ANOMALOUS RETINAL CORRESPONDENCE (ARC) With normal retinal correspon ence !

NRC) the tr"e anatomic #o$eas o# each e%e are #"nctionall% lin&e to'ether in the occipital corte() Anomalo"s retinal correspon ence (ARC) is associate in#antile stra*ism"s +here the an'le o# e$iation is too lar'e to allo+ peripheral #"sion))The an'le o# e$iation associate +ith ARC is "s"all% *et+een l, an -. PD) Li&e mono#i(ation) ARC is a sensor% a aptation that acts to eliminate the con#"sion o# ima'es #allin' on noncorrespon in' retinal points) The *rain a apts to the ima'e misali'nment *% acceptin' the eccentric ima'e location as the center o# the e%e) Th"s/ ARC is a cortical chan'e in the central re#erence point o# e$iate e%e #rom the anatomical #o$ea to a peri#o$eal location that correspon s to the an'le o# e$iation (0i') 1234/ A)) This ne+ central point o# re#erence in the e$iate e%e is calle the pse" o2#o$ea an correspon s to the tr"e #o$ea o# the ominant #ello+ e%e) The #"nctional reor'ani5ation o#)the e$iate e%e is pres"ma*l% one at the cortical le$el o# $is"al processin') Th"s/ ARC is sensor% a aption +here the *rain reor'ani5es it6s retinal orientation to compensate #or oc"lar misali'nment) 7% corticall% esta*lishin' a ne+ #o$ea that lines "p +ith the #o$ea o# the e$iate e%e/ the retinal ima'es can *e s"perimpose / e$en tho"'h the ima'es are on anatomicall% noncorrespon in' retinal points) I# a patient +ith ARC has his stra*ism"s partiall% or #"ll% correcte *% s"r'er% or a prism/ this isplaces the ima'e o## the pse" o2#o$ea onto retina that is corticall% percei$e as *ein' o## center (0i') 1234/ 7)) The patient sees o"*le e$en i# the ima'e #alls on the tr"e anatomic #o$ea) This t%pe o# iplopia is calle para o(ical iplopia *eca"se e$ent tho"'h the e%es are place in ali'nment the patient sees o"*le) Remem*er that "n er *inoc"lar $ie+in'/ the pse" o2#o$ea is the central orientarion o# the e%e an ima'es isplace o## the pse" o2#o$ea +ill *e percei$e as o## center) 0i'"re 1/34 sho+s the retinal a aptation o# a patient +ith 8. PD esotropia an ARC) Note that a#ter partial correction o# the esotropia +ith a l, PD *ase2 o"t prism/ the ima'e is no+ temporal to the pse" o2#o$ea (0i') 1234/ 7)) This patient +ill ha$e crosse iplopia *eca"se the ima'e #alls on retina that is temporal to the pse" o2#o$ea/ an temporal retina pro9ects to opposire hemi#iel ) The patient +ill ha$e crosse iplopia as lon' as the ima'e is temporal to the pse" o2#o$ea/ e$en i# the e%es are per#ectl% ali'ne so the ima'e #alls irectl% on the tr"e #o$ea) A "lt patients +ith ARC +ill o#ten e(perience iplopia a#ter correction o# their stra*ism"s) An eas% +a% to pre ict i# a stra*ismic patient has ARC an +ill)ha$e postoperati$e para o(ical iplopia is to ne"trali5e the an'le o# e$iation +ith a prism) I# the patient has iplopia +ith prism ne"trali5ation o# the e$iation/ then the patient has ARC an the patient sho"l *e in#orme that postoperati$e iplopia ma% occ"r a#ter the e%es are strai'htene ) 0ort"natel%/ para o(ical iplopia is "s"all% not as correspon ence) In most cases para o(ical iplopia +ill $anish +ithin a #e+ +ee&s a#ter s"r'er%) Onl% in rare circ"mstances is posroperati$e paraclo(ical iplopia so *othersome that it inter#eres +ith e$er% a% acti$ities) E$en so/ in rare instances/ persistent/ postoperati$e para o(ical iplopia has re:"ire a re2operation to recreate the intial stra*ism"s in or er to eliminate para o(ical iplopia that *others the patient/ one can prescri*e press on prism (prism a aptation) to see i# the iplopia s"*si es o$er se$eral +ee&s) 7a'olini striate lenses on the patient +ith a 8. PD esotropia an ARC is epicte in 0i'"re

