ASTIGMATISM

The discussion of the refractive conditions thus far has focused on spherical ametropia. Nevertheless, astigmia-whether
found in emmetropes, myopes, or hyperopes presents a greater diagnostic challenge. Most spectacle lens
compensations include some degree of astigmatic correction. Low amounts of astigmia may have varying anatomical
etiological origins, but large astigmatic errors are primarily a result of corneal curvature.

Normal regular astigmatism presents the two principle meridians at right angles to each other. An interesting facet of
regular astigmatism is that the principle meridians often tend to approach the same amount of cylinder power in the
two eyes. Obviously, exceptions to regular astigmatism occur and are called irregular astigmatism, in which the two
principle meridians are not at right angles to each other. Irregular astigmatism usually results from a secondary cause,
such as corneal disease or trauma, coloboma of the lens zonules, pterygium, iris adhesions to the lens, subluxation of
the crystalline lens, or cataract surgery. The correctable visual acuity is somewhat reduced because of the limitations in
measuring and managing irregular astigmatism. 3 Correction of irregular astigmatism is covered in Chapter 34, and cases
of regular astigmatism are discussed here.

HERE SHOULD BE FIGURE 22-17

Spherical corrections, particularly of high degree, present adaptation problems to some patients because of the changes
in magnification and the resulting retinal image size produced or because of lack of adjustment to newly imposed
accommodative demands. Astigmatic corrections that have any significant change in either power or axis position, or if
newly initiated, tend to greatly increase the difficulties associated with patient acceptance. These are primarily due to
the perceptual changes induced by the alteration of the shape of the ocular image resulting from altered meridional
magnification and oblique prism projections. This can be elaborated in the following simplified explanation. If a patient
requires a significant amount of astigmatic correction, the retinal image of a fixated circle formed before correction by
the astigmatic eye at the outer limiting membrane of the retina will be an oval. This oval varies in shape and position of
the longer axis according to the degree of the difference in power between the two chief meridians and their protractor
arrangement. An actually fixated oval might form an image that was a circle. The subject will have learned by experience
and the aid of other senses (such as the tactile), during the years prior to correction, to automatically accept the oval
image on the retina as representing an actual circular object, while the circular image on the retina represented an
actual oval one. If the astigmatic error is now abruptly corrected, and a fixated circle now suddenly presents a circular
image at the outer limiting membrane, it may be some time before a new perceptual interpretation is learned and the
perceived image is actually recognized as a circle. The same, of course, holds true for a fixated oval target forming an
oval image.

HERE SHLOULD BE TABLE OF INFORMATION 22.9

The result is not merely one of simple confusion but often of disorientation due to the perceived alterations of the
elements making up judgment of linear space. If the axis of astigmatism is likewise sufficiently altered, so that the near
elements are not only affected in range but in orientation, the patient may perceive marked tilting of the floor (and walls
of a room). Many problems with spectacle adaptation by the patient can be traced either to a marked change in cylinder
axis or power from that previously worn, or to an initial introduction of cylinder power in a new correction compared
with one in which it was habitually absent.

Thus, giving even a partial magnitude of the cylinder in an initial prescription (albeit providing clearer vision) may cause
distortion, uncertainty in walking around, actual vertigo, and a "funny" appearance of objects as typical symptoms. If the
patient is nervous, or a supercritical observer, and rigid in subjective responses, the amount of cylinder may need to be
reduced (or in extreme situations even eliminated) to minimize the adaptive difficulty. Subsequent cylinder increases in
smaller doses accompanied by a step-by-step adaptation may be necessary to achieve consequentially full correction.
On the other hand, a "laid-back" person who is not hypercritical might accept the total correction and fully adapt to the
cylinder at once. The younger the patient, the easier adaptation should be to cylindrical changes; the converse is likely
true for older patients. Although the axis is critical to acuity in large-magnitude astigmats, care should be taken before
shifting the cylinder axis from what has been habitually worn. With proper management, follow-up, and patient
indoctrination, most patients can be guided through adaptation to the full cylinder compensation.

The symptoms of patients with uncorrected or undercorrected astigmia frequently are similar to those of the
uncorrected hyperope-asthenopia and headaches. Astigmats may also exhibit signs similar to those revealed by myopes,
such as reduced visual acuity and squinting to help increase clarity. Some patients discover that tilting their habitual
spectacle prescription to induce a cylindrical component by obliquity gives increased clarity of vision, indicating an
element of uncorrected astigmatic ametropia.

Low Degrees of Astigmatism

Some low astigmatic errors are difficult to observe via retinoscopy, which may reveal little of any cylinder objectively,
although low amounts may be revealed by a probing subjective refraction. A reliable subjective cylinder probing
technique (see Chapter 20) is necessary for correctly establishing the existence of low astigmia in such doubtful
situations. Low amounts of against-the-rule cylinder may be suspected if the patient's corneas are spherical allowing the
approximately 0.50 DC against-the-rule physiological cylinder to manifest itself in the refraction. Decisions affecting the
management of low-magnitude astigmia must weigh the symptoms against the reliability, certainty, and critical acumen
of the patient's responses.

Low amounts of uncorrected cylinder (i.e., 0.75 DC or less) are more likely to induce a complaint of visual fatigue at far
and near than of poor unaided acuity. However, because of the orientation of conventional print and, in general, a
vertically oriented social environment, uncorrected against-the-rule cylinder appears to be a greater deterrent to visual
acuity than does uncorrected with-the-rule astigmia. In low degrees of uncorrected astigmatism, the image produced is
a Sturm's conoid of a low dioptric value with a small circle of least confusion. Although the patient cannot eliminate the
astigmatism by accommodating, accommodation may enable the circle of least confusion to be moved to the retina,
improving acuity. The continuous accommodative effort to effect this results in eventual fatigue and asthenopia.

Figure 22-18 illustrates a patient with mainly complaints of uncomfortable vision when reading. Unaided visual acuities
of 20/15 at far and 20/20 at near, normal lags of accommodation unfused and fused, adequate convergence
demand/reserve relationships at far and near, normal-range AC/A ratio, and adequate PRA/NRA ranges show no real
indications of a problem. However. Keratometry, retinoscopy, and manifest refraction indicate ametropia that might not
impede standard uncorrected acuity but shows the potential for uncomfortable vision. It cannot be emphasized enough
that this type of patient will more likely complain of discomfort than of reduced acuity.

HERE SHOULD BE FIGURE 22-18

Compensation for the patient's symptoms entail correction of the relatively low astigmatism accompanied by a
moderation of the plus spherical power to facilitate adaptation. This patient was given +0.25 -0.50 x180 au to be worn
full time for 1 week to aid adaptation, after which they were to be worn as needed, mainly for reading and near work.
The patient must be counseled that the lens correction is not intended to clarify visual acuity but to provide comfort
during visual performance.

Were such a patient asymptomatic, the low ametropia would have been compensated by the depth of focus or the
ability to accommodate for the circle of least confusion. An alternative might be that the patient was not a critical
observer and would accept a poorer focus without attempting to correct it. In either situation, no lens compensation
would be prescribed. As a general rule, the final criterion helping determine the need for prescribing a low-cylinder lens
rests with the patient symptoms. If near symptoms are present and no other convergence or accommodation problems
are indicated in the refractive sequence, the uncorrected cylinder should be incorporated into the final prescription. If
the patient is asymptomatic with good visual acuities and normal accommodative convergence function, correcting the
low astigmia might be of little benefit. Even in the presence of large overall ametropias, patient's symptoms should still
be a guiding factor as to when to incorporate low cylinder into prescriptions.

On progressive follow-up visual evaluations of patients exhibiting low refractive astigmia, slight changes in the cylinder
power, axis, or both may be noted over the years, usually with little or no visual acuity change. Generally, the power and
axis shifts are not pronounced and vary only about ±0.25 DC in power and ±10 degrees in the axis. The patient's
sensitivity to lens changes, changes in near visual demands, and prior lens habituation should be considered in judging
the necessity of low-cylinder adjustments. As a general rule, conservative changes result in fewer adaptation problems.

