Development of new methodologies for the clinical, objective and automated evaluation of visual function based on the analysis of ocular movements : application in visual health

Healthy visual function not only relies on good visual acuity. Other systems such as accommodation or binocular vision need to be effective. Binocular vision is the ability of the visual system to coordinate and integrate the information received separately from the two eyes into a single binocular percept. Anomalies in the binocular vision system lead to dysfunctions which are often associated with symptoms like asthenopia, diplopia, or ocular strain. The most prevalent non-strabismic binocular dysfunction is convergence insufficiency. The tests typically used to evaluate binocular vision and diagnose binocular dysfunctions essentially consist in eliciting eye movements and asking the patients to report when they perceive diplopia or single vision. In a conventional optometric clinical setting, they are generally run subjectively, as their results depend on the answers of the patients or on the examiner’s criteria. However, there exist instruments to determine the gaze position and measure ocular movements objectively, i.e. eye-trackers. These instruments are used as research tools in a wide range of applications (neuroscience, psychology, marketing, computer science, ophthalmology, etc.). Eye tracking systems are seldom used in optometric clinical practice, although it seems reasonable to think that the evaluation of binocular vision could better rely on eye tracking systems rather than subjective observations. In this context, the main objective of this thesis is to develop new methodologies for the clinical, objective and automated evaluation of visual function based on the analysis of ocular movements. This thesis is divided in 4 studies. In the first study, new methods for an eye tracking system based on multiple corneal reflections are proposed. The other 3 studies aim to analyze ocular movements in clinically interesting situations for the objective and automated evaluation of binocular vision. The results of the first study showed that the light sources configurations that produced the reflections in the lower region of the cornea showed higher accuracy. Vertical accuracy was slightly better with a higher number of corneal reflections. However, the proposed normalization methods improved vertical accuracy and counteracted the tendency for increasing accuracy with the number of glints. As a result, if the light sources are optimally positioned to avoid the interference of the eyelids and the normalization methods are applied, there is no need for more than two light sources. In the second study, an automated and objective method to measure phoria was proposed. It was significantly more repeatable than two other conventional clinical methods. However, the phoria results of the three tests were not interchangeable. This study brings to light several advantages of using eye-trackers in optometric clinical settings. The third study analyzes the characteristics of saccadic movements that occur during the near point of convergence test. The results showed that saccadic amplitude increased and rate decrease at closer viewing distances. These changes might be explained by the more rapid change of vergence demand and the greater angular size of the fixation target at near than at far. In general, saccades contributed to correct vergence errors and fixation position errors of the dominant eye. Finally, the fourth study focuses on the effects of the stimulus’ predictability on the latency and response time of vergence step movements. The results confirmed that vergence movements to predictable stimulus had shorter latency and response time than when the stimulus was random. Latency of convergence and divergence movements was influenced by the direction of the phoria. Other factors such as attention or voluntary effort might also affect vergence responses. All these effects might influence the final result of the vergence facility test, although further research is needed to specify the impact on the clinical test.Una bona funció visual no és sinònim exclusivament de bona agudesa visual. Cal que altres sistemes com l’acomodatiu o la visió binocular siguin eficaços. La visió binocular és la capacitat del sistema visual per coordinar i integrar la informació que reben els dos ulls en una única percepció. Anomalies en el sistema de visió binocular poden donar lloc a disfuncions associades a símptomes com astenopia, o visió doble. La disfunció no estràbica de la visió binocular més prevalent és la insuficiència de convergència. Els tests que normalment es fan per avaluar la visió binocular es basen en estimular moviments oculars i demanar als pacients que indiquin quan veuen doble i quan fusionen. A la pràctica clínica convencional, aquests tests solen ser subjectius. No obstant, hi ha instruments que serveixen per determinar objectivament la posició de mirada i mesurar els moviments oculars: els eye-trackers o instruments de seguiment de mirada. Aquests instruments s’utilitzen en recerca en moltes disciplines (neurociència, psicologia, marketing, oftalmologia, etc.). Tot i que una aplicació directa dels eye-trackers podria ser en l’avaluació de la visió binocular, els sistemes de seguiment de mirada gairebé no s’utilitzen en la pràctica clínica optomètrica. En aquest context, l’objectiu principal d’aquesta tesi és desenvolupar noves metodologies per a l’avaluació clínica, objectiva i automatitzada de la funció visual basades en l’anàlisi dels moviments oculars. La tesi està estructurada en 4 estudis. En el primer, es proposen nous mètodes per a un eye-tracker basat en múltiples reflexos corneals. Els altres 3 estudis tenen com a objectiu analitzar els moviments oculars en situacions d’interès clínic per avaluar objectiva i automàticament la visió binocular. Els resultats del primer estudi demostren que les configuracions d’il·luminació dels eye-trackers que formen les reflexions corneals a la zona inferior de la còrnia són més precises. La precisió vertical és lleugerament millor amb més fonts de llum. Tot i això, els mètodes de normalització proposats milloren considerablement la precisió vertical i contraresten la tendència de més precisió amb més fonts de llum. D’aquesta manera, si les fonts de llum no interfereixen amb les parpelles i s’apliquen els mètodes de normalització, no cal que els eye-trackers tinguin més de dues fonts de llum. En el segon estudi s’ha proposat un mètode automàtic i objectiu per mesurar la fòria. Aquest mètode és significativament més repetitiu que dos altres mètodes clínics. Tot i això, els resultats amb els tres mètodes no són intercanviables. Aquest estudi posa de manifest avantatges que podrien tenir els eye-trackers a la pràctica clínica optomètrica. En el tercer estudi s’analitzen les característiques dels moviments sacàdics que es produeixen durant la prova del punt proper de convergència. Els resultats demostren que l’amplitud dels sacàdics augmenta i la freqüència disminueix a mesura que s’escurça la distància. Aquests canvis poden ser deguts a que la demanda de vergència canvia més ràpid a distàncies properes que llunyanes, i a l’increment de la mida angular de l’objecte de fixació. En general, els sacàdics contribueixen a corregir els errors de vergència i els errors de fixació de l’ull dominant. Finalment, el quart estudi se centra en els efectes de la predictibilitat de l’estímul en la latència i temps de resposta dels salts de vergència. Els resultats confirmen que els moviments de vergència tenen una latència i temps de resposta més curts quan l’estímul es predictible que quan és aleatori. La latència dels moviments de convergència i divergència està influenciada per la direcció de la fòria. Altres factors com el grau d’atenció o d’esforç voluntari pot ser que afectin els moviments de vergència. Tots aquests efectes probablement influencien en el resultat final de la prova de la instal·lació de vergència, encara que es necessiten més investigacions per especificar l'impacte en la prova clínica

