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PubMed2000

Accommodative and vergence findings in ocular myasthenia: a case analysis.

Myasthenia gravis (MG) is a neuromuscular disorder that affects skeletal muscles, in particular, the extraocular muscles. Response variability is a hallmark sign. Detailed findings are described in a patient with MG in which the presenting sign was accommodative insufficiency. Objective accommodative findings were recorded 3 years before the onset of myasthenia, soon after the initial diagnosis was made, and then after the treatment commenced with pyridostigmine. In addition, clinical measurements were obtained periodically at different times of the day for various binocular motor functions, including near point of convergence, phoria, fusional and accommodative amplitudes, and relative accommodation. The disease adversely affected all accommodative and vergence findings, with fatigue being the primary disturbance. The therapeutic administration of pyridostigmine improved static measurements of accommodation and vergence and reduced asthenopia. The objective dynamic measurements of accommodation, vergence, and versions were less affected. These findings provide a clear demonstration that both intrinsic and extrinsic ocular muscles may be affected in the prepresbyopic myasthenic patient.

Accommodation, Ocular↗
PubMed2006

Effect of aging on stereoscopic interocular correlation.

PURPOSE: This study was designed to evaluate the minimum interocular correlation (IOC) needed by the visual system to correctly perceive a static stereoscopic stimulus as a function of normal aging. It was also our goal to evaluate the feasibility of clinical charts testing this aspect of visual perception. METHODS: Stereoscopic IOC threshold was determined in 100 normal observers (average age +/- standard deviation, 45.7 +/- 20.4 years) drawn from a clinical population between the ages of 10 and 85. We used partially correlated red-green random dot stereograms (RDS) displaying flat, square surfaces at 360 arcsec of either crossed or uncrossed disparity. RESULTS: Older observers needed a higher binocular correlation to perceive the stereoscopic stimuli when compared with the younger groups. There is a slight increase in the threshold value of the individuals in the 45- to 64-year-old group and a further effect on the observers over 65 years of age. Data did not reveal any effects of gender, near point phoria, or fixation disparity on IOC thresholds. CONCLUSIONS: Normal aging produces a statistically significant deficit in binocular correlation processing. This process is marginally correlated with stereo acuity measures even when stereoacuity floor effects are factored out. Although further experiments directly comparing stereoacuity and IOC are necessary and more refining is required to obtain optimum parameters, clinical stereoscopic IOC test charts appear feasible and may not assess the same processes as stereoacuity charts.

Adolescent↗
PubMed2006

The Study of Progression of Adult Nearsightedness (SPAN): design and baseline characteristics.

PURPOSE: The Study of Progression of Adult Nearsightedness (SPAN) is a 5-year observational study to determine the risk factors associated with adult myopia progression. Candidate risk factors include: a high proportion of time spent performing near tasks, performing near tasks at a close distance, high accommodative convergence/accommodation (AC/A) ratio, and high accommodative lag. METHODS: Subjects between 25 and 35 years of age, with at least -0.50 D spherical equivalent of myopia (cycloplegic autorefraction), were recruited from the faculty and staff of The Ohio State University. Progression is defined as an increase in myopia of at least -0.75 D spherical equivalent as determined by cycloplegic autorefraction. Annual testing includes visual acuity, noncycloplegic autorefraction and autokeratometry, phoria, accommodative lag, response AC/A ratio, cycloplegic autorefraction, videophakometry, ultrasound, and partial coherence interferometry (IOLMaster). Participants' near activities were assessed using the experience sampling method (ESM). Subjects carried a pager for two 1-week periods and were paged randomly throughout the day. Each time they were paged, they dialed into an automated telephone survey and reported their visual activity at that time. From these responses, the proportion of time spent performing near work was estimated. RESULTS: Three-hundred ninety-six subjects were enrolled in SPAN. The mean (+/- standard deviation) age at baseline was 30.7 +/- 3.5 years, 66% were female, 80% were white, 11% were black, and 8% were Asian/Pacific Islander. The mean level of myopia (spherical equivalent) was -3.54 +/- 1.77 D, the mean axial length by IOLMaster was 24.6 +/- 1.1 mm, and subjects were 1.7 +/- 4.0 Delta exophoric. Refractive error was associated with the number of myopic parents (F = 3.83, p = 0.023), and the number of myopic parents was associated with the age of myopia onset (chi2 = 13.78, p = 0.001). In a multivariate analysis, onset of myopia (early vs. late) still had a significant effect on degree of myopia (F = 115.1, p < 0.001), but the number of myopic parents was no longer significant (F = 0.65, p = 0.52). For the ESM, the most frequently reported visual task was computer use (mean, 18.9%; range, 0-60.0%) and, overall, subjects reported near work activity 34.1% of the time (range, 0-67.3%). CONCLUSIONS: The design of SPAN and the baseline characteristics of the cohort have been described. Parental history of myopia is related to the degree of myopia at baseline, but this effect is mediated by the age of onset of myopia.

