O

ur ability to focus
easily with both eyes is
essential to our viewing
comfort in the modern
computerised workplace.
The synkinesis between
accommodation and convergence is
what affords us this advantage, enabling
stable and clear binocular vision (BV)
across a range of fixation distances. In
combination with pupil miosis, these
functions play an influential role in
our close range in a relationship better
known as the near triad.
Convergence is defined as the
inward rotation of both eyes to
retain binocular single vision for near
viewing. Aside from the cover test
(CT), it is one of the most well known
BV tests, providing a swift indication
of the capacity for binocular function
and its relative strength. It should be
tested routinely in children, adults with
moderate to large exophoria, or any
symptomatic individuals to screen for
convergence insufficiency. Our ability
to converge begins as early as one month
of age, improving in accuracy with
time thereafter. It is assessed practically
by evaluating pursuit convergence to
measure the near point of convergence
(NPC).
Accommodation anatomically
refers to the increase in convexity of
the crystalline lens that enables our
eyes to focus clearly on a near target.
The system becomes fully active by
six months with slow adjustments
limited to a short range of 20-75cm in
the first 8-12 weeks. Peak amplitude
can be measured at the age of 10
years, receding thereafter to a clinically
insignificant level at 55 years,
accompanied by the compensatory
need for reading spectacles. Anomalies
of accommodative function have
been associated with a wide variety of
conditions from metabolic disorders
to developmental anomalies such as
Downs syndrome and cerebral palsy.
Testing is recommended routinely
in children and any symptomatic
In the last in our series on binocular vision assessment and management, Priya Dabasia looks at
near vision. Module C16784, two general CET points for optometrists and DOs
pre-presbyopic patients where a
deficiency is suspected.
This article aims to detail the practical
procedures and results interpretation,
followed by a brief synopsis of
anomalies of both functions commonly
encountered in practice.
Convergence
The near point of convergence is
measured using an accommodative
target readily resolved by each eye
that also enables blur to be easily
distinguished from diplopia, such as
the line target of the near budgie stick
or Mallett unit. Most practitioners,
however, prefer to use the Royal Air
Force (RAF) rule as it incorporates
a centimetre scale as well as cheek
pads for comfortable and accurate
measurement (Figure 1). For younger
children, a medium-sized coloured
picture such as the budgie target on
the near stick will suffice, or simply
ask them to try to cross their eyes to
demonstrate voluntary convergence.
The use of a pen-tip is discouraged as
it fails to stimulate accommodation
sufficiently and confuses the perception
of diplopia and blur.
The practitioner should be seated
directly in front of the patient to
view both eyes simultaneously, using
additional light to illuminate both
the fixation target and the patients
eyes, angled to avoid shadows. Place
the resting pads of the rule carefully
against the patients cheeks depressed
at the natural reading position, and
ask the patient to stabilise the rest with
their hands for added safety during
testing. For this test, ensure the patient
is wearing any near correction for
accurate fixation.
1) Rotate the carrier of the RAF rule so
that the patient views the central black
circle with a bisecting vertical line,
approximately 30cm from the patients
eyes.
2) Direct the patient to fixate on
the central black circle and confirm
that the target is perceived clear and
single. If the vertical line is perceived
as double, you may have to begin at a
further distance of 50cm. Warn older
patients that they may experience blur
before doubling given that the NPC is
closer to the eyes than the near point of
accommodation.
3) Move the carrier towards the
patients eyes in a slow and steady
motion, observing carefully for any
outward movement or pupil dilation
on failure of convergence. The author
recommends fixating on the bridge of
the patients nose so that peripheral
vision is used to gauge any subtle
Figure 1a Setting up the RAF rule Figure 1b RAF rule NPC fixation target
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Binocular vision
Part 6 Convergence and accommodation
movements of either eye. Remind the
patient periodically to fixate on the
dot and report when the vertical line
appears to jump or become double.
4) When you observe that one eye
deviates and/or the patient responses
indicate failure of convergence at the
break point, stop moving the carrier
and encourage the patient to make an
effort to rejoin the images into a single
percept, noting the ease at which this
is achieved. You may need to move
the carrier away from the patient for
this to occur recording this distance as
the recovery point. If your objective
measurement does not correspond
with the subjective responses, the
patient may be confusing blur with
diplopia, verified by occluding one eye.
