Patricia M. Riddell

Developing visual systems and exposure to virtual reality and stereo displays: some concerns and speculations about the demands on accommodation and vergence

Little is known about the developmental plasticity of the vergence and accommodative systems, an important issue since abnormalities can lead to visual problems, e.g. strabismus. One way of artificially altering the links between accommodation and vergence is to vary the stimulus to vergence while fixing the accommodative stimulus, as is found in virtual reality displays. While it would be of interest to study developmental plasticity in this situation, since many children are exposed to games machines which use this arrangement, no studies to date have tackled this issue. There is, however, some indication that long-term VR viewing in adults can lead to visual problems. It seems important to determine the safety of these systems for the developing human visual system before they come into common use. In this paper, adaptation of the accommodation and vergence systems and the effect of VR viewing in adults is discussed. The sparse literature on adaptation in children is then reviewed, and suggestions made for approaches that would enhance our knowledge of plasticity of accommodation and vergence in children.

Development of accommodation and convergence in infancy

Paraxial photorefraction was used to assess the development of accommodation and convergence in a large sample of infants under 1 year of age. The infants viewed small dolls placed at various distances (200-25 cm). The majority of infants at all ages demonstrated appropriate convergence for target distance, regardless of manifest refractive error. However, accommodation lagged behind convergence in development. Infants under 2 months tended to demonstrate either flat accommodation responses with a fixed plane of focus at around 30 cm, or accommodated appropriately for near targets, but failed to relax their accommodation sufficiently for the more distant targets. Thus, the focussing error increased with increasing target distance. Since the manifest refractive error was estimated by extrapolating the accommodation function to 0 diopters demand, these infants demonstrated spuriously myopic behavior. After 2 months, the majority of infants showing emmetropic behavior had accommodation responses that changed appropriately with target distance. However, infants with myopic or hyperopic manifest refractive errors displayed a variety of accommodative styles.

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.

Comparison of Measures of Visual Acuity in Infants: Teller Acuity Cards and Sweep Visual Evoked Potentials

Purpose: This study compares the development of acuity in the same infants during one testing session using Teller acuity cards (TAC) and sweep visual evoked potentials (sVEP). We asked whether different testing methods in two centers would produce different developmental time courses. Methods: Forty-eight infants were tested in two centers. The standard procedure for TAC was used. For sVEP acuity, the amplitude response curve derived from time-locked cortical activity was used to extrapolate to zero response, giving an acuity estimate for each infant. Results: sVJEP acuity was generally higher than TAC acuity. The rate of development was steeper for TAC than sVEP acuity with TAC starting at a much lower level. The ratio of sVEP to TAC acuity decreased exponentially with age reaching an asymptote of about 1.44 at 6 months. Conclusions: Results were indistinguishable between centers suggesting that comparison of acuity measures obtained using variations of these methods across centers is possible.

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.

Variability of the accommodation response in early onset myopia

Purpose. Hyperopic retinal defocus (blur) is thought to be a cause of myopia. If the retinal image of an object is not clearly focused, the resulting blur is thought to cause the continuing lengthening of the eyeball during development causing a permanent refractive error. Both lag of accommodation, especially for near targets, and greater variability in the accommodative response, have been suggested as causes of increased hyperopic retinal blur. Previous studies of lag of accommodation show variable findings. In comparison, greater variability in the accommodative response has been demonstrated in adults with late onset myopia but has not been tested in children. This study looked at the lag and variability of accommodation in children with early onset myopia. Methods. Twenty-one myopic and 18 emmetropic children were tested. Dynamic measures of accommodation and pupil size were made using eccentric photorefraction (PowerRefractor) while children viewed targets set at three different accommodative demands (0.25, 2, and 4 D). Results. We found no difference in accommodative lag between groups. However, the accommodative response was more variable in the myopes than emmetropes when viewing both the near (4 D) and far (0.25 D) targets. Since pupil size and variability also varied, we analyzed the data to determine whether this could account for the inter-group differences in accommodation variability. Variation in these factors was not found to be sufficient to explain these differences. Changes in the accommodative response variability with target distance were similar to patterns reported previously in adult emmetropes and late onset myopes. Conclusions. Children with early onset myopia demonstrate greater accommodative variability than emmetropic children, and have similar patterns of response to adult late onset myopes. This increased variability could result in an increase in retinal blur for both near and far targets. The role of accommodative variability in the etiology of myopia is discussed.

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.

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.