Bill B. Rainey

Inter-examiner repeatability of heterophoria tests.

Relatively few studies have reported on the repeatability of heterophoria (phoria) measurement procedures. The purpose of this study was to assess the inter-examiner repeatability of seven clinical tests of phoria measurement, using correlational and mean difference analyses. Two experienced optometrists performed each of the 7 phoria tests on 72 healthy adult subjects. Subjects ranged in age from 22 to 40 years, had visual acuity correctable to 20/20 in each eye, had no strabismus or amblyopia, and had normal eye health. The seven phoria tests used were: (1) the estimated cover test, (2) the prism-neutralized objective cover test, (3) the prism-neutralized cover test with subjective reporting of target movement, (4) the von Graefe phorometry with continuous target presentation, (5) the von Graefe phorometry with flashed target presentation, (6) the Thorington method, and (7) the modified Thorington method. All tests were performed in the same way by both examiners in random sequence, using standard clinical procedures. Inter-examiner correlations were determined for each test, as well as the mean and standard deviation of the differences between each examiner measurement (in prism diopters) on each subject. The modified Thorington method had the smallest mean difference and standard deviation of all tests and, thus, may be considered the most repeatable. This test also had the highest inter-examiner correlation. The prism-neutralized cover test with subjective reporting of target movement had the second highest correlation and the second lowest 95% limits of agreement, but had the largest mean difference of all tests, von Graefe phorometry methods were the least repeatable of the phoria tests.

Reliability of and comparisons among methods of measuring dissociated phoria.

Many methods of heterophoria measurement are available clinically. This paper reviews several studies which have examined the reliability of phoria measurements, and have compared various tests of phoria measurement. Different methods of data analysis make comparison of studies difficult. Two studies indicated 95% limits of agreement of 2 to 4 delta for reliability of modified Thorington, von Graefe, and Maddox rod phoria tests. Studies using correlational analysis to compare different measurement methods have found a high degree of association of the results of these methods. Studies using statistical methods assessing the agreement of test results found a high level of agreement among some tests and a low level of agreement among some tests. Some of the various phoria measurement methods differ in the technique used for dissociation, in the ability to control accommodation adequately, in the level of proximal convergence induced, or in the method by which the phoria is quantified. These differences can result in different phoria measurements on the same patient.

Sensory, Cognitive, and Linguistic Factors in the Early Academic Performance of Elementary School Children The Benton-IU Project

Standardized sensory, perceptual, linguistic, intellectual, and cognitive tests were administered to 470 children, approximately 96% of the students entering the first grade in the four elementary schools of Benton County, Indiana, over a 3-year period (1995-1997). The results of 36 tests and subtests administered to entering first graders were well described by a 4-factor solution. These factors and the tests that loaded most heavily on them were reading-related skills (phonological awareness, letter and word identification); visual cognition (visual perceptual abilities, spatial perception, visual memory); verbal cognition (language development, vocabulary, verbal concepts); and speech processing (the ability to understand speech under difficult listening conditions). A cluster analysis identified 9 groups of children, each with a different profile of scores on the 4 factors. Within these groups, the proportion of students with unsatisfactory reading achievement in the first 2 years of elementary school (as reflected in teacher-assigned grades) varied from 3% to 40%. The profiles of factor scores demonstrated the primary influence of the reading-related skills factor on reading achievement and also on other areas of academic performance. The second strongest predictor of reading and mathematics grades was the visual cognition factor, followed by the verbal cognition factor. The speech processing factor was the weakest predictor of academic achievement, accounting for less than 1% of the variance in reading achievement. This project was a collaborative effort of the Benton Community School Corporation and a multidisciplinary group of investigators from Indiana University.

Relationship of accommodative response and nearpoint phoria in a sample of myopic children.

Esophoria has been associated with onset and progression of myopia in children. The induction of myopia by optical defocus shown by animal models suggests that a high lag of accommodation during near work may contribute to myopia in children. This paper examines the relationship of nearpoint phoria and accommodative response in a sample of children with myopia. Accommodative response was measured under binocular conditions with the Canon Autoref R-1 autorefractor with a 40 cm viewing distance. Phorias were measured with the von Graefe method using a 40 cm test distance. In the statistical analysis exophoria was scored as a negative number and esophoria was scored as a positive number. The coefficient of correlation of accommodative response with phoria was -0.32 (n = 73; p<0.01), thus showing an association of a more positive (more convergent) near phoria with lower accommodative response. The correlation coefficient increased to -0.39 when an exponential function was used. When only esophores were considered, the correlation coefficient was -0.59 (n = 44; p<0.001). Lower accommodative response (higher lag of accommodation) was associated with greater esophoria.

Reliability of and comparisons among three variations of the alternating cover test.

One of the most commonly used methods for measuring heterophoria is the alternating cover test. Differences in specific procedures and observational criteria used by examiners may result in different measurements of heterophoria on the same patient. This study evaluated the inter‐examiner reliability of three different cover test techniques: the estimated cover test, the prism neutralized objective cover test, and the prism neutralized subjective cover test. Two examiners performed each technique on each of 72 subjects. Reliability was assessed using correlational methods and mean difference calculations. Although there were some inter‐examiner differences for the different techniques, all of these differences were within previously determined minimum detectable eye movement ranges. Therefore, when used by experienced clinicians, each of these techniques appears to be a reliable method of heterophoria determination, and their results are comparable.

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.

The effect of prism adaptation on the response AC/A ratio

Vergence adaptation, also known as prism adaptation, is a phenomenon in which a patients heterophoria changes after prolonged viewing through prism. The effect of prism adaptation on the accommodation–convergence relationship, quantified by the AC/A ratio, is not known. Previous studies of AC/A ratio stability and alterability have used only stimulus AC/A ratio calculations, or have measured accommodative responses to only one or two stimuli. The ideal study of AC/A ratio stability and alterability would measure accommodative responses to several accommodative stimuli, and use these along with vergence responses to calculate response AC/A ratios, rather than stimulus AC/A ratios. In addition, the gradient method should be used to avoid any effect of proximal vergence resulting from changes in target distance. This paper describes a project which investigated the effect of vergence (prism) adaptation on the gradient response AC/A ratio, using accommodative responses measured for five different accommodative stimuli. The response AC/A ratio did not significantly change following a period of adaptation to base‐in prism for six of the eight subjects in this study. In addition, the response AC/A ratio did not significantly change following a period of adaptation to base‐out prism for six of the eight subjects.