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Optometry & Vision Science:
doi: 10.1097/OPX.0b013e318269e569
Original Articles

Accommodative Response/Stimulus by Dynamic Retinoscopy: Near Add Guidelines

Goss, David A.*; Rana, Sania; Ramolia, Julie

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Author Information

*OD, PhD, FAAO

OD

School of Optometry, Indiana University, Bloomington, Indiana (DAG, SR, JR).

Received October 4, 2011; accepted June 18, 2012.

David A. Goss School of Optometry, Indiana University 800 East Atwater Avenue Bloomington, IN 47405 e-mail: dgoss@indiana.edu

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Abstract

Purpose. Monocular estimation method (MEM) dynamic retinoscopy and low neutral (LN) dynamic retinoscopy are common procedures for evaluating the need for near-point plus adds for improved near-point performance in non-presbyopes. A combination of MEM and LN has been suggested to be a method of plotting accommodative response/accommodative stimulus functions and evaluating guidelines for prescribing from MEM.

Methods. Using a combined MEM-LN procedure, MEM was performed on 80 young adults at 40 cm, with distance correction and with plus adds in 0.25 D steps up to and including +2.00 D. Modified Thorington dissociated phorias were also performed with each of the plus adds. Subjects picked a preferred add, which subjectively made print easiest and most comfortable to read.

Results. The mean preferred add was +0.58 D over the distance prescription. The add derived from subtracting 0.25 D from the lag of accommodation with distance correction averaged 0.10 D more plus than the preferred add. The add at which dynamic retinoscopy showed a “with” motion of 0.25 D averaged 0.54 more plus than the preferred add. The add at which dynamic retinoscopy showed a “with” motion of 0.50 D averaged 0.16 more plus than the preferred add.

Conclusions. Adds derived from subtracting 0.25 D from the lag with distance correction and from finding the add that yields 0.50 D of “with” motion compared favorably with the preferred adds on average, but the standard deviations of the differences were high. Those guidelines could be reasonable starting points for the prescription of near-point plus adds for non-presbyopes, but follow-up testing to confirm or adjust add power would be advisable in the clinical setting.

Dynamic retinoscopy is often used in the prescription of plus adds in non-presbyopic accommodative disorders to improve near-point performance. There are a number of dynamic retinoscopy procedures.1,2 The most commonly used dynamic retinoscopy method is probably the monocular estimation method (MEM).3,4

In MEM retinoscopy, the patient views a near-point target in the plane of the retinoscope, while the examiner estimates the dioptric amount the reflex is away from neutral.58 This can be confirmed by the brief interposition of a lens. The dioptric estimate represents the difference between the accommodative stimulus (AS) and the accommodative response (AR). Thus, the estimate of the dioptric amount of a “with” motion is a measure of the lag of accommodation. Normal values for MEM lag reported in the literature have varied from one source to another, but usually are about 0 to 0.75 D.5,9

Another dynamic retinoscopy procedure is low neutral method (LN), also done with the patient viewing a near-point target in the plane of the retinoscope.4,9 LN retinoscopy is usually done in the phoropter, with phoropter lenses added until a neutral reflex is observed, at which point AS and AR are equal. On LN retinoscopy, lens adds are kept in place, allowing accommodation to change in response to the add. The plus found on LN is often greater than the lag found on MEM because AR will decrease as plus is added.

Haynes10,11 described a dynamic retinoscopy procedure, which he called MEM-LN because it combined principles of MEM and LN. In the MEM-LN procedure, MEM is performed through the distance subjective refraction as it is usually done. Then a separate MEM retinoscopy is performed with a +0.25 D add in place, followed by separate additional MEM retinoscopy findings obtained through several more plus adds, increasing in 0.25 D steps. With testing at 40 cm, this would mean that separate MEM findings are obtained at AS levels of 2.50, 2.25, 2.00 D, and so forth. This makes possible the plotting of AR as a function of AS, as each MEM finding represents the difference between AS and AR at a given level of AS. Haynes referred to this procedure as MEM-LN because MEM was performed several times, but plus adds were kept in place like LN.

