The NAFX and LFD data from these Figures plus data from the effects of BMR and BOPr therapies were used to construct the illustrative examples shown in Figs. They are complementary and may be combined for maximal therapeutic improvements in specific patients. These eye movements can cause problems with your vision, depth perception, balance and coordination. 40. Halmagyi GM, Cremer PD, Anderson J, Murofushi T, Curthoys IS. Figure 3 (Post) shows that after therapy, although the peak acuity is improved, the off-peak acuities are improved to a much greater extent. In patients with SN-like nystagmus, accurate diagnosis is the most important factor. The intensity of INS increases on lateral gaze and becomes right beating in right gaze and left beating in left gaze. Ocular motor research in the past half-century has produced remarkable advances in our understanding of the underlying mechanisms of the several types of nystagmus seen in infancy and childhood. There are also cotton wick electrodes. Horizontal pendular nystagmus MedGen UID: 356175 Concept ID: C1866180 Congenital Abnormality; Finding HPO: HP:0007811 Definition Nystagmus consisting of horizontal to-and-fro eye movements of equal velocity. Nystagmus may consist mainly of sinusoidal slow phase oscillations (pendular nystagmus) or, more commonly, of an alternation of slow drift and corrective quick phase (jerk nystagmus). 2009;1164:316323. The accuracy, repeatability, and duration of the foveation periods are the most critical features of INS waveforms' effect on visual acuity. Strabismus is essential for FMNS but incidental to INS. These times, reflecting peak latency, are referred to as "implicit times." Distinguishing this variable phase relationship between the pendularoscillations of both eyes requires DC-coupled, high-bandwidthrecordings of both eyes simultaneously. 4 6. In most individuals with INS, the head position corresponds roughly with the minimal intensity zone of the nystagmus. Pendular pseudonystagmus arising as a combination of head tremor and. This includes choosing a reference frame to describe the axes or planes and direction of eye movements. Figure 1. Measured VA vs. Gaze Angle plots for patients with high VApk = NAFXpk in or near primary position and low HAgar = LFD including: VAf = VAn, strabismus and VAf < VAn, no strabismus. 2011;77(21):1929. In Type I, the extended foveation periods will increase the NAFX over that measured during binocular fixation. Benign paroxysmal positional vertigo: Diagnostic criteria. [from HPO] Term Hierarchy GTR MeSH CClinical test, RResearch test, OOMIM, GGeneReviews, VClinVar CROGVHorizontal pendular nystagmus Making Sense of Acquired Adult Nystagmus During clinical examination, HAgar can be determined directly from BCVA measurements made at different gaze angles; it is the clinical and numerical equivalent of the INS-waveform-determined LFD (HAgar=LFD). That is, there is no nystagmus when both eyes are viewing, but when one eye is occluded, jerk nystagmus develops in both eyes, with the fast phases toward the uncovered eye. A regular, repetitive, involuntary movement of the eye whose direction, amplitude and frequency are variable. This includes minute-to-minute variability and long-term changes associated with age and other ocular and systemic conditions. Pathologic forms of nystagmus generally result from diseases affecting the peripheral vestibular apparatus, brain stem, or cerebellum; less commonly, they affect the anterior visual pathways or cerebral hemispheres. The confluence of accurate methods of recording eye movements, the application of the rules of physics, waveform analysis techniques, and control-systems analysis allowed replacement of inaccurate terminology, erroneous concepts, and the ensuing diagnostic and therapeutic quagmire. Foveation accuracy also depends on which type of waveform (INS or FMNS) is present. In addition to occlusion, intent or darkness also may alter FMN; the direction of FMN depends on the eye intended for fixation. Latent, manifest latent and congenital nystagmus. This true null (in the mathematical sense) differs from the Alexanders-law induced damping occurring in other types of nystagmus (see Section 3). This information should not be considered complete, up to date, and is not intended to be used in place of a visit, consultation, or advice of a legal, medical, or any other professional. Several attributes are used to describe nystagmus: binocularity, conjugacy, velocity, waveform, frequency, amplitude, intensity, temporal profile, and age at first appearance. Binocular acuity is tested first, and if tolerated, monocular testing is then attempted. The NBS has been reported in an exotropic patient41 and also in a congenitally blind patient.42. pendular nystagmus - Medical Dictionary Pendular nystagmus The eye movement for this type is more like a pendulum moving back and