ANOMALOUS R E T I N A L CORRESPONDENCE*

ITS ESSENCE AND ITS SIGNIFICANCE I N DIAGNOSIS AND TREATMENT

HERMANN M. BURIAN, M.D.

Boston, Massachusetts

INTRODUCTION us only of the position of visual objects

relative to each other and to the fixation
The attempt is made in the following
point and that only in the horizontal and
pages to give a succinct survey of normal
vertical extent of the field of vision. They
binocular vision in so far as it is of im­
do not inform us about the relative position
portance for the understanding of the visual
of the visual objects in the third dimension
act in strabismus and especially of anoma­
(depth) or about the absolute (or ego­
lous retinal correspondence. This is followed
centric) position of visual objects—that is,
by a discussion of the essence of anomalous
their position relative to our body (to the
correspondence and of its importance in
right or the left of us, above or below the
diagnosis and treatment.
level of our eyes, near or far from us).
This presentation is largely didactic in
Properly speaking, therefore, the spatial
purpose. It is therefore somewhat dogmatic
values of the retinal elements transmit a
in form, and opinions of other authors are
relative subjective visual direction.
not reviewed critically. The literature is not
quoted because of the character of this arti­ 2. CORRESPONDING AND DISPARATE RETINAL
cle. It is readily available in other publica­ ELEMENTS
tions.
The visual apparatus of man is so or­
NORMAL CORRESPONDENCE AND THE ganized that within the region of binocular
BINOCULAR VISUAL ACT
vision there are pairs of retinal elements in
the two eyes which have the same relative
1. T H E SUBJECTIVE VISUAL DIRECTIONS subjective visual direction. These pairs of
Each retinal element conveys when stimu­ retinal elements are termed corresponding
lated not only a sensation of brightness and retinal elements (fig. 1). Since correspond­
color, but also a sensation of direction—that ing retinal elements have a visual direction
is, every visual sensation is localized in a in common, they are also defined as retinal
definite direction. This direction is de­ elements which have a common visual di­
termined by the "local sign" pertaining to rection. Such corresponding retinal ele­
the stimulated retinal element; we speak of ments are, for example, the two foveas, but
a spatial value inherent in every retinal ele­ every other retinal element within the area
ment. of binocular vision also has a corresponding
The visual directions determined by the partner in the other eye.
spatial values of the retinal elements are not Vertical and horizontal rows of corre­
absolutely fixed in space; they change with sponding retinal elements are corresponding
the position of the eyes and are only fixed retinal meridians; the horizontal and verti­
relative to the visual direction of the fovea cal meridians which intersect at the fovea
which is termed the principal visual direc­ are the principal horizontal and the principal
tion. vertical corresponding retinal meridians.
The visual directions, therefore, inform Retinal elements in the two eyes which
have different visual directions are termed
* Read before the eighth annual meeting of the
American Association of Orthoptic Technicians, noncorresponding or disparate retinal ele­
Chicago, October, 1949. ments. In analogy to die corresponding
237
238 HERMANN M. BURIAN

retinal meridians, one speaks of noncorre- retinal elements in the two eyes. Knowing an
sponding or disparate retinal meridians. individual's horopter, we know, therefore,
Grossly, one may say that retinal elements how his corresponding retinal elements are
in the two eyes which have the same relative distributed.
position to the fovea (that is, which are for
example equally far to the right and below 3. N O R M A L CORRESPONDENCE

each fovea) are corresponding points. Normal retinal correspondence is said to

Actually, however, the distribution of the exist in a person when retinal elements in
corresponding retinal elements is neither the two eyes (for example, the two foveas),
which should have a common visual direc­
tion, actually prove to possess it.
Normal retinal correspondence is the most
fundamental fact in binocular vision. It is
apparent from the foregoing discussion that
it must be considered to be innate, not ex­
periential. In other words, normal retinal
correspondence is based on the anatomic and
physiologic organization of the organ of
vision; it is phylogenetically acquired and
not acquired in the course of individual de­
velopment.

4. SENSORY FUSION AND P A N U M ' S AREAS

Since the foveas are corresponding points,

the fixation point is localized in the common
visual direction of the two foveas and the
fixation point is, therefore, seen singly.
Likewise, any other object point which
stimulates corresponding retinal elements is
seen singly. The sensory unification of two
retinal images impinging on corresponding
Fig. 1 (Burian). Normal retinal correspondence. retinal elements, based on the fact that corre­
The foveas (fL and fB) have a common visual di­
rection (<f) as do the corresponding points b L and sponding retinal elements have a common
K (P). visual direction, is termed sensory fusion.
Contrariwise, an object point which is
regularly progressive from the fovea toward imaged on disparate elements in the two
the periphery nor symmetrical. The actual retinas (if it is, for instance, nearer or
distribution of the corresponding retinal farther than the fixation point) is localized in
elements can, therefore, only be determined two different visual directions and is, there­
by subjective methods. fore, seen double. However, within certain
This is a task for the laboratory, not for narrow limits the simultaneous stimulation
clinical investigation, and it suffices here to of disparate retinal elements may produce a
say that the best method for the determina­ single visual impression.
tion of the distribution of corresponding Every corresponding retinal element
retinal elements consists in the determination forms the center of a more or less sharply
of the horopter. T h e horopter is defined as defined area of disparate retinal elements.
the locus of the object points in space which These areas are equal in the two eyes.
produce the stimulation of corresponding Sensory fusion occurs when elements
 ANOMALOUS RETINAL CORRESPONDENCE 239

within the equivalent areas in the two retinas direction of the corresponding retinal ele­
are simultaneously stimulated. The resulting ments which form the frame of reference.
fused visual impression is localized in the To make this a little clearer. A simple
common visual direction of the retinal ele­ stereoscopic picture consists of two sets of
ments which form the center of the two vertically arranged dots, one set seen by
areas. each eye (fig. 3—A).
These areas are known as Panum's areas The images of the upper and lower dots,
of single vision. Thus, for instance, if we seen by the right and the left eye (1, 1'; 3,
fixate an object point and then move a
second object point in the midline toward
us or away from us, starting at the fixation
point, the second object will be seen singly
up to a certain distance from the fixation
point. Beyond this distance it will be seen
double.
The distance within which the moving
object point is seen singly is a measure for
the horizontal extent on the retina of the
area of Panum which has the fovea as its
center (fig. 2).

