Reliability of rotary prism fusional vergence ranges.

BACKGROUND: The measurement of fusional vergence ranges is an important clinical test in the assessment of binocular vision status. Fusional vergence ranges are typically measured by recording a patient's reports of blur, break, and recovery to base-in (BI) and base-out (BO) prism. Published reliability data on fusional vergence ranges are very limited. METHODS: Eight subjects underwent four testing sessions, at which repeated measurements of fusional vergence ranges were taken. Near ranges were tested at the first session only Distance ranges were tested at all four sessions. Intra-examiner standard deviations were calculated for each fusional vergence test result (BI and BO; blur, break, and recovery) for each session. Intra-examiner standard deviations were averaged. These values were used to determine 95% limits of agreement. RESULTS: The 95% limits of agreement were between 2 delta and 2.5 delta for the distance BI break and recovery and for the near BI recovery; between 3 and 4 delta for near BI break and near BO break; between 4 and 5 delta for distance BO blur and recovery and for near BI blur; and between 5 and 5.5 delta for distance BO break and near BO blur and recovery.     

A longitudinal study of vergence adaptation in incipient presbyopia

BACKGROUND: To investigate vergence adaptation during the incipient phase of presbyopia, when the amplitude of accommodation approaches the level where the first reading addition is required. The study aimed to assess the ability of the vergence system to counteract changes in the component contributions to the overall vergence response with the decline in the amplitude of accommodation in presbyopia, although previous reports on the nature of changes in accommodative, tonic and proximal vergence are equivocal. METHODS: Using a 'flashed' Maddox rod technique, an assessment of vergence adaptation to 6delta base-out and 6delta base-in prism was made for 28 subjects (aged 35-45 years at the commencement of the study). The measurements were taken four times over a 2-year period. RESULTS: Using a repeated measures analysis of variance, the results show that with the decline in amplitude of accommodation, there is a statistically significant reduction in the magnitude of vergence adaptation to both base-out (p < 0.05) and base-in prism (p < 0.01). CONCLUSIONS: This study shows that with ageing, there is a decrease in the ability of the slow vergence mechanism to overcome a change in fusional vergence demand and would suggest that either the fast component of fusional vergence must cope with any change in fusional vergence demand or that the sum of the accommodative, tonic and proximal vergence responses are virtually stable with age.     

Effect of Induced Vertical Disparity on Horizontal Fusional Reserves

Purpose: The aim of this study was to investigate the effects of induced vertical disparity on horizontal fusional reserves at near. Materials and Methods: In 170 healthy subjects wearing best corrective refraction, the negative and positive horizontal fusional reserves were measured with base-in (BI) and base-out (BO) prisms, respectively, in the presence of 0.5 prism diopters (^?) and 1^? vertical prisms placed in trial frames in front of the right eye. The prism power was slowly increased step by step until the subject reported sustained blur, break, and recovery. These were compared to horizontal fusional reserves in the same subjects without a vertical prism. Data were analyzed in SPSS.17 software using a repeated measures ANOVA. Results: Induced vertical disparity decreased negative fusional reserves (NFR) horizontally and was more significant with 1^? vertical disparity (P<0.001). There were significant differences between the blur (P<0.001), break (P<0.001), and recovery (P<0.001) for NFR before and after induced vertical disparity and no significant difference between blur (P=0.173) and recovery points (P=0.261) with a marginal difference for break points (P=0.045) for the positive fusional reserves (PFR). Conclusion: Inducing vertical disparity even with small magnitudes affects all 3 aspects (blur, break, and recovery) of horizontal negative fusional reserves while only break is affected in positive fusional reserves. These changes are statistically significant but do not seem to be clinically significant except for cases accompanied by symptoms.     