Low-cylinder changes can also result from changes in the aging eye. Usually exhibited after the fifth decade of life, the
customary with-the-rule cornea becomes less so with age. As the low-magnitude against-the-rule physiological lenticular
cylinder increasingly affects the manifested refraction, the amount of with-the-rule astigmatism may be decreased. The
amount of against-the-rule astigmatism can increase or may even manifest itself in patients that may have had a
spherical refraction for years.

Against-the-Rule Astigmia

The previously mentioned anatomical influences tend to result in a lesser dioptric magnitude of against-the-rule
astigmatic errors as compared with that of with-the-rule errors. In this type of visual pattern, the corneas are spherical
to slightly against-the-rule, the retinoscopy and manifest refraction show the indicated cylinder, and few
accommodative/convergence maladjustments are associated with the usual relatively low magnitude of the uncorrected
cylinder. A discernible reduction of unaided acuity is exhibited at both far and near in direct correlation to the amount of
uncorrected astigmia. Because even a low cylinder against-the-rule may slightly decrease the visual acuity,
compensation is advisable.

Figure 22-19 furnishes an example of a patient with against-the-rule cylinder as the main reason for the patient's
symptoms. The visual acuities are slightly reduced at both test distances, with discomfort and fatigue mainly at the near
point. The keratometry readings are relatively spherical. The against-the-rule cylinder is measurable both objectively and
subjectively, and the remainder of the refractive sequence is relatively free of malalignments.

The patient was prescribed plano -0.75 D x 90 OU. The spherical component was cut from +0.25 DS to plano OU to aid
adaptation. The choice of cylinder axis was in accord with the keratometry and retinoscopy measurements and, being
closer to 90 degrees, should also afford the patient easier adaptation. The patient was counseled concerning possible
problems of initial and subsequent adjustments to wearing the spectacles. The spectacles were to be worn full-time for
1 week, and then as needed for comfort and clarity of vision. Because of the low magnitude of the cylinder and because
the accommodation and convergence were not grossly affected, follow-up evaluation of the patient was not considered
necessary. If the patient's personality had indicated more conservative management, a routine 4- week follow-up
evaluation would have been prudent and appropriate.

High-Degree Astigmatism

Large amounts of uncorrected cylinder (i.e., greater than 0.75 DC) also produce some secondary near asthenopia but
may also reduce visual acuity for both distance and near targets. Large amounts of astigmia usually are with-the-rule or
oblique. The prevalence of large amounts of with-the-rule astigmatism has been ascribed to genetic disposition; other
assumptions have faulted the physiological juxtaposition and pressure of the upper eyelids on the cornea. The oblique
form is likewise considered congenital or often a precursor to conical corneal distortion.] Patients with large amounts of
with-the-rule uncorrected cylinder usually exhibit a "fixed squint" and a possible "furrowed brow" due to attempts to
increase the clarity of vision by narrowing the lid apertures to simulate the effect of a stenopaic slit. Such persons
sometimes pose challenges in ascertaining true visual acuity because of the strong habitual tendency to squint. If a
large-magnitude astigmia has been uncorrected for a long period of time and vision has not been achieved via the focus
of the circle of least confusion, it is possible that one meridian may have been focused on or close to the outer limiting
membrane while the other has consistently presented a blurred image. A tendency for the development of meridional
amblyopia ex anopsia is ascribed to such circumstances, with a net effect that the patient's visual acuity is not
correctable to standard levels initially.] Depending on the age of the patient on the initial correction, acuity levels may
increase with corrective lens wear.

HERE SHOULD BE FIGURE 22.19

The patient in Figure 22-20 exhibits reduced acuity at both 6 m and 40 cm by approximately the same magnitude, a
strong indicator of large, uncorrected astigmia. The history, keratometry readings, retinoscopy, and manifest refraction
indicate a large amount of with-the-rule astigmia, it should be remembered that an uncorrected or undercorrected
ametropia of large magnitude can affect the rest of the refractive sequence because of the habitual visual pattern
established to compensate for the uncorrected ametropia. With patients of this type, subjective refraction is often
frustrating because the patient has grown firmly adjusted to the perceived image structure of the habitual retinal focus.
The patient may subjectively reject all the retinoscopically determined cylinder on the Jackson Cross-Cylinder (JCC)
subjective refinement. Prudent clinical observation substantiates the need for the large cylinder compensation; the
cylinder usually improves visual acuity, even with questionable JCC responses. The same influences tend to affect and
make variable the subjective responses on the near cross-cylinder test because of the nature of the target. Reduced and
limited ranges on the relative accommodative tests and the positive and negative vergences and irregularities of the
convergence demand/reserve are likewise influenced by the longstanding uncorrection.

HERE SHOULD BE FIGURE 22-20

It is hoped that wear of the large-magnitude cylinder by the patient in Figure 22-20 will overcome the possible
meridional amblyopia from prolonged uncorrection, increase corrected visual acuity, and result in a better alignment of
the accommodative and convergence aspects of the visual system. The adaptation considerations discussed earlier must
also be considered in determining the amount of cylinder prescribed.

Because the patient in Figure 22-20 was relatively young, the full manifest refraction, as indicated by the positive
correction of the keratometry readings and objective measurements, was prescribed. A follow-up evaluation 1 month
later revealed standard acuity through the spectacle lenses prescribed. As indicated in Figure 22-21, the accommodative
responses were closer to the clinical norms, the convergence ranges were more extended in both the positive and
negative direction, and the relative accommodation ranges were more clinically acceptable. The patient was satisfied
with the clarity and comfort of the vision achieved and reported that the initial counseling as to what to expect
appropriately anticipated the problems of adaptation.

The magnitudes of the astigmatic correction, both for axis and for power, should change little during the patient's
lifetime. Large changes would indicate marked changes in the corneal curvature and portend sudden or continued
changes that would make similar changes in the correction appear inadvisable.

HERE SHOULD BE FIGURE 22-21

Oblique Astigmatism

The least prevalent type of cylindrical ametropia is oblique astigmatism, in which the axis of the compensating cylinder
lies within a range of 20 degrees to either side of the 45 or 135 meridians. Although high degrees of oblique astigmatic
errors are occasionally found in very irregular or distorted corneas, most oblique astigmatism, like against-the-rule
astigmatism, usually occurs in low amounts, and the two eyes are often mirror images of each other. The corneas tend
to be oblique in shape. These patients, as illustrated by the patient in Figure 22-22, are compensated similarly to the way
low astigmatic patients are, in accordance to the symptoms.

HERE SHOULD BE FIGURE 22.22

The patient in Figure 22-22 complains of near reading difficulty. The refractive data show normal convergence
demand/reserve relationships at far and near, normal lags of accommodation, and adequate relative accommodation
ranges. The oblique cylinder, as indicated by the oblique corneas and the objective and subjective refraction, appears to
be the main reason for the patient's complaints. The two axes are relatively mirror images, and the cylinder power is
roughly the same. The manifest cylinder was prescribed for the patient to wear for near-point activities, with
appropriate patient counseling. If large degrees of oblique astigmatism are manifested or if the degree of astigmatism in
oblique cases tends to increase markedly, attention should be immediately given to the potential for conical cornea
(keratoconus).
High-Spherical and Low-Astigmatic Combinations

In large magnitudes of uncorrected myopia and hyperopia accompanied by relatively low degrees of astigmatism, it
becomes necessary to estimate whether the cylinder is an integral cause of the patient's symptoms and whether
compensation of this cylinder is required. The choice of either compensating or not compensating for the cylinder
initially becomes a matter of diagnostic judgment. Often, wearing the large spherical correction alone provides
satisfactory acuity, as well as brings the accommodative/convergence relationships to what would normally be clinically
expected. The patient's symptoms on subsequent evaluations will possibly indicate whether the initially omitted cylinder
should be incorporated in follow-up prescriptions. Providing the cylindrical correction immediately, while providing clear
vision with the intent of avoiding the onset or the postponement of possible adaptation problems, may depend for its
success on the actual extent of the astigmatism and the age and accustomed previous spectacles of the patient.

