Optokinetic Nystagmus in Strabismus: Are Asymmetries
Related to Binocularity?
Christophe Valmaggia,1 Frank Proudlock,2 and Irene Gottlob2
PURPOSE. Strabismus may be associated with an asymmetry of
monocular horizontal optokinetic nystagmus (OKN). It is un-
clear whether OKN asymmetries are associated with deficiency
in binocular and/or stereovision. In the current study, patients
with different degrees of binocularity were investigated.
METHODS. OKN was examined in the dominant and nondomi-
nant eyes of four groups of patients: (1) no measurable binoc-
ularity (NB), (2) poor binocularity (PB)—that is, showing bin-
ocularity on the Bagolini Test and/or rudimentary stereovision,
(3) good binocularity (GB) with good stereoacuity after squint
surgery, and (4) a control group. Monocular OKN was elicited
with black-and-white stripes moving temporally to nasally (TN)
or nasally to temporally (NT) at velocities of 15, 30, 45, and 60
deg/s. Eye movements were recorded with infrared oculogra-
phy.
RESULTS. Only subjects in the NB group showed a significant
OKN asymmetry, with preference for TN stimulation in dom-
inant and nondominant eyes. Subjects with PB did not have
significant OKN asymmetries but reduced OKN gains in both
stimulus directions. Subjects with GB had normal mean OKN
gains without asymmetry. Larger OKN asymmetries were cor-
related with younger age at detection of strabismus if NB and
GB were grouped together, but not if each group was analyzed
separately.
CONCLUSIONS. For the first time, a large groups of patients
classified by level of binocular vision has been investigated.
The results show that OKN gain and asymmetry are associated
with the development of binocular vision. OKN investigation
may be helpful to identify patients with binocularity or binoc-
ular potential in strabismus. (Invest Ophthalmol Vis Sci. 2003;
44:5142–5150) DOI:10.1167/iovs.03-0322
O KN is a rhythmic involuntary eye movement elicited by
large moving patterns.1 It consists of a slow component
with eye movements in the same direction as the movement of
a target and a fast component with saccadic eye movements in
the opposite direction.2 OKN can be quantified by measuring
the gain, which corresponds to the ratio of slow-phase eye
velocity and stimulus velocity.
Horizontal OKN asymmetry is evident in early normal in-
fancy,3,4 and in patients who have normal visual development
disrupted by unequal visual inputs from the two eyes due to
strabismus,5 amblyopia,6 or unilateral congenital cataracts.7
This asymmetry of OKN is due to a larger gain elicited by
From the 1Department of Ophthalmology, Kantonsspital, St.
Gallen, Switzerland; and the 2Department of Ophthalmology, Univer-
sity of Leicester, Leicester, United Kingdom.
Submitted for publication March 28, 2003; revised July 13, 2003;
accepted August 5, 2003.
Disclosure: C. Valmaggia, None; F. Proudlock, None; I. Gott-
lob, None
The publication costs of this article were defrayed in part by page
charge payment. This article must therefore be marked “advertise-
ment” in accordance with 18 U.S.C. §1734 solely to indicate this fact.
Corresponding author: Christophe Valmaggia, Department of
Ophthalmology, Kantonsspital, CH-9007 St. Gallen, Switzerland;
christophe.valmaggia@kssg.ch.
5142
temporal to nasal (TN) stimulus motion compared with nasal to
temporal (NT) stimulus motion when the stimulation is applied
monocularly.8 Hoffmann9 hypothesized that horizontal TN
OKN present early in life is mediated entirely by subcortical
projections to the pretectal nucleus of the optic tract (NOT)
and the dorsal terminal nucleus (DTN) of the accessory optic
system. Cortical projections to NOT-DTN develop later, and,
once established, the subcortical projections lose influence
over NOT-DTN cells. Thus, the increasing dominance of the
cortex allows the development of the symmetrical OKN re-
sponse in normal subjects. OKN symmetry and binocular vi-
sion in infants develop simultaneously.3,4 If binocular vision is
disrupted, it is likely that subcortical pathways, which favor
nasalward motion, will dominate.
It has been reported that the OKN deficit is more prevalent
when strabismus manifests itself early, between the first 6 and
24 months of life.5,10 –16 However, it is usually difficult to know
the exact time of onset. Most studies have examined older
subjects, in whom the onset of strabismus was evaluated ret-
rospectively, without clinical examination data available from
the time of onset. Only a few studies have investigated the
relationship of binocular function and OKN asymmetry, and
these have suggested that there is no correlation.12,17–19 One
study, however, showed a relationship between stereopsis and
symmetry of OKN gain.20
In this study, our purpose was to investigate the relation
between horizontal OKN asymmetries and clinical characteris-
tics such as binocular- and stereovision, visual acuity or age of