forth. Leech J, Gresty M, Hess K, Rudge P. Gaze failure, drifting. Wang Z, Dell'Osso LF, Jacobs JB, Burnstine RA, Tomsak RL. Warm water in the same ear produces the opposite effect (ie, a horizontal nystagmus directed to the right or toward the same side the water . Other signs are needed to distinguish true SNS from similar looking nystagmus associated with central nervous system disease.56. Quantitative characteristics of the. Kim HA, Yi HA, Lee H. Apogeotropic central positional, 52. There are some who have INS and FMNS equally. Another visual function deficit not measured in the office but amenable to therapy is foveation time (ie, target acquisition time).58; 59 This is important in every-day activities like, quickly scanning a room for familiar faces, reading street and traffic signs while driving, and all sports. Patients with FMNS always have strabismus and, to eliminate diplopia, vision from thetropic eye is suppressed (occluded) in thecortex. The presence or absence of an underlying visual sensory deficit does not affect the time of onset of INS. (See "Jerk nystagmus" and "Pendular nystagmus" .) Leigh RJ, Tomsak RL, Seidman SH, Dell'Osso LF. Gottlob et al found a high incidence of esotropia, latent nystagmus, dissociated vertical divergence, and amblyopia in children with SNS.43 Conversely, rare patients with infantile esotropia display horizontal or vertical head oscillations that resolve following surgical realignment of the eyes. OCT depends on optical ranging; in other words, shining a beam of light onto the object, then recording the echo time delay of light measure distances. 34. In cases of INS with a latent component, gaze-angle BCVA should also be measured OD and OS. 2. Binocular pattern stimulation, which facilitates attention and fixation, may be useful to evaluate overall visual function. Acquired pendular nystagmus in multiple sclerosis typically has a higher frequency (>4 Hz) and lower amplitude (<4) than that associated with oculopalatal tremor. All content on this website, including dictionary, thesaurus, literature, geography, and other reference data is for informational purposes only. In Type I, the IN either damped or stopped entirely upon willful esotropia, in much the same way as with true convergence. Periodic alternating nystagmus clearing after vitrectomy. Figure 5. In logical terminology, strabismus is a necessary (but not sufficient) condition for FMNS (ie, all individuals with FMNS have strabismus but not all with strabismus have FMNS). Included in the definition of strabismus, is latent strabismus(ie, the phoria resulting when you cover an eye). Because chiasmal and retrochiasmal diseases may be missed using a single channel, three channels using the midline and two lateral active electrodes are suggested for INS patients. In contrast, the otoliths respond to linear accelerations of the head and to gravity when the head is tilted. They may be measured by the NAFX at different gaze angles. The sometimes-intense desire to stop the wiggling (especially on the part of concerned parents) must not be allowed to overrule this constraint on safe and effective INS therapy. Temporal profile: Continuous, intermittent, or changing over time. Dell'Osso LF, Daroff RB. This small but difficult groupof patients must be recorded for accurate diagnosis. Venkateswaran R, Gupta R, Swaminathan RP. The aims of INS treatments should be to: 1) maximize visual function while preserving all other ocular motor functions; 2) alleviate the need for head postures that may cause secondary problems; and 3) damp the nystagmus for cosmetic reasons. Without accurate, monocularly calibrated eye-movement data the relative positions of each eye, the determination of the fixating eye, and differentiating between INS with a latent component, FMNS, or the NBS would not be possible. Ochs AL, Stark L, Hoyt WF, D'Amico D. Opposed adducting saccades in convergence-retraction, 66. In those exotropic FMNS patients for whom fusion is impossible, recessions of all four horizontal recti with a large differential (more on the lateral than the medial recti) has proven successful in treating both the exotropia and the motor component of the nystagmus. What Is Nystagmus? - American Academy of Ophthalmology The eyes may shake more when looking in certain directions. Teaching video neuroimages: alternating horizontal single saccadic pulses in progressive supranuclear palsy. The dorsal stream (the "where" or how stream) is involved in spatial attention and communicates with regions that control eye and hand movements, and the ventral stream (the "what" stream) is involved in the recognition, identification, and categorization of visual stimuli. The movement can be horizontal, vertical, torsional or a combination of these movements. Jerk nystagmus is slow in one direct and fast in the other. It is also possible to surgically enhance the acuity