Cylinder Axis Change

The perceptual effects of changes of the position of the cylinder axis were briefly discussed earlier in this section on
astigmatism. Nevertheless, situations arise in which changes in axis position introduce definite changes in acuity or
appear to affect the basic cause of patient problems. If the cylinder axes tend to be near the vertical and horizontal
meridians, the axis may be placed at 180 or 90 degrees even if the exact axis is not precisely at these meridians. This
often interferes least with orientation of vertical and horizontal planes and may be preferable for patients in whom
relatively strong amounts of cylinder are revealed at oblique axes but who have not worn a cylinder before. Similar
considerations may be needed for indicated axis positions that are fairly oblique to the entering prescription axes
positions to which the patients are well adapted. Modification of the axis toward the accustomed position may be
advisable. One must sometimes choose between a position that definitely improves the acuity but threatens to
markedly disturb orientation, and one that tends to affect either to a lesser extent. The younger the patient, the more
pliable the vision system, and the more readily changeable the axis should be. In younger patients, the placement of the
appropriate cylinder axis may be either deferred to subsequent prescription adaptations with perhaps readier
acceptance of the immediate malalignment or placed so as to require immediate adaptation, depending on judgment of
the type and temperament of the individual involved. Caution is needed in following this regimen in the older patient, in
whom adaptability is less likely and the cylinder axis location more precisely affects either acuity or orientation. Table
22-10 gives a summary of astigmatic options.

PRESBYOPIA

The theories and physiological aspects assumedly underlying the onset of presbyopia are discussed in Chapter 4.
Clinically, it is assumed that comfortable near-point vision prevails when the amount of accommodation employed is
less than one-half the total amplitude of accommodation. The onset of presbyopia is usually anticipated by age 40 years
or slightly thereafter because the amplitude of accommodation tends to drop below 5.00 D, and the accommodation
required for the ordinarily assumed near-point working distance of 40 cm is 2.50 D. 3 The onset of near complaints
usually begins around that age, with the near blur getting progressively worse during the ensuing years. Similar to an
uncorrected hyperope, the beginning presbyope may complain initially of only discomfort during near vision because the
accommodative amplitude may still be sufficient to afford clear reading vision, often at a distance farther than 40 cm. As
the years pass, the uncorrected near blur will be a more pertinent problem, often expressed in the worn-out adage "my
arms are not long enough." The onset of individual near-vision complaints are precipitated by the specific occupational
and near recreational demands of each patient relative to the patient's age, physical structure, and refractive error.

The wearing of bifocals in the early 40s is not a comfortable concept for the average adult entering midlife, particularly
because it is so obviously equated with aging. Many patients try to explore any option other than that of a bifocal and a
separate pair of glasses powered for reading, progressive or invisible bifocals, and contact lenses provide variations in
the management for such patients. The final lens prescription must account for the patient's unique working
environment, the varying working distances, and the recreational activities. Spectacle correction of the presbyope is
discussed in detail in Chapter 24.

HERE SHOULD BE TABLE OF INFORMATION 22-10

Evaluations of the distance ametropia of the presbyopic patient are in accord with the same criteria as apply to
prepresbyopic patients. A major difference is that as the patient gets older, the distance prescription changes should be
more conservative. Presbyopic geriatric patients may have major troubles adjusting to distance spectacle prescription
changes even though these may result in marked increases in distance acuity. The distance convergence
demand/reserve relationships should still be evaluated on the basis of Sheard's criterion.

Because presbyopes usually cannot comfortably see standard acuity at 40 cm through their manifest distant refraction,
the refractive routine at near point needs to be modified. An addition of convex lens power needs to be provided to
ensure standard acuity at the near-point test distance. This so-called control lens can be in the form of either the
addition disclosed in the 40 cm fused cross-cylinder lens, an add arbitrarily based on the patient's age, or the minimum
plus build-up in plus lens addition to the distance subjective values until standard acuity at 40 cm is reached. These
estimations are strictly a starting point for near-vision testing and do not account for the particular near-point demands
of the patient. The values obtained through the near control lens provide a reference point for the analysis of the near
vision and for the appropriate near add determination.

Addition Determinations

Clinicians employ four main methods for determining the near addition power: age, half-amplitude of accommodation,
40-cm fused cross-cylinder, and PRA/NRA balance. Each of these methods has advantages and disadvantages, which will
be explored in the prescribing considerations.

The age of the patient is a guiding factor in the add determination because the accommodative amplitude itself is age-
dependent. The Hofstetter age table gives good guidance for add considerations for patients who read at about 40 cm
(Table 22-11 ).3 However, it must be realized that this table indicates a fairly wide range of "normal" amplitudes for each
age level and simple discrepancies from some average expected that fall within these ranges may not indicate any
significant variation. However, if a determined add is way out of line for the patient's age criterion at 40 cm, the
manifest refraction or the near tests may need to be cautiously re-evaluated because of possible error in either patient
response or doctor-patient communication. The resulting bifocal addition also needs to be modified for the near reading
range that is desired by the patient for optimal near performance.

HERE SHOULD BE TABLE OF INFORMATION 22-11

Caution should be taken in prescribing the near plus add for the first time to beginning presbyopic patients. Patients
tend to become acclimated to whatever amount of plus they habitually wear for reading. For example, if a patient is
prescribed too much plus add, not only are the near ranges of clear vision constricted, but the patient becomes
accustomed to the magnification that the extra plus power provides. This extra magnification is then desired for all
subsequent increases in the addition, with the patient complaining of near "blur" even though the 20/20 near acuity
level is attained. It cannot be emphasized enough that the add should be relevant to the ranges of amplitude applicable
to the patient's age for subsequent add determinations and consequential modification of the bifocal addition.

As adults proceed through the beginning decade of presbyopia, the amplitude is sufficiently reduced to induce
symptoms of discomfort in addition to the near blur noted by the presbyopic neophyte. The application of an add for
near of such strength that not over one-half of the total amplitude of accommodation is used underlies the methods for
determining the near-point add that follow.

The simplest method measures the amplitude of accommodation by the Donders or Duane method, also known as the
"push-up" method, in which the finest line of type visible is simply brought toward the patient until the legible print
blurs. This point, the punctum proximum on the linear scale, is converted into its dioptric equivalent. It may be taken
monocularly or binocularly, although the latter is the common clinical preference (see Chapters 10 and 21). It has a
potential error induced by the increase in the size of the target as the target is brought closer to the eye.

Another method of measuring the amplitude is Sheard's method, in which the print is held at a constant near point, such
as 40 Cm, while minus power is added before the eyes until the print blurs. The amount of added minus represents the
amplitude of accommodation. The possible errors in this method are the minification of the print with added minus
power and the fact that the convergence-accommodation portion of the accommodation reflex is ignored. Actually,
Sheard recommended the method as only a monocular test. The Sheard method becomes identical with the PRA
measurement when performed on a presbyope with the manifest refraction in place.

The PRA is the maximum minus power added before the patient up to blur. Even though the PRA is begun through the
near control lens on a presbyope, the manifest refraction is always the point of reference for the accommodative
amplitude determination. This method may also account for the particular working distances of the patient by being
performed at that distance. If the manifest refraction is +1.00 -1.00 x 180 OU and the net 40 cm PRA lens in place is
+0.50 -1.00 x 180 OU, an additional -0.50 DS of power was added over the manifest. Because the stimulus to
accommodation at 40 cm is 2.50 D, the 2.50 D combined with the added 0.50 D indicates an accommodative amplitude
of 3.00 D. It would be the desirable for the patient to accommodate only 1.50 D (half the available amplitude) for any
reading distance. If the patient reads at 40 cm, a +1.00 D add over the manifest refraction is needed. If the patient reads
at 33 cm, the bifocal addition would be +1.50 D, still leaving the patient only accommodating 1.50 D.