Characteristics of visual function in Asperger’s syndrome and the autism spectrum

Autism is a pervasive developmental disorder and Asperger’s syndrome is part of the spectrum of autism disorders. This thesis aims to: • Review and investigate current theories concerning visual function in individuals with Asperger’s syndrome and high functioning autism spectrum disorder and to translate the findings into clinical practice by developing a specific protocol for the eye examination of individuals of this population. • Investigate whether those with Asperger’s syndrome are more likely to suffer from Meares-Irlen syndrome and/or dyslexia. • Assess the integrity of the M-cell pathway in Asperger’s syndrome using perimetric tests available in optometric practice to investigate and also to describe the nature of any defects. • Evaluate eye movement strategies in Asperger’s whilst viewing both text and images. Also to evaluate the most appropriate methodology for investigating eye movements; namely optical digital eye tracking and electrophysiology methodologies. Findings of the investigations include • Eye examinations for individuals with Asperger’s syndrome should contain the same testing methods as for the general population, with special consideration for clear communication. • There is a depression of M-pathway visual field sensitivity in 57% (8/14) of people with Asperger’s syndrome, supporting previous evidence for an M-cell deficit in some individuals. • There is a raised prevalence of dyslexia in Asperger’s syndrome (26% of a sample of 31) but not necessarily of Meares-Irlen syndrome. • Gaze strategies are abnormal in Asperger’s syndrome, for both reading and viewing of images. With increased saccadic movement and decreased viewing of faces in comparison to background detail

Development of new methodologies for the clinical, objective and automated evaluation of visual function based on the analysis of ocular movements : application in visual health

