Correlation of Stereopsis and Ocular Dominance Distribution in

children with intermittent exotropia

Desheng Song, Huiming Qian, Lu Zhou
Department of Ophthalmology, Children’s Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210008, China.
Corresponding author: Desheng Song, Department of Ophthalmology, Children's Hospital of Nanjing Medical University, 72
Guangzhou Road, Gulou District, Nanjing，210008, China, E-mail: songdesheng123456@qq.com

Abstract:
Purpose: To investigate the relationship between stereopsis and exodeviation angle, fusion vergence, and ocular dominance (OD)
distribution in patients with intermittent exotropia (IXT).
Methods: This study included patients aged 4 to 13 years with IXT treated at our hospital from October 2022 to December 2023.
Stereoscopic function was assessed using the Titmus stereogram, the angle of deviation was measured by the prism alternating cover
test, fusion vergence was evaluated using a synopter, and sensory ocular dominance was determined via the card-hole method.
Participants were divided into four groups based on stereopsis: Group I (40 ~ 60 arcseconds), Group II (80 ~ 140 arcseconds), Group
III (200 arcseconds to no stereopsis detected), and Group IV (no binocular fusion function). Differences in exodeviation angle, fusion
function, and ocular dominance among the groups were compared.
Results: A total of 186 subjects were included. Findings indicated that IXT patients lacking fusion (Group IV) exhibited significantly
larger distance and near exodeviation angles compared to those with stereopsis in Groups I, II, and III (p < 0.05). Convergence and
divergence amplitudes were substantially lower in subjects with poor or absent stereopsis (Group III) compared to those with good
(Group I) or moderate (Group II) stereopsis (p < 0.05). Among patients with IXT, the proportions of right, left, and uncertain OD were
46.77%, 35.48%, and 17.74%, respectively. As stereopsis decreases, the proportion of right eye dominance decreases, while unclear
dominance proportionately increases.
Conclusion: Patients with IXT who lack fusion function exhibit a significantly greater angle of exodeviation. Additionally, fusion
vergence function is positively associated with stereopsis in individuals with IXT. The distribution of OD among these patients varies
from that in normal individuals and is related to stereoscopic function.
Keywords: Intermittent exotropia; Stereopsis; Ocular dominance

Introduction
Ocular dominance (OD) plays a key role in visual perception. Compared to the non-dominant eye, the dominant eye generally
provides clearer and more stable imaging[1]. OD is primarily influenced by genetic factors or established in early childhood and is
generally difficult to modify[2]. Based on various examination methods, OD can be categorized into sighting, motor, and sensory
dominance. Sighting OD is widely used in clinical practice due to its reliable results[3, 4]. A thorough literature review reveals a
consistent pattern in OD distribution among normal individuals, with proportions of approximately 6:3:1 for right OD, left OD, and
indeterminate OD, respectively. For instance, Porac and Coren observed proportions of 65%, 32%, and 3% in their study population[3]
, while Chia’s research on typically developing children in Singapore found that 58% showed right OD, 30% left OD, and 12%
indeterminate OD [5]. What factors influence the distribution of OD within the population?
The dominant eye is the eye people instinctively prefer when focusing on an object. It plays a role in spatial orientation and visual
target search, requiring coordinated binocular activity to achieve differential processing of visual pathways[6, 7]. Thus, factors
influencing OD should be examined from a binocular vision perspective. Previous studies have mainly concentrated on monocular
indicators such as refraction [8-11] 、 nerve fiber layer thickness [12] 、 and macular area structure[13]. This focus on monocular
indicators may account for the lack of statistically significant factors identified in these studies. Research by Romano et al. on
stereopsis development in typically developing children revealed that at age 3, the average stereopsis value was 200"; at age 4, it was
90", and by age 5, it was 40". This pattern in OD distribution aligns with the 6:3:1 ratio observed in individuals with normal
stereopsis[14]. An exception was noted in Coren’s study involving 68 infants with an average age of 44.5 weeks, who had immature
stereopsis development. This discrepancy may explain the deviation in OD distribution from that seen in the general population [15].
Currently, there is limited research on whether abnormalities in binocular vision function affect OD distribution.
Intermittent exotropia (IXT) is a condition positioned between exophoria and constant exotropia, exhibiting varied levels of fusion
capability and unique stereopsis characteristics [16, 17]. Therefore, analyzing OD distribution among patients with IXT can help
address the question of whether abnormalities in binocular vision function influence OD distribution.
In surgical treatment for IXT, when it is challenging to identify the more frequently deviated eye before unilateral surgery [18]，the
sighting OD examination method is commonly used to determine the dominant eye. Surgery is then performed on the non-dominant
eye [19]. Clinically, there is growing uncertainty in accurately identifying sighting OD in patients with IXT, which complicates the
decision of which eye to select for unilateral surgery. Our research aims to address two primary questions: What is the proportion of
individuals with IXT experiencing uncertainty regarding their sighting OD, and how should we proceed in selecting the surgical eye
for this specific subgroup? Additionally, does the distribution of sighting OD in the IXT population align with that of individuals
without the condition, and is there a correlation with stereopsis function?

