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www.journalofoptometry.org

ORIGINAL ARTICLE

Accommodative and binocular vision dysfunctions in a

Portuguese clinical population
Sandra Francoa,*, Alexandra Moreirab, Ana Fernandesb, Anto

nio Baptistaa

a
Centre of Physics, University of Minho, Braga, Portugal
b
Clinical Practice, Braga, Portugal

KEYWORDS Abstract
Accommodation; Background: Several studies have suggested that accommodative and non-strabismic binocular
Binocular vision; dysfunctions are commonly encountered in optometric practice. This study aims to verify
Dysfunction; whether these findings apply to a Portuguese clinical population.
Normative values Methods: This study included consecutive nonpresbyopic subjects that came to two Portuguese
optometric clinics over a period of six months. A complete visual exam was conducted and
included the measurement of visual acuity (VA), refraction, near point of convergence (NPC),
distance and near phoria, near and distance fusional vergences, amplitude of accommodation
(AA), monocular accommodative facility (MAF), relative accommodation and lag of
accommodation.
Results: 156 subjects with a mean age of 24.9 § 5.3 years (from 18 to 35 years old) participated
in the study. Of all subjects, 32 % presented binocular vision and/or accommodative disorders
accompanied or not by refractive errors. Moreover, 21.1 % had accommodative disorders, and
10.9 % had a binocular vision dysfunction. Accommodative insufficiency (11.5 %) was the most
prevalent disorder, followed by convergence insufficiency (7.1 %) and accommodative infacility
(5. 8 %).
Conclusions: Clinicians should be aware that about one third of the optometric clinical popula-
tion could have accommodative and/or non-strabismic binocular disorders. Accommodative
insufficiency was the most prevalent dysfunction presented in the studied population, followed
by accommodative infacility and convergence insufficiency.
© 2021 Published by Elsevier España, S.L.U. on behalf of Spanish General Council of Optometry.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Introduction vision tasks. Several studies have suggested that accommo-

dative and non-strabismic binocular dysfunctions are com-
Accommodative and non-strabismic binocular vision dys- monly encountered in optometric practice. However, there
functions are visual disorders that could affect the visual is still certain discrepancy with regard to the prevalence val-
performance of subjects, particularly when performing near ues presented by different authors (Table 1). One of the
main reason for these discrepancies may be the various diag-
nostic criteria used to classify the accommodative and bin-
* Corresponding author.
E-mail address: sfranco@fisica.uminho.pt (S. Franco). ocular dysfunction1 as well as different study populations.2

https://doi.org/10.1016/j.optom.2021.10.002
1888-4296/© 2021 Published by Elsevier España, S.L.U. on behalf of Spanish General Council of Optometry. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: S. Franco, A. Moreira, A. Fernandes et al., Accommodative and binocular vision
dysfunctions in a Portuguese clinical population, Journal of Optometry (2021), https://doi.org/10.1016/j.
optom.2021.10.002
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S. Franco, A. Moreira, A. Fernandes et al.