Convergence Insufficiency Neuro-Mechanism Adult Population Study: Phoria Adaptation Results

PurposeThe purpose of this study was to compare changes in phoria adaptation between young adult binocularly normal controls (BNCs) and participants with symptomatic convergence insufficiency (CI), who were randomized to either office-based vergence accommodative therapy (OBVAT) or office-based placebo therapy (OBPT).MethodsIn the double-masked randomized clinical trial, 50 BNC and 50 CI participants were randomized to the following therapeutic interventions: OBVAT or OBPT with home reinforcement for 12 one-hour office sessions. A 6∆ base-out and 6∆ base-in phoria adaptation experiment at near (40 cm) was conducted using the flashed Maddox rod technique at baseline and at outcome. Measurements included the rate and the magnitude of phoria adaptation.ResultsAt baseline, BNC and CI participants had significantly different rates and magnitudes of base-in and base-out phoria adaptation (P < 0.001). When comparing the outcome to baseline measurements, significant main effect differences in longitudinal measurements were observed for the magnitude and the rate of phoria adaptation for both base-out and base-in experiments (P < 0.05). For the magnitude and rate of phoria adaptation, post hoc analyses using paired t-tests revealed that the CI group administered the OBVAT intervention exhibited a significant increase in the magnitude and rate of phoria adaptation compared to baseline for both base-in and base-out phoria adaptation (P < 0.01) but not for those administered OBPT.ConclusionsPhoria adaptation is significantly different at baseline between those with normal binocular vision and symptomatic CI participants. OBVAT significantly improves the rate and magnitude of both base-out and base-in phoria adaptation at near compared to OBPT. Results have clinical implications for new therapeutic interventions.     

A normative study of step vergence in elementary schoolchildren

The purpose of this study was to develop normative data for step vergence testing in children age 6-12. Such data are not currently available for this age group. Base-in and base-out step vergence testing with a prism bar was performed on 386 elementary schoolchildren who had all passed a modified clinical technique (MCT) screening. A new polarized target was developed which enabled us to detect suppression, as well as diplopia or blur. The findings suggest significant differences from normative data previously reported for adults. Because the data for 6-year-olds were different from the rest of the group, we suggest that lower norms be used for this age group. This study provides expected findings for step vergence testing outside the phoropter, which can be used clinically for the assessment of disparity vergence ranges in young children.     

Comparison of two fixation disparity determinantions

Fixation disparity values derived from horopter measurements are compared with those determined using the disparometer on seven subjects wearing lateral prisms. Although the two measures are intrinsically different, five subjects showed similarity in the form and position of the two fixation disparity-forced vergence functions. Two subjects manifested fixation disparities that indicated the use of proximal or voluntary control of relative eye position for both base-out and base-in forms of lateral prism. Another subject showed a paradoxical response to base-out prism that could be attributed to recovery from previous application of base-in prism, adaptation to base-out prism, or both. An additional subject showed irregular alterations in vergence posture during nonius horopter measurements. The clinical implications of vergence responses other than those associated with fusion and accommodation are discussed and the effect of this form or eye movement control is related to the change in position and shape of the equidistance horopter when it is measured through lateral prism.     

The Glenn A. Fry award lecture: adaptive regulation of accommodative vergence and vergence accommodation

The tonic resting level of accommodation, measured with an objective infrared optometer in an open-loop state (pinhole pupil or empty field), was increased by more than 1.75 D from baseline measures of resting focus after adapting monocularly for 1 min to a 2 D minus lens. The accommodative aftereffect disappeared in darkness, but returned when a visible stimulus reappeared in the open-loop state. Stimulation of disparity vergence with 10 delta, while accommodation was in an open-loop state, also increased the resting focus of accommodation. Similarly, the tonic resting level of vergence became more esophoric after adapting for less than 1 min to base-out prism or to a minus lens presented while the vergence loop was opened. The effects of tonic accommodation on accommodative vergence and the effects of tonic vergence on vergence accommodation were investigated with the temporal frequency responses of the AC/A and CA/C ratios to sinusoidal variations in blur (2 D) and disparity (10 delta), respectively. Accommodative vergence was unresponsive to low temporal frequency sinusoidal variations in blur (less than 0.1 Hz). Similarly, vergence accommodation was unresponsive to low temporal frequency sinusoidal variations in disparity. However, accommodative vergence and vergence accommodation were responsive to higher temporal frequency stimuli (up to 0.5 Hz). When negative feedback to the stimulated system (accommodation or vergence) was cancelled electronically, the low temporal frequency response increased for the AC/A and CA/C ratios, respectively. There was also a nonlinear increase of both AC/A and CA/C ratios as stimulus amplitude increased. It is hypothesized that the nonlinearity resulted from limitations of adaptation to small stimuli. An inverse complementary relation is suggested between the amplitude of the AC/A ratio and adaptable tonic accommodation, and between the amplitude of the CA/C ratio and adaptable tonic vergence. This model predicts that in this complementary relation, adaptable tonic elements would sustain motor responses of accommodation and vergence that were initiated by phasic elements and cross-link interactions. It also predicts that the AC/A and CA/C ratios would decrease in time as dynamic control shifted from the phasic to the adaptable tonic control mechanisms of accommodation and vergence, respectively.     