Another example is a jeweler who presents with a unique occupational demand of having to examine fine jewelry at a
distance of 25 cm. The patient's manifest refraction is -2.00 -1.50 x 175 OU. The 40 cm PRA blur out at 40 cm is -2.00
-1.50 x 175 OU. The amplitude of accommodation would then be 2.50 D for the 40 cm stimulus because no additional
minus or plus power was added over the manifest refraction. Because the one-half amplitude method is being utilized,
the patient should only use 1.25 D of accommodation when looking at the 4.00 D stimulus at 25 cm. Therefore, a +2.75 D
bifocal addition over the patient's manifest refraction is needed. Additional examples are given in Figures 22-23 to 22-
26.

Another simple method for indicating the add is the 40-cm fused (binocular) cross-cylinder method. The additional plus
found through the 40-cm fused cross-cylinders on the crossed lines at near point represents the bifocal addition over the
manifest refraction. If the manifest refraction is +0.25 OS OU and the 40-cm fused cross-cylinder total is +2.00 DS OU, a
+1.75 DS add would be indicated if the patient desired to work and read at 40 cm. However, if this same patient desired
to read at 33 cm, the addition would be adjusted for the additional half diopter of stimulus necessitated by the change in
fixation from 40 cm (2.50 D) to 33 cm (3.00 D). The add would then be 0.50 DS more plus, or +2.25 D OU. Again, refer to
the examples in Figures 22-23 to 22-26.

HERE SHOULD BE FIGURE 22-23

The reliability of the 40-cm fused cross-cylinder is sometimes questionable. This fact should be remembered in
considering the appropriate bifocal addition. This method appears to be more consistent when the level of illumination
is lowered. Additionally, this method may often give the most plus power of all the bifocal addition methods. For these
reasons, the method is most desirable for advanced presbyopes who have little accommodative flexibility. However, it
provides a ready and quick way of introducing a control lens, which may also prove to be the actual near add. To be
assured in its use, it is well to compare its results with the range of clear vision it provides, as well as with the amplitude
method and age criteria.

HERE SHOULD BE FIGURE 22-24

The "middle third" or PRA/NRA balance method places the patient's accommodation in use in the middle of the
accommodative ranges as determined by the sum of both the 40-cm PRA and NRA tests. The total plus power that
places the patient in the mid-range is determined by adding the NRA and PRA lens values and dividing by 2 to obtain the
midpoint. For example, a patient's manifest refraction is determined to be plano OU. The 40-cm PRA lens to blur point is
+1.50 DS OU, and the NRA lens to blur point is +2.50 DS OU. The sum total of the two is 4.00 DS, which divided by two
gives a resultant plus power of +2.00 DS for the midpoint. If the patient is looking through a total power of +2.00 DS OU,
the patient is then in the midpoint of the relative accommodation range and the net PRA and NRA values through the
+2.00 D lens would be equal (i.e., -0.5 D and +0.50 D, respectively). Thus, this patient's prescription is plano with a +2.00
D addition for a 40-cm reading distance.

If a patient was a -1.00 DS myope and the PRA was plano and the NRA was +0.50, the total power midpoint would be
+0.25 D. This is the midpoint of the PRA/NRA ranges, again with equal relative accommodation nets of 0.25 D. Thus, this
patient's prescription is -1.00 D OU with a +1.25 D addition to give a total Reading power of +0.25 D, Additional
examples are given in Figures 22-22 to 22-25 (Table 22-12).

HERE SHOULD BE FIGURE 22-25

Although this method appears theoretically usable, the actual ranges of the PRA and NRA may be affected by
convergence/accommodation innervation (see Chapter 4). The determination of the amplitude based on age has value
in indicating gross variations from the normal, but the ranges of each age category within the Hofstetter tables make
actual application to an individual patient from the tables relatively difficult. Most clinicians tend to rely on the Donders,
Sheard, or near-point cross-cylinder method.

HERE SHOULD BE FIGURE 22-26

Once the add power is determined, a judgment must be made to ensure that the clear near-point range through the
proposed bifocal prescription is adequate. The range is tested by simply having the patient view the near standard acuity
line through the proposed near correction and moving that line both further and closer until a position is reached at
each in which the row of letters is no longer clear. The patient is then asked to adjust the distance of the near acuity row
until it looks the clearest. In principle, this point should coincide with the desired or accustomed working distance for
the patient. In practice, the clearest point may actually be a range of points, rather than a single point. The three
distances are customarily notated in the form of a triple fraction (i.e., closest in distance/clearest distance/farthest out
distance). If a notation was charted as 25 cm/40 cm/67 cm, this would mean the patient's range of clear vision is from 25
cm out to 67 cm, with the clearest point being at 40 cm. If this range of vision is adequate for the patient, the
determined near addition is acceptable. If the outer limit of the patient's range needs to be further away, the plus add
can be reduced by 0.25 D steps, which moves the entire reading range further out, including the close-in point and the
clearest point. If preferred, increasing the addition by 0.25 D steps moves the reading range closer in.

Sometimes, especially when the bifocal additions rise above +1.75 D, the bifocal addition does not provide the desired
reading ranges for the patient, particularly toward the distant end. In such cases, trifocal or progressive addition lenses
are required to afford the patient an extended range of clear near vision. The specifications, advantages, and
disadvantages of each are covered in Chapter 24, dealing with multifocal lenses. For the patient to be satisfied with the
new prescription, the near-point correction must provide adequate vision throughout the patient's near-point working
or reading distances.

HERE SHOULD BE TABLE OF INFORMATION 22-12

When a presbyope presents for visual evaluation, the total near plus power in the patient's entering prescription can
help determine the extent of total plus power that may be incorporated in the new prescription. Generally, the total
plus power should not be decreased on subsequent prescription changes for a patient who has become habituated to
the current plus power for reading. Even though clarity or acuity of vision may be the same with a decreased plus total in
the new correction, the extra plus power in the habitual prescription tends to add magnification. Decreasing this power
often causes patients to complain that they could read better with the old glasses than with the new ones. This problem
is often manifested by patients who have fitted themselves at the drug store or supermarket with "over-the-counter"
reading glasses or even bifocals. Such patients usually over-plus the power needed for their indicated reading demands
because of the additional magnification provided by the stronger plus lenses. Once such wear has become customary, a
prudent practitioner will not decrease the habitual total plus worn. If the excessive plus power restricts the near reading
ranges, a trifocal or progressive addition lens might be an indicated option.

For the elderly patient experiencing intumescent cataract, the manifest refraction decreases in plus power because of
changes in the index of refraction of the crystalline lens. The usual complaint is of distance blur through the habitual
prescription. There is ordinarily no complaint of the vision at the near point, even though the patient finds it necessary
to hold reading material closer than is customary. Most frequently, more minus is required in the distance power to
improve the distance visual acuity. The bifocal addition may need more plus power to keep the near plus power at the
same habitual total, even though this additional plus power requires the patient to read at a closer-than-normal
distance. Problems of adaptation can be minimized by maintaining the accustomed additional magnification or the
habituation to the established working distance.

Presbyopes with Secondary Convergence Insufficiency

The customary near-point tests for a presbyopic patient are performed with the near control lens or the proposed near
addition before the eyes. Convergence interaction with accommodation is overshadowed by the need for the plus-
power addition.

Because the presbyopic patient's accommodation decreases with age, the consensual accommodative convergence
innervation is decreased, resulting in a more pronounced shift toward a greater near exophoria, even to the point of
diplopia, through the proposed reading addition. The near plus cannot be decreased to attempt to reduce the exophoria
because this causes a reduction in near acuity. Fortunately, many presbyopic patients exhibiting large amounts of
exophoria at near also have sufficient fusional convergence innervation to help compensate (and the near convergence
position can be evaluated via Sheard's criterion). It is interesting to note that many presbyopic patients maintain fusion
and comfortable near vision with convergence indications which a non-presbyopic patient would find intolerable.