Haynes10,11 suggested that the patterns of AR/AS plots generated with the MEM-LN procedure could be used to evaluate guidelines for prescribing plus adds from dynamic retinoscopy. One such guideline for prescribing in cases with high lag of accommodation is to use an add power equal to 0.25 D less than the lag obtained with MEM.12 Another recommendation is to prescribe the amount of add that reduces the “with” motion of the reflex on MEM to within the 0.12 to 0.50 D range.13

The purposes of this article are to examine the use of MEM-LN retinoscopy to determine plots of AR as a function of AS, and to investigate how commonly used clinical guidelines for prescribing plus adds represented by points on those plots relate to subjectively preferred add power in non-presbyopes. Also included in this article are comparisons of subjectively preferred add power with adds determined based on modified Thorington dissociated phoria findings and based on an analysis of a combination of phoria and dynamic retinoscopy results.

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METHODS

Data Collection

This research followed the tenets of the Declaration of Helsinki. Eighty subjects participated in this study. Eligibility criteria were (1) 18 to 30 years of age, (2) best-corrected visual acuity of at least 20/25 in each eye, and (3) no strabismus at distance or near as determined by cover test. There was no regard for accommodation or vergence findings other than lack of strabismus or for presence or absence of near-point vision problems in the recruitment of subjects. Experimental protocols were approved by the Indiana University Human Subjects Committee. After subjects signed the consent form, the following tests were done: (1) distance visual acuity with best correction, OD, OS, OU; (2) unilateral and alternating cover tests at distance and near with habitual prescription (Rx); (3) distance and near interpupillary distances (PD); and (4) spherical over-refraction while subjects were wearing their habitual spectacle or contact lens corrections.

The over-refraction was performed in the phoropter, with subjects wearing their habitual spectacles or contact lenses behind the phoropter. The over-refraction consisted of monocular sphere check, binocular balance, and binocular sphere check for maximum plus to best visual acuity. If the sphere for each eye in the over-refraction was <±0.50 D and the interocular difference on the balance was <0.50 D, subjects wore their habitual corrections for subsequent testing. If not, those with contact lenses wore a trial frame with the over-refraction and their contact lenses, and those with spectacles wore the sum of their habitual Rx and the over-refraction in a trial frame. A difference of ≥0.50 D was used because most studies suggest the limits on the repeatability of refraction is about 0.25 D.14 Because a refraction was not performed without spectacles or contact lenses, the exact refractive errors of the subjects were not known, but most subjects had myopia.

Two sets of spectacles, with each set in identical or nearly identical frames, were made. Each set consisted of nine pairs of spectacles with the following powers: 0, +0.25, +0.50, +0.75, +1.00, +1.25, +1.50, +1.75, and +2.00 D. The lateral separations of the optical centers of the lenses were the same for all spectacles within a set: 62 mm for one and 59 mm for the other set of frames. The study spectacles were made in frames with large lens sizes so that they could fit closely to the habitual spectacles of subjects who wore spectacles. Most subjects in the study had either contact lenses or no refractive correction. Powers of the lenses were etched in very small numerals in the upper temporal aspect of each left lens to allow the examiners to identify their powers. When presenting the spectacles to the subjects for the test of their preference (as described later in the text), the spectacles were laid out so that the numbers were not immediately visible.

One examiner performed the MEM-LN dynamic retinoscopy procedure with a Welch Allyn streak retinoscope. For testing, the study spectacles were placed over the distance refraction lenses as described earlier in the text. MEM-LN retinoscopy was performed with subjects wearing each lens power in the following order: 0, +0.25, +0.50, +0.75, +1.00, +1.25, +1.50, +1.75, and + 2.00 D. In the Haynes MEM-LN procedure, lens adds are used in this ascending order. It is possible that this order may induce slight accommodation or vergence adaptation effects that may be different than if lenses were presented in random order. The examiner used the set of study spectacles that were closest to the subject's near PD.