5. STEREOPSIS

The object point which is moved away

from the fixation point is seen singly as long
as it is imaged within Panum's area, but it
also appears nearer or farther than the fixa­
tion point. A new quality is added to the
visual impression, the quality of depth or
stereopsis. Fig. 2 (Burian). Panum's areas of single binoc­
ular vision. Any point lying on the line AB, in­
Stereopsis, the relative subjective localiza­ cluding the fixation point F, is seen singly since it
tion of object points in the third dimension, stimulates retinal elements within the areas of
is brought about by the simultaneous stimu­ Panum (bLaL and aRbH) which have the foveas
fL, fR for their center. Any point nearer than B
lation of horizontally disparate retinal ele­ (such as P) or farther than A is seen double
ments located within Panum's areas. Vertical (physiologic diplopia).
disparity does not produce stereopsis.
Within limits the depth effect bears a 3') fall when fused on corresponding retinal
quantitative relation to the disparity of the areas (fig. 3—B). They lie on corresponding
retinal images; the greater the horizontal meridians and are, therefore, seen in a verti­
disparity, the greater is the depth effect. Be­ cal plane parallel to the forehead of the ob­
low a certain minimum of disparity there is server; that is, they appear equidistant (fig.
no stereopsis, above a certain maximum 3—C).
there is diplopia. The middle dots are shifted to the left in
For our consideration, the most important the right half of the stereogram, to the right
characteristic of stereopsis is the assimila­ in the left half of the stereogram. This
tion of the visual directions of the retinal means that they are imaged in crossed (tem­
elements which takes place in stereopsis; poral) disparity and that their fused image
the fused stereoscopic mental image of the must appear in front of the dots 1, 1' and
disparate retinal images is seen in the visual 3,3'.
240 HERMANN M. BURIAN

T h e middle dot is, however, seen neither disparate points belong (in our example, the
to the right nor to the left of the dots 1, 1' foveas).
and 3, 3 ' but in line with them (fig. 3—A, B, According to the foregoing, stereopsis is
C ) . It is seen, in other words, in the visual more than, and essentially different from,
direction of the corresponding meridian on the simple unification of corresponding
which the upper and lower dots are imaged; retinal images. A new factor, the assimila­
the fused image of 2 and 2 ' has assimilated tion of the visual directions, makes its ap­
the visual direction of the corresponding pearance and this new factor is responsible
retinal elements which form the center of for the sensation of stereopsis.
the Panum's areas to which the stimulated
E S S E N C E OF ANOMALOUS RETINAL
CORRESPONDEN CE
/'• O. •/
6. ADAPTABILITY OF T H E ORGAN OF VISION

While normal correspondence is innate

and fixed, this does not imply that it is so
rigid that no change may occur if abnormal
conditions warrant a change.
Actually, one of the most striking features
of the organ of vision is its adaptability.
There is no visual function which is abso­
lutely rigid. Accommodation, dark adapta­
tion, the existence of P a n u m ' s areas, and of
fusional movements are a few of the most
obvious examples.
W h e n there is an extreme disturbance of
the motor conditions in a patient—as in a
case of concomitant strabismus—a profound
upset in the visual act occurs which finds its
expression in the sensory symptoms of
strabismus.
But it must be kept in mind that none of
these symptoms adds anything new to the
visual act; they are all only pathologic exag­
gerations of physiologic phenomena. Sup­
pression and amblyopia are closely related to
suppression and retinal rivalry as they nor­
mally occur; anomalous correspondence is
an extension, as it were, of the assimilation
Fig. 3 (Burian). Stereopsis. (A) Stereoscopic of the visual directions within P a n u m ' s areas
targets; the dots 1', 2', 3' are seen by the left, the
dots 1, 2, 3, by the right eye. which normally takes place in sensory fusion.
(B) Schematic presentation of the images of the
dots in A on the retinas of the two eyes (seen 7. E S S E N C E OF ANOMALOUS CORRESPOND­
from in back) ; 1, 1'; 3, 3' are imaged on cor­ ENCE
responding meridians; 2, 2' are imaged on tem­
porally disparate elements. The fovea is not stimu­ T h e last sentence has already indicated
lated. the essence of anomalous correspondence. It
(C) Appearance of targets to the observer. 1 + 1'
and 3 + 3' appear in a frontoparallel plane; 2 + 2' consists of a rearrangement of the common
nearer and in the median plane. visual directions of the retinal elements of
 ANOMALOUS RETINAL CORRESPONDENCE 241

the two eyes. Corresponding retinal elements When one hand is now shifted relative to
lose their common visual direction; disparate the other (fig. 4—B), this gives a picture of
retinal elements acquire a common visual anomalous correspondence. The two
direction. "foveas" have no longer a common visual
A patient with a manifest strabismus may direction; the middle finger of the right hand
develop anomalous correspondence. From (the "fovea of the deviated eye") is super­
the foregoing, this condition can be defined imposed on the index finger of the left hand
in two ways. (the "extramacular element of the fixating
One can say that in anomalous correspond­ eye") and the two have now a "common
ence the two foveas which are normally cor­ direction."

