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General binocular dysfunctions
in
an
urban optometry clinic 
Steven
C.
Hokoda,
0.0.
Abstract: The prevalence
oj
general binocular dysfunction
with
asthenopia
was
determined for non-presbyopes
aJ.
an urban optometry clinic serving municipal workers
and
their dependents.
Of
the
sam:"
pIe
of
119
patients.
42.9%
had
jobs
wilh
heavy desk work
de-
mands (primarily secretarial
and
clerical)
and
39.5%
werestudertls.
De
prevalence
ot
s
'm
tomatic
en
7
bmocu-
'S
untion
was
21.0
o.
Accommodative ysJunctions
were
the most commonly' encountered condition
aC
16.8%.
. SJ'mplomatic near esophoria
was
found in
5.9%
of
paJients
and
convergence insufficiency
in
4.2%.
Both vergence dysfunci ions overlapped. with
ac-
commodative dysfuncliQns.Key
words:
prevalence, general binocular ·dysfunction. esophoria, convergence
insuf 
jiciency. accommodative dysfunelion. asthenopia 
(ntroduction
Although general binocular dysfunctions (non-strabismic
or am
blyopic) are a popuJar topic in
the
ophthalmic literature,' very littleprevalence
data
is
available.
2
For the
one condition that has been frequently reported on, convergence
i
nsu fficiency, a wide range
of
prevalence rates are seen, although mostare between one and ten percent.
2
,)
Accommodative dysfunctions arealso
commonly discussed;
but
prevalence
data
is
sparse,l
Robinson" found a 14.4% preva'lence
of
accommodative insufficiency in a small group (n
=
13)
of
normal children, while Hoffman
s
found clinically
abnonnal
accommodation in 44%
of
twenty-fivenon-learning disabled children. Neither study reported on associatedasthenopia. Hennessey et al
6
had a23.3% prevalence rate for symptomatic accommodative infacility
among
sixty randomly selected children who had previously passed acomprehensive visual screening.Morgan's' normative
data
predictsabout twelve percent
of
non-presbyopes will have significant nearesophoria
(>2
prism diopters),
but
prevalence
of
symptomatic nearesophoria has not been reported.Presented here are prevalencefigures for symptomatic general binocular dysfunctions (near
es0-
phoria, convergence insufficiency,accommodative insufficiency, accommodative infacility,
and
accommodative spasm) among non-presbyopic clinic patients
at an
urbanoptometry clinic for municipalworkers and their dependents.
Method
Clinic records were reviewed for
pa-
tients seen by the
author
betweenSeptember, 1981, and March, 1982,
at
a municipal workers' union optometry clinic serving union
mem
bers and their dependents in NewYork City, New York.
The
author
saw patients on a part-time basis
and
examined approximately
390
patients. An estimated 4000
pa-
tients were seen at the clinic duringthis period. Only records for
pa-
tients aged thirty-five years
and
younger were reviewed in
order
tominimize overlap
of
accommodative dysfunctions with presbyopicchanges.General binocular dysfunctionpatients had both
abnonnal
clinicalfindings and associated asthenopic
symptoms
which would not
be
addressed by correction
of
the refractive error alone. They had healthyeyes
and
no strabismus
or
amblyopia. Patients with abnormal clinical findings
but
who were asymptomatic were excluded
and
countedas normals, as were those patientswith asthenopia
but
whose accom
modative-convergence
findings
were normaL Dysfunctions were divided into vergence dysfunctions(near esophoria
and
convergence insufficiency)
and
accommodativedysfunctions (insufficiency, infaciJity,
and
spasm). Table 1 lists criteriafor inclusion within each dysfunction group.
Qinical
norms
were derived from Morgan's
norms'
andPacific University College
of
Op
tometry
norms,'
and
generally represent
at
least
one
standard deviation from the mean finding for thatmeasure
..
Results
One
hundred
and
nineteen nonpresbyope records were reviewed.Errors in recordkeeping probably
account
for
about
a ten percent unselected undercount
of
patients
ex-
amined.
Mean age for the
&roup
was
22.9
±
9.0 years, with the youngestbe.ing four years
of
age (one girl and
one
boy).Table 2 presents the generalbinocular dysfunction data. Overall.21.0% showed
abnormal
clinicalfindings
and
associated asthenopia.
Mean
age
of
dysfunction patients,22.7
±
8.3 years (youngest, a six yearold girl), was not significantly differ
ent
from the mean age
of
all patients(t
=
0.83,
p>
0.20). Female to maleratio for general binocular dysfunction patients,
68.0%/32.0%,
did notdiffer significantly from the ratio
for
non-dysfunction patients, 67.0%/
33.0%
(x
2
=
0.02,
p>
0.20).
560 Journal of
the
American Optometric Association
 
Near esophoria had a 5.9%prevalence rate, with 71.4%
of
thesepatients showing an accommodative dysfunction (57.1
%
with insufficiency and 14.3% with infacility).Convergence insufficiency occurredin 4.2%
of
patients, with 40.0% alsohaving
an
accommodative dysfunction (20.0% with insufficiency and20.0% with infacility).
The
mostprevalent conditions were accommodative dysfunctions, with a16.8% occurrence rate.
The
most
common
accommodative dysfunction was insufliciency. 9.2% (36.4%
of
these patients had near esophoriaand
9.1
%had convergence insufficiency), followed by infacility,
5.1
%
(16.7% with esophoria),
and
spasm.2.5% (33.3% with convergence insufficiency), Table
J
provides abreakdown
of
the accommodativedysfunction data.