of some patientswith FMNS at the same time as correcting the strabismus and head posture. However, head turns are not defects associated with the INS, FMNS, or NBS, but rather, constitute purposive and therapeutic patient-administered therapy. Successful amelioration of a head turn can only occur if its advantages, vis a vis better visual function, are otherwise achieved (eg, surgically moving the IN null to primary position or inducing convergence that both damps and broadens the IN null). Finally, a thorough examination of the retina, including the foveal area and optic nerve should be performed. The independent oscillation of one or both eyes is a characteristic of SNS. A unifying model-based hypothesis for the diverse waveforms of infantile nystagmus syndrome. Jacobs JB, Dell'Osso LF. The term, FMN refers to thissingle type of nystagmus that is present in most FMNS patients withboth eyes open while one is fixating but, in some patients, may only bepresent when one eye is occluded. Clinical INS Assessment to Determine Maximally Effective Therapy: What can the Physician Apply from the Bench to the Bedside? There are several approaches to INS treatment: physical/optical; pharmacological; and surgical. 24. When a peripheral etiology is suspected, added Dr. Eggenberger, look for a mixed pattern of nystagmus such as torsional horizontal, in which the slow phase rotates toward the ear with hearing loss. Tectal and pretectal midbrain areas contribute to the near triad (simultaneous convergence, accommodation of the lens, and miosis), occurring during shifts in fixation between distance and near. At various times they exhibit the INS waveform, FMNS waveform, or the dual jerk waveform. Seven PD BO has worked well for most patients although 8-9 PD BO may provide higher acuity for some while preserving their gaze and convergence ranges. Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Nystagmus in pediatric patients: interventions and patient-focused Flash VEPs are much more variable across subjects than pattern responses but show little interocular asymmetry. Summarizing, INS can occurwith or without strabismus; all FMNS patients have strabismus. to maintaining your privacy and will not share your personal information without Characteristics and mechanism of apogeotropic central positional, 53. Abbreviations: LA, left anterior; LP, left posterior; RA, right anterior; RP, right posterior; LARP, left anterior-right posterior; RALP, right anterior-left posterior; SCC, semicircular canal. This consists of the retina/optic nerve, optic nerve, lateral geniculate, geniculostriate, association cortex, and ocular motor proprioception. Congenital pendular nystagmus present as binocular, conjugate, horizontal nystagmus with variable wave forms which change to a jerk nystagmus on lateral gaze. A large percentage(80%) will be INS and 15% FMNS with only a small percentage, mixtures. The nystagmus was predominately horizontal in 4 patients, torsional in 5, vertical in 3 and mixed in trajectory in 8. The sub-clinical see-saw nystagmus embedded in infantile nystagmus. There are yet other simpler ERG recording devices using gold Mylar tape that can be inserted between the lower lid and sclera/cornea. The therapeutic choice will depend on the patients individual nystagmus type(s) and characteristics. Thus, in the tradition of, do no harm, no treatment should be considered that diminishes or prevents good visual function in real-world situations (ie, reading an eye chart with a still head in a specific position and without time constraints does not begin to simulate real-world situations). Nystagmus is a condition where the eyes move rapidly and uncontrollably. This consists of the smooth pursuit, saccadic, vergence, and visuo-vestibular (vestibular and optokinetic) subsystems. Attempts to do either could result in broken fusion, diplopia, and loss of stereopsis. Weissman BM, Dell'Osso LF, Abel LA, Leigh RJ. A useful clinical sign in differentiating NBS from other forms of convergence excess esotropia is the absence of pupillary constriction. A more thorough and fully referenced presentation of ocular motor research foundations, diagnostic findings, clinical pearls, and therapeutic approaches and outcomes may be found in the book on the subject by Hertle and DellOsso2 and the many scientific citations contained therein. There are no good long-term, multi-subject studies (greater than 10 years) that characterize the aging process and its effects on INS, but we do know that changes can occur in the INS oscillation as a result of aging, medications, and degenerative and neurological illnesses. Please try after some time. Electroretinography (ERG) evaluation of children with nystagmus has both diagnostic and prognostic value. Mechanisms underlying nystagmus - PMC - National Center for 35. Direct interaction with the child can help maintain attention