the onset of squint. OKN was examined in four groups of
subjects divided according to binocular vision: (1) no measur-
able binocular vision (NB); (2) poor binocularity (PB) when
tested on the Bagolini Test and/or gross stereopsis; (3) good
binocular vision (GB) with a normal or almost normal level of
postoperative stereoacuity; and (4) normal subjects. In the NB
and GB groups, we selected only subjects for whom the age of
onset of strabismus had been documented in our department.
METHODS
Patients
The ethics committee of the Kantonsspital St. Gallen approved the
study. Informed consent was obtained from all subjects after explana-
tion of the nature of the investigation. The study was performed in
accordance with the tenets of the Declaration of Helsinki.
Patients were recruited from the Department of Strabismology and
Neuroophthalmology of the Kantonsspital St. Gallen. At the time of
OKN examination, all subjects were old enough to cooperate easily
with all tests. The subjects had no ophthalmic abnormalities other than
squint or amblyopia and were otherwise healthy. A full ophthalmic
examination, including visual acuity, binocular function (Bagolini test),
stereoacuity (TNO test [Richmond Products, Boca Raton, FL)]and Tit-
mus fly for gross stereopsis of 3000 seconds of arc), ocular motility,
cover test, slit lamp examination, funduscopy, and cycloplegic refrac-
tion, was performed in all subjects. Patients with latent nystagmus
were excluded from the study because this form of nystagmus interacts
with OKN, slowing down the NT slow phase and speeding up the TN
slow phase.21
Four different groups of subjects were examined:
Investigative Ophthalmology & Visual Science, December 2003, Vol. 44, No. 12
Copyright © Association for Research in Vision and Ophthalmology
IOVS, December 2003, Vol. 44, No. 12
1. Twenty patients with no measurable binocularity (NB; 8 males,
12 females; mean age at time of OKN examination: 17.5 ⫾ 13
years; SD). Strabismus was documented before or at 18 months
of age in all patients in this group. Twelve patients had disso-
ciated vertical deviation (DVD), and 16 had occlusion therapy
for amblyopia. All subjects underwent strabismus surgery be-
fore OKN examination. After surgical correction of squint, ste-
reopsis (measured using the Titmus fly) or binocular vision
(measured by absence of suppression of the nondominant eye
on the Bagolini test) was not detectable in any of the subjects of
this group. Details of patients with NB are listed in Table 1.
2. Twenty patients with poor binocular vision (PB; 10 males, 10
females; mean age at time of OKN examination: 15.6 ⫾ 13.9
years; SD)—that is, with peripheral fusion on Bagolini test with
central scotoma and/or stereopsis measured with the Titmus fly
(15 subjects). None of the patients with PB demonstrated ste-
reopsis when examined with the TNO test. At the time of
examination, they all had small squint angles, which corre-
sponded either to primary or secondary postoperative micro-
tropia. Ten of these patients had a history of sudden increase of
squint angle when they first were examined in our department.
Photographs of the patient before onset of strabismus con-
firmed this, although the photographs did not exclude micro-
tropia. These patients underwent squint surgery and achieved
rudimentary binocular vision after surgery. Because of the small
squint angle in the PB group, strabismus was most frequently
detected after the screening tests for amblyopia or because of
the sudden development of a large strabismus (with possible
preexistence of microtropia). Therefore, it was unlikely that the
time of first examination in our department had any correlation
with time of onset of squint in this group. In the PB group 10
patients had occlusion therapy for amblyopia. None of the
subjects in this group had DVD. Details of patients with PB are
listed in Table 2.
3. Fifteen patients (seven males, eight females; mean age at time of
OKN examination: 10.2 ⫾ 3.1 years; SD) who achieved binoc-
ular vision on the Bagolini test and good levels of stereovision
on the TNO test (15–240 seconds of arc) at the time of exam-
ination (GB). All had late-onset strabismus and had a well-
documented sudden onset of strabismus between 18 and 36
months of age. History and/or examination revealed that,
shortly after onset of squint, all had diplopia or signs indicating
diplopia, such as frequently closing one eye. Two patients in
the GB group had eyes patched for amblyopia. None of them
had DVD. All had undergone strabismus surgery and had no
postoperative manifest squint. In Table 3 further details of
patients with GB are listed.
4. Twenty control subjects (8 males, 12 females; mean age 14.8 ⫾
7.2 years; SD) without squint or history of squint surgery, with
visual acuity of 1.0 or better in each eye, and stereoacuity
between 15 and 120 seconds of arc on the TNO test.
In the NB and GB groups, only patients who had been examined in our
