Anna M. Horwood

The use of cues to convergence and accommodation in naïve, uninstructed participants

A remote haploscopic video refractor was used to assess vergence and accommodation responses in a group of 32 emmetropic, orthophoric, symptom free, young adults naïve to vision experiments in a minimally instructed setting. Picture targets were presented at four positions between 2 m and 33 cm. Blur, disparity and looming cues were presented in combination or separately to asses their contributions to the total near response in a within-subjects design. Response gain for both vergence and accommodation reduced markedly whenever disparity was excluded, with much smaller effects when blur and proximity were excluded. Despite the clinical homogeneity of the participant group there were also some individual differences.

Development of the response AC/A ratio over the first year of life.

This study investigated the development of the link from accommodation to vergence in infants by occluding one eye thus removing binocular cues. Occluded adults continue to converge partially demonstrating that the accommodative drive to vergence (the AC/A link) and proximal cues are sufficient to drive vergence. For infants of all ages, AC/A ratios were found to be in the normal adult range. We conclude that infants can use monocular cues to drive vergence and that this occurs before the age when there is a substantial increase in the accuracy of oculomotor processes. There is flexibility in the developing visual system which is able to produce early vergence responses by relying upon alternative cues.

Variations in accommodation and convergence responses in a minimally controlled photorefractive setting.

Purpose A remote haploscopic photorefractor, designed for assessment of accommodation and convergence in infants and clinical groups, was used to determine heterophoria accommodative convergence/accommodation (AC/A) ratios in normal naïve adults. These were compared with conventional clinical measures. Methods Twenty-one naïve subjects were used to compare occluded and unoccluded prism cover test responses with the remote haploscopic photorefractor using a text and picture target. Results Although luminance was generally low for both targets, binocular vergences were appropriate for target demand in both studies. Binocular accommodation showed greater lag for the highest target accommodative demand and the less demanding target. Occlusion not only reduced vergence response, but also frequently caused a marked reduction in accommodation, especially to the picture target. Normal mean AC/A values were found, but with wide variations between individual subjects. Conclusions Although mean accommodation, vergence, and AC/A values were comparable with published data, we suggest that in these conditions using naïve subjects, accommodation is frequently inaccurate, especially on occlusion, without concomitant loss of vergence, at least at low light levels. Accommodative convergence may play a less important part in, and other cues contribute more to, the near reflex than has been previously suggested.

Compliance with first time spectacle wear in children under eight years of age.

An anonymous prospective survey was carried out of children under 8 years of age prescribed a first pair of spectacles from the Royal Berkshire Hospital between August 1995 and May 1996, focusing on compliance in relation to refractive error, visual status and social factors. One hundred and thirty-three children were surveyed. Mean compliance was high (79.5/100) and spectacles were well liked by most children. Improvement in vision had little or no relationship with compliance. Significant factors were fit and what friends said about the spectacles. Adverse comments were rare, especially in the younger children, but increased with age. In pre-school children spectacles did not appear to be the salient feature in negative social judgements that has been found to occur in adults.

Evidence that convergence rather than accommodation controls intermittent distance exotropia

Purpose:  This study considered whether vergence drives accommodation or accommodation drives vergence during the control of distance exotropia for near fixation. High accommodative convergence to accommodation (AC/A) ratios are often used to explain this control, but the role of convergence to drive accommodation (the CA/C relationship) is rarely considered. Atypical CA/C characteristics could equally, or better, explain common clinical findings.

Differences between naïve and expert observers’ vergence and accommodative responses to a range of targets

Purpose:  Vergence and accommodation studies often use adult participants with experience of vision science. Reports of infant and clinical responses are generally more variable and of lower gain, with the implication that differences lie in immaturity or sub‐optimal clinical characteristics but expert/naïve differences are rarely considered or quantified.