HERE SHOULD BE FIGURE 22-27

If diplopia prevails, BI prism is the only available assistance. Because peripheral fusion plays so prominent a role in
binocular vision and the conventional phoropter restricts peripheral vision, it is recommended that the determination of
the minimum amount of near prism for comfortable fusion be attempted without use of the phoropter. One quick and
easy method is to determine the near point of convergence with varying amounts of loose prism while the proposed
total near plus power is before the eyes via a trial frame. The goal is to determine the least amount of BI prism that gives
the patient single, comfortable vision in the midpoint of the presbyopic range. The starting amount of prism can be
assumed from either the tonic position or a rough estimate based on Sheard's criterion or Percival's criterion. Figure 22-
27 gives an example of management and prescription by this method.

ACCOMMODATIVE DYSFUNCTION

Because of the pronounced near-point requirements of modern society, a normally functioning visual system may at
times have unreasonable demands placed on it. Consequently, a patient, who may have gone for years with no visual
complaints and with adequate visual acuity, may complain of difficulties that accompany sustained reading or near
activities, such as suddenly developing asthenopia, headaches, watery-red eyes, near blur, or even secondary distance
blur. The same complaints, at the presbyopic age levels, are attributable to the physiological changes associated with
reduced accommodative amplitude, but when exhibited during the pre-presbyopic years, with a customary onset in the
mid-twenties, indicate a type of anomaly classified as an accommodative dysfunction.

Some of the significant indications of the visual examination of a patient with accommodative dysfunction are low near
lags of accommodation, both fused (binocular) and unfused (monocular) and objective and subjective. Often also
evident are reduced PRA and NRA ranges; normal convergence ranges, albeit somewhat constricted; and reduced
amplitude of accommodation for the patient's age. The measured refractive condition is usually of low magnitude or
around plano with minimal or no cylindrical component. Similar to the secondary myopia that can result from
accommodative stress, to which accommodative dysfunction is closely related, low myopia is frequently the refractive
status.

Figure 22-28 shows the typical refractive pattern or profile for such a patient. This patient has adequate distance and
near convergence demand/reserve relationships, but decreased near lags of accommodation on the near retinoscopy
and near cross-cylinder tests, and reduced relative accommodation ranges on the PRA and NRA. Comparison of the
fused and unfused near cross-cylinder findings indicate that convergence is not affecting the patient's near
accommodation. The low lags indicate that the patient is overaccommodating for near distances.

HERE SHOULD BE FIGURE 22-28

Ordinarily, the practitioner may be inclined to offer no options because of the limited refractive malalignments. But in
this case the extended patient symptoms and complaints warrant some form of management, usually in the form of
low-plus power for reading. The amount of plus recommended would be about that which would put the patient's
accommodative lag within a normal range of 0.50 to 0.75 D. The prescription given was +0.75 DS OU for reading only.
The half diopter more plus than the manifest refraction may be presumed to give the patient a normal accommodative
lag value, in that the patient would be accommodating 0.50 0 less than the stimulus. This is calculated to give the patient
more comfortable vision for longer time periods of reading. The distance vision through the proposed near prescription
would be slightly reduced but not enough to limit most distance tasks performed indoors, where the near spectacles
usually are worn.

Mention should be made of the fact that even if a visual pattern appears normal in that adequate convergence
demand/reserve relationships are measured at far and near, normal accommodative lags are present, and acceptable
relative accommodative values are manifest, the patient may still complain of discomfort associated with prolonged
near work. In this case the symptoms must be addressed, even if the data do not appear supportive. The same premise
would be used to give relief to the patient (i.e., low plus for reading, not to exceed distance blur discomfort) (Box 22-3).

CONVERGENCE ANOMALIES

When ametropia has been disclosed and subjective complaints remain that cannot be assuaged solely by managing the
accommodative problems, the convergence function should be addressed. Convergence problems are identified as
those whose causes arise within the convergence mechanism itself and not as the byproducts of troubled
accommodation or uncorrected ametropia.

HERE SHOULD BE BOX 22-3

Classic detailed considerations for analyzing vergence and accommodative-convergence problems include the graphical
analyses developed by Hofstetter and the statistical system derived by Morgan. These are explained in the third edition
of Clinical Refraction but have been amended by the most recent concepts and applications covered in Chapter 21.
Chapter 21 evaluates and presents detailed discussion of convergence problems and examination routines providing
diagnostic import. Among such, Sheard's and Percival's criteria have been used through the years as a major clinical
basis for indicating prismatic or lenticular management of convergence anomalies. 3 Of the two, Sheard's criterion,
which states that the fusional innervation demand represented by the phoria should not exceed one-half of the
measured fusional innervation reserve and represented by either the blur or the break of the compensating version test,
has been the more widely accepted method. However, Percival's criterion offers guidance between determining an
acceptable amount of prism to be prescribed. The patient's phoric demand should be in the middle third of the base-in
and base-out vergence ranges for the specified distance.

Morgan's normative values also give guidance when the phorias and vergence ranges vary markedly outside the clinical
normative values. The clinician decides how much prism compensation would be necessary to place the patient within
the normative values.

Once the determination is made that the patient is deficient concerning convergence etiologies, then the appropriate
method of managing the patient needs to be considered. The prismatic amount determined can be adjusted by the
addition of plus power or minus power over the manifest refraction, if applicable. Also by means of orthoptic training,
the compensatory vergence ranges can be expanded to assist the patient in handling the convergence demand. The
three methods of managing patient's convergence problems (i.e., prism, modifying the manifest refraction, and
orthoptic training) have to be evaluated for the specific needs of the individual patient.

HERE SHOULD BE TABLE OF INFORMATION 22.13

Esophoria Convergence problems evidenced as pronounced esophoria can be classified into two divisions (Table 22-13):
divergence insufficiency, mainly exhibited as esophoria at distance, or convergence excess, mainly manifested as
esophoria at near and probably the result of a high AC/A ratio. If in either of these cases, the available NFC at the
appropriate distance is inadequate to meet Sheard's criterion for clear, single, comfortable vision, the patient is
symptomatic.

Divergence Insufficiency

A patient manifesting divergence insufficiency complains of occasional diplopia, tired eyes, sometimes having to use
forced blinking to hold fusion, and frontal type headaches. These symptoms usually increase as the day proceeds.
Ensuing diplopia may not be a symptom if this condition is longstanding and the patient has begun suppressing one eye.

At the 6-m test distance, divergence insufficiency reveals distance esophoria greater than 3Δ with low NFC reserves. The
cover tests may even demonstrate infrequent intermittent esotropia. Poor stereopsis may result from the fragile
binocularity. If the condition has been uncorrected for a lengthy period, deterioration into esotropia may result, with
possible suppression of the vision of the deviating eye.

It is important to ensure that the manifest refraction is correct so that the tonic position can be properly evaluated. An
overminused refraction would induce secondary esophoria that would not be the true tonic esophoria position. Noting a
change in the phoria at 6 m when plus power is added to the assumed subjective finding at 6 m might verify the
patient's tonic position. If the distance phoria becomes less esophoria or more exophoria with the addition of plus-
powered lenses before the eyes, the manifest refraction is overminused (i.e., accommodation has not been fully
relaxed). A cycloplegic refraction may have to be employed to ensure proper accommodative control.

According to Sheard's guidelines, the NFC reserve, measured at 6 m, shows a low value relative to the convergence
demand. A low recovery may indicate that the demand/reserve relationship will worsen over time. Thus, the patient
may not be symptomatic early in the working day but may develop symptoms later. The remainder of the near refractive
findings also may be marginally out of line, but the key factor is that this is mainly a tonic convergence problem.

Considering Percival's criterion, the patient has a high tonic position, with the 6-m base-out vergence range being
skewed in the BO direction, and the BI vergence measuring below the third range limit. The patient's tonic position is
also beyond Morgan's normative value of approximately 1Δ exophoria. The near vergence ranges are adequately in line
with the 40 cm lateral phoria and a normative AC/A ratio.