The subjects were instructed to read the words on a Welch Allyn adult-level dynamic retinoscopy card. This card contains 28 words of two to five syllables each in approximately 10 point letter size. MEM-LN retinoscopy was performed on the right eye, with the estimation of lag confirmed by briefly placing a trial lens equal in power to the estimate over the eye to see whether neutral was obtained. If the trial lens was in place for >1 s, a delay of 3 s occurred before another estimate was made. The confirmed estimation was recorded for each lens power. Subjects were not informed about the powers of the lenses in the study spectacles.

Another examiner performed modified Thorington dissociated phorias at 40 cm using a Saladin near-point card.15,16 The 40 cm distance was measured from the spectacle plane for habitual spectacle wearers or from the bridge of the nose for subjects who did not wear a habitual spectacle correction. Subjects wore their habitual spectacle correction or habitual contact lens correction, or distance refraction lenses in a trial frame. A red Maddox rod with striations oriented horizontally (to produce a vertical red line) was held by the subject over the right eye. A phoria measurement was made with no additional power over the distance correction. Then phorias were performed with trial lenses held by the subject. Testing was done with powers of trial lenses in the following order: 0, +0.25, +0.50, +0.75, +1.00, +1.25, +1.50, +1.75, and + 2.00 D over the distance refraction lenses.

Subsequently, the second examiner worked with each subject to see which of the study spectacles the subject preferred. The subject was given an article from Contact Lens Spectrum to read. The examiner measured a distance of 40 cm from the spectacle plane of the subject to the paper and periodically reminded the subject to maintain a reading distance of 40 cm. The examiner instructed the subject to “try each of these pairs of spectacles (over your glasses/contact lenses) and pick the three pairs that make the print easiest and most comfortable to read. Then rate those three pairs as best, second best, and third best for ease and comfort of reading.” The add that subjects rated as the best will be referred to as the preferred add.

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Data Analysis

Four main analyses were performed: (1) determination of slopes of AR as a function of AS by linear regression, (2) comparison of preferred add with adds recommended by three dynamic retinoscopy guidelines, (3) comparison of preferred add with adds recommended from modified Thorington dissociated phoria findings, and (4) comparison of preferred add with add derived from a modification of the Pratt system of clinical accommodation and vergence analysis.

Comparisons were made by finding the means and the standard deviations (SDs) of the differences between the preferred add and the adds recommended by each of the guidelines. In addition, Pearson correlation coefficients of the difference between guideline results and preferred add with the mean of the guideline results and preferred add for each individual subject were calculated. This analysis was recommended by Altman and Bland17 to assess whether the difference could be dependent on the magnitude of the values being compared. If a correlation coefficient was statistically significant, an x-y coordinate graph of differences as a function of means, as recommended by Bland and Altman,18 was plotted.

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Comparison of Preferred Add with Dynamic Retinoscopy Guidelines

The preferred add was compared with three add powers based on the dynamic retinoscopy prescription guidelines mentioned earlier: (1) the add power equal to 0.25 D less than the lag of accommodation measured through the distance correction, (2) the minimum add power that yielded 0.25 D “with” motion (in other words, the minimum add power that makes AS minus AR equal to 0.25 D), and (3) the minimum add power that yielded 0.50 D “with” motion.

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Comparison of Preferred Add with Phoria Finding Guidelines

The preferred add was also compared with adds that would be recommended based on near dissociated phoria findings with the modified Thorington test. A common guideline for prescribing plus adds in near-point esophoria is to prescribe just enough plus to shift the near phoria to a low exo within the normal range8,13 (according to Morgan,19,20 the average near phoria is 3Δ exo and the normal range is ortho to 6Δ exo). Differences between the preferred add and the minimum add powers that resulted in each of the phoria findings of 1, 2, and 3Δ of exo were calculated. If one add resulted in a phoria less than the criterion level of 1, 2, or 3Δ exo and the next add resulted in a phoria more than the criterion level, the 0.12 D step between the two add powers was used as the recommended add in the calculations.