department and had well-documented clinical notes from the age of
diagnoses of squint were included in the study.
Methods
OKN stimulation, eye movement recordings and analysis were per-
formed with the vision monitor equipment (Metrovision, Perenchies,
France).22,23 Visual stimuli were generated on a monitor, measuring 51
cm in diagonal, placed 40 cm away from the patients with a frame rate
of 120 Hz. The patient’s head was stabilized with a head-chin rest. The
screen covered a visual field of 54° horizontally and 41° vertically.
OKN was elicited with alternating white (luminance, 70 cd/m2) and
black (luminance, ⬍1 cd/m2) vertical stripes. Each stripe covered 2° of
visual angle (equivalent to a visual acuity of 20/2400). Stripes moved in
random order at a constant velocity of 15, 30, 45, or 60 deg/s, either in
TN or NT direction for 40 seconds. Eye movements were recorded by
OKN and Strabismus 5143
measuring the position of the corneal reflex with respect to the center
of the pupil. The investigation was independent of head movements. A
near infrared illumination of the eye (880 nm) was used to produce the
corneal reflex and the pupil image. The system operated with a sam-
pling rate of 60 Hz and achieved a resolution of 10 minutes of arc. The
slope of the best-fit regression line plotted across the sample points of
the OKN slow phases was used to estimate the slow phase velocity.
Precision was no greater than 5%. The noise of the velocity measure-
ment was approximately 0.3 deg/s root mean square (RMS; manufac-
turer’s specifications). In the different strabismus groups, OKN gains of
the dominant and nondominant eyes were assessed. In the control
group, the mean OKN gain of the right eye was measured. Each eye
was investigated with the different stimulus velocities and directions,
with a time interval of 2 minutes between the trials. To record stare
OKN, subjects were instructed not to follow individual stripes across
the screen but to fixate stripes as they passed in the center of the
screen.
Eye movement analysis included the detection of OKN slow and
fast phases and calculation of the average velocity for the slow phases.
The mean velocity of consecutive slow phases was measured from 5
seconds after the stimulus onset, for a period of 10 seconds, at each
stimulus velocity and stimulus direction. Other investigators observed
that the early OKN is dominant in humans and has a stable velocity
after a time of approximately 0.5 seconds.8 Accordingly, the OKN slow
phases had reached a stable velocity over the time period that was
analyzed in our experiment.
Eye movement recordings were numbered, and analysis was per-
formed without knowledge of the clinical data of the patients. The
OKN gain, defined as the ratio of slow-phase velocity to stimulus
velocity, was measured for TN and NT stimulus directions. An OKN
asymmetry factor was calculated from the OKN gains by dividing the
TN gains by the sum of the TN and NT gains (TN/TN ⫹ NT) for each
velocity and for each examined eye. Asymmetry factors above 0.5
indicate a larger gain for TN stimulation, whereas asymmetry factors
below 0.5 correspond to a larger gain for NT stimulation. For each
group of patients the percentage of subjects outside of the 2 SD of the
normal subjects was calculated for the OKN gain and asymmetry index.
Analysis of variance was used to compare gains of different groups and
was corrected for multiple comparisons by Student-Newman-Keuls
test. Correlations coefficients were calculated between age of detec-
tion of strabismus and asymmetry factor. Differences were considered
as significant for P ⬍ 0.05.
RESULTS
Eye movement recordings are shown in Figure 1 in response to
stimuli moving at 45 deg/s in TN and NT directions from a
representative subject in each group. Whereas the NT re-
sponse was clearly reduced in the subject with NB (Fig. 1A),
there was no clear difference between NT and TN responses in
the patient with PB. However, the gain appeared slightly lower
in the patient with PB for both stimulation directions (Fig. 1B).
OKN recordings of the subject with GB (Fig. 1C) were similar
to those of the control subject (Fig. 1D).
In Table 4, the percentage of subjects with gains that de-
clined to below the 95% confidence interval of the gain for
control subjects are listed for dominant and nondominant eyes
at the four stimulus velocities. Whereas most patients in the NB
group had normal TN gains and abnormal NT gains, in the PB
group, the gain abnormality was similar for TN and NT stimu-
lation. More patients showed reduced OKN gains in the PB
group than in the GB group.
Figure 2 represents the mean OKN gains for dominant and
nondominant eyes, at different stimulation velocities, in each
group of subjects. In the NB group, OKN gains for NT stimu-
lation were significantly lower than in the control group, at
each velocity in the deviating and the nondeviating eye (P ⬍
 5144
Valmaggia et al.

