Fixation Disparity Analysis – Page 1

FIXATION DISPARITY ANALYSIS Dr. Kelly Frantz

I. Definitions

A. Fixation Disparity (FD) [versus dissociated (hetero)phoria]

1. FD is a small misalignment of the two eyes which occurs during normal fusion.

2. FD is measured in minutes of arc; typical values are less than 10 min. arc (approx.
1/3).

3. FD cannot be measured by a cover test; it requires special instrumentation with

monocularly seen nonius lines that project onto each fovea.

4. Excessive FD can result from large demands on the binocular alignment system, but a
small amount of FD may be necessary to drive the system (keep innervation flowing).
• “Control systems analysis” (of neurophysiological mechanisms) has shown that
the vergence system operates as a feedback loop.
• Fixation disparity is the stimulus to continue sending innervation to EOM’s.
- Controlling output this way is fast; but has low power.
• To keep the system going more efficiently, the slow vergence system assists.
- It takes 15-30 sec. to start, but provides long-term output (vergence
adaptation).

B. Associated Phoria (AP): amount of prism that compensates for (neutralizes) the FD
1. Note that AP is measured in prism diopters, NOT in min. arc. as FD is.
2. The AP prism puts the binocular system into “balance” so no residual FD manifests.
3. “Associated” means the patient is fused, as opposed to dissociated phoria.

C. Fixation Disparity Curve (FDC)

1. Graph demonstrating FD as a function of various amounts of prism (BO & BI)
2. Each has a characteristic type, slope, y-intercept and x-intercept (associated phoria).

II. Diagnostic Significance of FD Testing

A. Phoria, vergence, and FD findings were found to be correlated with patients’ symptoms
(accommodative tests were not used in this study). [Sheedy & Saladin, AJOPO 1978; 55:670-676.]

1. Sheard's criterion (whether or not it was met)

2. FDC type
3. FDC slope
 Fixation Disparity Analysis – Page 2

B. Some patients have a FD and a phoria in opposite directions; cannot predict without
testing.

C. Conclusion: Complete analysis of the binocular system should include accommodative,

phoria/vergence, and FD analysis.

III. Indications for FD Testing

A. When asthenopia is reported but there is no clear diagnosis based on lateral phoria and
vergence analysis

B. When a vertical phoria is present

C. Symptomatic presbyopes

D. Management decisions: prism or vision therapy (VT)

E. Monitoring progress of VT

Note: patient needs to give precise subjective responses (generally not young children).

IV. Types of FD Instruments (all utilize indirect projection and polarizing filters)

A. Bernell Near Point Analysis Slide or Binocular Refraction at Near Slide

1. Measures associated phoria (x-intercept of a curve) only

2. Horizontal and vertical
3. Near only

B. Bernell Fixation Disparity at Far

1. Measures associated phoria only

2. Horizontal and vertical
3. Distance only

C. Vectographic projector slide

1. Measures associated phoria only

2. Horizontal and vertical
3. Distance only
 Fixation Disparity Analysis – Page 3

D. Wesson card

1. Measures actual FD - can plot curve

2. Only 9 increments measurable
3. Horizontal and vertical
4. Near only

E. Saladin Near Point Balance Card

1. Measures actual FD - can plot curve

2. 22 increments measurable
3. Horizontal and vertical
4. Near only

5. How to plot a horizontal FD curve with the Saladin card:

• Use Polaroids over proposed Rx
• Use phoropter Risley prisms or loose prisms (check for polarization)
• Start with no prism, then 3-4 steps alternating BO/BI
• Hold penlight 2.5 cm behind Saladin card and for each measurement, illuminate
each polarized circle in turn until patient reports a set of lines that appears aligned
• Read corresponding min. arc measurement from back of card
• Plot prism diopters versus amount of FD in minutes on graph
• Make quick (<15 sec.) measurements (to reduce prism adaptation)
• Have patient close eyes between measurements
• Stop when diplopia occurs in each prism direction

V. Analysis of Horizontal FD: Four Variables

A. Curve type - based on change in FD as test prism increases

[* Prevalence info from Saladin & Sheedy, AJOPO 1978; 55:744-750.]