Fig. 4 (Burian). Symbolic presentation of normal and anomalous correspondence. (A) The two middle
fingers (the foveas) have a common direction q>. (B) The two middle fingers have different directions
(<pLand<pR).

responding points lose their common visual This crude simile must not be taken too
directions and acquire two different visual literally else it may lead to misunderstand­
directions. Or one can say that an extra- ing. But it demonstrates another feature of
macular element of the deviated eye adopts anomalous correspondence. When one hand
the visual direction of a disparate point, is shifted relative to the other, the fingers,
namely that of the fovea of the fixating eye. which are now superimposed, do not fit each
The shift of the visual directions which other. This may be thought of as denoting
occurs in anomalous correspondence may be­ the marked difference in visual acuity be­
come a little clearer by using the following tween the retinal elements which have a com­
simile (fig. 4). One can think of the fingers mon visual direction in anomalous cor­
of the two hands as of the retinal elements respondence.
and their spatial values. If the hands are
joined as in the act of prayer (fig. 4—A) this 8. ANOMALOUS CORRESPONDENCE AND BINOC­
can be taken as representing the cyclopean ULAR VISION
eye; the corresponding superimposed fingers
The fact that in anomalous correspondence
are then the common visual directions. We
the fovea of the fixating eye and an extra­
shall call the middle fingers the "foveas."
macular element of the deviated eye have a
242 HERMANN M. BURIAN

common visual direction implies single vision selective suppression in the deviated eye.
with these two, originally disparate retinal One such area is in the macular region, the
elements. It is apparent, therefore, that the other in the extramacular area upon which
acquisition of an anomalous correspondence impinges the image of the fixation point.
represents an adaptation of the sensory ap­ The co-existence of suppression and
paratus of the eyes to the abnormal position anomalous correspondence has always in­
of the eyes. Anomalous correspondence is an trigued the investigators interested in this
attempt of the organism to restore some subject. O n the one hand, it was considered
semblance of binocular vision. that suppression was necessary to loosen the
Whereas, such a teleologic interpretation normal correspondence. Suppression would,
of anomalous correspondence is forced upon therefore, be a necessary step in the estab­
us by all the observed facts, one must not lishment of anomalous correspondence.
assume that anomalous retinal correspond­ O n the other hand, some investigators
ence fully replaces normal correspondence in questioned the correctness of the whole con­
the visual act of the squinting individual. cept of anomalous correspondence because
This has been repeatedly pointed out and the of the presence of suppression. They
very term anomalous "correspondence" has reasoned that in the presence of suppression
been criticized on that basis. anomalous correspondence could not estab­
It has been emphasized that anomalous lish itself and that common visual directions
correspondence connects retinal elements of between a suppressed area in one eye and a
markedly different visual acuity, that in ad­ nonsuppressed area in the other eye could
dition suppression prevents these elements not be of any conceivable use to the
from cooperating, and that there is no organism.
stereopsis in anomalous correspondence— These objections are not justified. First
that is, no response to disparate stimulation. of all, they are not based on fact. In virtually
It is indeed not quite correct to say, as is every patient it is possible to demonstrate
sometimes done, that in anomalous cor­ the existence of common visual directions,
respondence the patient uses the fovea of one normal or anomalous, between the retinas of
eye with an extramacular area of the de­ the two eyes. Often it is not possible to do
viated eye. On the other hand, at least some this with a major amblyoscope because of
patients with anomalous correspondence do suppression and, if an investigator relies ex­
make use of both eyes in the binocular act in clusively on the synoptophore test, he may be
a way approaching normal binocular vision. led to the erroneous conclusion that there is
T h e fact of suppression may actually no "functional correspondence" between the
serve to equalize the acuity of the retinal two eyes. But if other tests are also em­
elements which have anomalous common ployed, normal correspondence or some type
visual directions. And when the central areas of anomalous correspondence is always
are not used together, vertical fusional evident.
movements can be elicited in anomalous cor­ Secondly, the objections rest upon false
respondence by peripheral disparate stimula­ premises. Anomalous correspondence is a
tion indicating a rather high degree of physiologic not a psychologic process. It is
binocular cooperation, although stereopsis is brought about by the abnormal stimulus
always absent. situation which exists when the fixation point
impinges upon the fovea of the fixating eye
9. A N O M A L O U S CORRESPONDENCE AND S U P ­ and an extramacular area of the deviated eye.
PRESSION This abnormal stimulus situation results
It has long been established that patients in some way in the loosening of normal cor­
with concomitant strabismus have areas of respondence and the creation of a new rela-
 ANOMALOUS RETINAL CORRESPONDENCE 243

tionship between the retinal elements of the U n d e r abnormal stimulus conditions, as in

two eyes. concomitant strabismus, we may assume that
Suppression in the deviated eye does not a change occurs in the threshold at the
interfere with this process. Even though the synapses, facilitating the transmission of the
patient is not aware of visual impressions impulses at some points, impeding it at
coming from certain regions of the retina of others, thus redirecting the flow of the
the deviated eye, the sensitivity of the retinal impulses.
elements and the function at least of the
11. CONDITIONS FOR ESTABLISHMENT OF
lower neurons is not impaired. There is no
ANOMALOUS CORRESPONDENCE
reason why the stimulation of the retinal
elements in the suppressed areas should not This conjecture may serve to emphasize
result in more or less normal excitations and the physiologic nature of anomalous cor­
exert a physiologic effect. That it actually respondence and to allow us to form a pic­
does is shown just by the co-existence of ture as to how the shift in visual directions
suppression and anomalous correspondence. comes about. T h e hypothesis may be incor­
rect in detail; for clinical purposes this is of
10. NEUROPHYSIOLOGY OF ANOMALOUS COR­
no concern, since we are thoroughly familiar
RESPONDENCE
with the conditions for the establishment of
H o w does the abnormal stimulus situation anomalous retinal correspondence and with
produce the loosening of normal correspond­ its clinical manifestations.
ence and the establishment of anomalous In contrast to normal correspondence,
correspondence ? anomalous retinal correspondence is acquired
Nothing is known about the neurophysi- by usage. T h e position of the patient's eyes,
ologic processes which are the correlative of the constancy of the angle of squint, the use
what appears subjectively as anomalous cor­ a patient makes of his eyes are, therefore,
respondence. But a conjecture may be of paramount importance in the establish­
permissible. ment of anomalous retinal correspondence.
O n e must first ask oneself what makes Also, normal correspondence is not at
normal correspondence possible. The tre­ once supplanted by anomalous correspond­
mendous arborization, both protoplasmic and ence. This is a process requiring time and
axonal, within the nervous structures sub­ the length of time necessary, as well as the
serving vision allows anatomically a poten­ success in the establishment of anomalous
tial contact of almost every retinal element correspondence, depend on the individual
with almost every cell in the visual cortex of adaptability.
the brain. T h e number of patients is considerable in
The physiologic point-to-point relationship whom normal, as well as anomalous, cor­
which we know to exist must result from the respondence can be elicited in one way or
fact that the impulses generated in the another. H o w easy it is to elicit normal cor­
retinal elements are normally conducted respondence depends on how deeply the
along physiologically predetermined path­ anomalous retinal correspondence is rooted.
ways. T h e predetermining physiologic factor If the angle of squint is unstable, as in the
is likely to be, as Lorente de N o assumed, accommodative type of strabismus, if it is
the threshold of excitation at the various markedly different for distance and near
synapses. vision, the likelihood is much less that an
Under ordinary conditions of binocular anomalous correspondence will be estab­
vision, a certain leeway exists which permits lished. T h e same holds true for the inter­
the assimilation of visual directions within mittent type of strabismus in which the eyes
Panum's areas. of a patient are straight a good deal of the
244 HERMANN M. BURIAN