Horizontal fusional amplitudes after adaptation to prism

Horizontal fusional limits and lateral phorias were measured subjectively on five normal subjects after adaptation to increments of base-in and base-out prism. Both the phoria and the fusional limits were found to change by approximately the amount of the adapting prism. The fusional amplitudes (the difference between the phoria and the fusional limits) were relatively unaffected by vergence adaptation except at the largest values of adapting prism. These results are in agreement with current models of disparity vergence eye movement control which suggest that there are independent fast and slow fusional vergence mechanisms, each with its own saturation limit.     

Vertical vergence adaptation does improve with practice.

PURPOSE: To investigate the effect of repeated testing on adaptation to a 2 Delta vertical prism in subjects with normal binocular single vision. METHODS: Subjects were required to have good visual acuity and normal binocular single vision. The residual deviation was measured after a 1-min period of adaptation to a 2 Delta vertical prism using a modified Maddox Rod technique. This measurement was repeated 10 times, with a 5-min rest period between each trial. RESULTS: For eight young adult subjects, the mean residual deviation at 1 min reduced with consecutive trials, and this effect was statistically significant (p < 0.0001). No significant correlation was present between the amplitude of vertical vergence and the increase in adaptation with repeated demand. CONCLUSIONS: A practice effect for vertical vergence adaptation appears to be present in young adult subjects with normal binocular single vision.     

Repeatability and agreement in the measurement of horizontal fusional vergences

PURPOSE: This study was designed to determine the repeatability of fusional vergence ranges measured using the rotary prisms in the phoropter and in free space using the prism bar. The level of agreement between the two methods was also investigated. METHODS: In two separate sessions, negative and positive fusional vergence ranges (NFV and PFV, respectively) were measured at distance and near in 61 young adults (mean age 19.74, S.D. 2.5 years) who were unfamiliar with the methods used. Base-in and base-out blur, break and recovery points were sequentially determined. Both sets of measurements were obtained by the same examiner. At each distance, NFV was determined first and then PFV. The repeatability of the tests and agreement between measurements made with the phoropter rotary prisms and the prism bar were estimated by the Bland and Altman method. RESULTS: For both the phoropter rotary prisms and prism bar, NFV measurements showed better repeatability than PFV at both near and distance. Mean differences recorded for the NFV break and recovery points were non-significant (under 0.5Delta), while those observed for PFV were generally greater than 2Delta. When agreement between the two tests was assessed, it was found that break points were higher when determined using the phoropter rotary prisms, while recovery points were generally higher for the prism bar method. In clinical terms, according to the expected values of the NFV and PFV, agreement between the two techniques can be described as fair, because although mean differences were never greater than 5.5Delta, 95% agreement intervals were as wide as +/-8.00Delta for NFV and +/-13.19Delta for PFV. CONCLUSIONS: The two methods used to measure fusional vergences showed fairly good inter-session repeatability for measuring NFV but repeatability was reduced for PFV measurements. The level of agreement observed between the two methods was such that their interchangeable use in clinical practice is not recommended.     

Prism adaptation without binocular vision

The assumption that vergence adaptation to a prism could only take place during single binocular vision was investigated by having subjects wear a prism while fusion was dissociated. Adaptation was evaluated by its effect on lateral heterophoria. Dissociation and measurement of heterophoria were by means of an automated version of Duane's screen and parallax test. A preliminary investigation with 37 subjects fixating at 6 m while wearing 4 delta base-out and with 33 other subjects fixating at 50 cm while wearing 3 delta base-in showed that at least 25% adapted to the prism. Results of an investigation with 2 subjects fixating at 6 m (4 delta base-out and base-in) and with 3 subjects fixating at 50 cm (3 delta base-in) are presented as evidence that prism adaptation can take place. It was also found that the power of the added prism could just as well be provided by the phoria test's variable prism. In other words, there is a possibility that adaptation will occur when heterophoria is measured with a variable prism.     

The influence of rapid prism adaptation upon fixation disparity.