Figure 22-29 gives the data of a classic divergence insufficiency pattern. The distance refraction is not overminused, but
a 6Δ esophoria tonic phoria position is measured. The 6-m NFC reserve is 6Δ, with a low recovery. The patient has a
relatively normal AC/A ratio, with normal near accommodative lags. The near convergence demand of 6Δ esophoria is
met by an adequate NFC reserve of 12Δ. The PRA net is slightly low because of only 12Δ of NFC, but the NRA net is
normal. Most of the patient's problems are at distance. Because the ametropia is minimal for a 17-year-old patient and
because of normal accommodation, a diagnosis of divergence sufficiency is clinically acceptable.

The management options open to the clinician are BO prism, orthoptics therapy, or both to increase the negative
fusional reserves. In appropriate instances, additional plus power over the manifest refraction is recommended to
assumedly relax active accommodation and consensually relax convergence, decreasing the esophoria. Such
management would not be effective here because the refractive end point is maximum plus to best acuity.

Prescription of BO prism is a method that often can bring about immediate relief of the symptoms. The amount of the
prism recommended is that which meets the criterion by placing the resultant demand at one-half of the available
convergence reserve.

The patient in Figure 22-29 shows a demand of 6Δ of NFC, whereas the NFC reserve is 6Δ. If one prism diopter of BO is
prescribed, the demand would be shifted to 5Δ of esophoria and the reserve increased to 7Δ of NFC; Sheard's criterion
would not be met. If the amount of BO prism is increased to 2Δ, the demand is 4Δ esophoria, with an acceptable NFC
reserve of 8Δ. For this patient, 2Δ BO prism would be indicated by Sheard's criterion. If worn full-time, this prescription
would not adversely affect the near convergence demand/reserve relationship. Disadvantages of this management
modality is that the patient must wear spectacles and may experience subjective adaptation problems. Symptoms such
as nausea, headaches, a "funny sensation," and a change in perspective regarding distance targets are all possible
complaints. Proper management and patient counseling can help the patient through the initial adjustment, with a
resulting resolution of symptoms.

Because the middle-third vergence range at 6 m is approximately 7.5Δ, about 1.5Δ BO prism would be indicated to
satisfy Percival's criterion. This amount compares favorably with Sheard's indicted value of 2Δ BO prism. This range of
prism could be well tolerated by the patient for full-time wear.

The NFC reserve also can be increased by vision therapy. The age of the patient is pertinent when considering this
option. Good results are more likely with younger patients, who have a more pliable vision system. Once the
convergence reserves have been increased to adequately meet the convergence demand, BI maintenance therapy
should be used to keep the reserves adequate. Although this method affords the patient the option of not having to
wear glasses, the relief of symptoms may be delayed until the increase in reserve meets the necessary level.

HERE SHOULD BE FIGURE 22-29

Convergence Excess When an esophoria patient at near point exhibits an inadequate NFC reserve for sustained near
comfortable vision, it is called convergence excess. Near-point convergence excess symptoms are usually evidenced in
an inability to read for long periods of time without the onset of discomfort, such as asthenopia, possible diplopia when
reading, frontal headaches, tired eyes, and short attention span while reading. Convergence excess manifestations in the
examination are an AC/A ratio greater than 6Δ/D, a normal to high tonic position at far with adequate reserves, marked
esophoria at 40 cm with limited NFC reserves, possible near intermittent esotropia on cover testing, and possible near
suppression, if the condition has been present for a considerable time.

The near BI vergence measurements will be of lower magnitude than the near BO vergences because the base-out
vergences are artificially inflated by inclusion of the near esophoria values, plus the fact that the patient has exhausted
much of the available NFC to maintain fusion. The near PRA test will be low because the additional accommodation
demanded by the addition of minus secondarily increases the esophoria, with a subsequent lowering of the already
depleted NFC reserve. In the PRA test, the patient exhausts the NFC long before the accommodative amplitude is
depleted.

The lag of accommodation will be above normal, as measured on the near fused cross-cylinder and near retinoscopy.
The high lag on the binocular tests, both objectively (near retinoscopy) and subjectively (near cross-cylinder), is due to
the fact that relaxation of accommodation causes an associated relaxation of convergence, producing less resultant
esophoria. The patient is reluctant to give up the added plus, because of the easier fusion accompanying the reduction
in the esophoria. The near unfused cross-cylinder will be unaffected because no convergence demand is affecting the
accommodative response under monocular conditions.

Figure 22-30 illustrates a normal tonicity of 3Δ esophoria and a high AC/A ratio pattern, within the aforementioned
refractive tendencies. The demand/ reserve relationship is adequate at the distance (i.e., 3Δ esophoria demand and 9Δ
NFC in reserve and acceptable vergence ranges BI and BO). But the 10Δ demand at 40 cm affords the patient only 4Δ of
NFC in reserve (i.e., Sheard's criterion is not met). Additionally, Percival's criterion is also not met, as indicated by the
fact that the lower vergence value (BI) is not equal to a third of BI and BO range of about 5.5Δ. Morgan's normative
values are met for the BO vergence range but are reduced for the BI vergence ranges, as would be consistent for a
symptomatic esophoric patient. Additional confirmation of the near esophoria problems are the reduced PRA, normal
NRA, and high lag of accommodation on the fused cross-cylinder, with a normal lag on the unfused cross-cylinder. The
PRA finding of -0.50 D is due to the patient having adequate NFC reserves for the increase in esophoria as the minus
power is increased. The patient's compound myopic astigmia must be corrected to assist the reduced unaided visual
acuities at 6 m. Aside from the minus lenses, the near esophoria must be managed as well.

The management options for the near esophoria are threefold. First, a BO prism could be used in the amount of about
5Δ to satisfy Sheard's criterion for 40 cm or about 1.5Δ to satisfy Percival's criterion. However, the patient's tonic
position at 6 m is 3Δ esophoria, the 5Δ BO prisms would violate the habitual tonicity. This might make the patient
adaptation for full-time wear difficult. Prescribing up to 3Δ base-out prism for full-time wear would be in the range of
the tonic position and in the range of the prism indicated by Percival's and Sheard's criterion.
Second, a bifocal addition might be a better alternative for full-time spectacle wear. Because this patient's AC/A ratio is
about 9Δ/1, a +0.50 to +0.75 D addition might obtain the same effect of 1.5Δ to 5Δ. A 0.50-D add is usually the minimum
add available, with 0.75D more readily available in stock lenses. Use of such spectacles would also give the patient
immediate relief and improved performance. If a patient of this age is averse to wearing bifocal spectacles, the patient
could be fit with contact lenses for the distance compensation of the myopia, with plus-powered reading glasses to be
worn over the contact lenses for relief of the near esophoria.

Third, if the previous options were not acceptable, considering the age of the patient, orthoptic training could be a
realistic alternative of great appeal for increasing the negative fusional reserves. Orthoptics training would require
extended time to build up the NFC reserves, and further maintenance therapy would possibly be required to keep these
reserves adequate.

The patient in Figure 22-31 has a high tonic position as well as a high AC/A ratio (i.e., 9Δ/1D). Correction of the
compound myopic astigmatism is needed to increase visual acuity and answer the chief complaint of distance blur. The
8Δ of esophoria at distance calls for an NFC demand of 8Δ, leaving a reserve of 10Δ of NFC. Therefore, 2Δ BO prism is
needed in order to satisfy Sheard's criterion. However, Percival's criterion is satisfied due to the lower BI vergence of
10Δ being greater than the third of the range, valued at approximately 8Δ. No additional distance convergence problems
are indicated from the vertical phoria/duction relationship.