Accommodation, Ocular↗
PubMedDate not supplied

Reliability of the response AC/A ratio determined using nearpoint autorefraction and simultaneous heterophoria measurement.

BACKGROUND: Clinicians frequently assess the accommodative convergence to accommodation (AC/A) ratio using near phoria measurements and accommodative stimuli. The purpose of this study was to evaluate the repeatability of AC/A ratio measurements and to compare the response AC/A ratio to stimulus AC/A ratios determined two different ways. METHODS: Heterophorias and accommodative responses to different stimuli were measured simultaneously on eight subjects at two visits. A Canon Auto Ref R-1 autorefractor was used to measure accommodative response, while vergence posture was measured using the modified Thorington heterophoria technique. These results were used to calculate response-slope, stimulus-slope and stimulus-gradient AC/A ratios and the means of these ratios for each session were compared. Correlations between the response AC/A ratios and the stimulus AC/A ratios were calculated. RESULTS: The mean response AC/A ratios for the two sessions were 3.8 prism dioptres per dioptre for each session. The correlation between the slope-determined ratios was 0.56, and between the response-slope and the stimulus-gradient AC/A ratios the correlation was -0.03. The regression equation for the slope-determined AC/A ratios was calculated. CONCLUSIONS: Means for the two sessions were not significantly different for any of the AC/A ratios. The response-slope and stimulus-slope AC/A ratios had a moderately significant correlation and a predictive regression equation was determined. The stimulus-gradient AC/A ratios were not correlated with the response-slope AC/A ratios.

Journal Article↗
PubMed2005

A bitoric rigid contact lens with base down prism to eliminate binocular vertical diplopia.

Prism base down can be incorporated into a rigid gas permeable contact lens to align the diplopic images in a patient who has a significant vertical phoria. A rigid lens may also incorporate both vertical base down prism and a toroidal back surface - the vertical prism to correct the heterophoria and the toric back surface to improve the physical fit of the lens on a highly toric cornea. This paper presents a case where vertical diplopia due to a post-surgical left hyperphoria of about four prism dioptres was eliminated by the incorporation of the appropriate amount of base down vertical prism into a bitoric rigid gas permeable contact lens.

Contact Lenses↗
PubMed1989

Adaptive disorders of accommodation and vergence in binocular dysfunction.

Disturbances of binocular vision are described clinically by the Duane-White classification in terms of the magnitude of the accommodative-convergence ratio (AC/A). Convergence excess and convergence insufficiency are assumed to result from high and low AC/A ratios respectively. It is assumed that the abnormal AC/A ratio is an independent variable that underlies abnormal phorias. However, recent studies have demonstrated that the AC/A ratio is inversely related to the adaptability of tonic accommodation (lens adaptation) and directly related to adaptability of tonic vergence (prism adaptation). We have tested whether clinical categories of convergence excess and convergence insufficiency are associated with insufficient and excessive adaptation of tonic accommodation and tonic vergence. Results demonstrate greater amplitude and duration of accommodative after-effects (lens adaptation) in the convergence insufficiency than the convergence excess group. Vergence after-effects (prism adaptation) had the reverse trend for the two groups. These results indicate that adaptive disorders of accommodation and vergence may underlie binocular disorders in symptomatic patients categorized as convergence excess and convergence insufficiency.

Accommodation, Ocular↗
PubMed1993

Influence of proximal, accommodative and disparity stimuli upon the vergence system.

The most important cues to the normal vergence response are retinal disparity, accommodative effort and perceived distance (proximal cue). In the past, proximal cues have been thought to contribute little to the total vergence response but more recent studies have suggested that they play an important role. The relative contributions of the proximal, accommodative and disparity cues to the vergence response were assessed by measuring the effect upon the vergence system when each of these cues were altered. The effect upon the vergence system was measured by the change in 'phoria, the change of fixation disparity and the amount of prism adaptation after 210 s of binocular viewing. The results indicate that the greatest effect of cue disharmony occurred when the proximal and disparity cues were altered. A finding which signifies the importance of the proximal cue to the overall vergence response.