Premi Extraordinari de Doctorat, promoció 2018-2019. Àmbit de CiènciesHealthy visual function not only relies on good visual acuity. Other systems such as accommodation or binocular vision need to be effective. Binocular vision is the ability of the visual system to coordinate and integrate the information received separately from the two eyes into a single binocular percept. Anomalies in the binocular vision system lead to dysfunctions which are often associated with symptoms like asthenopia, diplopia, or ocular strain. The most prevalent non-strabismic binocular dysfunction is convergence insufficiency. The tests typically used to evaluate binocular vision and diagnose binocular dysfunctions essentially consist in eliciting eye movements and asking the patients to report when they perceive diplopia or single vision. In a conventional optometric clinical setting, they are generally run subjectively, as their results depend on the answers of the patients or on the examiner’s criteria. However, there exist instruments to determine the gaze position and measure ocular movements objectively, i.e. eye-trackers. These instruments are used as research tools in a wide range of applications (neuroscience, psychology, marketing, computer science, ophthalmology, etc.). Eye tracking systems are seldom used in optometric clinical practice, although it seems reasonable to think that the evaluation of binocular vision could better rely on eye tracking systems rather than subjective observations. In this context, the main objective of this thesis is to develop new methodologies for the clinical, objective and automated evaluation of visual function based on the analysis of ocular movements. This thesis is divided in 4 studies. In the first study, new methods for an eye tracking system based on multiple corneal reflections are proposed. The other 3 studies aim to analyze ocular movements in clinically interesting situations for the objective and automated evaluation of binocular vision. The results of the first study showed that the light sources configurations that produced the reflections in the lower region of the cornea showed higher accuracy. Vertical accuracy was slightly better with a higher number of corneal reflections. However, the proposed normalization methods improved vertical accuracy and counteracted the tendency for increasing accuracy with the number of glints. As a result, if the light sources are optimally positioned to avoid the interference of the eyelids and the normalization methods are applied, there is no need for more than two light sources. In the second study, an automated and objective method to measure phoria was proposed. It was significantly more repeatable than two other conventional clinical methods. However, the phoria results of the three tests were not interchangeable. This study brings to light several advantages of using eye-trackers in optometric clinical settings. The third study analyzes the characteristics of saccadic movements that occur during the near point of convergence test. The results showed that saccadic amplitude increased and rate decrease at closer viewing distances. These changes might be explained by the more rapid change of vergence demand and the greater angular size of the fixation target at near than at far. In general, saccades contributed to correct vergence errors and fixation position errors of the dominant eye. Finally, the fourth study focuses on the effects of the stimulus’ predictability on the latency and response time of vergence step movements. The results confirmed that vergence movements to predictable stimulus had shorter latency and response time than when the stimulus was random. Latency of convergence and divergence movements was influenced by the direction of the phoria. Other factors such as attention or voluntary effort might also affect vergence responses. All these effects might influence the final result of the vergence facility test, although further research is needed to specify the impact on the clinical test.Una bona funció visual no és sinònim exclusivament de bona agudesa visual. Cal que altres sistemes com l’acomodatiu o la visió binocular siguin eficaços. La visió binocular és la capacitat del sistema visual per coordinar i integrar la informació que reben els dos ulls en una única percepció. Anomalies en el sistema de visió binocular poden donar lloc a disfuncions associades a símptomes com astenopia, o visió doble. La disfunció no estràbica de la visió binocular més prevalent és la insuficiència de convergència. Els tests que normalment es fan per avaluar la visió binocular es basen en estimular moviments oculars i demanar als pacients que indiquin quan veuen doble i quan fusionen. A la pràctica clínica convencional, aquests tests solen ser subjectius. No obstant, hi ha instruments que serveixen per determinar objectivament la posició de mirada i mesurar els moviments oculars: els eye-trackers o instruments de seguiment de mirada. Aquests instruments s’utilitzen en recerca en moltes disciplines (neurociència, psicologia, marketing, oftalmologia, etc.). Tot i que una aplicació directa dels eye-trackers podria ser en l’avaluació de la visió binocular, els sistemes de seguiment de mirada gairebé no s’utilitzen en la pràctica clínica optomètrica. En aquest context, l’objectiu principal d’aquesta tesi és desenvolupar noves metodologies per a l’avaluació clínica, objectiva i automatitzada de la funció visual basades en l’anàlisi dels moviments oculars. La tesi està estructurada en 4 estudis. En el primer, es proposen nous mètodes per a un eye-tracker basat en múltiples reflexos corneals. Els altres 3 estudis tenen com a objectiu analitzar els moviments oculars en situacions d’interès clínic per avaluar objectiva i automàticament la visió binocular. Els resultats del primer estudi demostren que les configuracions d’il·luminació dels eye-trackers que formen les reflexions corneals a la zona inferior de la còrnia són més precises. La precisió vertical és lleugerament millor amb més fonts de llum. Tot i això, els mètodes de normalització proposats milloren considerablement la precisió vertical i contraresten la tendència de més precisió amb més fonts de llum. D’aquesta manera, si les fonts de llum no interfereixen amb les parpelles i s’apliquen els mètodes de normalització, no cal que els eye-trackers tinguin més de dues fonts de llum. En el segon estudi s’ha proposat un mètode automàtic i objectiu per mesurar la fòria. Aquest mètode és significativament més repetitiu que dos altres mètodes clínics. Tot i això, els resultats amb els tres mètodes no són intercanviables. Aquest estudi posa de manifest avantatges que podrien tenir els eye-trackers a la pràctica clínica optomètrica. En el tercer estudi s’analitzen les característiques dels moviments sacàdics que es produeixen durant la prova del punt proper de convergència. Els resultats demostren que l’amplitud dels sacàdics augmenta i la freqüència disminueix a mesura que s’escurça la distància. Aquests canvis poden ser deguts a que la demanda de vergència canvia més ràpid a distàncies properes que llunyanes, i a l’increment de la mida angular de l’objecte de fixació. En general, els sacàdics contribueixen a corregir els errors de vergència i els errors de fixació de l’ull dominant. Finalment, el quart estudi se centra en els efectes de la predictibilitat de l’estímul en la latència i temps de resposta dels salts de vergència. Els resultats confirmen que els moviments de vergència tenen una latència i temps de resposta més curts quan l’estímul es predictible que quan és aleatori. La latència dels moviments de convergència i divergència està influenciada per la direcció de la fòria. Altres factors com el grau d’atenció o d’esforç voluntari pot ser que afectin els moviments de vergència. Tots aquests efectes probablement influencien en el resultat final de la prova de la instal·lació de vergència, encara que es necessiten més investigacions per especificar l'impacte en la prova clínica.Award-winningPostprint (published version