time. I n all these patients the anomalous cor­ anomalous angle between the visual direc­
respondence, if it is at all present,- is un­ tions of the two foveas (the angle of
stable and in many tests these patients can anomaly) may be equal to the deviation. F o r
be made to localize either according to nor­ instance, if there is a concomitant esotropia
mal or anomalous correspondence. of 15 degrees, the angle of anomaly (found
In general, one can say that the more time say in the after-image test) may also be IS
which has elapsed since the onset of the degrees. If this is the case, the anomalous
strabismus or since a change in the condi- correspondence is termed harmonious (fig.

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Fig. 5 (Burian). (A) Diplopia test in right esotropia of 12 degrees with harmonious anomalous cor­
respondence. The extramacular point p R l situated 12 degrees nasally from fR, and the fovea fL have a
common visual direction. The fovea fR is not stimulated. The fixation light and the red image seen by the
right eye coincide.
(B) Postoperative paradoxic diplopia. The patient's eyes have been straightened and the fixation light
is imaged on ih and fR. The pre-operative anomalous correspondence persists: the two foveas have different
visual directions (cpL and <pR) and the patient has crossed diplopia of 12 degrees.
(C) Binocular triplopia. The pre-operative right esotropia of 12 degrees with harmonious anomalous
correspondence has been reduced by surgery to two degrees. The fixation light is imaged on aR, two
degrees nasally from the fovea fR. aR has a normal common visual direction with a n (ocn) and an anomalous
common visual direction with b ( a a ) . b is situated 10 degrees nasally from the fovea fL. The right eye sees
two red images; the fixation light is seen in the visual direction tp of the fovea fT/ The element p K , situated
12 degrees nasally from fR, receives no stimulation.

tion has occurred spontaneously or under 5 — A ) , since the sensory condition is fully
the influence of therapeutic measures and the adapted to the deviation. Often it is, how­
more stable the deviation is, the more one is ever, found that the angle of anomaly is
likely to find a stable anomalous correspond­ smaller than the angle of squint. Sensory and
ence. motor conditions are then not in accord and
this type of anomalous correspondence is
12. CLINICAL MANIFESTATIONS OF A N O M A ­ termed unharmonious or subharmonious.
LOUS CORRESPONDENCE A harmonious anomalous retinal cor­
In testing for anomalous correspondence, respondence can only develop under especial­
one may find a normal sensory relationship ly favorable conditions. Frequent changes
of the two retinas or an anomalous cor­ in the angle of squint make a development of
respondence, or both. a harmonious anomalous correspendence im­
If there is anomalous correspondence the possible and the best the organism can do
 ANOMALOUS RETINAL CORRESPONDENCE 245

under the circumstances is to choose an binocular triplopia (fig. 5—C).

average common visual direction and form This phenomenon occurs only in patients
an unharmonious anomalous correspond­ with relatively labile anomalous correspond­
ence. ence in whom there is a rivalry between the
In some patients one may find that the normal and anomalous mode of localization.
retinal relationship is harmonious for cer­ It is most frequently seen as a transitory
tain conditions (for example, when the pa­ stage after operations when the normal
tient is tested with his glasses on), but un­ retinal relationship is beginning to get the
harmonious for other conditions (for exam­ upper hand. Presumably it is also present as
ple, when the patient is tested without his a stage in the development of anomalous cor­
glasses). respondence. We have now learned from the
A special type of unharmonious anoma­ work of Frances Walraven that it can be
lous correspondence is the so-called para- artificially produced by macular stimulation
doxic diplopia (fig. S-B). A patient who has on the synoptophore in many more cases
been recently operated upon (or whose than was thought possible before.
angle of squint is corrected by glasses or Binocular triplopia may thus acquire in­
prisms) may present this type of diplopia. If creasing practical significance for the or-
the patient was previously esotropic, he will thoptists. Also, its understanding leads to a
now present crossed diplopia; if he was full appreciation of the essence of anomalous
exotropic he will show uncrossed diplopia. correspendence. It is therefore important to
This is explained by the persistence of the make quite clear to oneself what binocular
anomalous retinal relationship which has as triplopia represents.
yet not had time to catch up with the changed This may best be grasped if one thinks
motor conditions. first of paradoxic diplopia. In paradoxic
Since patients in all stages of development diplopia the anomalous correspondence con­
or regression of anomalous correspondence tinues to exist after the angle of squint has
present themselves for examination, there is been changed and the patient localizes there­
a wide variety of its clinical manifestations. fore according to anomalous correspondence.
There are patients whose anomalous cor­ If, at the same time, normal correspondence
respondence is so deeply rooted that normal is present the patient has two subjective
correspendence can only be elicited with the angles on the synoptophore and triplopia in
greatest difficulty if at all. At the other end the double image test; one of the secondary
of the scale are the patients whose anomalous images is seen in paradoxic diplopia, the
retinal correspondence is so superficially other is localized normally.
established that it may be only fleetingly Essentially this means that the fovea and
present and only in tests which simulate in all other retinal elements in the deviated (or
so far as possible the conditions to which the formerly deviated) eye have actually and
patients are adapted. Between these extremes simultaneously two spatial values; that eye
there are many shades and gradations. possesses two systems of retinal correspond­
As a rule, if the anomalous retinal cor­ ence, one normal and one anomalous (fig.
respondence is unstable, normal and anoma­ S—C).
lous localization appear successively in the One must get away from the idea that the
same or different tests. There are, however, extramacular area in the deviated eye on
rare cases in which a normal and anomalous which the fixation point was originally
response is elicited at the same time. imaged plays a role in this phenomenon.
These patients localize simultaneously in Using the neurophysiologic explanation of
two visual directions with the deviated eye anomalous correspondence already given one
and are said to have monocular diplopia or can assume that, in monocular diplopia, im-
246 HERMANN M. BURIAN