Accommodation, Ocular↗
PubMed2004

Statistical normal values of visual parameters that characterize binocular function in children.

A wide range of visual parameters used to evaluate binocular function were evaluated in a paediatric population (1056 subjects aged 6-12 years). Mean values are provided for these ages in optometric tests that directly assess the vergence system, horizontal phorias for near and far vision (measured by a modified version of the Thorington method), negative and positive vergence amplitude for near and far vision (step vergence testing), vergence facility (flippers 8 Delta BI/8 Delta BO), and near-point of convergence (penlight push-up technique and red-lens push-up technique), as well as stimulus accommodative convergence/accommodation ratio and stereoacuity (Randot test) which provide an overall evaluation of the vergence, accommodative and oculomotor systems. A statistical comparison (anova and Bonferroni post hoc test) of these values between ages was performed. The differences, although statistically significant, were not clinically meaningful, and therefore we identified two trends in the behaviour of these parameters. For all parameters, except for vergence facility, we established a single mean reference value for the age range studied. The difference between the means for vergence facility indicated the need to divide the population into two age ranges (6-8 and 8-12 years). This study establishes statistical normal values for these parameters in a paediatric population and their means are a valuable instrument for separating children with binocular anomalies from those with normal binocular vision.

Aging↗
PubMed2005

Accuracy of accommodation in heterophoric patients: testing an interaction model in a large clinical sample.

A model of the cross-link interactions between accommodation and convergence predicted that heterophoria can induce large accommodation errors (Schor, Ophthalmic Physiol. Opt. 1999;19:134-150). In 99 consecutive patients with intermittent tropia or decompensated phoria, we tested these interactions by comparing their accommodative responses to a 2.50-D target under binocular fused conditions (BFC) and monocular occluded conditions (MOC). The accommodative response in BFC frequently differed from that in MOC. The magnitude of the accommodative errors in BFC, ranging from an accommodative lag of 1.80 D (in an esophoric patient) to an accommodative lead of 1.56 D (in an exophoric patient), was correlated with distance heterophoria and uncorrected refractive errors. These results indicate that heterophoria affects the accuracy of accommodation to various degrees, as the model predicted, and that an accommodative error larger than the depth of focus of the eye occurs in exchange for binocular single vision in some heterophoric patients.

Accommodation, Ocular↗
PubMed2006

The Mallett Fixation Disparity Test: influence of test instructions and relationship with symptoms.

Fixation disparity is a minute ocular misalignment under conditions of binocular single vision and is typically detected in primary eye care practices in the UK using the Mallett Unit Fixation Disparity Test. This instrument creates natural viewing conditions, when the patient's binocular system is fused using both central and peripheral fusion locks. This allows the examiner to determine the minimum prism power that eliminates the fixation disparity: the associated phoria or aligning prism. The spherical power that eliminates the fixation disparity, the aligning sphere, can also be determined. The near Mallett Unit Fixation Disparity Test has been shown to have good sensitivity and specificity for detecting symptomatic heterophoria. Cases of decompensated heterophoria tend to have a fixation disparity and the aligning prism or aligning sphere is a good indicator of the correction that will render the heterophoria compensated. The purpose of this study was, for the first time, to investigate the effect of test instructions on the results of the Mallett Unit Fixation Disparity Test. In study 1, we surveyed and observed practitioners to determine the instructions that are typically used. In study 2, we compared results obtained with this "standard" method of questioning with a more "specific" form of questioning that has been suggested in the literature. The participants for study 2 were 105 patients aged 7-70 years who were randomly selected from those attending a community optometric practice. Significantly different results were obtained with the two sets of instructions. The specific form of questioning revealed more cases of fixation disparity and the results with this method showed a better correlation with symptoms. This only held for near vision: for distance vision, symptoms were not significantly correlated with the presence of fixation disparity. This agrees with previous work with the Mallett unit, which showed a significant relationship with symptoms only at near. We also found that patients with more severe symptoms had greater degrees of aligning prism. Our study supports previous work indicating that the Mallett unit is a useful tool for detecting symptomatic heterophoria at near. However, we found that the testing method is important: patients need to be asked not just whether the nonius strips are aligned but also whether one or both of the strips ever moves. More research is needed to investigate the significance of precise test instructions in other optometric and orthoptic tests.