Materials and Methods

1. Materials
1.1. clinical case data
(1) Case Source: Clinical data were collected from 543 patients diagnosed with IXT who received outpatient treatment at Children's
Hospital of Nanjing Medical University between October 2022 and December 2023. Of these 543 patients, aged 4 to 13 years, 8 were
excluded due to systemic diseases, including 4 cases of upper respiratory tract infection, 1 case of premature ventricular contraction, 1
case of type 1 diabetes, 1 case of acute laryngitis, and 1 case of growth retardation. Additionally, 73 cases with anisometropia ＞2D
were excluded. Patients with a horizontal deviation angle difference exceeding 5 PD between the eyes, amblyopia, monocular
suppression during synoptophore examination, or those uncooperative in certain assessments were also excluded. Consequently, 186
patients were included in the study.
(2) Inclusion Criteria: 1) Diagnosis of IXT with an exodeviation of at least 10 PD, 2) Best-corrected visual acuity of 20/20 or better in
each eye, 3) Demonstrated ability to alternate fixation freely between both eyes.
(3) Exclusion Criteria: 1) Constant exotropia, 2) Incomitance in horizontal and vertical deviations, 3) Vertical deviation angle ≥5 PD,
4) Significant abnormalities in the oblique muscles, 5) Anisometropia ≥1D, 6) Presence of ocular or neurological disorders unrelated
to strabismus, 7) History of eye surgery or trauma.
(4) Ethics Approval: The study received approval from the Ethics Committee of Children's Hospital of Nanjing Medical University.
All participants voluntarily agreed to participate in the study and provided signed informed consent.
2. Methods
2.1 Clinical Examination
All children diagnosed with IXT underwent comprehensive assessments of ophthalmic and visual functions. These evaluations
included measurements of visual acuity, examination of the anterior segment and fundus, exodeviation angle, stereopsis, and sighting
OD. All examinations were performed under best-corrected refraction. Among the study participants, all children with IXT displayed
normal monocular visual acuity (≥20/20) and unremarkable findings in anterior segment and fundus examinations. The angle of
exotropia was measured using prism and alternate cover tests at distances of 6 m and 33 cm.
2.2 Assessment of Fusion Function and Binocular Vision Tri-Level Functions
The L-2510HB synoptophore (Inami & Co., Ltd., Japan) was used to evaluate fusion function, including convergence and divergence
amplitudes. Fusion convergence and divergence amplitude measurements were performed approximately one hour after the prism
examination to allow sufficient fusion recovery time. Horizontal fusion convergence and divergence were assessed using slides with a
horizontal angle of 6 degrees and a vertical angle of 8 degrees to determine fusion amplitude. During convergence, the synoptophore
arm was gradually moved outward at a rate of 2 PD per second to identify the fusion break point, where the images separated into two
distinct entities. For divergence, the synoptophore arm was moved inward to locate the fusion break point. The break points and
simultaneous vision points were recorded using the synoptophore, and measurements were expressed in prism diopters. Each child
underwent three repetitions of these measurements, with the average value taken as the final result. For this study, specific definitions
were applied to the parameters measured by the synoptophore. Fusion amplitude was defined as the distance between the break point
and the simultaneous vision point. Convergence or divergence amplitude was calculated by subtracting the prism diopter value at the
break point (during convergence or divergence) from the prism diopter value at the simultaneous vision point. Each parameter was
measured three times and recorded in prism diopters, with the mean of these three measurements considered the final result.
2.3 Stereopsis Function Assessment
Stereopsis function was assessed using the Titmus Stereopsis Test (Stereo Optical Co., Inc., Chicago, IL, USA), which measured
visual disparity within a range of 40 to 3000 arcseconds. Participants wore polarized glasses and viewed stereo images at a
standardized distance of 40 cm, initially tasked with "grasping" the wings of a fly. Upon successful completion, they were asked to
sequentially identify circles that appeared to float in front of the page, with the goal of detecting the circle that seemed closest. If an
error occurred, the previous target was reassessed. Consistent and accurate responses for the prior target confirmed the result, and the
corresponding disparity was recorded as the measurement outcome. Testing began with maximum disparity; participants unable to
identify this level correctly were documented as having no stereopsis.
2.4 Assessment of sighting ocular dominance
Sighting eye dominance was determined using the hole-in-card method. Participants extended their arm forward, holding a card with a
central aperture of 3 cm in diameter, and focused on a target located 6 meters away while keeping both eyes open. Each eye was then
alternately covered to identify the dominant eye, which was the eye through which the target remained visible when the other eye was
masked. A score of +1 was given for right eye dominance, while -1 indicated left eye dominance. Each participant repeated the test
four times, and those with a cumulative score of ≥2 or ≤-2 were classified as having right or left eye dominance, respectively. Scores