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Comparison of Preferred Add with Pratt Analysis Results

The last variable to be compared with the preferred add was the add determined by a modification of the Pratt system of accommodation and vergence analysis.9,21 The system of accommodation and convergence analysis developed by Pratt involved determining von Graefe dissociated phorias at near through a series of different add powers and binocular cross-cylinder test results at near through a series of different prism powers. Test results were plotted on an x-y coordinate graph of accommodation and convergence, with the placements of the resultant phoria and cross-cylinder lines compared with the stimulus or demand line. On average, the phoria and cross-cylinder lines intersected at about 1 D on the accommodation axis, and they were symmetrical around, and approximately equidistant from, the stimulus line.9,21 Plus adds were indicated when the cross-cylinder line was farther from the stimulus line than was the phoria line.

In the present study, modified Thorington dissociated phorias were used instead of von Graefe phorias, and one dynamic retinoscopy measurement was used instead of a series of binocular cross-cylinder test findings. The modified Thorington dissociated phoria test was used in this study because several studies have shown it to be more repeatable than the von Graefe test.2228

A linear regression equation of dissociated phoria as a function of AS was derived. The AS at zero phoria was determined based on that formula. The midpoint between that dioptric value and diopters of AR on dynamic retinoscopy with zero add was then found. The add that would achieve an AS at the dioptric level of that midpoint was taken as the add recommended by the modified Pratt system. Any negative value thus derived was considered to be zero in the data analysis, and any value >2.00 D was considered to be 2.00 D in the data analysis because 2.00 D was the highest power add used in the selection of preferred add.

Fig. 1 is an illustration of derivation of add power in the modified Pratt analysis used in this study. Convergence relative to a 40 cm stimulus is on the x axis, and accommodation is on the y axis. The x symbols represent the dissociated phoria measurements at the corresponding AS levels. The regression line through the phoria points crosses 0 on the x axis at 1.91 D on the y axis. The AR for an AS of 2.50 D for this subject was 1.50 D, so the point labeled AR is at 1.50 D on the y axis. The point labeled midpoint is halfway between the regression line and the AR point; that is, it is midway between 1.91 and 1.50 D, or at 1.71 D. The add power was found by determining the distance on the y axis between the midpoint and the 40 cm AS. Thus, in this example, the modified Pratt system add would be 2.50 D − 1.71 D = 0.79 D.

Figure 1
Figure 1
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RESULTS

Plot of AR as a Function of AS

The mean AR values for each AS level are shown in Fig. 2. Linear regression slopes for the 80 subjects ranged from 0.13 to 0.90 D/D, with a mean of 0.51 D/D (SD = 0.18) and a median of 0.52 D/D. Most subjects showed an AR/AS plot that was well fit by a linear model (Fig. 3). The Pearson correlation coefficient of AR vs. AS was in the range of 0.91 to 0.99 for 55 subjects, in the range of 0.81 to 0.89 for 13 subjects, and <0.80 for 12 subjects.

Figure 2
Figure 2
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Figure 3
Figure 3
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Preferred Add

The mean preferred add was +0.58 D over the distance Rx. The SD was 0.54 D, and the median was +0.50 D. The range of preferred adds was 0 to +2.00 D. The distribution of preferred adds is shown in Fig. 4. The mean difference between AS and AR at the preferred add was +0.67 D (SD = 0.52 D, median = +0.75 D).