Suppression is likely particularly in
longstanding anomalies if:
The patient reports a jump in the
vertical line image to one side
The patient fails to report diplopia
when you observe divergence of one
eye.
5) Repeat the test 2-3 times to assess
whether the NPC recedes with fatigue,
detailing the patients record with the
following:
Break point (subjective and
objective if different) specifying
the eye that diverged as it indicates
the non-dominant eye. Alternating
fixation is therefore indicative of
strong binocular function
Recovery point not required if
convergence was maintained with
ease to the nose
Any appreciation of diplopia at the
break point
Any suppression making note of
the affected eye
Any reduction with fatigue or
excessive effort in maintaining
convergence.
An example of a typical recording
is NPC 12cm, rec 15cm, R diverges
c Dp.
A deficient result can be investigated
further by assessing the voluntary
control of divergence as the patient is
asked to maintain fixation from the
near point back to 30cm from the eyes.
This can be followed with evaluation
of jump convergence in which the
patient is asked to perform repeated
changes in fixation between a near
and more distant target. An inability or
difficulty in conducting either task can
be associated with asthenopic symptoms
or a generally poor convergence
facility.
Accommodation
Amplitude is the most common facet
of the accommodative system to be
evaluated in daily practice. It refers
to the closest point at which the eyes
can focus, clinically measured by the
dioptric difference between the points
where accommodation is fully relaxed
and exerted. The RAF rule provides a
useful tool for this subjective assessment
as it incorporates a dioptric and age scale
for easier recording and interpretation,
while also enabling rapid collation of
data with the NPC.
The practitioner-patient set-up, rule
positioning and lighting is arranged as
per the NPC test, but with the patient
wearing their distance correction
placed in a trial frame to facilitate easier
occlusion of each eye on monocular
testing.
1) Rotate the carrier of the RAF rule
so that the patient views the N series
target (Figure 2) at a distance of
approximately 40cm.
2) Occlude the left eye.
3) Direct the patient to fixate on the
smallest line discernible. A partial
positive spherical addition (eg 1.00DS)
may be required for older presbyopes
between 45 and 55 years to ensure
they can perceive the target at the end
of the rule. On the other end of the
scale, using a -3.00DS lens before each
eye in younger children permits more
sensitive assessment as even a slight
movement along the rule in this higher
range corresponds to a significantly
large dioptric change.
4) Advance the carrier in a smooth,
steady motion towards the patients
eyes asking them to report when the
letters first blur; this is an important
distinction from when the line can
no longer be read. Make note of the
accompanied pupil miosis as the near
reflex is elicited. Bring the target to
a halt and encourage the patient to
refocus their eyes in an attempt to
regain clarity. If achieved, continue the
movement up the rule until sustained
blur is reported. At this point, make a
mental note of the dioptric power on
the left-hand edge of the rule as this
represents the push-up amplitude.
5) Position the carrier approximately
0.50 dioptres beyond the sustained
blur point to re-check that defocus
progressively worsens. Now gradually
pull the target away asking the
patient to report when the N target is
perceived clearly. The dioptric power at
this position indicates the push-down
amplitude.
6) Record the amplitude as the average
of the push-up and push-down
measures. Using a combination of the
two readings allows for overestimation
and underestimation errors inherent to
the push-up and push-down techniques
respectively. Ensure the final recording
is adjusted for any supplementary
lenses used by subtracting for positive
and adding for negative lenses.
7) Swap the occluder before the right
eye and repeat steps 4 to 6.
8) Remove the occluder and repeat
steps 4 to 6 with both eyes viewing,
directing the patient to the smallest
print discernible by the weaker eye.
9) Some practitioners routinely repeat
steps 4-6 a further two times to evaluate
whether the near point recedes with
fatigue.