At 40 cm there is a negative fusional demand of 16Δ and only a 9Δ NFC reserve, with a low recovery. The BO vergence
range is considerably larger than the lower base-in vergence range, with the middle-third value of 12Δ larger than the
lower base-in vergence value of 9Δ. The near accommodative/convergence pattern shows a normal unfused near
accommodative lag of 0.50 D but a fused near accommodative lag of 1.25 D, giving more credibility to the near
esophoria demand and limited NFC reserves. The pattern continues along classic lines, with the PRA being reduced and
the NRA normal. To satisfy Sheard's criterion, 8Δ BO prism would be needed, which would make the 40-cm esophoria 8Δ
indicating the negative convergence demand through the manifest refraction while increasing the NFC reserves to 17Δ.
Percival's criterion would be satisfied with 3Δ/D base out, elevating the lower BI vergence of 9Δ to the middle-third
value of 12Δ. So the range of 3Δ to 8Δ D of BO for full-time wear over the compound myopic astigmatic compensation
would not violate the tonic position at distance, and the patient should be able to wear the prism.

HERE SHOULD BE FIGURE 22-30

If adaptation problems troubled the patient, this situation might be managed by a combination of prism and a plus
bifocal add. A prescription for full-time wear containing 2Δ BO to help compensate for the high distance demand would
result in a near phoria of 14Δ of esophoria. Because the AC/A ratio is about 9Δ/D, a +0.75 D plus addition over the
manifest refraction would alter the near phoria by 6 to 7Δ into the desired range of 8Δ of esophoria.

Orthoptic training to increase NFC reserves would again be a management possibility. Thus, prism, or prism with a
bifocal addition of +0.75 D, and orthoptic therapy to increase the NFC reserve would all be options to discuss with the
patient.

HERE SHOULD BE FIGURE 22-31

Exophoria

Divergence excess is the term applied to the situation in which the tonic position is such that the patient has difficulty
exerting enough PFC to maintain comfortable clear single vision at the far point (Table 22-14), Convergence insufficiency
is the term that indicates a patient's AC/A ratio is so low that pronounced exophoria results at the near point. If the
patient's available PFC cannot compensate for this high exophoria, the patient may be symptomatic and have difficulty
at near point.

Divergence Excess

Symptoms of divergence excess include occasional diplopia, occasional distance blur, tired eyes, and forced blinking to
maintain fusion. The trouble signs are poor stereopsis, intermittent exotropia, and a tonic position not compensated for
by low positive fusional reserves. The patient may even try to overaccommodate to induce accommodative-convergence
innervation to reduce the demand on PFC, accepting blurred distance vision as the cost of seeing singly.

HERE SHOULD BE A TABLE OF INFORMATION 22-14

Figure 22-32 gives an anecdotal idea of what the patient examination would look like. The 9Δ of PFC in reserve relative
to the 7Δ of exophoria at distance does not meet Sheard's criterion and appears to be the most clinically significant
source for the patient's problems. To meet Sheard's criterion, the amount of prism needed for distance comfortable
vision is about 2Δ BI. This would make the patient's distance phoria 5Δ exophoria, with a new reserve of 11 Δ of PFC.
Also, the additional 2Δ Bl will alter the patient's near phoria to 5Δ exophoria with a PFC reserve of 16 Δ. The prism
option is a viable alternative for treating this patient because adaptation to prism Bl appears to be much less of a
problem than with prism BO.

The 6 m vergence ranges are lowered due to the high exophoric demand, yet the middle third value of 7Δ is less than
the base out vergence value, satisfying Percival's criterion. The 6-m BO vergence is also within the range of Morgan's
expected values. Consequently, Sheard's criterion is the only modality indicating a problem consistent with the patient's
complaints. The fact of the patient's complaints of diplopia and headaches being worse at the end of the day would
explain this apparent paradox.

In the patient mentioned in Figure 22-32, the AC/A ratio is 6Δ/D. Because 2Δ BI is needed for distance comfortable
vision, about -0.50 D of extra minus power could provide enough accommodative-convergence innervation to secure the
desired convergence movement without the need of wearing prism. When overminusing a patient, the accommodative
amplitude must be adequate to supply the extra accommodation comfortably so as not to induce secondary
accommodative fatigue. Because this patient is 25 years old and the amplitude measures about 6.50 D (based on the
PRA value), accommodative discomfort should not be a problem. Again, depending on the patient's daily routine and
need for immediate symptomatic relief, orthoptics could also be used to increase the positive fusional reserves. If the
patient maintains the adequate positive fusional reserves by maintenance therapy, this could allow for relief without the
necessity of wearing spectacles.

Convergence insufficiency symptoms are similar to those resulting from divergence excess, except that they are mainly
induced by near work. These include occasional diplopia, a "sleepy" sensation when reading, and near blur due to the
use of positive accommodative convergence to maintain fusion. The patient may manifest possible intermittent to
constant exotropia, especially when fatigued, and diplopia during phoropter testing while refraction is being performed.
Suppression is possible if the condition has been longstanding.

Convergence Insufficiency

A convergence insufficiency patient exhibits an AC/A ratio of less than 4Δ/D, orthophoria to moderate exophoria at
distance, but marked near exophoria with inadequate near PFC reserves. Because of the weak near-point convergence
demand/reserve relationship, the patient may tend to overaccommodate to aid fusion, as may be indicated by an
absence of near lag of accommodation on the 40-cm fused cross-cylinder test, near retinoscopy, or both. The 40-cm
unfused cross-cylinder tends to exhibit a normal lag of accommodation because monocularly, the accommodation may
be unaffected by the convergence.

HERE SHOULD BE FIGURE 22-32

Depending on the AC/A ratio, the NRA resultant can be lower, affected by the fact that added plus lens power tends to
increase the exophoria and the concurrent demand on an already limited PFC. The report of a blur in the NRA test
occurs when all of the PFC is exhausted but before all the accommodation has been relaxed. If the patient continued to
attempt to relax accommodation, it would be necessary to also relax the accommodative convergence innervation, with
resulting diplopia. Diplopia rarely does occur in the NRA test, but it can signify the end point of the NRA just as definitely
as does a blur. In patients with very low AC/A ratios, changes in accommodation produce little change in convergence,
and the NRA may be relatively normal. The PRA in convergence insufficiency cases may be normal to high. The response
to the added minus of the PRA test induces additional accommodative-convergence innervation, which replaces the
positive fusional innervation and reflexively reduces the near-point exophoria. However, the consistent increase in
convergence induced by the accommodative responses to added minus lenses eventually tends to overconverge the
fixation unless balanced by the NFC. The limit of the test is affected by the upper limit of the amplitude of
accommodation, the limit of the NFC, or both.

HERE SHOULD BE FIGURE 22-33

Figure 22-33 exhibits the classic pattern of a low tonicity at far combined with a low AC/A ratio. This patient has
convergence problems at near point, indicated by the pronounced near convergence demand to overcome 16Δ of
exophoria with only 16Δ of PFC in reserve, the overaccommodation result on the near fused cross-cylinder, and the
slightly reduced NRA. To meet Sheard's criterion, 5Δ BI prism would reduce the near exophoria from 16Δ to 11 prism
diopters and raise the PFC blur from 16Δ to 21Δ. This is acceptable for fulltime wear because it does not violate the
tonic distance position of 6Δ of exophoria. Percival's criterion gives borderline results, with Morgan's expected not being
met because of reduced BO vergence values.

Overminusing this patient would be inadvisable. The AC/A ratio is about 2Δ/D, requiring an additional 2.50 D of minus
over the manifest refraction to induce the desired change in convergence. Because this patient is 38 years old with close
to only 4.50 D of accommodative amplitude (from the PRA), the additional accommodative demand to compensate for
the overminusing would most likely be unacceptable. Also because of the patient's age, prognosis for orthoptic
alteration of the positive fusional reserves would be guarded.

Hyperphoria

Vertical misalignments can result from functional maladjustments or be secondary to ocular or head traumas,
neurological defects, or age-related weakening of the six extraocular muscles. Detailed exploration of the patient's case
history is advisable to rule out any underlying organic problem before attempting management of the vertical
hyperphoria. If neurological and macular etiologies are noncontributory, the evaluation of the patient's vertical
phoria/demand relationship can be attempted.