Characteristics of visual function in Asperger’s syndrome and the autism spectrum

Autism is a pervasive developmental disorder and Asperger’s syndrome is part of the spectrum of autism disorders. This thesis aims to: • Review and investigate current theories concerning visual function in individuals with Asperger’s syndrome and high functioning autism spectrum disorder and to translate the findings into clinical practice by developing a specific protocol for the eye examination of individuals of this population. • Investigate whether those with Asperger’s syndrome are more likely to suffer from Meares-Irlen syndrome and/or dyslexia. • Assess the integrity of the M-cell pathway in Asperger’s syndrome using perimetric tests available in optometric practice to investigate and also to describe the nature of any defects. • Evaluate eye movement strategies in Asperger’s whilst viewing both text and images. Also to evaluate the most appropriate methodology for investigating eye movements; namely optical digital eye tracking and electrophysiology methodologies. Findings of the investigations include • Eye examinations for individuals with Asperger’s syndrome should contain the same testing methods as for the general population, with special consideration for clear communication. • There is a depression of M-pathway visual field sensitivity in 57% (8/14) of people with Asperger’s syndrome, supporting previous evidence for an M-cell deficit in some individuals. • There is a raised prevalence of dyslexia in Asperger’s syndrome (26% of a sample of 31) but not necessarily of Meares-Irlen syndrome. • Gaze strategies are abnormal in Asperger’s syndrome, for both reading and viewing of images. With increased saccadic movement and decreased viewing of faces in comparison to background detail.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Prevalence of vision conditions in a South African population of African Dyslexic children.