In the absence of an RAF rule, the
amplitude can be determined from the
reciprocal of the near point distance
in metres, measured using either the
integral measuring tape of the Mallet
unit or any suitable alternative. Then
use the Duane-Hofstetter formulae
detailed in Table 1 to evaluate whether
the value is expected for the average
age-matched population. In general, a
difference under 1.5 dioptres between
the eyes and from the expected
age-matched result is not deemed
clinically significant, but it is prudent to
re-check and confirm any asymmetry,
annotating the records accordingly. The
binocular measurement is usually 1-2
dioptres greater than that with each
eye attributed to the stimulation of
convergence accommodation.
AC/A ratio
Any change in accommodation is
usually accompanied by a corresponding
alteration in vergence, otherwise known
as accommodative convergence. It is
measured clinically as the amount of
accommodative convergence induced
for each dioptre of accommodation
exerted, abbreviated to the AC/A
ratio. This measure is believed to be
Figure 2 RAF rule target to measure amplitude of
accommodation
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genetically predetermined, remaining
fairly constant throughout life until
the onset of presbyopia. The ratio
provides useful information for the
diagnosis of various BV anomalies
such as determining the true form of
intermittent distance exotropia or any
deviation that differs significantly
between near and distance fixation.
It can also be an influential factor in
considering management options for
near esophoria with accommodative
aetiology.
Practically, it is evaluated by changing
the stimulus to accommodation
by varying the fixation distance
(heterophoria method) or using
spherical lenses (gradient method),
and measuring the accommodative
convergence resulting from each
change. The latter is preferred for
accuracy as it prevents the influence
of tonic and proximal accommodation
generating a falsely high reading.
The full procedure for the gradient
method involves measuring the
heterophoria amplitude through
3.00DS lenses in 1DS steps. The results
are used to plot a graph of lens power
against heterophoria, extrapolating
the AC/A ratio as the gradient of
the best-fit line. This is simplified for
practice as follows:
1) Direct the patient to a detailed
distance target at 6 metres with the
patient wearing their full refractive
correction to relax accommodation.
2) Measure the heterophoria amplitude
in dioptres, ideally using the prism
cover test (PCT) for precision see
Part 1 of this series for full procedure
(Optician 24.09.10).
3) Add -3.00DS before each eye to
induce accommodation and repeat the
PCT at 6 metres.
4) Calculate the AC/A ratio as the
dioptric difference between the
measurement in steps 2 and 3 divided
by 3.00DS, in which negative numbers
are used for eso deviations and vice
versa.
Alternatively steps 2-4 can be
performed at near fixation (1/3 metre),
using +3.00DS spheres to relax the
accommodative effort. However,
given the time pressures of high street
practice, the heterophoria method is
most popular as it makes use of data
already collected during the course of
a standard eye examination:
1) Direct the patient to a detailed target
at 6 metres wearing their full distance
correction to relax accommodation.
2) Measure the heterophoria ideally
using the PCT recording exo and
eso deviations as negative and positive
values accordingly.
3) Repeat the heterophoria assessment
for near fixation at 1/3 metre.
4) Measure the pupillary distance (PD)
in centimetres using a City Rule or
suitable alternative to allow for the
inward rotation of the eyes at near in
the calculation.
5) Calculate the AC/A ratio using =
PD + (near heterophoria distance
heterophoria) 3DS (accommodation
stimulated at 1/3 metre).
Historically, a normal AC/A ratio
ranges from 3-5:1 so that the patient
converges by 3-5 prism dioptres for
every dioptre sphere of accommodation
exerted. An excessively high reading
typically over 6:1 can therefore result in
near esophoria or even esotropia, while
an abnormally low measure usually
accompanies near exo deviations.
Alternative measures of
accommodative function
When the amplitude of accommodation
is found to be sub-normal, it may
be useful to test other aspects of
accommodative function such as
accommodative lag/lead and facility.
Accommodative lag and lead are
defined as the undershooting and
overshooting of focus to a near target
respectively, measured objectively
using dynamic retinoscopy. This makes
it a particularly useful tool for assessing
accommodative function in very young
patients or those unable to cooperate.
