University of Gondar

CMHS
Department of Optometry
Binocular vision and ocular motility for
2nd year Optometry students
By Abel S (BSc, MSc)
 Course content
• Accommodation
• Comitant heterophoria
• Investigation of heterophoria
• Fixation disparity
• Fusional reserves
• Stereopsis
Accommodation
 Objectives
 At the end of this session, the student will be
able to:
 Understand the concept of accommodation
 Explain the mechanism of accommodation
 Differentiate accommodative stimulus from
accommodative response
 Describe different accommodative tests
 Accommodation
• Refractive power changes by altering the shape of
crystalline lens
• It is a biophysical property of lens
• It enables both distant and close objects to be brought to
focus on the retina.
• At rest the ciliary muscle is relaxed and the zonules pull on
the lens
• The capsule under tension enabling the eye to focus on
distant objects
• The ciliary muscle contracts in response to
parasympathetic stimulation during accommodation
 Biomechanical & anatomical changes of
accommodation
• The contraction force of the ciliary muscle increases.
• The anterior zonular tension decreases and the
zonules relax.
• The elastic force and viscoelastic properties of the
capsule cause it to become more spherical.
• Thus the overall power of the lens increases
• The lens becomes more convex; ↑ in thickness and ↓
in diameter
• The equatorial diameter decreases by 0.4 mm (from 10
to 9.6 mm).

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 Cont’’’d
• The central thickness increases by 0.36 to 0.58 mm.
• The lens sinks 0.3 mm as a result of gravity
• The lens asphericity changes and the pupil
constricts.
• Accommodation is accompanied by an
increase in negative spherical aberration of
the eye
• The iris constricts during accommodation, to
decrease the optical entrance pupil of the eye
7
Cont’’’d
 Cont’’’d
• Accommodative response results from the
increase in lens convexity
• Elastic lens capsule curvature increases
especially in the front surface
• The posterior focal point is moved forward in
the eye during accommodation
• Correspondingly, the far point moves closer to
the eye
Neural pathways

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 Cont’’’d
• Near point: Nearest point clearly seen with
maximum accommodation
• Far point: Position of an object when its image
clearly falls on retina without accommodation
• Range of accommodation: Distance between
the far point and the near point
 Near point of accommodation
• NPA is the nearest point on which the eyes can
maintain clear focus for small prints.
• The point where accommodation maximally
exerted
• Measured with the RAF rule, the patient
fixates a line of print, which is then slowly
moved towards the patient until it becomes
blurred
• The distance at which this is first reported is
read off the rule and denotes the NPA.
• This is usually measured 1st monocularly then
binocularly
• The NPA recedes with age; when sufficiently
far away to render reading difficult without
optical correction, presbyopia is present.
• At the age of 20 years the NPA is 8 cm
and by the age of 50 years it has receded
to approximately 46 cm.
RAF rule
 Accommodation stimulus
 Accommodative stimuli
• Blur of the object
• Proximity of the target
• Changing target size
• Chromatic aberration
• Convergence of the eyes
 Accommodation stimulus
 Ways to stimulate accommodation
1. Placing test object closer at a distance
closer than infinity
2. Use of minus lens