Small errors of fusional vergence (fixation disparity) were examined as a function of the magnitude of horizontal prism stimulating convergence or divergence for a short (30sec) duration. Marked differences were observed between the amplitude of fixation disparity resulting from convergent and divergent stimulus disparities. In another experiment, subjects wore a horizontal prism for 30 sec after which time one eye was occluded for 40 sec. Measurements of vergence eye movements revealed an incomplete relaxation of fusional vergence (prism adaptation) after 40 sec of occlusion. Marked differences were observed between the amplitude of prism adaptation resulting from convergent and divergent stimuli. Maximum prism adaptationand minimum fixation disparity occurred with the same direction of prism, suggesting that a slow fusional vergence mechanism minimizes errors of binocular vergence.     

Prism induced accommodation in infants 3 to 6 months of age

Convergence-accommodation, one of several cross-linkages in the oculomotor system is manifested by opening the accommodative feedback loop and increasing the vergence input. We elicited this response in human infants aged 3-6 months by placing a 15 delta prism (base-out) before one eye while they viewed a diffuse patch of light. Accommodation was measured and ocular alignment was confirmed with a video photorefractor. The convergence-accommodation response is therefore present during a time when blur driven accommodation and disparity vergence are maturing. The gain of convergence-accommodation (expressed as the stimulus CA/C ratio) appeared to be greater for infants than adults.     

Fusional Vergence Measures and Their Significance in Clinical Assessment

Purpose: The aims of this study have been to evaluate differences between ranges in eso or exo deviances and with varying target size.

Methods: Evaluation of sensory status in compensated deviations included measures of fusional vergence (blur, break and recovery values) with randomization of target size and order of prism base. Angle of deviation measures were assessed for each case.

Results: Twenty-two subjects, 7 esophoric and 15 exophoric, were recruited. Median prism fusional vergence range at near fixation was 25BO to 10BI (central target); 35BO to 12BI (peripheral target). At distance fixation median range was 16BO to 6BI (central); 25BO to 6BI (peripheral). Esophorics had a range shift towards the base out range. Exophorics had a shift towards the base in range.

Conclusions: Smaller positive fusional vergence values were obtained with small compared with large target sizes. Additionally, esophoric subjects had a trend towards larger base out ranges while exophoric subjects had a trend towards larger base in ranges.     

Accommodative and vergence difficulties interfering with image clarity through a binocular indirect ophthalmoscope.

PURPOSE: This study sought to identify accommodative and vergence deficiencies that could explain why some students have difficulty seeing clearly when using a binocular indirect ophthalmoscope (BIO) containing its standard +2.00 D lenses. METHODS: A survey was distributed to Illinois College of Optometry 3rd- and 4th-year students. Based on the information supplied by the survey, students were divided into two groups: those who are unable ("BIO plano") and those who are able ("BIO plus") to obtain a clear image with the +2.00 D lenses in their BIO's. Forty-seven subjects participated: 22 in the BIO plano group and 25 in BIO plus group. Two of the authors, masked to subject group, measured all subjects' accommodative amplitudes and facilities, monocular estimation method (MEM) retinoscopy, negative relative accommodation and positive relative accommodation (NRA/PRA), distance and near vergence ranges, distance and near phorias, Worth 4-dot test, and near point of convergence (five times). RESULTS: The Mann-Whitney U analysis of numerical data for the two groups showed a statistically significant difference for accommodative facility in the right eye (p = 0.004). The difference between the two groups approached significance for accommodative facility with both eyes (p = 0.02), facility in the left eye (p = 0.03), distance base-out blur (p = 0.02), near base-out break (p = 0.02), and near base-out recovery (p = 0.04). For all findings in which the difference between the two groups was significant or approached significance, the BIO plus group had higher median values. When subjects were classified by difficulty with the plus side of the flippers during accommodative facility testing, there was a statistically significant difference with both eyes (Fisher exact test, p = 0.003) and with the right eye (p = 0.008) between the BIO plus and BIO plano groups. When subjects were classified by the presence or absence of an accommodative or binocular vision syndrome, categorical data analysis showed the difference between the two groups approached significance, with more BIO plano subjects having syndromes (p = 0.03). CONCLUSION: No one test absolutely defined who would have difficulty with the +2.00 D lenses in the BIO. There are several skills required; less developed plus acceptance and convergence may cause difficulties.     