and fixation, and two testers are beneficial, one to work with the child and the other to control data acquisition. ERGs have been shown to help in distinguishing between these conditions. SNS appears as a high-frequency, asymmetric, disjugate ocular oscillation. The optic nerve (cranial nerve II) is part of the central nervous system. Thus, more patients with predominantly FMNS will also havesome INS than patients with predominantly INS having FMNS. From the vestibular nuclei, projections go to the cerebellum, extraocular muscle nuclei, antigravity muscles, and opposite vestibular nuclei. Torsional. Acquired pendular nystagmus (APN) and pathological gaze-evoked nystagmus usually also have a brainstem or cerebellar localization . Effect of provocative maneuvers: Common triggers include changes in position, sound, Valsalva, headshaking, vibration, and hyperventilation. Neurology. Schwartz MA, Selhorst JB, Ochs AL, et al. Therefore, different therapies and adaptations by the patient can act in distinct mechanistic ways to damp the FMN and, in some cases, restore fusion. Nystagmus is an involuntary, rhythmic ocular movement that is initiated by a slow drift and comes in two varieties (Fig. Bronstein AM, Gresty MA, Mossman SS. Together with several brainstem structures, including the nucleus prepositus hypoglossi and the medial vestibular nucleus, it appears to convert velocity signals to position signals for all conjugate eye movements through mathematical integration. They include: 1) the Kestenbaum (Anderson-Kestenbaum) procedure; 2) the Anderson plus T&R procedure; 3) the BMR procedure; 4) the T&R procedure; 5) procedures on the vertical rectus and oblique muscles in combination with these INS procedures; and 6) strabismus procedures in combination with these INS procedures. Doing so will yield extraneous, lower values of acuity since the prisms will effectively shift the targets to lateral gaze (right gaze for OS viewing and left gaze for OD). Nystagmus - EyeWiki . Rather, it illustrates the diminished foveal visual acuity at different gaze angles lateral to that with the peak acuity (here shown as primary position). Nystagmus is a rhythmic regular oscillation of the eyes. Careful recordings have revealed that although INS may appear clinically horizontal, there are usually smaller, subclinical torsional and vertical components. Three major stimuli elicit vergences: (1) retinal disparity that leads to fusional vergence; (2) retinal blur that evokes accommodative vergence; and (3) motion that induces both disparity and accommodative vergence. Horizontal rectus muscle tenotomy in patients with infantile nystagmus syndrome: a pilot study. 1996;6(3):173184. Horizontal gaze palsy with progressive scoliosis syndrome in - LWW A nystagmus that has oscillations equal in speed and amplitude, usually arising from a visual disturbance. In contradistinction to INS, visual acuity is minimally affected in SNS. Halmagyi GM, Aw ST, Dehaene I, Curthoys IS, Todd MJ. Indeed, it can even present as spasmus nutans (see Section 4).28. Clearly, falling is neither the direct cause nor the specific cause of bone fracture; the direct cause in all of these cases and in others (eg, being struck by a hard object) is deformation of the bone beyond its limit of elasticity. Flowchart demonstrating how clinical observations and tests may be used to arrive at a nystagmus diagnosis. Additional information can be found in Chapter 6 of Nystagmus in Infancy and Childhood. Other visual system diseases associated with nystagmus in infancy include: Leber amaurosis, delayed visual maturation, albinism, optic nerve hypoplasia, achromatopsia, and X-linked congenital stationary night blindness. 2013;26(1):5966. Both ocular motor research and computer modeling support the conclusion that INS is caused (ie, direct=primary=if-and-only-if) by a failure in calibration of smooth-pursuit damping. The spasmus nutans syndrome (SNS)1 includes ocular oscillations, head nodding, and anomalous head positions that begins in infancy (usually between 4 and 18 months of age) and disappears clinically in childhood (usually before 3 years or age). As the name suggests, the nystagmus of these patients diminishes or disappears clinically with the act of willed esotropia while fixating a distant target. A key eye-movement recording observation is the variable phase difference between the 2 eyes, which is reflected clinically as an asymmetry in the oscillations between the 2 eyes. 57. Figure 3. Note that when the peak is high and the range of high-visual acuity (Hi VA) gaze angles is broad, their values cannot be significantly increased and, therefore, no waveform foveation improvements are possible; only under these simultaneous conditions is nystagmus therapy precluded. Infants up to about 6 months years of age can usually be tested without sedation by the parent holding them bundled