For example, extended focusing and vergence efforts lead to retinoscopy with the Monocular Estimate Method (MEM), and
adaptive behaviours in the accommodation and vergence the AF started with the plus lens and using a § 2.00 D flipper.
systems.3 and the university students, one of the main popu- 4 Horizontal phorias and positive and negative fusional ver-
lation studied, spend several hours performing near vision gences were determined for both distance and near
tasks what could result in an higher prevalence of accommo- vision with the von Graefe method. The negative fusional
dative and binocular dysfunctions compared to other popu- vergence was measured before the positive fusional ver-
lations.4 On the other hand, the norms used to compare the gence. The near point of convergence (NPC) was mea-
results of the clinical exams are usually the same for differ- sured with an accommodative target
ent populations, which can drive in some cases to false posi- 5 Ocular health exam with ophthalmoscopy and biomicro-
tives and, in other cases, to false negatives. scopy.
Considering that binocular and accommodative dysfunc-
tions are pointed out as common findings, the principal The selected optometric tests were due to their generali-
objective of this study is to determine their prevalence in a zation in the clinical practice and the availability of related
Portuguese population from optometry offices, with the normative data studies. Namely, the results of the tests
scope of guiding clinicians in their practice. We also aim to were compared with the expected values according to
compare our clinical exams results with the norms usually Morgan.12,13 Accommodative and nonstrabismic binocular
used and verify if the values found in our population are in dysfunctions were diagnosed according to the criteria pre-
accordance with them. Understanding the most frequent sented by Lara et al. (Table 2).5 These researchers divided
symptoms in this type of dysfunctions, as well as the most signals into two categories: fundamental and complemen-
altered clinical results, can help clinicians to diagnose these tary and to be diagnosed with a dysfunction, a subject has to
problems more easily. have the fundamental signals and at least two of the com-
plementary signals of the respective dysfunction. A subject
not satisfying these criteria or only with a refractive error
Material and methods were considered as “normal”.
Statistical analysis was performed using SPSS (Statistical
This study included 156 consecutive nonpresbyopic patients Package for Social Sciences, version 22) software. As a mea-
who visited two private optometric clinics located outside sure of central tendency the mean was used, and as a mea-
university campus over 6 months. Patients aged between 18 sure of dispersion the standard deviation. In order to apply
and 35 years old and visual acuity correctable to at least 6/6 the parametric and non-parametric statistical tests, it was
were included in the study whether they accepted the invi- verified the normality assumption of the distributions of the
tation to participate. Those with a history of systemic or variables. For that, the Kolmogorov-Smirnov (K-S) test was
ocular disease, taking any medication, wearing contact lens, used, which places the null hypothesis of the variable fol-
with strabismus or amblyopia were excluded. lowing a normal distribution. It was considered the existence
All the subjects signed an informed consent form and the of normality of the distribution of variables for values of sta-
protocol was approved by the Ethical Committee of the Sci- tistical significance p > 0.05.
ences School of University of Minho and posteriorly, by the The mean values were compared using the t-test and
Comissa

~o de Etica ~o em Cie
para a Investigaç a ^ncias da Vida e ANOVA, for variables with normal distribution and the Mann-
da Sau
de (CEICVS) of University of Minho Whitney and Kruskal-Wallis for variables without normal dis-
A complete visual exam was conducted and included the tribution. For all hypotheses tested, a p  0.05 was consid-
following procedures and tests: ered statistically significant.

Results
1 A case history, with particular attention for the symptom-
atology. It was asked how often (i.e., never, rarely, some- One hundred fifty-six subjects with mean age of 25.8 §
times, frequently or always) the patients had the typical 5.3 years (from 18 to 35 years old) participated in the study.
symptoms of accommodative and binocular vision disor- Fifty-eight percent were women and they all came to the
ders.22 These symptoms included asthenopia, headache, optometric clinics during the study period.
blur vision at near and/or at distance, diplopia, photo- The mean (§ SD) spherical equivalent was -0.80 §
phobia. The patient was considered as having a symptom 1.60 D, being myopia (49 %) the most prevalent refrac-
if he/she reported to feel it at least sometimes. tive error; followed by emetropia (33.3 %) and hyperopia
2 Objective and subjective refraction. Static retinoscopy (17.6 %). Thirty-nine percent of the subjects presented
was done, followed by the subjective exam with an end- at least one of the symptoms being distance blurred vison
point of maximum plus for best visual acuity. This correc- (23.7 %) the most prevalent, followed by asthenopia
tion was then used during all the accommodative and (17.3 %) (Figure 1).
binocular vision exams. In Table 3, it can be found all the binocular and accommo-
3 The accommodative tests performed were amplitude of dation clinical findings as well as their expected values
accommodation (AA), positive and negative relative according to Morgan.12,13 It can be seen that several clinical
accommodation (PRA and NRA), lag of accommodation findings are significantly different from the expected values.
and accommodative facility (AF). The amplitude of accommodation, PRA and MAF are lower
AA was determined by the minus lens method, the NRA was from the expectable findings, particularly for the AA and
obtained before PRA, the lag of accommodation by dynamic MAF values where there is a difference of 1,85 D and 3 cpm,

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Table 1 Prevalence of binocular vision dysfunctions obtain in different studies.

Authors (year) N Population/Country Results
5
Lara et al. (2001) 265 Optometric clinic/Spain Accommodative disorders: 9.4 %
Binocular dysfunctions: 12.9 %
Hoseini-Yazdi et al. (2015)6 83 Optometric clinic/Iran Accommodative disorders: 7.2 %
Binocular dysfunctions: 12.1 %
Richman and Laudon (2002)7 48 University students/USA Accommodative disorders: 15 %
Binocular dysfunction: 27 %
Porcar and Martinez-Palomera (1997)8 65 University students/Spain Accommodative disorders: 17 %
Binocular dysfunction: 15.3 %
Hokoda (1985)9 119 Optometric clinic/USA Accommodative disorders: 16.8 %
Binocular dysfunction: 4.2 %
Ovenseri-Ogbomo and Eguegu (2016)10 212 University students/Nigeria Binocular dysfunction: 12.7 %
~oz et al. (2016)11
García-Mun 175 University students/Spain Accommodative disorders: 2.3 %
Binocular dysfunction: 8 %

