Neuromuscular plasticity and rehabilitation of the ocular near response

The near response is composed of cross-coupled interactions between convergence and other distance-related oculomotor responses including accommodation, vertical vergence, and cyclovergence. The cross-coupling interactions are analogous to the body postural reflexes that maintain balance. Near-response couplings guide involuntary motor responses during voluntary shifts of distance and direction of gaze without feedback from defocus or retinal-image disparity. They optimize the disparity stimulus for stereoscopic depth perception and can be modified by optically induced sensory demands placed on binocular vision. In natural viewing conditions, the near response is determined by passive orbital mechanics and active-adaptable tonic components. For example, the normal coupling of vertical vergence with convergence in tertiary gaze is partly a byproduct of passive orbital mechanics. Both, adapted changes of vertical vergence in response to anisophoria, produced by unequal ocular magnification (aniseikonia), and adapted changes in the orientation of Listing's plane in response to torsional disparities can be achieved by a combination of passive orbital mechanics and neural adjustments for the control of the vertical vergence and cyclovergence. Adaptive adjustments are coupled with gaze direction, convergence angle, and head tilt. Several adaptation studies suggest that it is possible to achieve non-linear changes in the coupling of both vertical vergence and cyclovergence with gaze direction. This coupling can be achieved with changes in neural control signals of ocular elevator muscles that are cross-coupled with both convergence and direction of tertiary gaze. These linear and non-linear coupling interactions can be adapted to compensate for (1) anisophoria induced by spectacle corrections for anisometropia, (2) accommodative esotropia, (3) convergence excess and insufficiency, and (4) non-concomitant deviations with ocular torticollis associated with trochlear palsy. The adaptable near-response couplings form the basis of an area of orthoptics that optimizes visual performance by facilitating our natural ability to calibrate neural pathways underlying binocular postural reflexes.