Figure 4
Figure 4
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Comparison of Preferred Add with Dynamic Retinoscopy Prescription Guidelines

Comparisons of the outcomes of various guidelines with the preferred add are summarized in Table 1. The mean lag at the 2.50 D stimulus was 0.92 D (SD = 0.43, median = 0.75 D). Thus, the mean add based on the guideline of prescribing an add equal to 0.25 D less than the amount of the lag was 0.68 D. With the mean preferred add being +0.58 D, the mean difference between this guideline and the preferred add was 0.10 D (n = 80, SD = 0.70 D). The distribution of these differences did not show skew or kurtosis, as suggested by the low skewness and kurtosis values seen in Table 1.

Table 1
Table 1
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The Pearson correlation coefficient for differences between the add recommended by the MEM lag− 0.25 D guideline and the preferred add with the mean of those two values was −0.25 (p < 0.05). A plot of differences as a function of means is shown in Fig. 5. The correlation was significant, although low, because some subjects with low lags preferred adds higher than predicted by the guideline and some subjects with high lags preferred adds lower than predicted by the guideline.

Figure 5
Figure 5
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Not all subjects obtained the result of 0.25 D “with” motion because some had no lag with zero add and some still had an AS minus AR difference of >0.25 D with a +2.00 D add. The mean add was +1.14 D (SD = 0.52 D) for the 59 subjects who did have a point at which 0.25 D “with” motion was observed. The mean difference between the add to 0.25 D “with” motion and the preferred add was +0.54 D (SD of differences = 0.83 D). The correlation of differences between guideline add and preferred add with the mean of those two values (Table 2) was not statistically significant, indicating there was no relation of the difference between guideline and preferred add with the magnitude of findings.

Table 2
Table 2
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Similarly, not all subjects obtained 0.50 D “with” motion. For the 69 subjects who did, the mean add was +0.73 D, with an SD being 0.59. The mean difference between the add to 0.50 D “with” motion and the preferred add was +0.16 D, with an SD of the differences being 0.77 D.

Because there were some subjects who did not show a high correlation of AR and AS, we could ask whether the results would be any different for only those subjects who did. The adds recommended by the three prescription guidelines were compared with the preferred add for only the 68 subjects whose Pearson correlation coefficient of AR vs. AS was >0.80. The mean preferred add was +0.61 D (SD = 0.52, median = +0.50). For the guideline of prescribing 0.25 D less than the amount of the lag, the add averaged 0.01 D less than the preferred add (n = 68, SD of the differences = 0.64, median difference = 0). The add obtained at the point of 0.25 D “with” motion averaged 0.52 D more than the preferred add (n = 55, SD of differences = 0.76, median difference = +0.75). The add at 0.50 D of “with” motion averaged 0.09 D more than the preferred add (n = 59, SD of differences = 0.76, median difference = 0).

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Modified Thorington Near Dissociated Phoria

The mean modified Thorington near dissociated phoria through the distance correction was 1.2Δ exo (SD = 3.4, range = 13Δ exo to 5Δ eso). There were 26 subjects with an eso finding at near through zero add and 54 with ortho or exo. Mean dissociated phorias at each AS level are shown in Fig. 2. The mean phoria at the preferred add was 2.1Δ exo (SD = 3.1Δ, median = 2Δ exo). The mean preferred add for the 26 subjects with eso at near through distance correction was +0.77 D (SD = 0.55, median = +0.63 D). For the 54 subjects who had ortho or exo at near through zero add, the mean preferred add was + 0.49 D (SD = 0.51, median = +0.25 D).

There were 28 subjects who had a phoria of 1Δ exo within the range of adds presented, including seven subjects who had a phoria of 1Δ exo with zero add. For those 28 subjects, the minimum add to 1Δ exo averaged 0.07 D less than the preferred add (SD of differences = 0.75, median difference = 0).

There were 38 subjects who had a phoria of 2Δ exo within the range of adds presented. Among these 38 subjects, the phorias with zero add ranged from 2Δ exo to 4Δ eso. The minimum add to 2Δ exo averaged 0.12 D less than the preferred add (SD of differences = 0.68, median difference = −0.25 D).