TABLE 1. Details of Patients with No Measurable Binocularity

First First
Age at Measured Measured Strabismus SA at Age at VA at Time of VA at Time of Strabismus SA at Time of
Diagnosis VA VA Form at Presentation Occlusion OKN Test OKN Test OKN Test Form at Time OKN Test
Patient (mo) (DE) (NDE) Presentation (Degrees) DVD Therapy (y) (DE) (NDE) of OKN Test (Degrees)

1 14 0.8 0.6 R eso 11.4 N Y 9 1.0 1.0 Rexo 8.0

2 18 0.8 0.6 L exo 11.4 N Y 48 1.0 1.0 L eso 21.3
3 8 0.6 0.8 R eso 16.7 Y Y 7 1.0 0.6 Rexo 1.2
4 5 1.25 1.0 L exo 22.3 N N 33 1.25 0.8 L exo 8.0
5 3 0.5 0.4 L eso 19.3 Y Y 11 1.0 1.0 L eso 21.3
6 16 0.6 0.4 R eso 19.3 N Y 40 1.25 1.0 Rexo 8.0
7 4 0.8 0.6 L eso 11.4 Y Y 37 0.9 1.0 L exo 6.3
8 2 0.8 0.3 R eso 19.3 Y Y 14 1.0 0.6 R eso 12.5
9 4 1.25 0.1 L eso 19.3 Y Y 10 0.9 0.8 L eso 22.3
10 6 0.5 0.4 L eso 14.1 Y Y 13 1.0 0.9 L eso 8.0
11 12 1.0 0.8 L eso 23.4 N N 14 1.0 1.25 L eso 7.0
12 18 1.25 1.0 Rexo 14.1 Y N 9 1.0 1.0 Rexo 12.5
13 2 0.6 0.6 R eso 24.0 Y Y 6 0.9 0.7 Rexo 12.5
14 3 1.0 0.8 L exo 9.1 Y Y 10 1.0 0.9 L exo 2.3
15 2 0.8 0.5 R eso 24.0 N Y 36 0.6 0.6 R eso 20.0
16 1 0.5 0.3 L eso 40.0 Y Y 5 0.9 0.6 L eso 12.5
17 5 0.6 0.5 R eso 19.3 N Y 9 0.9 0.8 R eso 12.5
18 12 0.5 0.1 R eso 22.0 Y Y 9 0.6 0.6 R eso 21.8
19 16 1.0 0.5 R eso 19.3 N Y 8 1.0 0.8 R eso 15.7
20 1 1.0 0.4 L exo 14.1 Y N 22 1.0 1.0 L eso 12.5

DE, dominant eye; NDE, nondominant eye; SA, squint angle; R, right; L, left; eso, esotropia; exo, exotropia; y, yes; n, no.
IOVS, December 2003, Vol. 44, No. 12
TABLE 2. Details of Patients with Poor Binocularity