The monocular estimation method
(MEM) is the most widely recognised
technique used for this purpose:
1) Ensure the patient is wearing their
TABLE 1
Table of expected monocular amplitudes of accommodation (Donders) with
Duane-Hoffstetter Formula
Age (years) (Donders) Monocular expected ampli-
tude of accommodation (dioptres)
10 14
15 12
20 10
25 8.5
30 7
35 5.5
40 4.5
45 3.5
50 2.5
55 1.75
Duane-Hoffstetter formula for
probable amplitude of accommodation
(dioptres)
Average amplitude = 18.5
(0.30 x age in years)
Figure 3 MEM card with retinoscope in dynamic retinoscopy
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distance correction.
2) Attach a MEM card to the retinoscope
detailed with letters and/or pictures
arranged around a central aperture, or
alternatively position a budgie stick
to the front of the instrument. Use
additional lighting to illuminate the
target as necessary (Figure 3).
3) Perform retinoscopy on the right
eye at the patients habitual reading
distance, adding spherical lenses to
attain the neutral point. Interpretations
of the reflex must be quick as the
lens can only be held before the
eye for approximately 0.5 seconds
to avoid disrupting binocularity.
Ensure accommodation is maximally
stimulated by asking young children
to read letters or describe details of the
near target. A positive lens represents a
lag of accommodation, while a negative
lens is indicative of a lead.
4) Repeat Step 3 for the left eye.
Notts technique is a variation of
MEM whereby the retinoscope position
is moved relative to the patient as they
fixate on a target held at their reading
distance. The final result is recorded
as the dioptric difference between the
near fixation distance and the position
of the retinoscope at the neutral point.
A neutral point behind the fixation
target represents accommodative lag
and vice versa.
Our normal accommodative response
usually undershoots near targets by
approximately 0.50DS, attributed to
depth of focus. Accommodative lag
greater than or equal to 1DS is suggestive
of accommodative insufficiency or
infacility, while lead may be indicative
of an accommodative spasm.
Accommodative facility refers to
a patients ability to change focus,
measured practically as the rate of
change of accommodation. It is
evaluated at the patients near reading
distance using 2.00DS flipper lenses
comprised of two pairs of positive and
negative powered lenses mounted on a
horizontal bar. The patient is asked to
focus and achieve clear vision through
the +2.00DS lenses, then the -2.00DS
lenses, followed once again by the
positive lenses, collectively representing
one cycle. The practitioner is required
to count the number of cycles achieved
within 30 seconds monocularly and
then with both eyes viewing provided
that other BV tests have ruled out
suppression (Table 2 indicates the limit
of normal values).
Anomalies of convergence and
accommodation
In general, anomalies of accommodation
are relatively rare compared to simple
convergence insufficiency (CI) or
decompensating heterophoria, but
they can present in combination,
making it essential that we are armed
with the skills to diagnose and exercise
the most appropriate management.
Typical complaints include frontal
headaches, eyestrain with prolonged
Figure 4 Appreciation of physiological diplopia exercise
24.06.11 | Optician | 21
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TABLE 2
Summary of anomalies of convergence and accommodation
Convergence Anomaly type Definition Clinical features Treatment options
Insufficiency Inability to attain or
maintain adequate conver-
gence without undue effort
NPC more than 10cm, often
presenting with convergence
weakness exophoria
Identify and remove underlying
cause
Remedial exercises
Base-in prisms for temporary relief
Spasm Contraction of medial rectus
extraocular muscles
Usually presents with accom-
modative spasm
Issue cyclopegic refraction
Consider bifocal addition to inhibit
spasm with base in prisms
Paralysis Total loss of convergence
as both eyes cease fixation
simultaneously at near
Bilateral partial III oculomotor
nerve lesion with associated
pupil and accommodative
anomalies
Refer urgently for neurological
opinion
Accommodation Insufficiency Amplitude of accommoda-
tion consistently below that
expected for patients age
Usually bilateral and associ-
ated with convergence
insufficiency
Issue any significant hyperopia
Push-up accommodative exercises
Flipper lenses from 0.50DS to
3.00DS
Bifocal addition
Fatigue Poorly sustained accom-
modation over long periods
of near vision
Mild form of accommodative
insufficiency
Correct any significant hyperopia
Bifocal addition
Inertia Delay in exerting and relax-
ing accommodation