There were 32 subjects who had a phoria of 3Δ exo within the range of lenses presented. Among these 32 subjects, the range of phorias through zero add was from 3Δ exo to 4Δ eso. The minimum add to 3Δ exo averaged 0.28 D more plus than the preferred add (SD of differences = 0.70, median difference = +0.25 D).

Comparison of the add recommended by phoria results with the preferred add was also performed for a subset of subjects with eso at near through zero add, as prescription of plus adds is more likely in eso at near. The results are shown in Table 3. In general, the adds to low amounts of exo were a little more plus than the preferred add, but the numbers of subjects were low.

Table 3
Table 3
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Comparison of Preferred Add with Modified Pratt Analysis Add

The add recommended by the modified Pratt analysis using dynamic retinoscopy and dissociated phoria averaged 0.04 D less plus than the preferred add (SD of differences = 0.78 D, median difference = 0).

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DISCUSSION

Comparison of Results with Studies on MEM

MEM dynamic retinoscopy is usually performed with patients viewing through their distance refractive corrections, so MEM results from previous studies could be compared with the zero add (2.5 D AS) condition in the present study, for which the mean was 0.92 D. Average MEM lag values in the literature are 0.23 and 0.34 D in two studies with children29,30; 0.50, 0.56, 0.74, and 0.89 D in four studies in young adults3134; and 0.35 D in a study of patients with a wide range of ages.35 Thus, the average MEM finding with zero add in the present study is at the high end of the range of values reported for young adults.

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Use of MEM-LN Dynamic Retinoscopy for AR/AS Functions

Laboratory studies on AR as a function of AS have typically shown a lag of accommodation for accommodative stimuli of about 1 D or more, and slopes <1 D/D.3643 Laboratory studies have differed from the present study in that (1) they have often varied AS by changing distance or using a Badal system, (2) they have used a wider dioptric range of accommodative stimuli than is found in the present study with a 40 cm test distance and typical near-point adds, and (3) they have sometimes used monocular rather than binocular viewing. AR varies with many optical and non-optical factors, such as blur, target size, convergence, perception of proximity, voluntary effort, and depth of focus,43 so one would expect AR/AS functions to vary with different measurement methods.

Haynes10,11 presented seven representative cases with the MEM-LN dynamic retinoscopy procedure, but he did not report population summary data such as mean slopes of AR as a function of AS. In his seven representative cases, the slopes ranged from 0 to 0.55 D/D. The present study found a mean slope of 0.51 D/D (SD = 0.18), with a range of slopes of 0.13 to 0.90 D/D. A preliminary study of MEM-LN dynamic retinoscopy including 20 young adult subjects34 found a mean slope of 0.49 D/D (SD = 0.17), and a range of 0 to 0.68 D/D. These means could also be compared with a study using an open-view autorefractor with binocular fixation, a 40 cm test distance, and adds in 0.25 D steps from 0 to 2.50 D.44 In the autorefractor study, the mean AR/AS slope was 0.51 D/D (SD = 0.16), and the range of the slopes was 0.11 to 0.80 D/D.

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Comparison of Dynamic Retinoscopy Prescription Guideline Results with Preferred Add

This study compared values from common guidelines for prescribing plus adds for non-presbyopes with the subjectively preferred plus add power. The guideline of subtracting 0.25 D from the lag with distance correction averaged very close to the preferred add, but there were a number of subjects for whom that guideline differed significantly from the preferred add, as shown by the high SD of differences from the preferred add. Subtracting 0.25 D from the lag gave results slightly closer to the preferred add than finding the add that yielded 0.50 D “with” motion. Both of those guidelines were better than using the add to 0.25 D “with” motion. However, with all three methods, there was a high SD of the differences from the preferred add. The results of this study suggest that subtracting 0.25 D from the lag or adding plus to 0.50 D of “with” motion appears to give reasonable starting points for near-point plus in most persons, but follow-up testing with a trial frame may be necessary to confirm findings with individual patients in the clinical setting.