First First
IOVS, December 2003, Vol. 44, No. 12

Age at Measured Measured Strabismus SA at Age at VA at Time of VA at Time of Strabismus SA at Time of

Diagnosis VA VA Form at Presentation Occlusion OKN Test OKN Test OKN Test Form at Time OKN Test Titmus
Patient (mo) (DE) (NDE) Presentation (Degrees) Therapy Surgery (y) (DE) (NDE) of OKN Test (Degrees) Fly

1 46 1.25 0.1 R eso 4.6 Y N 7 1.0 0.8 R eso 4.6 Pos

2 44 1.25 0.8 Rexo 19.3 Y Y 8 1.0 0.8 R exo 3.5 Pos
3 56 1.25 1.0 L eso 16.7 N Y 12 1.0 1.0 L eso 4.6 Neg
4 73 1.0 1.0 L eso 23.8 N Y 14 1.0 1.0 L eso 4.6 Neg
5 56 0.8 1.25 L eso 19.3 N Y 9 1.0 1.0 L eso 4.6 Pos
6 66 1.0 0.6 R eso 16.7 Y Y 12 1.0 1.0 R eso 3.5 Pos
7 64 1.0 0.5 R eso 4.5 Y N 11 1.0 1.0 R eso 4.6 Neg
8 54 1.25 0.5 L eso 4.5 N N 12 1.25 0.6 L eso 0.6 Pos
9 48 1.25 1.25 R eso 14.1 N Y 9 1.25 1.25 R eso 4.6 Pos
10 51 0.9 0.4 L eso 16.3 Y Y 8 1.0 1.0 L eso 2.3 Neg
11 43 1.2 0.2 L eso 4.5 Y N 13 1.0 0.6 L eso 2.3 Pos
12 43 1.25 0.6 R eso 16.7 N Y 20 1.0 1.0 R eso 4.6 Pos
13 67 0.8 0.6 L eso 5.0 Y N 8 0.8 0.8 L eso 4.6 Pos
14 82 0.9 0.2 R eso 16.7 N Y 54 1.0 0.8 R eso 2.3 Pos
15 34 1.0 0.5 R eso 4.6 Y N 10 1.0 0.6 R eso 4.6 Pos
16 67 1.0 0.5 R eso 4.6 N N 5 1.0 1.0 R eso 1.2 Neg
17 81 0.6 1.0 L eso 3.5 N N 37 1.0 0.6 L eso 3.5 Pos
18 34 1.25 1.0 R eso 23.8 N Y 50 1.0 0.6 R eso 4.6 Pos
19 43 1.0 0.1 L eso 2.0 Y N 6 1.0 0.6 L exo 0.6 Pos
20 89 1.0 0.5 L eso 4.6 Y N 7 0.8 0.8 L eso 3.2 Pos

DE, dominant eye; NDE, nondominant eye; SA, squint angle; R, right; L, left; eso, esotropia; exo, exotropia; y, yes; n, no; pos, positive; neg, negative.
OKN and Strabismus
5145
5146 Valmaggia et al. IOVS, December 2003, Vol. 44, No. 12

(seconds of arc)
Stereoacuity
TNO Test

240
60
120
60
60
120
240
60
240
60
60
120
60
60
15
VA at Time of
OKN Test
(NDE)

1.00
1.00
1.00
1.25
1.00
1.00
1.25
1.25
1.00
1.25
1.25
1.00
1.00
1.00
1.00
VA at Time of
OKN Test
(DE)

1.00
1.00
1.00
1.25
1.00
1.00
1.25
1.25
0.90
1.25
1.25
1.00
1.00
0.90
0.90
OKN Test
Age at

(y)

6
11
14
10
8
6
6
16
10
11
6
12
14
9
13

DE, dominant eye; NDE, nondominant eye; SA, squint angle; R, right; L, left; Alt, alternating; eso, esotropia; y, yes; n, no.
Occlusion
Therapy

FIGURE 1. Original eye movement recordings during monocular TN

N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y

and NT stimulation at a velocity of 45 deg/s of the right eyes of (A)

patient 14 with NB, (B) patient 1 with PB, (C) patient 8 with GB, and
(D) a normal 22-year-old subject.
Presentation
(Degrees)
SA at