Contribution of vergence adaptation to difference in vertical deviation between distance and near viewing in patients with superior oblique palsy

PURPOSE: To evaluate the adaptive vertical vergence aftereffect and determine whether it contributes to a difference of vertical deviation with respect to gaze distance in patients with vertical strabismus. DESIGN: Prospective noncomparative studies. METHODS: Eighty-four patients with unilateral superior oblique palsies were enrolled and classified into three types-A, B, and C-based on the difference in vertical deviation between distant and near viewing. The prism adaptation test was performed for 2 to 3 hours to correct vertical deviation and the response of vertical deviation to the prism adaptation test was compared among the three types RESULTS: Adaptive vertical vergence aftereffect, defined as an increase of deviation by 5 prism diopters or more with the prism adaptation test, was identified in 13 patients (16%) at distance and in 23 patients (27%) at near viewing. Among the three types, the adaptive vergence aftereffect contributed mostly to the type B, in which distance deviation exceeds near deviation. Nine patients (39%) of type B changed to type A category with the prism adaptation test; and of these, 7 increased near deviation so that the deviation difference between distant and near viewing decreased. CONCLUSION: The adaptive vertical vergence aftereffect contributes to a difference in vertical deviation between distant and near viewing. The vertical prism adaptation test is specifically useful to determine the extent of surgery by breaking fusional vergence in patients with hypertropia in whom deviation differs with respect to viewing distance.     

Variability of Fusion Vergence Measurements in Heterophoria

Purpose: The aims of this study were to compare fusional vergence measurements between orthophoria, esophoria, and exophoria, and to determine the strength of correlations between fusional convergence and divergence and angle of deviation.

Methods and materials: A cross-sectional study was performed in children with best-corrected visual acuity of 0.0 LogMAR in either eye, compensated heterophoria within 10 prism diopters (PD), full ocular rotations, presence of fusional vergence, and stereopsis (60 seconds of arc or better). Fusional amplitudes were compared between orthophoric and heterophoric children. The fusion reserve ratio was determined as compensating vergence divided by alternating cover test.

Results: Five hundred and thirty children (7.66±1.20 years) were recruited to this study. The most common heterophoria was exophoria (n=181, 34.2% for near; n=20, 3.8% for distance). Exophoric children had significant lower mean positive fusional vergences (exophoria-orthophoria: P=0.003; exophoria-esophoria: P=0.035) for near (19.54±5.23 base-out) compared with children with orthophoria (20.48±4.83 base-out) and esophoria (22.27±5.60 base-out). Smaller convergence fusion amplitudes were associated with larger angles of deviation at near (r_s=-0.115; P=0.008) and lower fusion reserve ratios were associated with larger angles of deviation at distance (r_s=-0.848; P<0.001) and at near (r_s=-0.770; P<0.001).

Conclusions: Exophoric children have reduced convergence break points when compared with orthophoric and esophoric children. Vergence measurements, taking into consideration the baseline heterophoria, give important information about the ability of the patient to increase their vergence demand and maintain ocular alignment.     

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

Vergence adaptation, also known as prism adaptation, is a phenomenon in which a patient's 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.     

Short-term adaptation of accommodation,accommodative vergence and disparity vergence facility

Previous studies have found that subjects can increase the velocity of accommodation using visual exercises such as pencil push ups, flippers, Brock strings and the like and myriad papers have shown improvement in accommodation facility (speed) and sufficiency (amplitude) using subjective tests following vision training but few have objectively measured accommodation before and after training in either normal subjects or in patients diagnosed with accommodative infacility (abnormally slow dynamics). Accommodation is driven either directly by blur or indirectly by way of neural crosslinks from the vergence system. Until now, no study has objectively measured both accommodation and accommodative–vergence before and after vision training and the role vergence might play in modifying the speed of accommodation. In the present study, accommodation and accommodative–vergence were measured with a Purkinje Eye Tracker/optometer before and after normal subjects trained in a flipper-like task in which the stimulus stepped between 0 and 2.5 diopters and back for over 200 cycles. Most subjects increased their speed of accommodation as well as their speed of accommodative vergence. Accommodative vergence led the accommodation response by approximately 77 ms before training and 100 ms after training and the vergence lead was most prominent in subjects with high accommodation and vergence velocities and the vergence leads tended to increase in conjunction with increases in accommodation velocity. We surmise that volitional vergence may help increase accommodation velocity by way of vergence–accommodation cross links.