outside this range indicated ambiguous ocular dominance.
These assessments were conducted in well-lit, quiet conditions, allowing participants ample time for testing and brief rest
intervals.
3. Data Analysis
All statistical analyses were conducted using R software (version 3.2.2, http://www.R-project.org; The R Foundation, Vienna, Austria).
Following the Kolmogorov-Smirnov test, it was found that data for convergence and divergence amplitudes, as well as exotropia
angles, did not follow a normal distribution. Consequently, the Kruskal-Wallis (KW) test was applied to analyze these parameters,
with Dunn's test used for subsequent pairwise comparisons. The chi-square test was employed to assess the distribution patterns.
Statistical significance was set at p < 0.05 for all analyses.
Results
1. Evaluation of Stereoacuity
Participants were categorized into four distinct groups (Figure 1). Group I (n = 41) demonstrated good stereoacuity, ranging from 40 to
60 arcseconds, similar to the results observed in individuals without IXT on the Titmus test. Group II (n = 46) exhibited moderate
stereoacuity, within the range of 80 to 140 arcseconds. Group III (n = 73) included participants with reduced stereoacuity, spanning
from 200 arcseconds to no detectable stereoacuity. Participants in Group IV, who had IXT, showed a lack of binocular fusion. There
was a significant difference in mean age across the four groups. Pairwise comparisons revealed that Group IV had a higher mean age
than Group III (p < 0.05, Dunn's test), though no statistically significant age differences were noted among Groups I, II, and IV (p >
0.05, Kruskal-Wallis test) (Figure 1).
2. Exodeviation angle
Subjects in Group IV, who lacked fusion functions, showed a significantly larger exodeviation angle at distance compared to Groups I,
II, and III (p < 0.05, KW test; p < 0.05, Dunn's test for pairwise comparisons) (Figure 2A). A similar trend was observed in the near
exodeviation angle (Figure 2B) (p < 0.05, KW test; p < 0.05, Dunn's test for pairwise comparisons).
3. Fusion amplitude
Divergence amplitude in participants with poor or absent stereovision (Group III) was significantly lower than in those with good
(Group I) or moderate (Group II) stereovision (p < 0.05, KW test; p < 0.05, Dunn's test for pairwise comparisons) (Figure 3A).
Additionally, convergence amplitude in participants with deficient or absent stereovision (Group III) was also notably reduced
compared to those with good (Group I) or moderate (Group II) stereovision (p < 0.05, KW test; p < 0.05, Dunn's test for pairwise
comparisons) (Figure 3B).
4. Sighting dominant eye
Figure 4 shows the proportions of sighting OD across each group. Among participants with good stereovision, the distribution of
sighting dominance (right eye dominance: 58.57% ± 7.72%, left eye dominance: 41.42% ± 7.72%, and uncertain dominance: 0%)
significantly differed from the expected random distribution (p < 0.001, with expected values of 33% for right eye, left eye, and
uncertain dominance). For participants with moderate stereovision, the distribution also showed a significant deviation from the
expected distribution, marked by an increase in uncertain dominance and a reduction in left eye dominance (right dominance: 60.74%
± 7.28%, left dominance: 21.73% ± 6.21%, uncertain dominance: 17.52% ± 5.55%) (p = 0.04). In contrast, participants with unreliable
or absent stereovision did not display a significant deviation from the expected distribution in sighting dominance (right eye
dominance: 37.09% ± 5.88%, left eye dominance: 37.93% ± 5.88%, uncertain dominance: 24.98% ± 5.19%) (p = 0.38). Similarly,
participants lacking fusion function presented a distribution closely resembling the expected random distribution (right dominance:
30.33% ± 9.10%, left dominance: 42.05% ± 9.90%, uncertain dominance: 27.61% ± 9.33%; p = 0.21).
Discussion
The findings of this study demonstrate that, in patients with IXT, a lack of binocular fusion is associated with a significant increase in
the angle of exodeviation. Additionally, fusion vergence amplitude in these patients is positively correlated with stereopsis. Among the
IXT patients in this study, the distribution of right, left, and uncertain OD was 46.77%, 35.48%, and 17.74%, respectively, deviating
from the typical distribution in the general population (6:3:1). Notably, as stereopsis function declines, the proportion of right OD
decreases while the proportion of uncertain OD rises significantly.
This study also found that in patients with stereopsis, there was no correlation between the angle of deviation at distance or near
and stereopsis, consistent with Superstein et al.’s research, which similarly found no relationship between poorer stereopsis and a
larger angle of exodeviation. Each child may display unique combinations of stereopsis, control, and exodeviation angles [17] ,
potentially due to the variability in exodeviation angle and stereoacuity, which can fluctuate significantly throughout the day in IXT
patients, either worsening or improving [20, 21]. For instance, what appears as monocular fixation at one time might later shift to
sensory bifoveal fusion [21]. An important new finding in this study is that when patients exhibit only secondary fusion function, the
exodeviation angle increases substantially. We also observed that fusional convergence is related to stereoacuity. Divergence and
convergence fusion amplitudes were significantly lower in subjects with poor or absent stereopsis compared to those with good or