pulses reaching the retina are conducted whether his anomalous retinal correspond­
simultaneously along two channels. ence is stable or labile, whether and under
When anomalous correspondence was what conditions normal correspondence can
first investigated clinically, the term pseudo- be elicited, and so forth. All this cannot be
macula or pseudo fovea was coined to desig­ achieved with any one test, routinely
nate the area in the deviated eye which applied.
acquires a common visual direction with the It is one of the purposes of this presenta­
fovea of the fixating eye. tion to put in a plea to the orthoptists not to
It was soon found that this is a misnomer, restrict themselves to one single test, but to
since the extramacular area of the deviated avail themselves of all possible tests. The
eye on which the fixation point is imaged in application of various tests will not only
no way acquires macular properties, except make the work more interesting; the practi­
that it exhibits, in binocular vision, a com­ cal advantages gained will make the addi­
mon visual direction with the fovea of the tional effort put into the examination well
fixating eye. worthwhile.
One must, therefore, not expect, as some
14. BASIS OF TESTS
beginners do, that the cover test will be in­
fluenced by the type of the patient's retinal Owing to the shift in visual directions, a
correspondence. The deviated eye will al­ patient with anomalous retinal correspond­
ways assume fixation, if it can at all fixate, ence sees double with retinal elements with
when the fixating eye is covered, irrespective which he should see single (for instance the
of the state of the retinal correspondence. two foveas) and single with retinal elements
Eccentric fixation which is a monocular with which he should see double (for in­
phenomenon must not be confused with stance the fovea of the fixating eye and an
anomalous correspondence which is a binoc­ extramacular area of the deviated eye). This
ular phenomenon. And it is more than un­ behavior is utilized in the tests for anomalous
likely that anomalous correspondence will correspondence.
adversely affect the cosmetic result of opera­ Both criteria—double vision and single
tions by forcing the eyes back into a deviated vision—can be made use of and the methods
position. of clinical testing may be divided into two
groups.
DIAGNOSIS OF ANOMALOUS RETINAL In the first group, the deviation (the posi­
CORRESPONDENCE tion of the eyes) is compared to the subjec­
13. IMPORTANCE IN ORTHOPTIC DIAGNOSIS
tive localization or biretinal stimuli, or to the
angle at which the patient superimposes or
Well-established anomalous retinal cor­ fuses the visual impressions reaching the
respondence is a serious obstacle to the re­ retina.
covery of normal binocular vision. Herein In the second group, the visual direction
lies its significance for the orthoptic diag­ or directions of the two foveas are directly
nosis. determined.
It is, however, not enough simply to state In the first group belong the synoptophore
that a patient has anomalous correspondence. and red glass (diplopia) tests and their
The value of any diagnostic procedure is modifications. In the second group belong
determined by the amount of help it lends in the after-image test and the observation of
establishing the prognosis and in directing apparent movement (phi phenomenon).
the course of treatment.
It is essential, therefore, that it be investi­ 15. SYNOPTOPHORE TEST
gated whether a patient has harmonious or In the test using major amblyoscopes the
unharmonious anomalous correspondence, deviation (the objective angle) is first deter-
 ANOMALOUS RETINAL CORRESPONDENCE 247

mined in the usual manner and is then com­ overcome in the diplopia test than on the
pared with the subjective localization (sub­ major amblyoscope.
jective angle). This can be done in two ways. In the diplopia test, the patient is asked to
One may place the synoptophore targets fixate a small light source. After the objec­
at the previously determined objective angle. tive angle has been determined by the prism
If the patient superimposes the targets in and cover test or any other objective test, a
this position, he has normal correspondence. red glass is placed in front of one of the
If he sees them separated, he has anomalous patient's eyes. He will as a rule readily see
correspondence. two lights, one red one and one white one.
Or, if one wishes to determine the amount In normal correspondence the direction
of the subjective angle, one may ask the and amount of separation of the two lights
patient to adjust the targets until they appear correspond to the direction and amount of
to be superimposed. One then compares the the deviation. In anomalous correspondence
angle at which the patient does so with the the separation of the two images is smaller
objective angle. If the two angles are the than one would expect from the angle of
same, the patient has normal correspondence. squint; it may be zero (fig. 5—A), in which
If they differ, there is anomalous cor­ case the sensory anomaly is harmonious, or
respondence: superimposition at zero indi­ even opposite in direction (paradoxic di­
cates harmonious anomalous correspond­ plopia, fig. 5—B ).
ence ; superimposition anywhere between the The diplopia test is easily performed,
objective angle and zero indicates unhar- even in small children, but one must guard
monious anomalous correspondence. against certain errors and know how to avoid
When the targets of the major amblyo- difficulties which may arise.
scope are in the position of the objective The red filter must be sufficiently dark to
angle, the task assigned to the patient is to eliminate from the field of view everything
superimpose stimuli which reach simultane­ except the fixation light which appears as a
ously the two foveas. This is not always easy dark-red spot. The red filter should always
for the patient; simultaneous macular stimu­ be placed first in front of the eye which the
lation is the thing which squinting patients patient habitually uses for fixation. By dim­
try above all to avoid. ming first the dominant eye it is easier to
Also, bimacular stimulation is an unusual make the patient aware of diplopia, since the
condition and, in patients with labile anoma­ brighter white fixation light is less likely to
lous correspondence, one may under those be suppressed than the darker red light.
circumstances find a different subjective lo­ If the patient does not at once notice
calization than when the fovea of the fixat­ diplopia, the test is facilitated by covering
ing eye and an extramacular area of the de­ alternately first one eye of the patient, then
viated eye are simultaneously stimulated. the other, thus teaching him what he is sup­
The latter situation obtains when it is posed to see. If the patient nevertheless sup­
attempted to determine the subjective angle presses too strongly, one may place a prism
on a major amblyoscope. In using this meth­ base-up or base-down (5 to 101) in front of
od one finds, however, in a considerable per­ one eye. This displaces the images above or
centage of patients that they are unable to below the region of elective suppression and
superimpose the targets in any position, this device never fails to produce immediate
owing to suppression. diplopia, except in extreme and very rare
cases.
16. DIPLOPIA TEST
In general, however, I do not recommend
* This suppression of the extramacular area the use of prisms with the diplopia test, ex­
of the deviated eye is often more easily cept where the angle of squint is so large that
248 HERMANN M. BURIAN