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Comparison of Preferred Add with Adds Derived from Dissociated Phoria Findings

The results with dissociated phoria testing indicated, on average, a slightly better agreement of the add to 1 or 2Δ exo with the preferred add than of the add to 3Δ exo, using the modified Thorington testing method. Here again, the SDs of the differences from the preferred add were relatively high so that the add to 1 or 2Δ exo may be useful as a starting point, but confirmation with subjective evaluation in a trial frame would be indicated for individual patients. The fact that the mean phoria with the preferred add was 2.1Δ exo and the median was 2Δ exo appears to provide further support for low exo being a desirable phoria level. However, because the number of subjects with esophoria at near through zero add was fairly low, it is possible that the overall phoria guideline results may not generalize well to eso cases where prescription of plus adds is more likely.

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Pratt System of Accommodation and Convergence Analysis

A theoretical advantage of the Pratt analysis system is that it uses both accommodation and vergence findings. The mean difference of nearly zero between the preferred add and the modified Pratt analysis add suggests that it too, on average, is a reasonable starting point for near-point plus adds, but the high SD of the differences suggests that in many cases, additional testing is needed to arrive at the best lens power to be prescribed.

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Possible Applications to Myopia Control

Studies on the use of bifocals and progressive addition lenses have shown that rates of myopia progression are reduced by plus adds in children with esophoria at near.4,45 Prospective studies showing that outcome have used one add power for all experimental group subjects.4653 However, practicing optometrists attempting myopia control with bifocals have based the add power prescription on the individual characteristics of the patient. Prescription criteria for add power used by practicing optometrists in myopia have included standard optometric tests such as dissociated phoria, binocular cross cylinder, negative relative accommodation, and positive relative accommodation.13,54

Some investigators are developing models of accommodation and vergence relationships and parameters to predict the best adds for slowing myopia progression in different individuals based on their accommodation and vergence characteristics.5557 It has been suggested that the greatest reduction in childhood myopia progression with multifocal lenses would most likely be achieved with add powers that are individually prescribed for optimal near-point visual function and comfort.13,58 Perhaps, guidelines derived from dynamic retinoscopy and/or dissociated phoria findings could be adapted to develop procedures that would recommend individual myopia control adds.

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Effects of Plus Adds in Non-presbyopes

There were debates on the effects of low plus adds on near-point visual performance in the 1970s.5965 Today, the usual approach is to use plus adds in cases where esophoria at near and/or high lag of accommodation are found.8 Of particular interest relative to the present study are three studies that reported that plus adds based on dynamic retinoscopy resulted in improvements in various measures.

Sohrab-Jam66 studied eye movement patterns during reading in 38 4th- and 5th-grade boys who were behind grade level in reading achievement. The 19 boys who had higher lags of accommodation according to the dynamic retinoscopy procedure known as book retinoscopy showed improvements in numbers of fixations and regressions and in reading rate with +0.50 D lenses compared with plano lenses. The 19 subjects with low lags of accommodation or leads of accommodation did not show such improvements with +0.50 D lenses.

Caden et al.67 studied performance in 5- to 8-year-old children on the Winter Haven Copy Forms Test, in which geometric forms are copied. Each subject was tested first with lenses equal in power to the MEM retinoscopy lag and then again with the habitual prescription. Scores for the completed forms, evaluated based on the manual for the test, were better with the lenses based on dynamic retinoscopy for the group of 15 subjects.

Price and Maples68 used measurements of muscle strength performed by a physical therapist as an assessment of physiological stress during reading in 5th-grade students. Strength of arm muscle contraction was assessed first with subjects looking at distance and then when reading aloud from Gray Oral Reading paragraphs through adds ranging from +0.25 to +1.25 D. Twenty of 33 subjects showed improved muscle testing results with the plus adds. The add power that yielded the best muscle test outcome showed a significant correlation with lag from Nott retinoscopy (r = 0.50, p = 0.02), with the best add tending to be slightly lower than the Nott retinoscopy lag. Although the exact mechanism by which this physiological measure may relate to visual function is unclear, it is interesting that it correlated with dynamic retinoscopy results.