respectively. The phoria for near vision was lower than In our study, accommodative dysfunctions were pre-
expected. Conversely, most of the fusional vergence param- sented in 21.1 % of the subjects evaluated being the
eters were higher than the expected values. accommodative insufficiency the more prevalent accommo-
For all the findings, only PRA (p = 0.035) and MAF dative disorder (11,5 %).
(p = 0.032) were statistically significant different between The literature revised show a significant discrepancy
those subjects who were asymptomatic (mean PRA = -2.00 D regarding the prevalence of accommodative dysfunctions. In
(SD = 0.93 D) and mean MAF = 8.3 cpm (SD = 4.7 cpm)) and the study carried out by García-Mun ~oz et al.,11 the preva-
those symptomatic (Mean PRA = -1.80 D (SD = 0.95 D) and lence of accommodative dysfunctions found was 2.29 %,
mean MAF = 6.5 cpm (SD = 4.7 cpm)). For all the other clini- which is considerably lower than that obtained in our study.
cal findings, the differences were not statistically significant In turn, Lara et al.5 evaluated 265 symptomatic patients
(p > 0.05) between symptomatic and non-symptomatic sub- from a clinical population, aged between 10 years and
jects. 35 years, and they found a prevalence of 9.4 % for accommo-
Subjects who complain of asthenopia presented lower dative anomalies. Although this value is higher than that
values of MAF (p = 0.03), blur value of the distance PFV (p = obtained by García-Mun ~oz et al.11 still is considerably lower
0.014) and recovery value of the distance NFV (p = 0.04) than that obtained by us. Hokoda9 found a prevalence of
(Table 4). The amplitude of accommodation was lower for 9.2 % for accommodation insufficiency, 5.1 % for accommo-
those subjects with complaints of near blurred vision (p = dative infacility and 2.5 % for accommodation excess, which
0.013) and subjects that complains from distance blurred are also lower than the findings of our study. However, the
vision presented a lower PRA (p = 0.009) and a more myopic diagnostic criteria used by Hokoda were different from ours.
refractive error (p = 0.019). Diplopia was related with the The prevalence of accommodative disorders found in our
distance phoria (p = 0.024). study is higher than the prevalence presented by other
Of the 156 subjects examined (Table 5), 32.0 % presented authors 5 11 except for those findings reported by Montes-
a binocular vision or accommodative disorders accompanied Mico
14 in a clinical population of Valencia, Spain. The author
or not by refractive errors. Of all the subjects, 21.1 % had found that 34.6 % of subjects presented an accommodative
accommodative disorders and 10.9 % had a binocular vision disorder being the accommodative insufficiency the most
dysfunction (Table 5). Accommodative insufficiency (11.5 %) prevalent (11.4 %), followed by accommodative infacility
was the most prevalent disorder followed by convergence (10.3 %).
insufficiency (7.1 %) and accommodative infacility (5.8 %). Like other studies, we obtained a higher prevalence of
The normal group represents the subjects who presented accommodative dysfunctions than binocular vision
just a refractive error or no visual/ocular problems. disorders.9,11 However, other authors reported a higher
prevalence of binocular vision disorders.5 8,11 For instance,
Lara and colleagues5 found a higher prevalence of binocular
vision disorder (12.9 %) compared to accommodative disor-
Discussion ders (9.4 %). These authors also reported a higher preva-
lence of accommodative excess (6 % ) than accommodation
Several studies have suggested that accommodative and insufficiency (3.0 %). These findings are also closer to those
non-strabismic binocular dysfunctions are commonly reported by Porcar and Martinez-Palomera.8 They studied
encountered in optometric practice.5 11 As the prevalence the prevalence of general binocular dysfunction in a univer-
of these dysfunctions among the Portuguese population was sity students’ population. García-Mun ~oz et al.11 research
not well known, our study evaluated its prevalence in a clini- also pointed out that binocular dysfunctions were more
cal population of the north of Portugal and one-third of the prevalent than accommodative disorders in a university stu-
participants have accommodative or binocular dysfunctions dent’s population.
stressing the importance of discarding these dysfunctions The described differences could be related to the type of
during an optometric examination. population studied, i.e., clinical or non-clinical, the