19.3
21.9
20.9
15.2
26.7
15.2
19.3
16.7
19.3
28.0
15.2
16.7
19.3
20.0
16.7

0.05). In contrast, no difference was present for TN stimula-

tion. In the PB group, OKN gains were lower than in the
control group in both directions, for the deviating and the
nondeviating eye. This difference increased with increasing
stimulus velocity and was significant for TN and NT stimulation
at 60 deg/s in both eyes (P ⬍ 0.05). No significant differences
Presentation
Strabismus

were found between TN and NT asymmetry. In the GB group,

Form at

R eso
L eso
R eso
R eso
Alteso
L eso
R eso
R eso
L eso
Alteso
Alteso
Alteso
Alteso
R eso
R eso

there were no significant differences compared with the con-

trol group.
The percentages of subjects falling outside of the 95% con-
fidence interval of the asymmetry index for control subjects are
listed in Table 5, for dominant and nondominant eyes at the
four stimulus velocities. A large percentage of subjects in the
Measured

(NDE)
First

1.00
0.50
1.25
0.80
1.00
0.30
0.90
1.00
0.80
1.00
0.63
0.90

0.50
0.80
VA

1.0
TABLE 3. Details of Patients with Good Binocularity

TABLE 4. The Percentage of Patients with OKN Gain Below Normal

95% Confidence Interval

TN (deg/s) NT (deg/s)
Measured

(DE)
First

1.00
0.50
1.25
0.80
1.00
0.30
0.90
0.80
0.80
1.00
0.63
0.90
0.80
0.50
0.80
VA

15 30 45 60 15 30 45 60

No binocularity
DE 0.0 5.0 10.0 0.0 60.0 55.0 60.0 60.0
NDE 0.0 0.0 0.0 0.0 80.0 60.0 70.0 55.0
Diagnosis

Poor binocularity
Age at

(mo)

24
32
28
36
19
35
27
36
29
18
32
27
22
29
34

DE 5.0 10.0 20.0 10.0 25.0 10.0 10.0 5.0

NDE 15.0 20.0 25.0 10.0 25.0 25.0 15.0 20.0
Good
binocularity
DE 0.0 0.0 13.3 0.0 13.3 0.0 6.7 0.0
Patient

NDE 6.7 0.0 6.7 0.0 0.0 0.0 6.7 0.0

10
11
12
13
14
15
1
2
3
4
5
6
7
8
9

DE, dominant eye; NDE, nondominant eye.

IOVS, December 2003, Vol. 44, No. 12 OKN and Strabismus 5147

significant correlation was found between the age of detection

of strabismus and OKN asymmetry at the four stimulus veloc-
ities for dominant eyes (P ⬍ 0.05 for 15 and 30 deg/s, P ⬍
0.005 for 45 deg/s, and P ⬍ 0.0005 for 60 deg/s) and nondomi-
nant eyes (P ⬍ 0.01 for 15 and 30 deg/s, P ⬍ 0.001 for 45
deg/s, and P ⬍ 0.0001 for 60 deg/s). However, when the
correlation between age and asymmetry factor was analyzed
within groups (i.e., NB and GB separately), there was no
significant correlation.
In the NB group, at higher stimulus velocities, patients with
DVD showed larger OKN asymmetry than patients without
DVD, in dominant and nondominant eyes, but differences were
not significant (Fig. 4). No correlation was found between
OKN asymmetry and visual acuity at the time of onset or of
OKN measurement.