moderate stereopsis. Vergence fusion, which stabilizes eye alignment by detecting retinal image disparity and generating corrective
eye movements, is a critical motor function. Ale Magar et al. reported a positive correlation between fusion amplitude and IXT
control[22]. In addition, Superstein et al. noted that poorer control was associated with reduced stereoacuity [17]. This study provides
clear evidence of the relationship between fusion capacity and stereopsis, highlighting that fusion is a level II binocular vision function
and forms the foundation for the development of stereopsis, a higher-level binocular function. While there are few studies specifically
examining the relationship between fusion ability and stereopsis, our findings indicate that with higher stereopsis (grades I and II),
there is no significant correlation between fusion vergence and stereopsis. However, when stereopsis deteriorates significantly (level
III), fusion function also declines significantly.
In this study, among subjects with stereopsis better than 140 arcseconds, the distribution of OD was as follows: right OD at 55.8%,
left OD at 31.2%, and indeterminate OD at 13%, aligning with the typical distribution of OD in the general population[5]. Notably,
patients with IXT display normal binocular function when their eyes are aligned [23]. Given that the Titmus test indicates a lower
stereopsis limit of 140 arcseconds for normal children at age 5 [14], it is reasonable to assume that IXT children with good stereopsis
would exhibit an OD distribution similar to that of normal children. The phenomenon of spontaneous dominance in one eye is
common among individuals with normal binocular vision, suggesting that OD itself does not inherently signify a pathological
condition. In contrast, partial monocular suppression linked to OD may have a physiological role in supporting the development of
stereopsis[24]. It is widely recognized that OD is partly associated with brain lateralization [25-27]. In an fMRI study on ocular
dominance conducted by Rombouts, it was observed that when the right eye was dominant, the primary visual cortex displayed both a
larger activation area and higher activation level than the non-dominant eye. However, this asymmetry was not observed with left-eye
dominance[26]. Possible explanations for this difference include a limited sample size, leading to statistically insignificant findings, or
the possibility of more extensive activation in the primary visual cortex when the right eye is dominant. Consistent with natural
selection theories, this pattern may explain the higher prevalence of right-eye dominance in the general population.
This study found that as stereoacuity surpasses 140 arcseconds, stereopsis function progressively declines until binocular fusion
function is lost, and the distribution of OD, right eye, left eye, and unclear dominance, approaches a 1:1:1 ratio. Specifically, the
proportion of right eye dominance significantly decreases, while left eye dominance and unclear dominance increase markedly. This
distribution of dominant eyes contrasts sharply with that observed in individuals with normal stereopsis and children with IXT who
maintain normal stereopsis. Similar patterns have been documented in children with hemiplegia; for instance, Cheryl et al. reported a
significant decline in right OD in children whose hand dominance shifted from right to left following brain injury. In normal binocular
vision, the integration of visual information from each eye enables “fusion,” or the formation of a single, clear image[23]. Intermittent
exotropia may result from weakened or atypical binocular cortical drive that fails to maintain fusion, leading to spontaneous
intermittent exotropic eye movements. Neuroimaging studies indicate that patients with IXT exhibit notable changes in cortical
regions associated with binocular fusion, compared to those without the condition[28]. In IXT patients, the occipital and temporal
lobes show notable activation, suggesting that these individuals require more effort than typical individuals to achieve binocular
fusion. The interaction within binocular vision is intricate and not fully understood[29]; however, OD is generally recognized as a key
factor in this process, significantly influencing the success of monovision [30]. Handa et al. [31] demonstrated that binocular fusion
only occurs when monovision is successful, linking OD directly to the fusion process. Nevertheless, further research is essential to
identify the factors contributing to the near-equal distribution of dominant eye proportions in children with IXT, particularly in
connection to their atypical secondary fusion function. Future investigations, such as neuroimaging studies examining OD in IXT
patients without stereopsis function, could provide further insights.
The overall pattern of OD distribution can be summarized as follows: as binocular vision function declines, the proportion of right-
eye dominance decreases, while the proportion of unclear dominance rises. Literature suggests that this increase in unclear dominance
is associated with conditions such as dyslexia[32, 33] and nystagmus[34]. Additionally, it has been proposed that unclear dominance
may relate to the cerebral hemisphere governing visual attention [35]. Research by Stein and Fowler indicated that children with
underdeveloped OD experience poor binocular control during prolonged target fixation. The brain integrates visual inputs from both