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Table 2 Fundamental and complementary signs used as diagnosis criteria for accommodative and binocular dysfunctions.
(Adapted from Lara et al.5).
Dysfunction Fundamental signs Complementary signs
Accommodative Reduced AA: 2.00 D < Minimum AA (15 - BAF < 3 cpm (difficulty with -2.00 D lenses)
insufficiency 0.25x age) MAF < 6cpm (difficulty with -2.00
D lenses)
MEM  + 0.75 D
PRA < 1.25 D
Acommodative excess MAF < 6 cpm with + 2.00 D lenses BAF < 6 cpm (difficulty with +2.00 D lenses)
MEM  + 0.25 D
NRA < 1.50 D
Accommodative MAF < 6 cpm with § 2.00 D lenses
infacility BAF < 3cpm (difficulty with § 2.00 D lenses)
PRA  1.25 D
NRA  1.50 D
Convergence insufficiency Significative exophoria at near vision ( 6 PFV at near  11/ 14/ 3 D (at least one of
D), greater than far vision three)
NPC  6 cm
MEM  0.25 D
NRA < 1.50 D
Convergence excess Significative esophoria at near vision ( 1 D), NFV at near  8/ 16/ 7 D (at least one of
greater than far vision three)
MEM > + 0.75 D
PRA < 1.25 D
Divergence excess Significative exophoria at far vision ( 4 D), NFV at far  X / 3/ 1 D and  8/ 16/ 7 D at
greater than near vision (the difference must near (at least one of three)
be > 5 D)
Basic esophoria Significative esophoria at far and near vision NFV at far  X /3/1 D and ¨ 8/16/7 D at
of equal amount near (at least one of three)
MEM  + 0.75 D
PRA < 1.25D
Basic exophoria Significative exophoria at far and near vision PFV at far  4/10/5D and  11/ 14/ 3 D at
of equal amount near
MEM  + 0.25 D
NRA < 1.50 D
AA: Monocular Amplitude of Accommodation; MAF: Monocular Accommodative Facility; BAF: Binocular Accommodative Facility; MEM:
Monocular Estimate Method retinoscopy; PRA: Positive Relative Accommodation; NRA: Negative Relative Accommodation; NPC: Near Point
of Convergence; NFV: Negative Fusional Vergence; PFV: Positive Fusional Vergence.

methods used to evaluate both accommodation and binocu- According to Burns et al.,15 there is no agreement in the
lar vision, and the diagnosis criteria. For binocular vision, literature about the best method to access accommodation
the fundamental signs (Table 2) compare near and far pho- amplitude. Moreover, five different methods may be used:
rias and the amplitude of phorias. According to the norms, push- up, push-down, push-down to recognition, negative
the mean far and near phorias obtained are closer to each lenses (Sheard's method) and dynamic retinoscopy.15 Rosen-
other than expected and with diminished amplitude. On the field and colleagues16 reported that the push-up, push-down
other hand, the normative values in the set of complemen- and negative lens methods had good repeatability. They also
tary signals (Table 2) are smaller than the mean values reported that push-up values tend to be abnormal higher
obtained. Both situations might have resulted in a relatively than those obtained with the push-down and negative lens
reduced number of positives for binocular dysfunctions. methods. These differences are related to the increase of
The amplitude of accommodation is an important param- the accommodative response induced by the approximation
eter for the diagnostic of accommodative dysfunctions, and of the target17 to the subject and the increase of the letter's
this is of great relevance since the method used for its deter- angular size produced. These two factors delay the moment
mination can influence the final results. In our study, the the patient reports blur vision.
accommodation amplitude was measured by the Sheard On the other hand, Taub et al.18 reported that the neg-
method. It was obtained a mean value of 8.90 D, which was ative lens method produces lower accommodation ampli-
lower than the minimum expected for age (10.7 D). This dif- tude results. The push-up method produces the most
ference was statistically significant (P0.001). consistent results in adults when faced with the normative

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Fig. 1 Frequency of the symptoms reported by subjects.