in a blanket. As visual information passes forward through the visual hierarchy, the complexity of the neural representations increases. Prior to the application of ocular motor research to the nystagmus of infancy, only clinical observation (albeit astute observation by pioneers like Kestenbaum and Anderson)3-5 was available. They may be useful in patients who are unable or unwilling to cooperate for pattern VEPs, and when optical factors such as media opacities prevent the valid use of pattern stimuli. Similarly, the Faden operation may benefit those with NBS. Nystagmus Types - StatPearls - NCBI Bookshelf Often, there is marked asymmetry and dissociation between the eyes. That is, all patients with NBS have strabismus but clearly all with strabismus do not have NBS. Kim JI, Dell'Osso LF, Traboulsi E. Latent/manifest latent and uniocular acquired pendular nystagmus masquerading as spasmus nutans. FMNS exhibits: a jerk nystagmus with either a linear or decreasing-velocity exponential slow phase identical to that of gaze-paretic nystagmus; strabismus; alternating hyperphoria/dissociated vertical deviation; and pendular torsional nystagmus in primary position.1 The constantly present, conjugate, horizontal, jerk nystagmus increases in intensity by monocular occlusion, blurring, or reducing image brightness. Nystagmus is an involuntary, rapid, rhythmic, oscillatory eye movement with at least 1 slow phase. Ocular motor research had shown that, given the right ratio of sensory to motor deficit, these patients may benefit most from INS therapy.69-72. That will provide most of the improvement in distance BCVA available to the patient while still allowing further convergence for middle-distance and near targets (see Section 7). 2008;68(3):241254. Infantile nystagmus: an optometrist's perspective - PMC Nystagmus | Johns Hopkins Medicine The most characteristic form of infantile nystagmus is a jerk or pendular horizontal, uniplanar eye movement. An expanded nystagmus acuity function: intra- and intersubject prediction of best-corrected visual acuity. Sincethey do not have INS, they do not have NBS. Keyword Highlighting Teaching neuroimage: Oculomasticatory myorhythmia: pathognomonic phenomenology of Whipple disease. Biologically relevant models of infantile nystagmus syndrome: the requirement for behavioral ocular motor system models. Methods of measuring BCVA at different gaze angles in the clinical office may be found elsewhere.2; 51 Only by making gaze-angle acuity measurements the standard of care for nystagmus patients, can adequate data be collected from which prospective therapies may be chosen and their visual function improvements determined. Jacobs JB, Dell'Osso LF, Wang ZI, Acland GM, Bennett J. In Type II, because of the Alexanders law variation of FMN, a large head turn is common. That broadens the range of gaze angles within which high visual acuity is possible and makes identification of those individuals on both sides much easier. Measurements of P2 amplitude should be made from the positive P2 peak at around 120ms to the preceding N2 negative peak at around 90 ms. VEPs should be recorded when the infant or child is in an attentive behavioral state. The global or full-field ERG is a mass electrical response of the retina to photic stimulation and is used worldwide to assess the status of the retina in eye diseases in human patients and in laboratory animals used as models of retinal disease. The same is not true for nystagmus types associated with neurological disease. Illustrations of the clarity of portions of the visual field in an INS patient with a narrow, central, null (sharp, central NAFX peak) before (Pre) and after (Post) tenotomy and reattachment surgery. [From Figure D.4, Hertle, R. W. & Dell'Osso, L. F. (2013) Nystagmus in Infancy and Childhood. The substantia nigra pars reticulata funnels inputs from the frontal cortex and acts as a gate for the voluntary control of saccades, keeping in check the superior colliculus activity. Thus, although the percent improvement in VApk is directly related to the pre-therapy NAFXpk, the actual magnitude of post-therapy VApk will be limited by the magnitude of the sensory deficit. your express consent. Penlight-cover test: a new bedside method to unmask, 7. It may consist of alternating phases of a slow drift in one direction with a corrective quick "jerk" in the opposite direction, or of slow, sinusoidal, "pendular" oscillations to and fro. Several forms of saccades, the fastest eye movements, can be observed: voluntary saccades to objects of interest, reflex saccades to unexpected new stimuli, spontaneous saccades that occur in normal inactive subjects, saccades that form the quick phases of vestibular and optokinetic nystagmus, and braking saccades that stop or reverse accelerating slow phases of nystagmus. Dell'Osso LF, Hertle RW, Daroff RB. Some of the putative