eyes to produce a unified image, and monocular vision fusion enables a single image that enhances stereoscopic depth perception[36].
Stereopsis, an advanced visual function, depends on the integration and fusion of monocular images from each eye, improving
progressively throughout visual development [37-39]. In experimental and clinical contexts, one eye typically assumes dominance,
while the other undergoes suppression. The mechanisms of binocular integration and suppression are components of the binocular
neural network, which supports various visual functions, including integration, fusion, and stereopsis. These processes work in unison
to suppress specific image components from one eye through interocular suppression, thereby generating a cohesive three-dimensional
perception[40]. The OD mechanism is essential for successful monovision [41]， as it reflects the dominant eye’s role in binocular
vision function. Mitchell et al. found that binocular contrast integration in the primate primary visual cortex (V1) is influenced by
neurons’eye preference. Contrast presented to a neuron’s dominant eye significantly impacts binocular response formation more than
the same contrast presented to the non-dominant eye. This asymmetry is positively correlated with the neuron’s OD index, suggesting
that OD serves as a gain control mechanism for non-dominant eye contrast during binocular response formation. When images are
presented simultaneously to both eyes, V1 neurons reduce contrast gain in proportion to their OD when contrast is applied to the non-
dominant eye. Consequently, changes in OD lead to reduced binocular integration, which, in turn, impacts stereoscopic function[42].
What mechanism contributes to the increased proportion of unclear OD in patients with IXT? Insights may be gained from the
experimental findings of Song et al. In their study, the researchers developed an “off-eye backward video” paradigm, where one eye of
the subject views a video in normal playback, while the other eye views the same video in reverse. Although both eyes receive
identical visual content, the backward video lacks coherence, making it difficult to interpret and causing subjects to focus more on the
forward video. This setup results in disproportionate allocation of attentional resources to the eye watching the forward video (the
attentional eye) rather than the one viewing the backward video (the non-attentive eye). To assess perceptual OD, participants
completed a binocular rivalry task before and after the video session. The study found that after one hour of viewing the off-eye
backward video, the non-attentive eye gained a longer duration of dominant perception in the binocular competition task compared to
pre-test levels, indicating an OD shift toward the non-attentive eye. Additionally, the degree of attention focused on the video stimulus
correlated with the extent of the OD transfer effect, emphasizing the critical role of eye-based attention in facilitating this shift. The
results also suggest that the binocular competition mechanism plays a vital role in the OD shift induced by eye-based attention[43].
Further support comes from Wang and Lunghi, who found that enhanced attention during monocular patching treatment for amblyopia
promotes OD switching [44, 45], suggesting that eye-based attention may become particularly influential when normal input from one
eye is disrupted. In children with IXT, when one eye deviates outward, the brain primarily receives input from the fixating eye, while
input from the deviated eye is suppressed. Based on these findings, it is plausible that the dominant eye may change under such
conditions. This hypothesis, however, requires validation through further experimental research.
The incidence of exotropia is approximately 1%, with IXT being the most common form [46]. In cases of mild IXT, it is standard
practice to perform surgery on the non-dominant eye [47]. However, in some IXT patients, the dominant eye remains unclear.
According to the findings of this study, the proportion of patients with an unclear OD increases as stereoacuity decreases in children
with IXT. Consequently, selecting the optimal surgical eye for these patients presents a challenge for surgeons. Given that the
dominant right eye is prevalent in the general population, it is advisable to operate on the left eye when performing single-eye surgery.
This approach increases the likelihood that the dominant eye post-surgery will align with the dominant eye prior to the onset of
strabismus, potentially enhancing the restoration of stereoscopic vision.
In the management of IXT, surgical correction of eye position is essential, with the recovery of binocular vision function as a key
objective in strabismus treatment [48]. IXT often progresses gradually, with the eye position potentially drifting outward and
regressing even after surgery, a likelihood that increases over extended follow-up periods [49, 50]. Importantly, the neural basis for
binocular vision typically remains intact in cases of IXT [51] , suggesting that a cure may be achievable if strategies are developed to
prevent intermittent disruptions in fusion. Given the close association between OD and binocular fusion and stereopsis, our next
research focus will examine whether surgical eye selection in IXT can be effectively guided by sighting OD results. Additionally, we
will explore whether eye-based attention influences OD shifts in intermittent exotropia.
Abbreviations
IXE: intermittent exotropia
OD: ocular dominance
PD: prism diopter