As
for near visual demands,48.0% (n
=
12)
of
dysfunction patients had primarily desk work related jobs (largely secretarial
and
clerical): 40.0%
(0
=
10)
were students; and 12.0% (n
=
3)
had
minimal near visual demands.
For
nondysfunction patients, 41.5% (n
=
37) had
jobs
primarily near workoriented (again largely secretarial
and
clerical); 39.4% (n
=
34) werestudents;
and
19.1% (n
=
18)
had
minimal near visual demands. Achi-square comparison
of
dysfunction patients
and
non-dysfunctionpatients showed no significant difference io these visual
demand
distributions
(x
2
=
0.77.
p>
0.20).
Discussion
The
population sample reviewedhere showed overall strabismus andamblyopia prevalence rates similar
to
previously reported general population figures (5.9% strabismusprevalence versus a general population prevalence
of
about
six per
cent,l
and 20/40 or
worse best spectacle corrected amblyopia prevalence
of
2.5% versus a general population figure
of
about
three
IO
percentl.
).
Further, the 4.2% convergence insufficiency occurrencerate was consistent with previouslyreported prevalence rates.
2•3
Thesesimilarities allow
one
to look
at
theesophoria
and
accommodative dysfunction occurrence rates, as well as
the
overall 21.0% general binocular
Table. 1:
~Jassification
criteria
for:
general
binoc~lar
dysfuri<?tions,"
Vergence
Dysfunctions
Esophoria 
. Patient
must
show
both: 
1.
Near
fj:SOphoOa
>2
prism diopters. 
'.
'.
2. 
Symptoms
with
vergence
testing
sUnitar
to
those
wfth
habCtuaI
use
of
the
eyes.
8.r'd/or
~ ~
..
CXX'!lfort
with
COflY8X
laos
adds
redodng
the
eso
de~tion.
. .
.'
..
' .
In
additioo.
patient
must
have
either.
1.
Decreased
refative
~«geoc:e.
::s9/17/8.
tor
~ur.
diplopia.
and
fusion
recovery
(at
least
one
finding
1oW).
2.
Eso~ation
disparity
at
near
(rnooocuIaI1y
seen
fiduciary
lines
wfth
8
3.6
degree
round
first
f u ~
con~.
Convorgence
Insuftidency 
PatHiKlt
must
show: 
1. Symptoms
associated
with
V6f"genc6
tosting similar
to
symptoms
habituaftv
Olq...A1enoed
wtth near
visual
demands.
In
addition,
patient
must
have
ettner:
..
.'
.
1.
Convergence nearpoklt equal to or
o u ~
5"[7"
for
bss
and
re<::oYe(y
Of
fuston.
aoo/Of'
excesstve,
s ~
to maintain
fusion
It
or
outside
8"'.
. 
•....
. 
Decreased
~tive
convergence.
:s
12/15/4.
for
bkK,
diplopia,
and
fusion
reco
"'1
(at
least
one
w,,<
..
Aoc;ommodative
Dysfunctions .
In6ufflc;iency
Patient must
show:
1.
Symptoms
with
aocommodative testing
sit"nKar
toflatlftual
~ye
~ ;
and/or
i\cr8ased
comfort
wtth
c:onvex
lens
adds. 
In
addition,
patient
must
ha\<e
either:
'.'
. : 
1. 
Decreased
positive
reCative
accommodation,
:51.250. . . .
2. 
Push-up
accommodative
ampfitude
at
least
two
diopters
be40w
Hofstette('s
calculation
for minimum
ega
apprOjlOate
ampItude:
15
-
.25
x
age
In
years.' "
.'
.
InfadIity
Patient
must
have
ooth; . . ,
1.
8rur
end/Of"
ast:h8nopic
symptoms
with
habitual near
tasks
simRar
to
symptoms generated
by
accommodativ~
t ~ .
eM/«
increased
comfort
with
convex
lens
adds.'
. ;
2. Normal
positive refaUve
accommodatioo
and
accommodatfve
arnpfitude
(pustHJp
amplitude
not
routinely
measured). 
In
addftion,
patient
must
have
eCther: 
1.
Deaeesec1
accommodative
-rocks.-
:515
cydes/minute
with
-2.000
add
over
the
subjective
refraction
~
20/20
!:;:ttera
el
40cm. .
.'
'.
. 
Increased
aocommodatfve
lags:
binocular
cross
cyiinder
add,
<1.250;
M~M
retinoscopy
lag.
C!!O.750; and/CK
low
neutral
retinOscopy
add.
~1.500.
Aft
referenced
to
the
subjective
r e ~
(both
retlnoscopytecflnlques
hadthe
patient
0f8Ity
read
201
100
letters
at
40
em.). .
I)pasm Patient
must
have: 
1. 
History
of
variable acufty.
asthenopia,
end/Of
symptoms from accommodative testing
similar
to
habitual
symptoms.
2. A
difference
of
at leastone
diopter
(ffiO(e
p4us
or
leSs
minus
measured)
between
stali<;
retinoscopy and
the
subjoctive refraction
with
varia~
subjective
responses.
.Variable visual
acuity
at
distance
without
change
of
lenses.
Volume 56, Number
7,
7/85
561
of 00

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