it must be reduced. But it should not be harmonious anomalous correspondence he

fully corrected by prisms, unless this is done will see single in the diplopia test, but if the
with the special intention of studying the deviation is reduced he will have crossed
response to bifoveal stimulation. For, when diplopia. The situation is analogous in the
the angle of squint is offset by prisms, the synoptophore test.
fixation light stimulates the foveas of both Not so in the after-image test. It is in the
eyes and this may lead in cases of labile nature of this test, and one of its great
anomalous correspondence to a change in the advantages, that it is entirely independent of
sensory response. This has been pointed out the position of the eyes, since the stimulation
already in the discussion of the synoptophore of the two retinas is successive. Each eye is
test. fixating during the stimulation and the result
While it is advisable to begin the diplopia of the test is solely determined by the visual
test by placing the red filter in front of the directions of the two foveas.
habitually fixating eye, one should never fail The after-image test is performed in the
to place the filter also in front of the habitu­ following way: The eyes of the patient are
ally deviated eye. In so doing one may find successively exposed to a lamp with straight
that the response of the patient varies ac­ filament, one eye receiving a horizontal, the
cording to which eye is used for fixation. other a vertical stimulus. During the ex­
What occurs is that these patients localize posure of one eye the other eye is well pro­
anomalously when fixating with the habitual­ tected from the light of the lamp. The cen­
ly fixating eye but localize normally when tral part of the lamp is concealed by a metal
they fixate with the habitually deviated eye. ring which bears a fixation mark. This is the
This is interpreted as meaning that the essential part of the whole arrangement,
patients are not adapted to this condition and without which the test is pointless.
revert therefore to the innate normal cor­ By means of the ring, the foveas remain
respondence when they are forced to fixate unexposed to the stimulus and the region of
with the habitually deviated eye. It indicates the foveas appears as a gap in the vertical
that the anomalous retinal relationship is not and horizontal after-images which have been
deeply established and offers, therefore, a produced. The relative position of the gaps,
significant prognostic and therapeutic hint as seen by the patient, indicates the condi­
to the orthoptists. tion of the retinal correspondence.
The Lancaster red-green test and the con­ If the two foveas have the same visual
gruence test of Tschermak are modifications direction, as in normal correspondence, one
of the diplopia tests which have been dis­ gap will be seen at the center of a cross
cussed elsewhere and need not be gone into formed by the after-images, no matter what
in this paper. the relative position of the eyes and regard­
less of changes in the relative position of
17. AFTER-IMAGE TEST the eyes during the observation of the after­
In all tests mentioned so far the two images.
retinas are simultaneously stimulated (by If the foveas have two different visual
one stimulus in the diplopia test, by two directions, as in anomalous correspondence,
stimuli, one for each eye, in the red-green the vertical after-image with its gap will
and synoptophore tests). The patient's re­ appear shifted to the right or left on the
sponse depends, therefore, on the relative horizontal line.
position of his eyes, since this determines the Again this relation is not affected by a
relative position of the retinal images. For in­ temporary change in the relative position of
stance, if the patient has an esotropia with the eyes during the observation of the after-
 ANOMALOUS RETINAL CORRESPONDENCE 249

images or by a permanent alteration of the Some patients may, for instance, localize the
position of the eyes. It is, for instance, the positive after-images normally, the negative
same prior to and after a successful opera­ ones anomalously; or they may localize dif­
tion for strabismus, provided the sensory ferently when their eyes are dissociated than
retinal relationship has remained unchanged. when they are straight, and so forth.
T h e angle of anomaly is determined with This variability in localization in the after­
satisfactory accuracy by means of the after­ image test is found in transitional periods in
image test. If the length of the filament of which an anomalous localization is well on

B A 3 A

Fig. 6 (Burian). Phi phenomenon in normal and anomalous correspondence. (A) In normal correspond­
ence no apparent movement is seen when the two foveas are successively stimulated by the luminous
points A and B.
(B) In anomalous correspondence such a movement is noted. When the right fovea is first stimulated,
the movement is in the direction <pR to <pL, as indicated by the upper arrow; if the left fovea is first stimu­
lated the movement is in the direction (pL to (pR.

the lamp is known and if the patient is at a the way to being established but has, as yet,
known distance from the lamp during the not succeeded in replacing completely the
exposure, the angular size of the filament normal retinal relationship.
relative to the eye can be computed, and the
distance between the gaps is a direct meas­ 18. OBSERVATION OF SUBJECTIVE MOVEMENT

ure of the angle of anomaly. (PHI PHENOMENON)

One finds, as a rule, in the after-image Another method of determining directly

test, during one test or a series of tests under the visual directions of the two f oveas, which
varying conditions, only one mode of locali­ so far has not been applied clinically to any
zation. But even in the after-image test, dif­ extent, consists of the application of the so-
ferent types of response may be obtained. called phi phenomenon.
250 HERMANN M. BURIAN