Acknowledgements
Not applicable.

Authors’ contributions
Desheng Song contributed to study design and coordination, conducted the data analysis, and assisted in drafting the manuscript.
Huiming Qian contributed to edit this paper. Lu Zhou were involved in data acquisition, data interpretation, and critical revision of the
manuscript. Desheng Song helped to interpret the data and to draft the manuscript. All authors have given final approval of the version
to be published.

Funding
This study was funded by the project of Children's Hospital of Nanjing Medical University (LCYJY202319)

Data Availability
The datasets generated and analysed during the study are not publicly avail able but are available from the corresponding author on
reasonable request.

Declarations
Ethics approval and consent to participate
We adhered to the tenets of the Declaration of Helsinki. Ethics approval was obtained from the the ethics committee of Children’s
Hospital of Nanjing Medical University. All participants involved were informed of the purpose and methods of this study and a
written consent was obtained from their parent or guardian.

Consent for publication

Not applicable.

Competing interests
The authors declare that they have no competing interests.

Author details
Department of Ophthalmology, Children’s Hospital of Nanjing Medical University, Nanjing 210008, China.

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Figure 1. Scatter plot illustrating the relationship between age and stereopsis. Subjects were categorized into four distinct levels
based on the quality of their stereoscopic function: Group I (Level I) includes individuals with stereopsis better than or equal to 60 arc
seconds, indicating good stereoscopic vision; Group II (Level II) encompasses those with stereoscopic function ranging from 80 arc
seconds to 140 arc seconds, representing moderate stereopsis; Group III (Class III) consists of subjects with stereopsis equal to or
greater than 200 arc seconds, as well as those exhibiting no measurable stereopsis, indicating unreliable stereopsis; and Group IV
(Class IV) signifies the absence of binocular fusion. In the plot, red and blue circles denote the mean and median age for each
category, respectively.

Figure 2. Scatter plot illustrating the relationship between exodeviation angle and stereopsis. (A) exodeviation angle at distance.
(B) exodeviation angle at near. Level IV subjects exhibited significantly greater exodeviations compared to the other three groups. The
red and blue circles indicate the mean and median values for each category, respectively.

Figure 3. Scatter plot illustrating the relationship between vergence amplitude and stereopsis. (A) divergence amplitude. (B)
convergence amplitude. The vergence amplitudes of subjects in Group III (Level III) were significantly smaller than those of subjects
in Group I (Level I) and Group II (Level II). The red and blue circles indicate the mean and median values, respectively, for each
group.

Figure 4. Line drawing illustrating the changes in distribution for subjects exhibiting varying levels of binocular vision. The
graph indicates the percentage of right eye dominance (red), left eye dominance (blue), and indeterminate dominance (black). The circles represent
the mean values, while the vertical lines denote the standard deviation, calculated from 10,000 bootstrapping.