values obtained with the application of the Hofstetter

formula.18
Regarding non-strabismic binocular vision, 10.9 % of the
Table 3 Binocular and accommodative findings and subjects were diagnosed with a binocular vision dysfunction.
Morgan’s expected findings.12,13 This prevalence is close to those obtained by Lara et al.5
Test Mean § SD Expected P (12,9 %), Hoseini-Yazdi et al.6 (12.1 %), and Ovenseri-
findings Ogbomo and Eguegu (12.7 %).10 The first two studies from a
clinical population and the last from university students.
AA (D) 8.91 § 1.95 10.76 § 1.58a < 0.001
García-Mun ~oz et al.11 found a smaller prevalence (8.0 %).
MEM (D) +0.70 § 0.22 +0.50 § 0.25 0.016
PRA (D) -1.99 § 0.94 -2.37 § 1 < 0.001 Richman and Laudon7 (27 %) and Porcar et al.8 (15.3 %) found
NRA (D) +1.95 § 0.42 +2.00 § 0.50 0.17 higher prevalence. These last three studies derived from
MAF (cpm) 8§5 11 § 5 < 0.001 university students’ population. Hussainde et al.19 (19.7 %)
NPC break(cm) 5.9 § 2.9 5 § 2.5 0.007 and Monte
14 (21.7 %) also found higher prevalence the

s-Mico
NPC recovery (cm) 7.6 § 3.5 7§3 0.13 first from an urban pediatric population and the second also
Phoria (D) from a clinic population.
Distance 0.85 § 3.3 1§2 0.15
In our study, convergence insufficiency was the more
Near 1.8 § 5.2 3§3 < 0.001
PFV (Distance) (D) prevalent binocular disorder (6.9 %) followed by conver-
Blur 14 § 7 9§4 < 0.001 gence excess (3.8 %). Similarly to Hussainde et al.18 (con-
Break 22 § 8 19 § 8 < 0.001 vergence insufficiency: 16.5 %; convergence excess: 1.4
Recovery 10 § 5 10 § 4 0.35 %) using the Modified Thorington to assess the horizontal
NFV (Distance) (D) phoria and García-Mun ~oz et al.11 (convergence insuffi-
Break 12 § 7 7§3 < 0.001 ciency: 3.4 %; convergence excess: 2.3 %) using the cover
Recovery 6§4 4 §2 < 0.001
test to assess the horizontal phoria. In Porcar and Marti-
PFV (Near) (D)
Blur 20 § 8 17 § 5 < 0.001
nez-Palomera8 study they used the von Grafe technique
Break 27 § 9 21 § 6 < 0.001 for measure the horizontal phoria and they reported con-
Recovery 17 § 8 11 § 7 < 0.001 vergence insufficiency as the most prevalent binocular
NFV (Near) (D) condition (7,7 %). However, this figure was aggregated to
Blur 14 § 5 13 § 4 0.03 accommodative excess. Also, Monte
s-Mico
14 found con-
Break 19 § 6 21 § 4 0.002 vergence insufficiency as the most prevalent (5.9 %) but
Recovery 12 § 5 13§5 0.002
in this study convergence excess was the less prevalent
a
Computed from age according to Hofstetter formula (1.5 %). Although they also used the von Grafe method to
AA=18.5 0.3 £ age. evaluate the horizontal phoria, the diagnostic criteria
AA: Monocular Amplitude of Accommodation; MAF: Monocular were different from our study.
Accommodative Facility; MEM: Monocular Estimate Method reti- Once more, differences could be explained by the type of
noscopy; PRA: Positive Relative Accommodation; NRA: Negative population studied, i.e., clinical or non-clinical, the meth-
Relative Accommodation; NPC: Near Point of Convergence; NFV:
ods used to evaluate the binocular vision parameters, and
Negative Fusional Vergence; PFV: Positive Fusional Vergence.
the diagnosis criteria. Patients who visit an optometry clinic
are more likely to have complaints of a visual anomaly than

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Table 4 Differences in the test results between symptomatic and asymptomatic subjects.
Symptom Exams

MAF (cpm) PFV (Distance): Blur (D) NFV (Distance): Recovery (D)
Asthenopia Yes 6 10.3 4.4
No 8 14.6 5.9
p-value 0.03 0.014 0.04
Near blurred vision Amplitude of
accommodation (D)
Yes 7.0
No 9.1
p-value 0. 013
Distance blurred vision PRA (D) Refractive error (SE) (D)
Yes -1.74 -1.10
No -2.06 -0.65
p-value 0.009 0.019
Diplopia Distance phoria (D)
Yes 3.3
No 0.6
p-value 0.024
MAF: Monocular accommodative facility; cpm: cycles per minute; PFV: positive fusional vergence; NFV: negative fusional vergence;
PRA: positive relative accommodation; SE: spheric equivalent.