Slow change of focus exceed-
ing normal delay of 300ms
Correct any latent hyperopia
Consider base-in prism
Bifocal addition
Lag Undershooting of focus Dynamic retinoscopy of
+1.00DS lag or greater
See treatment options for
Accommodative Insufficiency
Infacility Diminished ability to change
focus with ease
Adult less than 11 cycles per
minute (monocular)/ 8 cycles
per minute (binocular)
Child: less than 5 cycles per
minute (monocular)/ 2.5 cycles
per minute (binocular)
i
Accommodative rock exercises with
flipper lenses, initially monocularly
and then binocularly
Spasm Excessive accommoda-
tion with ciliary muscle
contracted
Associated with pseudo-
myopia and pupil miosis
See treatment options
convergence spasm
Paralysis Complete lack of
accommodation
Complete III nerve paresis with
mydriasis and incomitancy
Urgent referral for neurological
evaluation
i
Elliott DB (2003) Clinical Procedures in Primary Eye Care (Third Edition), p 144, Butterworth-Heinemann
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near work, difficulty reading and/
or changing focus, and intermittent
diplopia when presenting with CI.
Their onset can often be attributed
to fatigue, poor health, systemic
medications with anti-muscarinic
effects (eg antihistamines) and
environmental factors such as poor
lighting, glare sources or an increase
in near working hours. For this reason,
the first line of treatment is to identify
and remove any underlying causes
and contributing factors, followed by
a regime of exercises and/or refractive
therapy as needed (see Table 2 for
summary of anomalies of convergence
and accommodation).
The normal value for convergence
varies in texts from 6cm to 10cm. CI
is defined as the inability to attain
or maintain adequate convergence
without undue effort. A poor result
necessitates further BV evaluation with
near and distance CT, measurement
of fusional reserves and fixation
disparity, as it frequently presents with
convergence weakness exophoria.
Both these anomalies respond well
to remedial exercises, with vast
improvements evident within a couple
of weeks, regardless of the patients age.
A typical treatment regime is described
as follows:
1) Begin by teaching an appreciation of
physiological diplopia using two targets
held along the median line against a
plain background while the patient
alters fixation to perceive the object
of interest single and clear, with the
target not fixated seen in physiological
diplopia (Figure 4).
2) Pen to nose most practitioners
prefer the use of an accommodative
target such as a small black letter/ spot
against a white background in lieu of
a pen tip, particularly if the primary
deficiency affects both convergence
and accommodative function. Begin
with the target 50cm from the eyes and
advise the patient to draw it closer in a
slow, steady motion until double vision
is experienced or an observer reports
that one eye has ceased to converge.
At this point encourage the patient
to keep their eyes focused and regain
clear single vision. If this cannot be
achieved, move the target slightly away
and repeat, resting between attempts.
This exercise should be undertaken for
5 minutes repeated 2-3 times daily.
3) Combine the pen to nose regime
with jump convergence exercises in
which the patient is required to make
a target at far distance clear and single,
and then switch fixation to a near
image, repeating the cycle as many
times as possible in a 10-minute period,
twice a day.
4) Dot cards can be used once the
convergence improves to within 24cm
of the eyes. The card displays a line of
dots on one side with letters on the
reverse to increase both convergence
and accommodative function. These
physiological diplopia exercises can
be supplemented further with CAT
stereograms designed to develop
positive fusional reserves when CI
presents with convergence weakness
exophoria (Figure 5).
The eventual goal of treatment is
to achieve voluntary convergence,
or at the least the ability to maintain
convergence on removal of a near
target with smooth divergence as it is
moved from the near point. Based on
patient circumstances, base-in prisms
may be prescribed for temporary relief
(eg students with imminent exams),
determined by the weakest power that
enables smooth convergence with no
slip on the near fixation disparity test.
In the treatment of accommodation
insufficiency, consider a temporary
reading addition one third of the
amplitude required for the patients
Figure 5 Dot
Card and CAT
Stereogram
Orthoptic
Exercise Cards
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MULTIPLE-CHOICE QUESTIONS take part at opticianonline.net
1
Which of the following statements regarding the development of
the near triad is TRUE?