 Either methods increases vergences of rays of

light in the eye and measured in diopter
 Accommodation stimulus
• Small, high contrast objects stimulate
accommodation mechanism better
• The stimulus for large and low contrast
object is poor.
• In emmetropic eyes
• At 40cm from the spectacle plane requires
2.50D accommodation. So the stimulus for
accommodation at this distance is 2.50D
• If you place -2.50D lens in spectacle: the
stimulus for accommodation is 2.50D.
• The two methods may be used together
• Example
A test object placed at 50cm and -2.00D lens
placed in front of the eye. The stimulus of
accommodation is 4.00D.
 Question
• A patient with myopic vision that were
prescribed incorrectly with an overminus of
1.00 D. What is the stimulus for
accommodation at 20 cm fixation distance?
 Accommodative response
• The response of accommodative system when the eye
changes fixation from one point into another point in
space
• The reaction time is about 370ms
• Haploscope: a device used in research to measure
accommodative response
• Clinically measured with dynamic retinoscopy and
binocular cross cylinder technique
• Static retinoscopy: objectively determines patient
refractive error/ prescription at distance
• Dynamic retinoscopy: objectively determine patients
accommodation/ prescription at near point.
 Dynamic retinoscopy
• Worked without use of working distance
• Patient fixates a target in plane of retinoscope
• Assess accommodation of patient
• Normal value is +0.25 D to +0.75D
• With or against movement on retionscopy
• With movement=lag of accommodation
• Against movement = lead of accommodation
• At distance closer than the resting point , the
amount of accommodation is less than that
required by the stimulus of
accommodation=lag of accommodation
• At distance beyond the resting point, the
amount of accommodation exceeds that
required by the stimulus= lead of
accommodation
 Measurement of accommodation
• Lag of accommodation
• Amplitude of accommodation
• Accommodative facility
• Relative accommodation
 Lag of accommodation
• The amount by which the accommodative response of
the eye is less than the dioptric stimulus of
accommodation.
• The neutral point in dynamic retinoscopy situated
further from the eye than the retinscopic target.
• > +0.75D is clinically significant
• Usually associated with other anomalous
• Assessed with dynamic retinoscopy/ MEM
• Depends on depth of focus
• Depth of focus varies with pupil size and size of objects
 Amplitude of accommodation
• The maximum amount of accommodation the
eye can exert
• Expressed in Diopter
• It is the difference between far point and near
point with respect to either spectacle plane or
corneal apex
• Declines from 14D at age of 14 years to 0.50D
at age of 60 years
 Expected AA at various ages
 Hoffstetter formula for expected amplitude as
a function of age
 Maximum AA = 25-0.4x age
 Average AA = 18.5-0.3x age
 Minimum AA = 15-0.25x age
 Two techniques to measure AA
• Push up/ Donder’s method
• Minus lens method
 Push up method
• First the distance correction must be inplaced
• The patient observes a small print that can be seen
clearly @40cm or arms length.
• Do slightly below eye level with RAF rule, so that the
eye is slightly depressed
• Start with the targets at arms length and slowly moves
the target towards the patient until he/she reports
sustained blur. Note this distance in cm.
• The target is then moved back until the patient can see
it clearly. This distance should be noted.
• Average this values to get average distance
• The dioptric value is the reciprocal of the distance in
meters
• This average dioptric value is the amplitude of
accommodation
• Accommodative amplitude should be measured both
monocularly and binocularly while the patient is
viewing near threshold-sized, high-contrast test letters.
• Monocular value (screen III nerve palsy) should be
more or less equal in each eye (0.25 D difference)
• Binocular value should be about 0.50D greater (at least
in children and young adults) because of the addition of
vergnce accommodation
 Minus lens method
• Distance correction should be inplaced first
• Instruct the patient to observe a finely detailed object
at 40cm
• Test the right eye by covering the left eye and then test
the left eye.
• Add minus sphere on top of distance prescription until
the patient reports blurring of letters
• AA= 2.50D (for a WD of 40cm )+ added minus lens
• This is not possible for binocular amplitude (disturbs
convergence and accommodation relationship)
• Example
If a -4.00 D minus sphere on top of distance
prescription blurs letters at 40cm, what will be
the amplitude of accommodation?
 Recording
• Recording of amplitude of accommodation
OD: 10D OS: 9D OU: 11D
• AA value with push up method is slightly higher
than minus lens method
• The normal AA decline with age until around 55
years, when all that is left is depth of focus
• Depth of focus increases due to miosis
associated with aging.
• So there is little point in measuring AA in
patients over the age of 55 years.
• A decline in AA with age is called presbyopia.
 Facility of accommodation
• Flexibility of the accommodative system by rapidly
alternating the viewing distance under monocular or
binocular conditions.
• The dynamics (latency and speed) of the
accommodative response
• It is the speed with which a patient increase or
decrease the amount of accommodative play
• This test is not appropriate for moderate (<4.5DS
amplitude of accommodation) or absolute
presbyopes
 Facility measurement
 Two techniques
 Near far test: the patient change their
accommodation from one distance to another
 Flipper lens test: by the alternate use of plus
and minus flipper lenses
 Flipper lens test
Children 8-12yrs: ±2.00D Flipper
13-30yrs: use amplitude scaled power & test
distance for BAF
Amplitude scaled power
-Test distance = 45% of amplitude Lens
-Power range = 30% of amplitude/2
 Question
• If the amplitude of accommodation is 9D,
what will be the testing distance and flipper
power of the facility test?
 Procedure
• If the patient wears glasses for close work,
these should be used.
• Hold smallest seen 6/9 target @40 cm from
the patient’s face at eye level
• Place the +2.00D lens in front of the patient’s
eyes.
• The test is initially performed binocularly
Accommodative Facility procedure
• Ask the patient to try to get the letters clear and single
• Instruct the patient to report clear (say “clear”)
• When the letters are reported to be clear, quickly flip the flipper so
the minus side is before the same eye, again instructing the subject
to read the letters and report when the letters appear clear
• Continue alternating sides of the flipper lenses for 1 minute,
calculating the cycles per minute achieved (1 cycle = plus and minus).
• Repeat the procedure monocularly if the patient is unable to pass
binocularly.
• Record the cycles per minute. Record if one side (plus or minus) of
the flippers was more difficult, or if neither side was more difficult.
• Monocularly, expect a minimum of 12 cycles per minute (6 cycles per
30 seconds).
 Recording
• The patient can complete 18 flips in 1 minute.
This equals 9 cpm.
• If the patient cannot clear −2.00 at all, record as
0 cpm, fails minus.
• If the patient cannot clear +2.00 at all, record as
0 cpm, fails plus.
• If the patient reports diplopia, record as 0 cpm,
diplopia with +2.00 or diplopia with −2.00
 Normal value is 11 cycle per minute for adults
 Relative accommodation
 It is the total amount of accommodation,
which can be exerted while the convergence
of the eyes is fixed.
 Performed binocularly only
 Target size: 6/6 letters on near acuity
 Can be positive and negative
• NRA
– A measure of the maximum ability to relax accommodation
– Plus to blur
– Expected value : +2.00+/-0.50D
– Shows positive fusional vergence limit.
• PRA
– A measure of the maximum ability to stimulate accommodation
– Minus to blur
– Expected value : -2.37+/-1.00D
– Shows negative fusional vergence limit
 PRA & NRA measurement
• Instruct the patient to look at the target and keep it clear and
single & tell to report as soon as the letters become blurry or
double
• Add plus lenses in +0.25 D increments until the patient reports
the first sustained blur or diplopia.
• Record the amount of plus added above the distance prescription
as the NRA.
• Remove the plus lenses and return to the distance prescription.
• Add minus lenses in −0.25 D increments until the patient reports
the first sustained blur or diplopia.
• Record the amount of minus added above the distance
prescription as the PRA.
Thank you!