Analysis, Interpretation, & Prescription for the Ametropias & Heterophorias Chapter 22 969

Morgan 18-20 derived the coefficients in Table 22-2

TABLE 22-1 Average Values for between the various tests in the clinical routine. Only a
Accommodation and
few tests were correlated with each other enough to be
Vergence of predictive value. Note that the stimulus AC/A ratio
was not correlated with any other test. The correlations
Standard did not support the expected relationship between the
Test Mean Deviation near phoria (13B) and lag of accommodation in terms
Phoria at distance (far) 1" Exo ±2" of dynamic retinoscopy (5) or cross-cylinder findings
Convergence at far (14A, B).
BO to blur at far 9" ±4" Although the correlations between most tests were
BO to break at far 19" ±8" low, it was possible to categorize the tests into groups
BO to recovery at far 10" ±4" from the direction in which they varied. No single test
Divergence at far was reliable enough for diagnostic purposes nor would
BI· to break at far 7" ±3" a test always deviate in a consistent direction in every
BI to recovery at far 4" ±2" case. However, if a group of tests as a whole varied in a
Lag of accommodation specific direction, it was assumed that the group result
Dynamic retinoscopyt +1.37 D ±0.37 D was diagnostically valid. This was thought true even if
Monocular cross-cylindert +1.00 D ±0.50 D one of the tests within the group did not agree with the
Binocular cross-cylinder t +0.50 D ±0.50 D rest. Morgan separated the tests into the three categories
Phoria at near 3"Exo ±5" in Table 22-3.
PRY: BO to blur at near 17" ±5" Morgan 20 later combined his studies into a single
PFV table (Table 22-4) that presented what was called
BO to break at near 21" ±6" Morgan's Expecteds for each accommodative and ver-
BO to recovery at near 11" ±7" gence test, the ranges based on a standard deviation
NRV: BI· to blur at near 13" ±4" either side of the norm, and the diagnostic category into
NFR which each fell. Since the AC/A ratio was not correlated
BI to break at near 21" ±4" with other tests, diagnoses based on an accommoda-
BI to recovery at near 13" ±5" tion-convergence relationship appeared insignificant.
PRA t: -2.37" ±1.l2 D The determination of a result as "high" or "low" was
NRA t : +2.00 D ±0.50 D based on a simple comparison of the specific result to
Stimulus AC/A ratio 4.0"/D ±2.0"/D the established Expecteds, which included the means
Amplitude of Based on ±2.00 D and ranges. For the amplitudes of accommodation, the
accommodationt agel formulas of Hofstetter21 are now generally used to
establish the norm and range on the basis of age instead
Modified from Morgan MW 1944. The clinical aspects of of, as Morgan did, referring directly to the amplitude
accommodation and convergence. Arch Am Acad Optom 21:301; tables of Donders 4 or Duane22 (see also Chapters 4, 10,
Morgan MW 1944. Analysis of clinical data. Arch Am Acad and 21).
Optom 21:477.
BO, Base-out; BI, base-in; PRY, positive relative vergence; PFR,
The results of dynamic retinoscopy, the cross-cylin-
positive fusional reserve; NRY, negative relative vergence; NFR, der tests, and the relative accommodation tests were
negative fusional reserve; PRA, positive relative accommodation; refractive powers that varied positively or negatively
NRA, negative relative accommodation; AC/A. accommodative from that of the subjective refraction. The dynamic
convergence/accommodation. retinoscopy result was the value found at the point of
•There is no BI to blur at far.
t Refractive powers relative to the subjective refraction at distance.
reversal as plus sphere power was added over the sub-
Note that the norm for dynamic retinoscopy is +0.50 to +0.75 jective with the patient fixating a near target. With this
greater than expected (see text). method, the optical conjugate of the retina was in front
'Amplitude in D from tables in Donders Fe. 1864. On the of the near target by approximately +0.50 to +0.75 D
Anomalies of Accommodation and Refraction of the Eye, with a when the endpoint was reached. Hence, the reader will
Preliminary Essay on Physiological Dioptrics. London: The New
Sydenham Society and Duane AA. 1912. Normal values of the
note that the norm for accommodative lag using
accommodation at all ages. lAMA 59(12):1010-1013. dynamic retinoscopy in Tables 22-1 and 22-4 is approx-
imately +0.50 to +0.750 greater than expected with
achievement of the dynamic endpoint at neutrality.
Morgan did not include far-point tests-apparently the
near-point tests alone sufficed. Vergence tests that
included a break and recovery were considered as a
single test and if either component was outside the
"Expecteds," the test as a whole was deemed abnormal.