DISCUSSION
In summary, we found that only subjects with NB showed
significant OKN asymmetry with preference for TN stimulation
rather than NT stimulation, in dominant and nondominant
eyes. Asymmetries were more frequent in nondominant eyes.
Subjects with PB did not have a significant preference for TN
stimulation, although the OKN gain of these subjects was
reduced for both stimulus directions and in both eyes. Subjects
with GB had normal mean OKN gains and showed no signifi-
cant preference in either stimulation direction. Larger asym-
metry factors were correlated with younger age at detection of
strabismus only if NB and GB were grouped together.
In the literature, OKN asymmetries have usually been ana-
lyzed in relation to onset of strabismus by comparing subjects
with early-onset with those with late-onset strabismus. The age
limit used to define early-onset strabismus varies in different
reports from 6 months,12 to 12 months,13 and up to 24
months.14 Several studies5,10 –14 have found a greater preva-
lence of asymmetry with earlier onset of strabismus. In all these
studies, asymmetries were present in the dominant eyes, but
were less common than in the nondominant eyes. Schor et al.5
found that monocular OKN asymmetries could be used to
predict whether esotropia had occurred before or after the first
FIGURE 2. Mean ⫾ SD of gains for the four different groups of subjects
at (A) 15, (B) 30, (C) 45, and (D) 60 deg/s for nondominant and
year of life. In our study, we found asymmetry in 75% to 85%
dominant eyes. For control subjects, gains of the right eyes are plotted of the nondominant eyes and in 50% to 65% of the dominant
in both the left and right columns. eyes in the NB group, depending on stimulation velocity.
Strabismus onset was documented as occurring before or at 18
months of age. In the PB group, up to 30% of subjects had
asymmetrical OKN with TN preference; however, some sub-
NB group showed significant asymmetries, with preference for jects also showed NT preference, reflecting a wider variation of
TN stimuli rather than NT stimuli. This TN preference was data. Consequently, only the NB group showed significantly
more frequently seen in the nondominant than in the dominant
eye at all velocities. In the PB group, the asymmetry factor was
also outside normal limits more frequently in the nondominant TABLE 5. The Percentage of Patients with Asymmetric OKN
than in the dominant eye. However, asymmetries were ob-
served with preference to both TN and NT directions. Asym- TN>NT (deg/s) NT>TN (deg/s)
metries also occurred in both directions (TN and NT) for
dominant and nondominant eyes in GB. This pattern of asym- 15 30 45 60 15 30 45 60
metry factors falling on both sides of the normal confidence
interval reflect the wider variation of the data in the patients No binocularity
with PB and GB than in the control subjects. DE 65.0 55.0 50.0 55.0 0.0 0.0 5.0 10.0
The PB group was divided into patients who had no surgery NDE 80.0 85.0 75.0 80.0 0.0 0.0 0.0 0.0
and those who had surgery. No significant differences in gain Poor binocularity
or asymmetry factors were found between the two subgroups. DE 15.0 5.0 5.0 5.0 0.0 0.0 5.0 25.0
NDE 20.0 30.0 10.0 25.0 10.0 10.0 5.0 25.0
Figure 3 represents the relationship between the age when Good
strabismus was detected and the asymmetry index for the NB binocularity
and GB groups at different stimulation velocities. The PB group DE 33.3 13.3 6.7 6.7 13.3 26.7 6.7 26.7
was not included in this analysis, because the detection of NDE 26.7 20.0 6.7 20.0 20.0 6.7 6.7 26.7
strabismus was unlikely to correlate with the time of onset of
squint, because of the small squint angle in these subjects. A DE, dominant eye; NDE, non-dominant eye.
5148 Valmaggia et al.
asymmetrical OKN as a group. Most studies have used ages
estimated retrospectively for onset of strabismus. However, it
is impossible to determine the exact time of onset of strabis-
mus by these means, because onset may remain long undetec-
ted by lay people before clinical examination. Also, a slow
increase in squint angle may lead to a wrong assumption of the
time of onset. The difficulty in determining the exact time of
onset of strabismus retrospectively may explain discrepancies
between findings.
We found that OKN asymmetries were consistently but not
significantly larger in patients with DVD than in subjects with-
out DVD (probably due to the small sample size within the NB
group) and appeared to increase with increasing stimulus ve-
locities. Because DVD is a strong indicator of early-onset stra-
bismus5 this may also indicate a relation between earlier onset
of strabismus and asymmetric OKN.
OKN responses have been reported as asymmetrical in
normal children between 3 and 24 months of age3,24,25 (Roy