It may also be noted that plus adds have been reported to reduce near-point asthenopic symptoms in accommodative insufficiency. For example, Daum's retrospective record review of accommodative insufficiency showed that 15 of 17 patients treated with plus adds had total or partial relief of symptoms.69 Two prospective studies found plus adds reduced asthenopia levels in subjects with accommodative insufficiency.70,71

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Variables That May Have Affected Results

Limitations of the present study include variables that may have affected study results. Because the lateral separation of optical centers of the plus add spectacles were 59 mm in one and 62 mm in the other set of spectacles, small prismatic effects would have been present for subjects with near PDs that differed from 59 or 62 mm. For example, Prentice rule72 suggests that a subject with a near PD of 56 mm would have had a prismatic effect of 0.6Δ base-out with the +2.00 D adds with a 59 mm lateral separation of optical centers.

Subjects read words on a Welch Allyn adult-level dynamic retinoscopy card, which contains 28 words of two to five syllables each. It was hypothesized that words of such length would better maintain the subject's attention than shorter words. However, because the words had to be read more than once, it is possible that some subjects may have had decreased attention later in the testing procedure, which in turn may have affected results.

Subjects were recruited for the study irrespective of presence or absence of near-point visual symptoms, or of diagnosed accommodation or vergence disorders. It was hypothesized that asymptomatic subjects would be likely to prefer no add or a low-power add, thus giving a wide range of preferred adds. Further, the goal of the study was to compare the results of the various guidelines with the preferred add in isolation from other test results or considerations. In light of the high SDs of the differences between guidelines and preferred add, one could speculate that the variability of the differences might have been less in subjects with near-point symptoms.

One could also wonder about the criteria that individual subjects used in picking the preferred add and how repeatable the determination of the preferred add may be. Subjects were instructed to make their selection based on ease and comfort of reading. How that instruction was interpreted may have varied from subject to subject.

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Confirmation Procedures for Plus Adds

In the present study, various guidelines for prescribing plus adds for non-presbyopes were compared with the subjectively preferred add. A subjectively preferred add was used in the comparison because many clinicians use subjective preference in a similar way to confirm add powers suggested by clinical test results. Other methods to confirm add power in the clinical setting include improvement on various tests, such as eye movements, stereopsis, or near point of convergence.13,66,73,74 Perhaps, an interesting topic of future study would be comparisons and repeatability of adds recommended by various confirmation procedures, including subjective preference.

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CONCLUSIONS

This study sought to identify dynamic retinoscopy guidelines that could be used to find the plus add power providing the best near-point visual comfort in non-presbyopes. Because the guideline of adding plus to 0.25 D with motion on dynamic retinoscopy differs by about half diopter, on average, from the subjectively preferred lens, it does not appear to be a useful guideline for prescription of plus adds for non-presbyopes. Subtracting 0.25 D from the MEM lag of accommodation and adding plus to a 0.50 D with motion yield adds that average close to the subjectively preferred add, but the SDs of the difference were relatively high. Either of the latter two guidelines could be a reasonable starting point for the prescription of near-point plus adds for non-presbyopes, but follow-up trial frame testing to confirm or adjust the add power is advisable.

David A. Goss

School of Optometry, Indiana University

800 East Atwater Avenue

Bloomington, IN 47405

e-mail: dgoss@indiana.edu

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ACKNOWLEDGMENTS

This study was supported by a grant from the College of Optometrists in Vision Development.

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accommodative response; dynamic retinoscopy; monocular estimation method; near-point lenses; plus lenses

© 2012 American Academy of Optometry

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