If retinal elements having different visual will not influence it. If, on the other hand,
directions are successively stimulated in the anomalous correspondence is more or
monocular or binocular vision, the observer less labile, different tests will yield different
will perceive an apparent movement. If modes of localization and the patient's re­
retinal elements having the same visual direc­ sponse can be modified by modifying the test
tion are stimulated successively, no apparent conditions.
movement will be noted. "Moving" advertis­ The type of response elicited depends then
ing signs are an example of this phenomenon on the nature of the test. Anomalous cor­
and the so-called prism-and-parallax test is respondence is a result of adaptation of the
based on it. organism. This adaptation occurs for the
Consequently, if the foveas of the two specific conditions of casual seeing under
eyes are successively stimulated with a suit­ which the patient uses his eyes. Therefore,
able arrangement, no movement should be the more closely a test duplicates these con­
perceived by the patient if he has normal ditions, the more likely is the patient to re­
correspondence (fig. 6—A), but if he has spond with an anomalous localization; the
anomalous correspondence, an apparent farther removed the test is from the condi­
movement should be noted (fig. 6—B). tions of casual seeing, the more frequently
Contrariwise, with stimulation at the sub­ one will find that the patients revert to nor­
jective angle no movement should be per­ mal correspondence. Only if anomalous cor­
ceived by a patient with anomalous cor­ respondence is very deeply rooted does the
respondence. nature of the test remain without influence;
It would seem that, at least from an aca­ the patients present then the same anomalous
demic point of view, this interesting situa­ correspondence in all types of tests.
tion should be well worth investigating and It seems to me that the synoptophore test
that the major amblyoscopes with their flash­ is closest to the natural conditions of seeing,
ing devices might offer a good opportunity the diplopia test is much less so, and the
for its study. after-image test is quite devoid of any con­
nection with the normal use of one's eyes.
19. EVALUATION OF TESTS FOR ANOMALOUS Instead of detracting from it, different
CORRESPONDENCE responses in the different tests add, on the
Two factors and their interaction deter­ contrary, significantly to their value as an aid
mine the result which is obtained in the in establishing the prognosis. The prospect
examination of a patient with anomalous of curing an anomalous correspondence is
correspondence. One is the condition of the least certain when a patient habitually has
patient, the other the nature of the test. anomalous correspondence in all tests; it is
Every individual is born with normal cor­ greatest when anomalous correspondence is
respondence ; it has to be overcome to estab­ found only in the synoptophore test. Be­
lish a new sensorial retinal relationship. Not tween these two extremes many transitional
every individual is equally well able to make types of response are met with.
this adjustment. Also, it is a slow process
ANOMALOUS RETINAL CORRESPONDENCE
and at first this new relationship is not very
IN TREATMENT OF CONCOMITANT
deeply rooted. But as it takes deeper roots it
STRABISMUS
will push the innate normal relationship
more and more in the background. 20. BASIS OF TREATMENT
Now, if the normal retinal correspondence The state of the sensorial retinal relation­
is stable or an anomalous correspondence ship is of small practical interest in patients
fully established, all tests will tend to give the in whom a satisfactory cosmetic result by
same result and modifications of the tests surgery is the only goal. But to the orthoptjst
 ANOMALOUS RETINAL CORRESPONDENCE 251

whose task it is to restore to the patient nor­ To accomplish a permanent cure a more
mal and comfortable binocular vision in active treatment is necessary than is
casual seeing, anomalous correspondence is afforded by occlusion alone.
a factor of major importance. Anomalous
22. TREATMENT BY OPERATION
retinal correspondence is the greatest single
obstacle in orthoptic treatment. The ideal treatment would seem to be to
Whereas anomalous retinal correspond­ place the eyes mechanically in such a position
ence may be considered to result from a that they are straight, thus creating a normal
purposeful adaptive process, it is not always stimulus situation. And, indeed, all writers
easy to reverse this process. All the factors seem to agree that the most favorable re­
that are operative in the establishment of an sults are obtained by operations. It is, how­
anomalous sensorial relationship (usage, ever, by no means true that operations in­
time, individual adaptability) are also opera­ variably insure a return to normal cor­
tive in the reestablishment of normal cor­ respondence.
respondence. First of all, even in the hands of the most
If it is correct that anomalous retinal cor­ experienced and skillful operator, the ideal
respondence is the result of the abnormal result which would exactly duplicate the nor­
stimulus situation which obtains when the mal conditions can only be approximated.
two eyes have a faulty relative position, then But even when they are as closely approxi­
the methods which might be expected to mated as our coarse surgical procedures per­
restore the normal retinal relationship must mit, normal correspondence is reestablished
avoid the abnormal stimulus situation. spontaneously only in a fraction of the cases.
This may be done in a passive way by The reestablishment must be encouraged by
preventing one eye from taking part in the other means.
act of vision, or in an active way either by
23. TREATMENT BY PRISMS
correcting the faulty position of the eyes
(operations, prisms), or by offering to the In principle, one should expect that the
eyes as frequently as possible an adequate normalization of the stimulus situation by
stimulus situation (orthoptic treatment). the use of prisms should be very beneficial
in the treatment of anomalous correspond­
21. TREATMENT BY OCCLUSION ence. It seems, however, that their usefulness
If one eye is excluded from the act of is not as great as one would anticipate. One
vision for a prolonged period of time, there of the reasons for this is that patients with
is no binocular stimulation and this may lead concomitant strabismus try to avoid simul­
to a loosening of the abnormal sensorial taneous macular stimulation.
retinal relationship. Any such loosening im­ If the image of the fixation point is
plies, however, automatically a restoration of brought by prisms on the two fovea, it will
normal correspondence and it is understand­ not stay there; the patient will change his
able, therefore, that occlusion of the better angle of squint until the image of the fixa­
eye (or alternate occlusion in alternating tion point is again removed from the macular
strabismus) has been generally recom­ area. This, of course, defeats the purpose for
mended as an essential adjunct in the treat­ which the prisms were given.
ment of anomalous correspondence. I believe, nevertheless, that prisms have
There are some rare cases in which oc­ not been sufficiently tried to permit a final
clusion alone appears to cure an anomalous judgement. I think that they are valuable, if
correspondence, but I know of no case in only as an adjunct, particularly for the cor­
which the cure is permanent. Sooner or later rection of small postoperative residues of
the eyes revert to anomalous correspondence. deviations, and more especially for the cor-
252 HERMANN M. BURIAN

rection of vertical deviations, and I should and deserving of widest attention.

