Temporal influences on retinal correspondence: ocular motor findings in paradoxical spatial projection

Paradoxical diplopia is a condition in which objective eye position contradicts subjective localization in visual space. The term "paradoxical" is usually reserved for instances when known sensory adaptations cannot explain the contradiction. The development of this condition begins with infantile or childhood strabismus, followed by the development of a common sensory adaptation, anomalous retinal correspondence (ARC). ARC causes a reduction in the subjective angle of strabismus compared with the objective angle, and in its completed form the subjective angle decreases to zero. There is no "adaptive" mechanism that would increase the subjective angle such that it would be greater than the objective. In cases of treatment by corrective surgery, the anatomically based motor correction leads to a contradiction between eye position and binocular perception. In this event, the objective angle is less than the subjective, and the result is a paradoxical perception. We encountered a 25-year-old woman who experiences paradoxical localization on cover testing in the absence of a manifest strabismus and with no previous surgical intervention.

Using a magnetic search coil technique, we evaluated eye movements during fixation, smooth pursuit, saccades, and during cover test conditions to determine how these eye movements correlated to the subjective perception in space.

Although smooth pursuit and saccades were normal, there were two elements during cover test that could explain the paradoxical projection. One was the phenomenon that during the cover test the paradoxical projection appeared only when the eye was covered for >4 s. The second was that there was a regression from the full exophoria position toward the midline while the eye was under cover that correlated with a possible paradoxical projection situation.

ARC, usually associated with a beneficial sensorimotor adaptation, can express itself as a detrimental sensorimotor manifestation. Paradoxical perception also can exist without previous surgical intervention and without the influence of prisms and instrumentation such as the synoptophore. Further studies are indicated to explore the sensorimotor feedback mechanism between eye position and spatial perception.