Eccentric fixation

Eccentric fixation (EF) is a visual adaptation that develops in response to foveal damage or developmental disorders such as amblyopia and strabismus, allowing patients to maintain binocular vision function, although it is associated with reduced visual acuity. Pathophysiological studies suggest that EF results from the interplay of adaptive theories, motor learning, and visual system development, with retinotopic factors, cortical plasticity, and changes in eye movement contributing to its development and maintenance. Neuroscience and functional imaging studies have shown that retinotopic maps of the visual cortex and higher visual areas are involved in fixation at a preferential locus outside the fovea. Today, advanced diagnostic methods such as microperimetry, optical coherence tomography fixation shift, and the Foveal Integrity Test allow precise assessment of fixation location, stability, and longitudinal changes, facilitating treatment planning. Treatment approaches have evolved from eye closure and traditional pleoptic and orthoptic exercises to modern methods, including biofeedback with microperimetry, active visual training, and virtual reality. Evidence suggests that treatments that utilise neuroplasticity and active patient participation are most effective in restoring the fixation locus to the fovea and improving visual function, even in adults. This review summarises the current knowledge about EF, highlighting its role as a neurobehavioral adaptation, mechanisms of development, advances in diagnosis, and classical and innovative treatment approaches. Understanding EF as a structural compensatory process, it provides a framework for designing individualised treatments and guiding future research.