Adolescent↗
PubMed1995

Myopia in teenagers. An eight-year follow-up study on myopia progression and risk factors.

UNLABELLED: A prospective 2-year study on myopia progression was commenced in 1984/85, with special attention to the rate of progression in a representative group of school children aged 9 to 12 years. A follow-up investigation of this group of myopic persons (now aged 17-20 years) was performed after 8 years, in order to describe the refractive error and possible risk factors for myopia progression over the period. The refractive error increased from -2.77 D to -5.14 D (mean values). PARAMETERS: age at début, degree of myopia, intraocular pressure, changes at the fundus, status of phoria, nearpoint of convergence and accommodation were all measured at the start and related to the refractive error measured 8 years later. No single parameter, apart from age at début, indicated that the individual would reach a high degree of myopia. The refractive error among the children with a début below 7 years of age was -6.60 D, but only -3.72 D among those with a début after 10 years. The change in refractive error over the 8-year period was not statistically related to the age at début, neither did the rate of progression depend on the degree of myopia, the changes at the fundus, nor the intraocular pressure. However, children could be found who had a high rate of progression, by using a combination of these parameters.

Accommodation, Ocular↗
PubMed2002

Adaptive control of vergence in humans.

Vergence eye alignment minimizes horizontal, vertical, and cyclodisparities to optimize stereo-depth perception. Only the horizontal component of vergence is under voluntary control. Couplings with voluntary version and horizontal vergence guide vertical vergence and cyclovergence. Can these couplings be modified in response to sensory demands on binocular vision? We have modified vertical vergence and cyclovergence in response to optical changes in disparity. Vertical vergence was stimulated with aniseikonic lenses that exaggerated vertical disparity in tertiary gaze. Vertical vergence adapted in an hour to produce nonconcomitant changes in vertical phoria that varied with vertical eye position in tertiary gaze. Cyclovergence was stimulated with cyclodisparities that varied with gaze elevation and convergence angle. Cyclovergence adapted within 2 hours to produce nonconcomitant changes in cyclophoria that varied with gaze elevation and convergence. The adaptive couplings for vertical vergence and cyclovergence are modeled as a combination of passive orbital mechanics and active gain control of the vertical recti and obliques. Vergence adaptation is a calibration process that adjusts the innervation for horizontal, vertical, and torsion components of vergence to the physical constraints set by the extraocular muscles and orbital connective tissues. Passive orbital mechanics simplify the neural control for precise vertical vergence and cyclovergence that are needed to achieve binocular alignment under open-loop conditions in response to perceived spatial location.

Adaptation, Physiological↗
PubMed1982

Ophthalmological findings in pupils of a primary school with particular reference to reading difficulties.

200 good readers and 41 poor readers selected from 718 pupils in a primary school, grade 1-6 were examined in respect of stereopsis, visual acuity, phorias, tropias, fusional breakpoint, fusional amplitude and objective refraction. No statistical difference was found between the 2 reader groups, and the need for optical aid was of the same order. 80 of the 241 children had unnecessary glasses, and many of those who needed spectacles were improperly aided.

Age Factors↗
PubMed1985

The value of sight-screening, a comparative study of the Rodenstock sight-screener and a clinical eye examination of 109 adult employees in a hospital.

A rodenstock sight-screener has been used in examinations of more than 20 000 employees in trade and industry by an organisation sponsored by Danish optical companies. In a following report it was stated, that a great deal of these people, because of reduced sight-function, would benefit from further examination by optician or ophthalmologist with prescription of glasses. On that background we undertook an examination of 109 adults working in our hospital. First they were tested with the Rodenstock sight-screener and afterwards they underwent orthoptic and clinical ophthalmological examinations in a blind design. The sight-screening included examination of vision for near and far, stereopsis, phoria, dark adaption and visual fields. We found some difference between our results and those published earlier. Furthermore we found bad clinical accordance. In conclusion, many people will be worried by this kind of sight-screening procedure and only few will benefit from it.

Adolescent↗
PubMed1986

Facilitation of vergence changes by saccades: influences of misfocused images and of disparity stimuli in man.