123; ) The patient percie$es a cross *% s"mperimposin' the line #rom each e%e e$en tho"'h the line in the e$iate e%e #alls nasal to the tr"e #o$ea thro"'h the pse" o2#o$ea) This critical reor'ani5ation o# ARC is onl% present "rin' *inoc"lar $ie+in') Note that +hen the ominant e%e is co$ere / the patient :"ic&l% reorients to the tr"e anatomical #o$ea (0i'/ 123;/ C)) ARC sho"l not *e con#"se +ith eccentric #i(ation) Remem*er ARC is onl% present "rin' *inoc"lar $ie+in' +hereas eccentric #i(ation represents a monoc"lar loss o# $ision (am*l%opia) an is present "rin' *oth monoc"lar an *inoc"lar $ie+in') (Compare 0i') 12 3. to 0i' 123;)) ARC pro$i es cr" e *inoc"lar $ision +ith s"perimposition o# retinal ima'es/ ho+e$er there is not tr"e #"sion) Patients +ith ARC o not ha$e #"sional $er'ence amplit" es an the% o not ha$e steeo ac"it%) ARC can acc"r in association +ith intermittent sta*ism"s) Some patients +ith intermittent e(otropia/#or e(ample/ ha$e *inoc"lar $ision +ith stereopsis +hen the% are ali'ne *"t s+itch to ARC +hen the% are tropic) In 'eneral/ ARC is associate +ith 'oo $ision or onl% mil am*l%opia) <ormonio"s ARC is thetrerm "se #or the sit"ation pre$io"sl% escri*e / +here the position o# the pse" o2#o$ea completel% compensates #or the an'le o# stra*ism"s (see 0i's)123. an 12 3;)) P"t another +a%/ the stra*ismic e$iation e:"als the pse" o2#o$eal o##set #rom the tr"e #o$ea) The amo"nt o# pse" o2#o$eal o##2set is terme the an'le o# anomal%) In patients +ith harmonio"s ARC/ the an'le o# anomal% is e:"al to the stra*ismic e$iation (o*9ecti$e an'le)) Clinicall%/ ho+e$er/ there are man% cases +here the an'le o# stra*ism"s oes not e(actl% match the location o# the pse" o2#o$ea so the tar'et ima'e oes not #all on the pse" o2#o$ea an this is calle "nharmonio"s ) ARC (0i') 123=)) In these cases/ it is li&el%t that the an'le o# stra*ism"s has chan'e ("s"all% increase ) a#ter the #ormation o# the pse" o2#o$ea an / there#ore/ the an'le o# the e$iation meam"res 'reater than the eccentricit% o# the pse" o2 #o$ea) Most patients +ith "nharmonio"s ARC s"ppress the tar'et ima'e/ so the% o not e(perience iplopia) Others/ perhaps those +ho ha a chan'e in the e$iation o# the pse" o2 #o$ea inlate chil hoo or a "lthoo ) o e(perience iplopia) In 0i'"re 12 I=) )>/ the an'le o# the stra*ism"s meas"res 8. PD (o*9ecti$e an'le) *"t the pse" o2#o$ea is onl% l, PD #rom the tr"e #o$ea (an'le o# anomal% ? I, PD)) Th"s/ the ima'e is #allin' , PD nasal to the pse" o2 #o$ea) A , pD *ase2o"t prism o$er the ri'ht e%e places the ima'e on the pse" o2#o$ea an eliminates the iplopia) The iscrepanc% *et+een the location o# the pse" o2#o$ea an the location o# the tar'et ima'e is calle the s"*9ecti$e an'le/ in 0i'"re 12l=/ 7/ the s"*9ecti$e an'le is , PD) Note that ne"trali5in' the s"*9ecti$e an'le eliminates iplopia associate +ith "nharmonio"s ARC/ *"t ne"trali5in' more than the s"*9ecti$e an'le res"lts in para o(ical iplopia (0i') 123=/ C)) See Chapter II "n er Am*l%oscope #or #"nther isc"ssion) Practicall% spea&in'/ the i##erentiation *et+een harmonio"s $ers"s "nharmonio"s ARC is not o# 'reat clinical importance@ ho+e$er/ para o(ical iplopia a#ter stra*ism"s s"r'er% is o# clinical concern) A "lt patients +ith lon' stan in' stra*ism"s sho"l *e e(amine #or ARC *% ne"trali5in' the e$iation +ith a prism) LARRAE REAIONAL SUPPRESSION

Chil ren +ho ha$e lar'e an'le stra*ism"s or se$ere "nilateral retinal iman'e *l"r e$elop a lar'e s"ppression scotoma to elimate the ima'e isparit%) Patients +ith lar'e2an'le constant stra*ism"s (e)' con'enital esotropia) +ill ha$e essentiall% no *inoc"larit%/ not e$en peripheral #"sion or ARC) Lar'e re'ional s"ppression/ ho+e$er is not al+a%s constant an can *e intermittent) Patient +ith lar'e an'le stra*ism"s an lar'e #"sional $er'ence amplit" es (e)' intermittent e(otropia) ha$e intermittent lar'e re'ional s"ppression) These patients s+itch #rom the state o# *inoc"lar #"sion to monoc"lar #"sion an s"ppression) Another e(ample o# intermittent lar'e re'ional s"ppression is in patients +ith con'enital incomitant stra*ism"s +here the e%es are strai'ht in one #iel o# 'a5e (D"ane6s s%n rome)/ or con'enital s"perior o*li:"e pals%)) These patients ha$e *inoc"lar #"sion +hen their e%es are ali'ne +ith a compensator% #ace t"rn *"t the% s"ppress +hen the% loo& into the #iel o# 'a5e +here the% ha$e stra*ism"s) Patients +ith intermittent e(otropia an D"ane6s s%n rome +ho ha$e e$elop s"ppression o not ha$e iplopia +hen the% are tropic)