Thesis (M.Optom.)-University of KwaZulu-Natal, Westville, 2010.Dyslexia is a neurological disorder with genetic origin that affects a person’s word processing ability, their spelling, writing, comprehension and reading, and results in poor academic performance. As a result, optometrists are consulted for assistance with the diagnosis and treatment of a possible vision condition. Optometrists are able to assist with treatment as part of a multidisciplinary management approach, where optometric support is necessary. International studies have indicated that up to 20% of Caucasian school children are affected by dyslexia, while there are no similar figures for African children. Studies have been done to assess the extent of visual defects among Caucasian dyslexics, but not among African dyslexic children. The aim of the study is therefore to determine the prevalence of vision conditions in an African South African population of dyslexic school children, and to investigate the relationship between dyslexia and vision. The possible relationship between dyslexia and vision conditions has been recognized as an important area of study, resulting in research being conducted in many countries. Studies have been undertaken by optometrists and ophthalmologists, who differ in their approach and attitude on how vision conditions affect dyslexia. A review of the literature revealed three broad areas of vision that may impact on reading ability, these being acuity defects, binocular vision and ocular pathology. Acuity defects consist of visual acuity and refractive error. Areas of binocular vision evaluated in the literature include near point convergence, heterophoria, strabismus, accommodative functions, vergence facility and reserves. Hyperopia was the only vision variable that was found to be consistently associated with difficulties with reading, but not causally while findings on other variables were inconclusive. However, all the studies acknowledged the complexity of the condition, and the need for a comprehensive multidisciplinary management approach for its diagnosis and management. The study was undertaken in the city of Durban, South Africa, using a case-control study of two groups of African school children between the ages of 10 and 15. Both study groups consisted of 31 children of normal intelligence, who were matched in gender, race and socio-economic status. The case group attended a school for children with learning disabilities, while the control group attended a mainstream school. At the time of the study, only one school catered for African children with learning disabilities, and only 31 of its pupils were diagnosed with dyslexia. Ethical approval was obtained from the University of KwaZulu-Natal; permission to undertake the study in the identified schools was obtained from the Department of Education, and the school principals consented on behalf of the learners, as it was not always possible to reach the individual parent. The researcher (an optometrist) visited both schools by appointment where rooms were made available to do the testing, and the tests were explained to all participants. The LogMar Acuity Charts were used to assess visual acuity, and static retinoscopy was used to assess refractive error. Binocular vision was tested using the cover test for ocular alignment, the Hirschberg test for strabismus, RAF rule for near point of convergence, ± 2 D flipper lenses for accommodation facilities, Donder’s push up methods, using the RAF rule for amplitude of accommodation, plus and minus lenses for relative accommodation, monocular estimation technique for accommodation posture, and prism bars for vergence reserves. Ocular pathology was assessed using a direct ophthalmoscope. The dyslexic group presented with the following: Refractive errors: hyperopia 6.5%, myopia 6.5%, astigmatism 10%, anisometropia 6.5%, remote near point of convergence 33%, esophoria at near 3%, exophoria at near 9.5%, accommodative infacility 54% and lag of accommodation 39.28%. The dyslexic group had relatively reduced fusional reserve compared to the control group. The control group presented with the following: Refractive errors: hyperopia 3%, astigmatism 13%, anisometropia 6.5%, remote near point of convergence 48%, esophoria at near 0%, exophoria at near 0%, accommodative infacility 33% and lag of accommodation 41.93%. The prevalence of a remote NPC was higher in the control group than in the dyslexic group and there was a statistically significant difference between the two groups: NPC break (p=0.049) and recovery (p=0.046). The prevalence of poor binocular accommodation facility at near was higher in the dyslexic group than in the control group and there was a statistically significant difference between the two groups (p = 0.027). Vision defects such as hyperopia, astigmatism, accommodation lag, convergence insufficiency, poor near point of convergence and accommodative infacility were present in the dyslexic pupils, but they were no more at risk of any particular vision condition than the control group. This study provided the prevalence of vision conditions in a population of African dyslexic children in South Africa, the only vision variable that was significantly more prevalent in the dyslexic population being the binocular accommodation facility at near, although the study was unable to find a relationship between dyslexia and vision. The statistically significant difference may not imply clinical significance due to the small sample size. However, it is recommended that any vision defects detected should be appropriately compensated for as defective vision can make reading more difficult for the dyslexic child. The sample size may have been a limitation; however, this was comparable with studies reviewed, most of which had sample sizes of less than 41. Due to the range of possible ocular conditions that could affect dyslexia, it is recommended that a larger sample size be used to ensure more conclusive results. Testing for relative accommodation with a phoropter would provide more accurate results, and accommodation facility and fusional reserves would be better assessed with suppression control. The study provides information and an indication of research needs regarding the prevalence of vision defects in an African South African population of dyslexic children.Table 2.1 found at the end of the thesis in the digital version