When confronted with randomly presented targets demanding change in mean visual direction (version of 4.5-7 deg) as well as a change in vergence (1.5-2.5 deg) both naive and experienced subjects can make short-latency saccades which differ markedly and appropriately in the excursion of the two eyes, and which thereby achieve a large fraction of the required change in vergence. Mean values for the portion of vergence change occurring during the saccades, over all target positions, ranged from 41 to 70% for the five subjects tested, but subject-specific directional biases in performance were also conspicuous. When such targets were presented randomly during monocular viewing, so that only accommodation cues could induce vergence change, a consistent fraction (13-48%) of the resulting vergence movement also occurred during the saccades. These data indicate that on average about one-quarter of the intra-saccadic vergence change achieved during binocular viewing could have been due to accommodation stimuli perceived by one eye. The monocular results indicate that the direction of image misfocus (nearer vs. farther), which guides accommodation-vergence, can be correctly distinguished for targets which are about 6 deg from the centre of the fovea, and that this assessment can be made within the 200-300 ms latency for saccadic eye movements, and hence without trial-and-error refocusing. The binocular inequality of saccades during monocular viewing involved conspicuous subject-specific right-left asymmetries, as well as consistently positive within-subject correlations between intra-saccadic vergence change and finally realized accommodation-vergence movement, and consistent correlations between phoria before the saccade and intra-saccadic vergence change.

Accommodation, Ocular↗
PubMed1994

Ophthalmic findings in dyslexic schoolchildren.

The ophthalmic findings of 55 dyslexic 12 to 13-year-old Finnish schoolchildren and 50 age, sex, and social class-matched control children were evaluated. On a neuropsychological basis the children could be divided into six subgroups: general deficiency, general language, visuomotor, naming, mixed, and normal. The two groups did not differ significantly from each other in visual acuity, cycloplegic refraction, the amount of phorias and tropias, stereo acuity, fusion, or accommodation. Convergence near point > or = 8 cm was, however, statistically more frequent in the dyslexic group. This finding was also significant in the general deficiency subgroup compared with the other subgroups. The most conspicuous common denominator in those with dyslexia was revealed to be the convergence insufficiency type of exodeviation, occurring in 38% of the general deficiency dyslexic subgroup and in 36% of the visuomotor dyslexic subgroup. This finding suggests a low accommodative convergence/accommodation ratio in these children.

Accommodation, Ocular↗
PubMed1988

[Sources of error in the performance of the R5 test].

A prospective study examining 48 children (age 3.5-7 years) without any ophthalmological symptoms was comparatively performed using the Rodenstock R5 screening test and free examination of visual acuity, phoria and stereopsis. Besides this retinoscopy, interpupillary distance and inclination to instrument accommodation were determined. Using stereopsis targets 121 and 122, the findings of Marquardt (3- to 4-year-old children incline to prefer certain figures, leading to wrong results) can be confirmed. If the actual interpupillary distance is apart from the instrument eyepiece distance, especially if the child's distance is smaller, esophoria can be simulated. Instrument myopia on the one hand may appear as decrease of visual acuity, on the other hand it can be misinterpreted as esophoria. Being aware of these possible errors, the rate of wrong results (mean 22%) can be reduced, leading to better agreement between both methods.

Accommodation, Ocular↗
PubMed2006

Effects of orthoptic treatment on the CA/C and AC/A ratios in convergence insufficiency.

PURPOSE: To evaluate the effect of orthoptic treatment on the AC/A (A, accommodation; C, convergence) and CA/C ratios in subjects with convergence insufficiency (CI). METHODS: The change in AC/A and CA/C ratios after a 12-week period of home-based orthoptic treatment was examined in 10 subjects (mean age, 25.4+/-4.1 years [SD]). Both the AC/A and CA/C ratios were measured by using gradient response methods. For the AC/A ratio, the gradient phoria method was used, and for the CA/C ratio the prism-induced change in accommodation was measured with a refractometer. RESULTS: No change in the AC/A and CA/C ratios (P>0.05) were found after orthoptic treatment. However, improvements were found (P<0.05) in the fast and slow vergence mechanisms. CONCLUSIONS: Despite improvements in the fast and slow vergence mechanisms no change was found in the AC/A and CA/C ratios after orthoptic treatment in CI subjects. This finding is unexpected in light of the present understanding of CI, and an alternative theory is proposed.

Accommodation, Ocular↗