurate determination