A Accommodation becomes fully active at six months of age with slow
adjustments in the first 4-8 weeks of life
B Our ability to converge is present at birth
C Accommodation is maximal at approximately 10 years of age
D Convergence function peaks at 10 years of age receding with time
thereafter
2
Which of the following conditions is NOT routinely screened using
a Royal Air Force Rule?
A Convergence insufficiency
B Ciliary spasm
C Accommodative fatigue
D Decompensated heterophoria
3
Using the Duane Hoffstetter formula, what is the average
amplitude of accommodation expected for a patient of 12 years?
A 15.1 dioptres
B 14.9 dioptres
C 13.7 dioptres
D 15.8 dioptres
4
The final amplitude of accommodation is determined by which of
the following?
A Push-up amplitude at which the letter target can no longer be resolved
B Average of the push-up and push-down amplitudes
C Difference between the push-up and push-down amplitudes
D Push-down amplitude where the patient regains clear vision
5
What does the acronym MEM refer to in MEM retinoscopy?
A Monocular estimation method
B Mohindra estimation method
C Monocular evaluation method
D Mohindra evaluation method
6
What is the final recording for the monocular and binocular
amplitudes of accommodation of 11.5/ 12.5/ 13.0 measured
using -3.00DS lenses before each eye?
A 14.5/ 15.5/ 16.0
B 11.5/ 12.5/ 10.0
C 8.5/ 9.5/ 10.0
D 11.5/ 12.5/ 16.0
7
Which of the following statements is FALSE?

A Using the heterophoria method, the AC/A ratio is calculated using a
positive sign for exo deviations and negative sign for eso deviations
B An accommodative lag of 0.50DS 0.75DS is considered within normal
range
C An AC/A ratio of 5.5:1 is considered high in the normal population
D Notts dynamic retinoscopy technique requires movement of the
retinoscope relative to the patient
8
What is the normal monocular and binocular accommodative
facility for an 8-year-old child using 2.00DS flipper lenses?
A 11 cycles per minute (monocular)/ 8 cycles per minute (binocular)
B 2.5 cycles per minute (monocular)/ 5 cycles per minute (binocular)
C 8 cycles per minute (monocular)/ 11 cycles per minute (binocular)
D 5 cycles per minute (monocular)/ 2.5 cycles per minute (binocular)
9
Which of the following is TRUE regarding the use of the gradient
method to measure AC/A ratio?
A The stimulus to accommodate is provided by a change in fixation
distance
B It usually generates a lower reading compared to the heterophoria
method on a given patient
C A +3.00DS lens is used to relax the accommodative effort at distance
fixation
D It is the method of choice in the time pressured high street practice
10
A practitioner uses Notts dynamic retinoscopy to determine a
neutral point of 33cm using a fixation distance of 40cm. What
does this indicate?
A Accommodative lead of 0.50DS
B Undershooting of accommodation by 2.50DS
C Accommodative lag of 0.50DS
D Overshooting of accommodation by 3.00DS
11
Which of the following is the most appropriate management
for a patient with convergence excess esophoria?
A Issue the full myopic refraction with a positive addition as necessary
B Identify and remove any underlying cause and review in 3 months
C Issue the full hyperopic refraction with a positive addition as necessary
D Issue the full hyperopic refraction with daily divergence exercises
12
Convergence insufficiency commonly presents with which of
the following conditions?
A Accommodative lead
B Divergence excess exophoria
C Accommodative spasm
D Convergence weakness exophoria
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habitual reading distance, along with a regime of push-up
accommodation exercises. These involve moving text from arms
length towards the eyes in a smooth, steady motion until blur is
perceived followed by withdrawal of the target back to the starting
point, repeating the cycle as many times as possible in a 8-10 minute
period. This can be supplemented with jump accommodation
exercises in which the patient focuses from 3m to 6m and back to
the near point in a repeated cycle for five minutes. Less commonly,
patients may require development of vergence or accommodative
facility using flipper prisms/spheres (0.50DS to 3.00DS) with
repeated cycles performed within a set time period while fixating
on a near target.