urge that the orthoptists insist that they be The monocular diplopia technique—and
more frequently used. for that matter any other orthoptic technique
—can be successful in reestablishing normal
24. TREATMENT BY ORTHOPTIC EXERCISES
correspondence only if the anomalous rela­
The type of treatment which aims most tionship is not too firmly rooted. Unless
directly at the re-awakening of normal cor­ there is a certain lability one cannot expect
respondence is the treatment in which a the normal correspondence to come readily
major amblyoscope is employed to produce to the surface by orthoptic means.
biretinal stimulation of selected areas.
It is not my task to enter into the details 25. PLACE OF ORTHOPTICS IN TREATING
of the techniques developed to this end and ANOMALOUS RETINAL CORRESPONDENCE
I am not qualified to do so. A few general The ophthalmologist has probably the
remarks may, however, be permissible. most powerful tool in his hands for the per­
When an image is moved over the retina manent correction of anomalous retinal cor­
of the deviated eye in binocular vision, respondence. This tool is the operative pro­
anomalous localization may be suddenly re­ cedure. And yet this correction is not as
placed by normal localization. This is utilized often achieved as might be expected, for
in orthoptic treatment either by "massaging" reasons inherent both in the operations and
the macula of the deviated eye or by "kinetic in the patients. The ophthalmologist needs
bi-retinal stimulation" at or near the objec­ the assistance of the orthoptist who will help
tive angle. prepare the ground by pre-operative train­
In these methods the normal correspond­ ing and establish the gains achieved in the
ence is reestablished, at least for the dura­ operations by postoperative treatment.
tion of the treatment, and the patient is made On the other hand, I feel very strongly
aware of the proper localization. that the orthoptist needs the help of the
Another approach to the problem has been ophthalmologist. The ophthalmologist must
discovered by Frances Walraven. In her be willing to operate when the orthoptist has
technique, alternating foveal fixation is prac­ achieved all she can reasonably expect to
ticed somewhere beyond the subjective angle achieve. Nowhere are proper timing and
and the deviating eye is trained to become cooperation between doctor and orthoptist
the fixating eye during the test. When this is more important than here.
achieved, the arms of the synoptophore are Also, the training with a major amblyo­
moved until the subjective angle is reached scope occupies only a small fraction of a
and at this point many patients will, accord­ week. During the rest of the time, the patient
ing to Miss Walraven, display monocular is on his own. I feel very strongly that week­
diplopia. ly or biweekly visits are rather useless and
If they do, they are then taught to distin­ I should like to insist that daily visits—■
guish between the two images and to sup­ even for a relatively short time—should be
press the image which is localized anoma­ instituted wherever this is possible. And it
lously. In the further course of the treat­ should be possible.
ment, the arms of the instrument are moved Orthoptic treatment of anomalous cor­
ahead until they reach the objective angle respondence is a luxury. Not every patient
and the treatment is continued at that angle. must be treated or should be treated. But
At the present time I am unable to tell you when treatment is undertaken it should be
how successful this treatment is in its prac­ carried out to best advantage, in fairness
tical application, but on theoretical grounds both to the patient and to the orthoptist.
it would seem to me to be most promising It goes without saying that, during the
 TORSIONAL EYE MOVEMENTS 253

periods in which no treatment is given, the ence is a difficult and thorny problem. Yet,
patient should wear an occluder over one eye. looking back over the past 15 years I can not
However, postoperatively or where the de­ help but feel optimistic. The progress made
viation is small the ophthalmologist, in co­ has been quite remarkable and the general
operation with the orthoptist, should attempt interest which has been aroused bodes well
the use of prisms in order to encourage the for further and even more significant
normal cooperation of the eyes rather than to advances.
discourage it.
The treatment of anomalous correspond- 520 Commonwealth Avenue (15).

TORSIONAL EYE MOVEMENTS

ROBERT S. HEWITT, M.D.
Lincoln Park, Michigan

Torsional eye movements have been the zontal (y), and the anteroposterior (z)
source of considerable confusion and con­ axes.
troversy in the study of ocular motility. Movements of the globe may be thought
This paper has been prepared with the hope of as being resolved into coordinates refer­
that it may assist in clarifying certain as­ able to these primary axes. Thus from the
pects of torsional eye movements. The re­ primary position a rotation occurring about
sults of a few simple experiments concerned the vertical axis results in a movement of
with torsion will also be reported. It is felt pure abduction or adduction. A rotation of
that a definite understanding of the rules or the globe occurring about the horizontal axis
laws that govern torsion may lead toward a results in a movement of pure elevation or
more simplified concept of the mechanics and depression. It is well accepted that such
physiology of ocular movements in general. movements can and do occur voluntarily.
For the sake of simplicity in terminology, A rotation of the globe occurring about
and ease of visualization by the reader, only the anteroposterior axis would result in a
monocular motility will be considered in movement of pure intortion or extortion.
this paper, when this is possible. However, The term cycloduction is used to denote
it will be necessary to make reference to such a movement.
binocular eye movements in order to clarify Duke-Elder 1 is quoted, "Cycloduction in­
certain concepts. dicates a wheel motion, dextrocycloduction
and laevocycloduction indicating a rotation
REVIEW
of the upper pole of the cornea to the right
Movements of the globe have often been and left respectively. . . . The term torsion,
described as occurring about a center of ro­ sometimes used in this sense, I am retaining
tation. Although it is known that the center for the physiologic wheel motion which oc­
of rotation is not a definitely fixed point, the curs when the eye is moved in a tertiary
assumption of such a point being fixed does position (for example, up and to the right)."
help in the visualization of ocular move­ For descriptive purposes in this paper
ments. cycloduction will sometimes be referred to
In 1854, Fick described three primary as a pure torsional movement. As for the oc­
axes, all perpendicular to each other and currence of cycloduction, it is usually ac­
all passing through the center of rotation. cepted that a pure torsional movement (in­
These were called the vertical ( x ) , hori- tortion or extortion) is possible but that such