truths they presented were: Ocular motor research demonstrated that all of the above truths were false. The null position is that range of gaze angles where the nystagmus waveform has minimal amplitude and has the highest foveation quality. Dell'Osso LF, Leigh RJ, Sheth NV, Daroff RB. Most external retinal layers, specifically the external limiting membrane, photoreceptor inner segment layer, and photoreceptor outer segment layer, appear normal, in agreement with histopathological studies and less detailed TD-OCT reported findings of either absent or rudimentary foveal pits in oculocutaneous albinism. The frontal eye fields can selectively activate superior colliculus neurons, playing a role in the selection and production of voluntary saccades. There is now general agreement that head nodding in SNS is compensatory. The slow vergence system is elicited by small disparity errors and/or disparity velocities of less than 3/sec. Those eye care professionals who care for patients with strabismus are as likely, if not more so, as any in health care to be confronted with the disorders of nystagmus and other ocular oscillations. Acquired pendular nystagmus - PMC - National Center for Biotechnology Fisher CM. Optic glioma masquarading as spasmus nutans. For the flash VEP, the most robust components are the N2 and P2 peaks. Spasmus nutans or congenital nystagmus? Horizontal rectus tenotomy in patients with congenital nystagmus. This chapter will concentrate on translating the above research results to better enable the clinician to make accurate diagnoses and provide safe and effective treatment (ie, multiple improvements in visual function) of patients with nystagmus. When INS first appears, it is often arrhythmic and intermittent, consisting of a series of irregular horizontal and oblique deviations of the eyes from side to side. The small group of patients with both INS and FMNS present a diagnostic nightmare. The intensity may dampen on convergence or eye closure, and there may be a region of gaze where it is minimal, or not discernible (null region). Thus, FMNS includes a pure latent form, where theeyes are straight with no nystagmus when both eyes are open and upon occlusion of one eye, an eso- or exophoria develops followed by manifest FMN in both eyes. In some cases, the APAN is so asymmetric that the interval exhibiting jerk nystagmus in one direction may far exceed that in the other. Cranial nerve III carries somatic motor fibers to the levator palpebrae, inferior rectus, medial rectus, superior rectus, inferior oblique, and sympathetic efferent fibers (preganglionic fibers) to the ciliary ganglion. They are mostly found in the peripheral retina, are insensitive to color, and are "coarse-grained" (relatively insensitive to detail), but are sensitive to motion. If the waveform is pendular, dou-ble-headed arrows are used. In much the same manner, INS patients turn their heads to exploit the gaze-angle null of IN and FMNS patients do the same to exploit the Alexanders law variation of their FMN. Therefore, to avoid the misunderstandings and misrepresentations resulting from that older terminology, the newer terminology and descriptions established by a workshop held at the turn of this century are used.1 Thus, INS (infantile nystagmus syndrome) replaces CN (congenital nystagmus) and FMNS (fusion maldevelopment nystagmus syndrome) replaces LMLN (latent/manifest latent nystagmus). If the child sees better in daytime or at night, this suggests congenital stationary night blindness or a rod-cone dystrophy. Johkura K. Central paroxysmal positional vertigo: isolated dizziness caused by small cerebellar hemorrhage. adj., adj nystagmic. Common waveforms are schematised in figure 1. Combined gaze-angle and vergence variation in infantile nystagmus: two therapies that improve the high-visual acuity field and methods to measure it. amblyopic nystagmus nystagmus due to any lesion interfering with central vision. Because the primary, real-world deficit in INS is a low HAgar, measuring BCVA only at the patients best gaze angle, either pre- or post-therapy, can neither fully describe the total INS deficit nor provide information necessary to evaluate its possible amelioration and improvements in visual function. Optic glioma presenting as spasmus nutans. The lack of specificity regarding the nystagmus types or waveforms present both pre- and post-convergence led to problematic diagnoses and interpretations of the clinical symptoms. De Stefano A, Kulamarva G, Citraro L, Neri G, Croce A. Spontaneous. The advantage of operating on all four horizontal recti is that, in addition to treating the strabismus and head posture there is the potential of fusion and further damping of the FMN produced by the T&R effect on the proprioceptive control of the small-signal gain of the extraocular muscles.
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