fMRI studies of amblyopia: Pediatric and adult perspectives

Functional magnetic resonance imaging (fMRI) is currently the technique of choice for mapping functional neuroanatomy in humans, and over the past 15 years there has been a dramatic growth in the number of studies that provide brain-behavior correlations in normal healthy adults. More recently, a few studies have begun to make such measures in healthy children. In addition, fMRI is increasingly being applied to study brain function in subjects with neurological disease. The overall aim of these studies was to apply fMRI methods to the study of amblyopia, the most prevalent developmental vision disorder. Amblyopia develops early in life, usually before 5 years old, and is most treatable during childhood. Our approach was to study both children and adults with either the strabismic or the anisometropic type of amblyopia. In our first experiment (Chapter 3), we applied fMRI techniques to map retinotopic visual organization in children. We conclude that cortical visual organization is measurable and highly mature in children aged 9 to 12 years. In our second experiment (Chapter 4), we applied similar techniques to adults with amblyopia. We conclude that visual field organization is abnormal in the brains of these adults. In our final experiment (Chapter 5), we applied these same techniques to children with amblyopia, and observed abnormalities similar to those seen in adults. These studies present a novel neurological characterization of amblyopia, and provide a basis for further studies of human visual development, in health and disease

Towards an integrated approach to the assessment and management of children with reading difficulties

Learning to read is a complex and demanding skill which is vital in order for children to be able to access a broad curriculum of learning within the school environment. Reading requires the integration of many different processes, it is possible that difficulties with one or more of these processes has the possibility to interfere with reading ability. The research aimed to investigate the presence and co-occurrence of difficulties across many factors thought to be involved in the reading process. Data were collected from 126 schoolchildren, aged 8-10 years on performance measures associated with reading; reading ability, visual sensory and oculomotor function, visual perception, attention, memory, phonological awareness and rapid naming. Differences in mean performance between different reading ability groups (ANOVA), and correlations between the variables studied, were used to investigate the presence and magnitude of any relationships. Many of the variables studied were found to be significantly different between reading ability groups and significantly correlated with reading ability to varying degrees. The analysis of multiple single-case studies determined that each child has a unique pattern of strengths and weaknesses and that many children including ‘average/above average’ readers, show below average performance on several measures included in the study, with affected skills rarely existing in isolation. Thus, it is recommended that an individualised multi-factorial approach is taken to the assessment of children struggling to read. This will require communication by a multi-professional team to ensure all possible contributing factors are explored to enable each child to achieve their potential.College of OptometristSome material in this thesis is unavailable for copyright reasons

Attentional Factors Underlying Binocular Vision Loss in Amblyopia

Amblyopia is a neurodevelopmental disorder of vision that results from abnormal visual experience during early development. In addition to significant vision loss in one eye, individuals with amblyopia experience binocular dysfunction, difficulty with visuomotor coordination and attentional deficits. A key component of the vision loss associated with amblyopia is strong, chronic suppression of the amblyopic eye. Clinically, suppression remains challenging to treat, and is a key obstacle to rehabilitating visual function in amblyopia. This thesis examines whether suppressed visual information from the amblyopic eye remains available for processing within the brain and whether higher-order attentional processing is affected in amblyopia. Emerging evidence suggests that attentional mechanisms may contribute to interocular suppression and vision loss in amblyopia. Across four experiments, the findings from this thesis provide several major insights about amblyopia. Visual information seen only by a suppressed amblyopic eye retains a presence within the brain that may subsequently be used for attentional processing. Attentional mechanisms in amblyopia were found to be intact to some extent and thus can be engaged. Orienting visual attention was effective for targets seen by a partially suppressed amblyopic eye and even for complex face cues. Selective attentional tracking by the amblyopic eye was intact in anisometropic amblyopia but was impaired for strabismic amblyopia. Additionally, the process of attentional disengagement and re-engagement may be impaired during amblyopic eye viewing. Overall, these results demonstrate that the amblyopic eye continues to influence visual perception despite being suppressed under normal viewing conditions. As a result, appropriate refractive correction of the amblyopic eye should be clinically prescribed to optimize image quality for binocular combination. Furthermore, amblyopia may affect how visual attention is allocated between the eyes, providing a therapeutic target to guide future rehabilitative efforts