Type I - 60% of population*

- Generally asymptomatic (unlike other types)
unless no horizontal section in center
- FD increases in both directions

Type II - 25% of population*

- Flat in BO direction
- Usually an eso FD
- May/may not cross x-axis
 Fixation Disparity Analysis – Page 4

Type III - 10% of population*

- Flat in BI direction
- Usually an exo FD
- May/may not cross x-axis

Type IV - 5% of population*
- Flat in both directions
- Unstable binocularity when found in non-presbyopes, if there is suppression

Irregular curve
- Accommodative inaccuracy or infacility
- Indication for (+) or vision therapy (VT)

B. Slope

- Indicates prism adaptation ability (slow vergence adaptation)

- Trend toward more symptoms with steeper slope
- Look at slope mainly between 3 BO & 3 BI
- Desired slope in this area is < 1 min. arc / prism diopter (or <45° angle with x-axis)

C. Y-intercept

- Actual amount of FD with no prism (often 0)

- Trend toward more symptoms with greater magnitude (especially if eso FD)

D. X-intercept (associated phoria)

- Prism needed to eliminate FD (often 0)

- What we measure by neutralizing FD with prism
 Fixation Disparity Analysis – Page 5

VI. Management (Horizontal FD)

A. General Considerations

1. Non-type I and/or steep slope in the central area are most often correlated with
patients having symptoms
2. FD parameters and patient motivation can help to determine whether a plus add,
prism, or VT is appropriate

B. Prism prescription (for patients WITHOUT much suppression)

1. Consider prescribing the associated phoria value (especially if eso at far).

2. Alternatively, using FDC, give just enough prism to shift the flat portion of the curve
to the y-axis. (Prism shifts FDC to the left or right.)

3. This might be less prism than associated phoria value

4. Do not create opposite direction of FD with prism Rx

5. Consider acceptability at all distances for which it will be worn

6. Check for prism adaptation (PA): Have patient wear prism for 10 minutes; if PA
occurs (original FD without prism is now measured through the prism), prism is NOT
indicated

C. Plus add for near

1. Treatment of choice for eso FD at near (harder to treat with VT alone)

2. Plus reduces eso: shifts curve downward

3. Attempt to reduce y-intercept to 0

4. MEM or other findings may suggest less plus is indicated

5. Can check acceptability with MEM through tentative (+)

 Fixation Disparity Analysis – Page 6

D. Vision Therapy

1. Effect is to flatten curve and expand fusional ranges, not necessarily decrease FD

2. Prism adaptation is developed by VT

3. Treatment of choice for symptomatic type I (VT for vergence ranges, jump vergence)

4. Irregular curves often normalize with accommodative therapy

5. Type IV (in a non-presbyope) also needs therapy to reduce suppression

6. Types II and III do not usually respond as readily to VT: already have a flat portion

E. Summary: Preferred treatment based on horizontal FDC variables

Type I with steep slope: VT

with eso FD at near: plus add
Type II with eso FD at near: plus add
with eso FD at far: BO prism
Type III with exo FD at near and/or far: BI prism or VT
Type IV in non-presbyope: VT
Irregular curve with accommodative fluctuation: VT or plus add

VII. Analysis and Management of Vertical FD

A. General Considerations

1. Vertical phoria often produces vertical FD

2. Induced vertical disparity also may result from anisometropic Rx with bifocal

3. Vertical associated phoria measurement is indicated because presence of deviation

under binocular conditions is most important (may influence horizontal FD)
 Fixation Disparity Analysis – Page 7

B. Management of Vertical FD

1. Prescribe prism by neutralizing FD with prism (i.e., associated phoria)

2. Check for prism adaptation and patient comfort

3. Vertical FD is not highly responsive to VT

Equipment Source

Bernell Corp. (Vision Training Products), www.bernell.com:

Bernell slides, Saladin Card, Vectographic projector slide, Wesson Card

References

Scheiman M, Wick B. Clinical Management of Binocular Vision: Heterophoric, Accommodative, and Eye Movement
Disorders, 4th ed. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins, 2013, chapter 15.

Saladin JJ, Sheedy JE. Population study of fixation disparity, heterophoria, and vergence. Am J Optom Physiol Opt
1978; 55:744-750.

Sheedy JE. Actual measurement of fixation disparity and its use in diagnosis and treatment. J Am Optom Assoc 1980;
51:1079-1084.

Sheedy JJ, Saladin JE. Association of symptoms with measures of oculomotor deficiencies. Am J Optom Physiol Opt
1978; 55:670-676.

KAF: 6/19