Objective Measurement of Fusional Vergence Ranges and Heterophoria in Infants and Preschool Children

PURPOSE: Binocular alignment typically includes motor fusion compensating for heterophoria. This study evaluated heterophoria and then accommodation and vergence responses during measurement of fusional ranges in infants and preschoolers. METHODS: Purkinje image eye tracking and eccentric photorefraction (MCS PowerRefractor) were used to record the eye alignment and accommodation of uncorrected infants (n = 17; 3–5 months old), preschoolers (n = 19; 2.5–5 years), and naïve functionally emmetropic adults (n = 14; 20–32 years; spherical equivalent [SE], +1 to −1 diopters [D]). Heterophoria was derived from the difference between monocular and binocular alignments while participants viewed naturalistic images at 80 cm. The presence or absence of fusion was then assessed after base-in (BI) and base-out (BO) prisms (2–40 prism diopters [pd]) were introduced. RESULTS: Mean (±SD) SE refractions were hyperopic in infants (+2.4 ± 1.2 D) and preschoolers (+1.1 ± 0.6 D). The average exophoria was similar (P = 0.11) across groups (Infants, −0.79 ± 2.5 pd; Preschool, −2.43 ± 2.0 pd; Adults, −1.0 ± 2.7 pd). Mean fusional vergence range also was similar (P = 0.1) for BI (Infants, 11.2 ± 2.5 pd; Preschool, 8.8 ± 2.8 pd; Adults, 11.8 ± 5.2 pd) and BO (Infants, 14 ± 6.6 pd; Preschool, 15.3 ± 8.3 pd; Adults, 20 ± 9.2 pd). Maximum change in accommodation to the highest fusible prism was positive (increased accommodation) for BO (Infants, 1.69 ± 1.4 D; Preschool, 1.35 ± 1.6 D; Adults, 1.22 ± 1.0 D) and negative for BI (Infants, −0.96 ± 1.0 D; Preschool, −0.78 ± 0.6 D; Adults, −0.62 ± 0.3 D), with a similar magnitude across groups (BO, P = 0.6; BI, P = 0.4). CONCLUSIONS: Despite typical uncorrected hyperopia, infants and preschoolers exhibited small exophorias at 80 cm, similar to adults. All participants demonstrated substantial fusional ranges, providing evidence that even 3- to 5-month-old infants can respond to a large range of image disparities.