On diagnosis of a high AC/A ratio with convergence excess
eso deviation at near, the first step is to issue the full hyperopic
refraction using cyclopegia as necessary. If this fails to provide clear
and comfortable vision, a further bifocal addition of up to +4.00DS
may be prescribed to relieve the accommodative effort and resulting
accommodative convergence. The eventual aim is to reduce the near
addition in intervals while stability is gradually regained.
For the assessment of binocular function, the most basic
equipment you require includes a pen torch, budgie stick, distance
chart, near Mallet unit and a stereopsis test, all of which are found
within most practices in the UK. The aim of this series has been
to review test procedures and highlight the ease and speed at
which they can be performed with regular use, indicating that the
challenge lies more in interpreting your results and exercising the
appropriate management. Often, simply identifying and removing
an underlying cause of visual stress such as improving lighting of a
near task can resolve a magnitude of symptoms.
As a general rule of thumb, any large change or newly presenting
anomaly particularly affecting a young child requires an urgent
referral to the hospital eye service for further investigation. Most
long-standing cases can, however, be managed in practice with great
success using refractive modification, prismatic correction and/or
orthoptic exercises, thus making BV assessment a highly rewarding
aspect of clinical practice.
References
1 Elliott DB. Clinical Procedures in Primary Eye Care (Third Edition), p 140,
Butterworth Heinemann 2003.
2 Ansons and Davis. Diagnosis and Management of Ocular Motility Disorders
(Third Edition), p 93, Blackwell Science, 2001.
3 Rowe F. Clinical Orthoptics, p 57, Blackwell Science, 1997.
4 Stidwell D. Orthoptic Assessment & Management (Second Edition), p 75,
Blackwell Science, 1998.
5 Rowe F.Clinical Orthoptics, p 160, Blackwell Science, 1997.
Priya Dabasia is a clinical optometrist at the Fight for Sight Optometry Clinic,
City University and Moorfields Eye Hospital
KEY LEARNING POINTS FROM BINOCULAR VISION PARTS 1-6
Cover test
The cover-uncover test distinguishes tropias from phorias and allows
evaluation of any detected tropia and the habitual angle of any phoria
The alternating cover test maintains full dissociation so is useful in
establishing the maximum size of any deviation
When assessing a phoria, remember to assess and make a note of the
speed and regularity of recovery of the aberrant eye as this is a useful
indication of the stability of the phoria
The distance cover test target should be a letter one line above the
line just seen by the weaker eye. For vision less than 6/18 a spotlight
may be used or a specific feature of a letter seen on a higher line (say,
the centre of an X or the top left of a T)
When measuring any deviation where there is a horizontal and a
vertical element, assess the larger deviation first
Ocular motility
An incomitancy is where the angle of deviation between the two
eyes differs for different positions of gaze
Any sudden onset incomitancy warrants urgent referral
Peripheral cover test will establish which is the deviating eye
Recently acquired incomitancies warrant urgent ophthalmological
investigation
A and V patterns count as incomitancies, though usually congenital
Compensation assessment
Symptoms of decompensation include headache, asthenopia, inter-
mittent diplopia, blurring of print and occasionally depth perception
difficulties
Causes of decompensation may be optical (such as refractive error),
medical (such as trauma, drug effects or extensive field loss) or
environmental (such as poor viewing environment conditions,
prolonged game playing and so on)
Sensory status
Tests for sensory adaptation include Bagolini lenses, the Worth 4-dot
test and modified OXO tests (on Mallet-type units)
The establishment of anomalous retinal correspondence allows
some degree of binocularity without diplopia in cases of small angle
strabismus
A normal level of stereoacuity would be 40
Convergence and accommodation
A normal near point of convergence is expected to be less than 10cm
A 10-year-old might be expected to have an amplitude of accommo-
dation of 14DS or more
Exercises for convergence insufficiency should be mindful of the
possibility of suppression by the patient so should include an appre-
ciation of physiological diplopia
24.06.11 | Optician | 25
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