Hyperphoric patients are often plagued with vertigo-like symptoms, along with characteristic complaints of occipital
headaches, skipping lines when reading, and intermittent blurring of vision (Table 22-15). The patient probably has a
history of motion sickness, nausea, and dizziness if the condition has been longstanding. Observations of the patient's
posture may reveal the characteristic head tilt and forced blinking to help maintain fusion. Obviously, if the patient has
fragile binocularity, poor stereopsis will result.

HERE SHOULD BE A TABLE OF INFORMATION 22-15

Because of the visual neurological pathways, accommodation has little association with vertical eye movements.
Consequently, the need for vertical prism compensation is evaluated almost solely by the vertical phoria
demand/duction reserve relationship. However, a unique characteristic of vertical problems is that they can spill over
into the lateral vergence system. Lateral convergence misalignments often show changes when vertical misalignments
are corrected and so further indicate that vertical hyperphorias relative to an accompanying skew in the balancing
vertical ductions have clinical significance.

The usual normal positioning of the vertical phoria is at the middle of the range of the superior and inferior vertical
ductions, resulting in equal reserves in both directions. When one is compensating for vertical misalignments and for
relief of their accompanying symptoms, a simple mathematical calculation enables the positioning of the vertical phoria
at that desirable midpoint. Once the midpoint is located, the indicated prism needs to be further refined because of the
testing circumstances. Because the phoropter negates the peripheral fusion, the measured phoria and duction ranges
may not be truly representative. The vertical phoria through the phoropter is often greater than found by trial frame
testing. Consequently, as a rule of thumb, about three-fourths of the prism indicated by the vertical phoria would be
prescribed for initial wear. The vertical duction midpoint tends to give a more reliable measure of the amount of prism
the patient should wear.
Figure 22-34 indicates 6Δ right hyperphoria on the phoria measurement and a skew in the vertical ductions, with the
right supraduction being greater than the left infraduction, and the right infraduction being greater than the left
supraduction. The PFC and NFC ranges are constricted at far and near, probably affected by the vertical misalignment.
Normal accommodation responses are manifested on the near cross-cylinder tests and the relative accommodation
measurements. The amount of prism that would place the fixation at the vertical midpoint and potentially relieve the
patient's symptoms would be about 2Δ base-down (BD) before the left eye (or 2Δ base-up (BU) before the right eye).
This amount of prism can be split between the two eyes (i.e., 1 BU OD and 1 BD OS). More reliability is placed on the
vertical ductions midpoint than on the vertical phoria measurement.

Figure 22-35 shows a right hyperphoria sequence. The esotropia exhibited via the cover test and the suppressions found
during the positive and negative fusional vergences at far and near seem secondary to the uncompensated hyperphoria.
The lateral convergence problems lend credibility to the vertical problems manifested by the refractive data. The patient
evidently has had unsuccessful management in the past, as indicated by the complaints and the history of previous
unsatisfactory spectacle prescriptions. The history of numerous traumas and diplopia should alert the clinician to
possible convergence problems. Neurological evaluation of this patient in the past had yielded negative results.

HERE SHOULD BE FIGURE 22-34

With manifestations of both vertical and lateral misalignments, compensation for the vertical misalignment should take
precedence, with possible resolution or reduction of the lateral misalignment following vertical prism wear. The
converse would not be likely, in that the vertical phoria/duction relationship is not affected by a lateral convergence
problem.

The 4Δ right hyperphoria correlates with the vertical ductions (i.e., the BD ductions OD and BU ductions OS are greater
in magnitude). The midpoint of the vertical duction range is 3Δ BD OD or 3Δ BU OS. Again, greater validity is placed on
the duction ranges.

Three prism diopters to compensate for the vertical hyperphoria was given in spectacles for full-time wear, along with a
presbyopic bifocal addition of +1.00 D over the manifest refraction to increase the patient's near visual acuity. On
subsequent follow-up examinations, the patient adequately adjusted to the bifocal correction and vertical prism, and
the measured magnitude of the esotropia decreased to about 4Δ of intermittent esotropia bordering on esophoria.

HERE SHOULD BE FIGURE 22-35

After about 1 year of only wearing vertical prism with the bifocal addition. 2Δ BO prism was added to the patient's
spectacle prescription. This was based on Sheard's criterion, because the patient now had reasonable binocularity but
some intermittent complaints at near point. The result is a marked improvement from the 10Δ alternating esotropia
revealed at the initial examination.

HERE SHOULD BE FIGURE 22-36

An old-age onset of vertical hyperphoria is illustrated in Figure 22-36. The history indicates that the patient's complaints
are recent and not associated with any medical or traumatic condition. The forced blinking reported subjectively by the
patient is a mechanism by which the patient is attempting to force fusion. It is interesting to note that the patient's
habitual prescription, only 6 weeks old, is unsatisfactory to the patient. The spectacle prescription immediately worn
prior to the current spectacles was broken. Because this patient subjectively noticed a pronounced subjective increase in
visual acuity (unusual for a patient of this age), the manifest refraction with a +2.50 D bifocal addition was prescribed to
increase visual acuity at far and near. Lateral phoria relationships were not clinically significant. Three prism diopters of
left hyperphoria was measured and substantiated by a 3Δ BD prism as the midpoint of the vertical duction range.

The patient was compensated for the left hyperphoria by the addition of 3 prism diopters, split between the two eyes, in
the form of 1.5Δ BD before the left eye and 1.5Δ BU before the right eye, along with the manifest refraction found for
distance plus and a presbyopic bifocal add. This was well tolerated by the patient and adequately answered the patient's
complaint. Proper patient preparation for the prescription change was a positive clinical management tool in answering
the patient's complaint and easing the adaptation.

SUMMARY

Refractive and convergence anomalies account for the bulk of the patient complaints and management time in a
primary care practice. Conservative management and critical analysis and test selection will, with clinical experience,
provide practice satisfaction and patient appreciation. Not all refractive tests discussed in this chapter will necessarily be
performed on every patient once a diagnostic pattern becomes a familiar routine. In general the analysis of the patient's
refractive or convergence state could follow this general pattern:

• Visual acuities, unaided and aided, at Far and near: What anticipated refractive condition is indicated by these results?

• Chief vision complaint and associated history: Does this correlate with the visual acuities?

• Habitual prescription: Does this correlate with the patient's complaints and visual acuities? What refractive patterns
can be anticipated by the patient's overcorrection or undercorrection?

• Objective refractive data (i.e., retinoscopy and keratometry): Do these test results correlate with the patient's visual
complaints and visual acuities?

• Subjective refraction: Does this correlate with the patient's complaints, visual acuity, or objective refraction? Does the
refraction reveal any convergence anomalies secondary to the need for ametropic correction?

• Vertical phorias/ductions: Is there any vertical misalignment that requires compensation?

• Lateral phorias/vergences at far and at 40 cm: Is the criteria for clear, single comfortable vision met through the
manifest prescription? Is any need for prism correction or orthoptics indicated?

• Fused and unfused cross-cylinder test at 40 cm: Is any accommodative or convergence anomaly revealed by the
comparison of the fused and unfused findings?

• Amplitude of accommodation and near relative accommodation: Is the amplitude and range of accommodation
adequate? Is a near-point correction above the distance required? Is an accommodative or convergence problem
indicated or confirmed by the relative accommodation findings?

• Does the patient need to wear the manifest refraction?

• Will the patient function adequately if uncorrected or undercorrected?

• Is a change from the patient's habitual correction necessary?

Generally, prudent patient management first compensates for any ametropia the patient may manifest or for which he
or she may be symptomatic, before becoming involved in how the convergence and accommodative systems realign.
Management of convergence problems or accommodative dysfunctions should only be pursued after the indicated
ametropia has been compensated for by successful wearing of corrective spectacles or contact lenses.