Hypo-accommodation Responses in Hypermetropic Infants and Children

Aims Accommodation to overcome hypermetropia is implicated in emmetropisation. This study recorded accommodation responses in a wide range of emmetropising infants and older children with clinically significant hypermetropia to assess common characteristics and differences. Methods A PlusoptiXSO4 photorefractor in a laboratory setting was used to collect binocular accommodation data from participants viewing a detailed picture target moving between 33 cm and 2 m. 38 typically developing infants were studied between 6 and 26 weeks of age and were compared with cross-sectional data from children 5–9 y of age with clinically significant hypermetropia (n=15), corrected fully accommodative strabismus (n=14) and 27 age-matched controls. Results Hypermetropes of all ages under-accommodated compared to controls at all distances, whether corrected or not (p<0.00001) and lag related to manifest refraction. Emmetropising infants under-accommodated most in the distance, while the hypermetropic patient groups under-accommodated most for near. Conclusions Better accommodation for near than distance is demonstrated in those hypermetropic children who go on to emmetropise. This supports the approach of avoiding refractive correction in such children. In contrast, hypermetropic children referred for treatment for reduced distance visual acuity are not likely to habitually accommodate to overcome residual hypermetropia left by an under-correction.

Screening for convergence insufficiency using the CISS is not indicated in young adults

Aim This paper presents Convergence Insufficiency Symptom Survey (CISS) and orthoptic findings in a sample of typical young adults who considered themselves to have normal eyesight apart from weak spectacles. Methods The CISS questionnaire was administered, followed by a full orthoptic evaluation, to 167 university undergraduate and postgraduate students during the recruitment phase of another study. The primary criterion for recruitment to this study was that participants ‘felt they had normal eyesight’. A CISS score of ≥21 was used to define ‘significant’ symptoms, and convergence insufficiency (CI) was defined as convergence ≥8 cm from the nose with a fusion range <15Δ base-out with small or no exophoria. Results The group mean CISS score was 15.4. In all, 17 (10%) of the participants were diagnosed with CI, but 11 (65%) of these did not have significant symptoms. 41 (25%) participants returned a ‘high’ CISS score of ≥21 but only 6 (15%) of these had genuine CI. Sensitivity of the CISS to detect CI in this asymptomatic sample was 38%; specificity 77%; positive predictive value 15%; and negative predictive value 92%. The area under a receiver operating characteristic curve was 0.596 (95% CI 0.46 to 0.73). Conclusions ‘Visual symptoms’ are common in young adults, but often not related to any clinical defect, while true CI may be asymptomatic. This study suggests that screening for CI is not indicated.

Developmental Changes in the Balance of Disparity, Blur, and Looming/Proximity Cues to Drive Ocular Alignment and Focus

Accurate coordination of accommodation and convergence is necessary to view near objects and develop fine motor coordination. We used a remote haploscopic videorefraction paradigm to measure longitudinal changes in simultaneous ocular accommodation and vergence to targets at different depths, and to all combinations of blur, binocular disparity, and change-in-size (‘proximity’) cues. Infants were followed longitudinally and compared with older children and young adults, with the prediction that sensitivity to different cues would change during development. Mean infant responses to the most naturalistic condition were similar to those of adults from 6–7 weeks (accommodation) and 8–9 weeks (vergence). Proximity cues influenced responses most in infants of less than 14 weeks of age, but sensitivity declined thereafter. Between 12 and 28 weeks of age infants were equally responsive to all three cues, while in older children and adults manipulation of disparity resulted in the greatest changes in response. Despite rapid development of visual acuity (thus increasing availability of blur cues), responses to blur were stable throughout development. Our results suggest that, during much of infancy, vergence and accommodation responses are not dependent on the development of specific depth cues, but make use of any cues available to drive appropriate changes in response.

A Novel Experimental Method for Measuring Vergence and Accommodation Responses to the Main Near Visual Cues in Typical and Atypical Groups

Binocular disparity, blur, and proximal cues drive convergence and accommodation. Disparity is considered to be the main vergence cue and blur the main accommodation cue. We have developed a remote haploscopic photorefractor to measure simultaneous vergence and accommodation objectively in a wide range of participants of all ages while fixating targets at between 0.3 and 2 m. By separating the three main near cues, we can explore their relative weighting in three-, two-, one-, and zero-cue conditions. Disparity can be manipulated by remote occlusion; blur cues manipulated by using either a Gabor patch or a detailed picture target; looming cues by either scaling or not scaling target size with distance. In normal orthophoric, emmetropic, symptom-free, naive visually mature participants, disparity was by far the most significant cue to both vergence and accommodation. Accommodation responses dropped dramatically if disparity was not available. Blur only had a clinically significant effect when disparity was absent. Proximity had very little effect. There was considerable interparticipant variation. We predict that relative weighting of near cue use is likely to vary between clinical groups and present some individual cases as examples. We are using this naturalistic tool to research strabismus, vergence and accommodation development, and emmetropization.