if they would have been selected at random from the gen- prevalence of non-strabismic binocular vision disorders,
eral population. Thus, this less representativeness of the namely convergence insufficiency and convergence excess,
general population and greater probability of bias towards found in the present study.
higher prevalence figures can explain differences between Blurred vision, headaches and asthenopia were the most
our results and those from Garcia-Mun ~oz et al.11 prevalent reported symptoms in our study. This is in accor-
There are different methods to measure the horizontal dance with the findings reported by other authors.19,22 The
phoria. According to Canto
-Cerda
n et al.20, von Graefe symptom of headache was more prevalent among those sub-
method produce more exophoric mean values than the cover jects who were diagnosed with an accommodative disorder
test. Maples et al.21 concluded that a higher percentage of while asthenopia was common to both accommodative and
patients would be classified with binocular vision anomalies binocular vision disorders. As expected, blurred vision was
if a clinician measure phorias using the von Graefe technique more prevalent among subjects with a refractive error, fol-
than would be classified using the modified Thorington tech- lowed by those diagnosed with accommodative and binocu-
nique. According to the authors, the Von Graefe method will lar vision disorders. The complaint of blurred vision at near
provide the diagnoses of convergence insufficiency and of was significantly more prevalent among those with an
convergence excess more often than the modified Thoring- accommodative disorder.
ton method.21 This can be a motif to explain the higher There are a number of limitations of our study. Although
it is one of the few studies characterizing the binocular and
accommodative status in terms of prevalence and symp-
Table 5 Prevalence of the accommodative and binocular tomatology associated with the Portuguese population, the
vision dysfunctions. results cannot be straight generalized to all population con-
sidering they came from clinical settings. In addition to
Dysfunction Number of Prevalence
these circumstances, the visual tests used to access vision
Subjects (%)
respected the exam routine of clinicians collaborating with
Accommodative 33 21.1 the study. In some cases, this resulted in preventing the
dysfunction selection of tests with better features for research pur-
Accommodative 18 11.5 poses. For example, measuring phorias with an objective
Insufficiency test like the Cover Test would be better than a subjective
Accommodative 9 5.8 test like von Graefe. In addition, the first has better
Infacility repeatability.
Accommodative Excess 6 3.8
Binocular dysfunction 17 10.9
Convergence 11 7.1 Conclusions
Insufficiency
Convergence Excess 6 3.8 Clinicians should be aware that accommodative and non-
Normal group 106 68 strabismic binocular disorders are common among non-pres-
Total 156 100 byope adult patients attending a general optometric office.
Accommodative insufficiency was the most prevalent

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dysfunction, followed by convergence insufficiency and 8. Porcar E, Martinez-Palomera A. Prevalence of general binocular
accommodative infacility. The amplitude of accommodation, dysfunctions in a population of university students. Optom Vis
PRA and MAF were lower than the reference values while the Sci.. 1997;74:111 113. https://doi.org/10.1097/00006324-
results for the binocular vision exams were similar. 199702000-00023.
9. Hokoda S. General binocular dysfunctions in an urban optome-
try clinic. J Am Optom Assoc. 1985;56:560 562.
Author Contributions 10. Ovenseri-Ogbomo GO, Eguegu OP. Vergence findings and hori-
zontal vergence dysfunction among first year university stu-
Conceptualization, Supervision SF.; Investigation, AM., AF.; dents in Benin City, Nigeria. J Optom.. 2016;9:258 263.
Formal Analysis and methodology, SF; AB.; Data Curation, https://doi.org/10.1016/j.optom.2016.01.004.
11. García-Mun
Carbonell-Bonete S, Canto
~oz A,
-Cerda

n M, Cacho-
SF; AB.; Writing—Original Draft Preparation, SF.; Writing—
Martínez P. Accommodative and binocular dysfunctions: preva-
Review and Editing, SF, AB.
lence in a randomised sample of university students. Clin
Exp Optom. 2016;99:313 321. https://doi.org/10.1111/cxo.
Acknowledgments 12376.
12. Scheiman M, Wick B. Clinical Management of Binocular Vision:
Heterophoric, Accommodative, and Eye Movement Disorders.
This work was supported by the Portuguese Foundation for
Philadelphia: Lippincott Williams & Wilkins; 2008.
Science and Technology (FCT) in the framework of the Stra- 13. Morgan MW. Analysis of clinical data. Am J Optom Physiol Opt.
tegic Funding UID/FIS/04650/2019. 1944;21:477 491.
14. Monte
s-Mico
R. Prevalence of general dysfunctions in binocular
vision. Ann Ophthalmol. 2001;33:205 208. https://doi.org/
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