MS, et al. IOVS 1987;28:ARVO Abstract 18; Lewis TL, et al.
IOVS 1991;32:ARVO Abstract 1437). Consequently, testing
IOVS, December 2003, Vol. 44, No. 12
FIGURE 3. Asymmetry index of non-
dominant and dominant eyes versus
age of detection of strabismus for pa-
tients with NB and those with GB at
the four stimulus velocities. An asym-
metry factor of 0.5 corresponds to
equal gain for TN and NT stimula-
tion. Larger asymmetry factors reflect
TN preference and smaller ones NT
preference.
observers with strabismus at an older age, as in our study,
may help differentiate between the normal maturation pro-
cesses for OKN symmetry, and its alteration by strabismus.
Our data were similar to those of Steeves et al.14 who
investigated patients older than 8 years with early-onset
strabismus.
Westall et al.17 found no clear relation between stereop-
sis and OKN deficits. Wright18 and Aiello et al.19 examined
three children who underwent unusual early surgery for
esotropia at 3 and 4 months of age. Although these children
eventually had normal stereoacuity, they had asymmetrical
OKN. In contrast to these findings, van Hof-van Duin et al.20
measured OKN in six normal, six stereodeficient, and six
stereoblind subjects. OKN was clearly asymmetric in pa-
tients with no stereovision, but symmetric in subjects with
rudimentary stereovision. This is in agreement with our
study. Patients with PB in our study had peripheral fusion
and/or stereopsis, but central scotomas in the nondominant
eye when tested binocularly with the Bagolini test. They had
small squint angles, which should easily be fused if normal
IOVS, December 2003, Vol. 44, No. 12
FIGURE 4. OKN gains in patients with no measurable binocularity
divided into subjects with and those without DVD at the four stimulus
velocities for dominant and nondominant eyes.
potential of fusion is present. Therefore, it is likely that PB
patients have inability of central fusion and small squint
from birth. The lack of OKN asymmetries in the PB group
argues, therefore, against the notion that OKN asymmetries
are mainly dependent on the age of onset of squint. In
monocularly deprived patients, OKN asymmetry is more
pronounced if the deprivation is less profound,26 because of
more interocular rivalry. Peripheral fusion may reduce ri-
valry between eyes in PB and prevent development of asym-
metric OKN.
In the PB group, the OKN gain was consistently lower for
TN and NT stimulation for dominant and nondominant eyes,
whereas the GB group had a normal OKN gain. This differ-
ence in the PB group increased with increasing stimulus
velocity (significant for 60 deg/s). Van Hof-van Duin et al.20
observed similar findings in a small group of patients. Re-
duced OKN gains in the PB group cannot be attributed to
amblyopia, because they were also reduced in dominant and
nondominant eyes and visual acuities of the nondominant
eyes were similar to those in the NB group, who showed
normal TN gains. We have found that young children, 1 to 2
years of age, with normal visual and binocular development,
have reduced but symmetrical OKN gain for TN as well as
NT stimulation, when compared with 20- to 40-year-old
subjects (Valmaggia C, unpublished observations, 2002).
Possibly in PB with microstrabismus, binocular cortical con-
nections are sufficient for development of monocular OKN
symmetry, but remain incomplete, preventing full OKN mat-
uration to adult levels. In the cat, cortical projections pro-
vide for binocularity in approximately 40% of cells in the
NOT, and are necessary for optokinetic responses for high
stimulus velocities.27 This could explain why gains were
affected more at higher velocities in our subjects, with
differences being significant only at 60 deg/s.
OKN and Strabismus 5149
Visual acuities, measured at the time of strabismus detection
or at the time of OKN measurement, were not correlated to
OKN asymmetries. At the time of OKN measurement, most of
our patients had relatively good visual acuity, some after oc-
clusion therapy.
Patients in the GB group had the potential of stereovi-
sion, but had strabismus associated with diplopia, or signs of
diplopia. Their mean OKN gain was similar to normal sub-
jects. The only difference was that more subjects had an
asymmetry factor out of normal range favoring either TN or
NT stimulation. Larger OKN variability reflects a less precise
OKN generation in the GB group. This may be associated
with a less robust binocular system, causing sudden onset
of strabismus at a later age, although binocular vision has
developed.
In conclusion, our study shows that OKN gain and asym-
metry are associated with the development of binocular vision.
OKN investigation may be helpful to identify patients with
binocularity or binocular potential in strabismus.
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