Accommodative Pattern

VISUAL PATTERN
• This visual pattern controls a dynamic refracting system
• Very early in the development of primary concepts
capable of adjusting its power so that spatial objects at
regarding functional optometry, it became evident that a
different distances can be clearly discerned.
visual problem could not be defined in terms of refractive
• This ability of the visual pattern is called
error.
accommodation.
• It has been a common clinical experience that a group of
• Accommodation is the mechanism of focusing,
individuals could all possess the same refractive error,
designating in the postural set-up by the measurable light
but some in this group could be no visual problem and
value brought a focus congenial to interpretation.
the reminder of the group could have all degrees of visual
• Accommodation is a lenticular-retinal-cortical process
problems.
which is used by the individual to obtain clear vision.
• It soon became evident that the refractive error was the
o Accommodation → crystalline lens changes its
result of some type of activity.
convexity
• This activity was related to the behavior pattern of the
o At least 5.00D AA is enough to able to see clearly
individual.
• It is always assumed that the distance between target and
the eye determine the amount of accommodation in
Behavior – is the reaction of the individual to his environment. It effect.
is defined as an enormous complex action in the central nervous
system which brings about certain activity desirable to the
individual. Accommodation changes with the age of the patient. The
accommodation found at each age level are as follows:
• All behavior patterns are motor patterns, they always
result in the activity of muscles and glands.
• The walking pattern of the child has built up upon AGE AMPLITUDE AGE AMPLITUDE
crawling pattern of the baby.
• In the initial development of a behavior pattern, the 10 14.00 45 3.50
movements are spastic, slow, and performed on the
cortical level of activity.
• As maturation and experience continues, the efficiency of 15 12.00 50 2.50
the pattern improves and soon its activity pattern is
relegated to the sub-cortical level. Smooth, efficient, fast 20 10.00 55 1.75
→ controlled by the peripheral nervous system by the
spinal cord → automatic
25 8.50 60 1.00

All behavior is based on the integrative of numerous

neurological patterns. All behavior involves motor activity. This 30 7.00 65 0.50
all-inclusive statement includes mental activity since any psychic
state must involve bodily tension. Therefore, all behavior is
35 5.50 70 0.25
motor.

40 4.50 75 0.00
Two of the most important components of the visual pattern are:

1. Accommodative pattern – ability of the eye to see clearly

2. Convergence pattern – provides mechanism for
maintaining single vision
Note: accommodate and convergence are directly dependent to
each other → following the 3 synkinetic movement
• 80% information obtained from visual pattern
• These segments of the visual pattern control the individual
need for single and clear and vision.
• These two patterns are so vitally an integral part of the visual
pattern that the complete visual examination is devoted to
investigating the extent, degree, and intensity of the
relationship between these two patterns by means of probe
bodies – lenses (spherical – accommodation) and prisms
(BI and BO – convergence).
Note: vertical phoria (BU and BD)
The act of accommodation is a complex pattern which made up
of many sub-patterns. Some of these sub-patterns can be
identified as:
Sub-patterns of Accommodative Pattern
1. Tonic accommodation – lenticular poise under the
condition of far point fixation with minimum inhibition to
activity.
2. Aberrational accommodation – is the range of
performance in the accommodative pattern due to the
modification in the flux conoid because of spherical and
chromatic aberration.
• Chromatic – spherical aberration → unwanted light in
lens affecting vision while wearing lenses → also
affecting due to pupils are widely dilated
3. Convergence accommodation – is the effect of
convergence upon the accommodative pattern. It’s
magnitude equal to that of accommodative convergence,
due to innervation.
4. Psychic accommodation – is the amount of lenticular
accommodation in action due to the emotional and
psychological reaction of the individual to the surrounding
environment.
If testing accommodation → convergence is at plane of regards
If testing convergence → accommodation is at plane of regards
Convergence Pattern
• It provides the mechanism with maintaining single
vision.
• The convergence pattern controls the posturing of the
eyes in their orbits.
• This controls of the posturing of the eye-globes is by
means of the nervous system which innervates the extra-
ocular muscle.
• The convergence pattern is the survival value to the
organism. The presence of diplopia will be catastrophic in
our efforts to survive.
o Normal NPC: 6-10cm or 60-100mm
o Convergence excess: less than 6
o Convergence Insufficiency: more than 10
o 8–10prism difference of phoria in far and near – to
identify convergence and divergence problem
of the accommodative performance. Hyperopia exists in
the central nervous system. It is measured by the change
in the accommodative mechanism induced by a plus lens
which does not create an undesirable change in the
pattern of convergence.
• Orthophoria – not desirable condition → should be
exophoria
o when looking at far, patients’ eye is orthophoric
→ so when looking at near, it will converge inside
→ somehow NOT maintaining the anatomical
position of rest.
• Best EXOPHORIA – normal value or physiologic
exophoria → 0.5exo at far and 6exo at near
o when looking at far, patients’ eye is slightly
exophoric → so when looking at near, it will
slightly converge → somehow maintaining the
anatomical position of rest (orthoposition)
• Worst esophoria – when looking at far, patients’ eye is
esophoric → so when looking at near, it will converge
more → not maintaining the anatomical position of rest

Emmetropia
Like accommodation, convergence is also made up of sub-
patterns namely: • Looking at far with relax accommodation → Exactly on
the retina
Sub-patterns of Convergence Pattern

1. Tonic convergence – is the point of the visual axis under

conditions of dissociation with far-point fixation. These are
the maximum conditions for inhibition to convergence.
2. Fusional convergence – Is the range of performance in
the convergence pattern to Panum’s area. It is psycho-
physiological range in the convergence pattern. (more
common)
• Tonic and fusional – common
3. Accommodative convergence – is the amount of Myopia
convergence in action due to innervation from • Looking at far with relax accommodation → in front of the
accommodation retina
4. Psychic convergence – is the amount of convergence
stimulated, because of the emotional and psychological
reaction of the subject to the surrounding environment.

Developmental research reveals that binocular vision develops

in the following sequence:

1. Fixation – first sign of development → especially bright

colors
Hyperopia
2. Coordinated vertical movements
3. Convergence • Looking at far with relax accommodation → behind the
4. Monocular accommodation retina
5. Binocular accommodation • Will both fall exactly on the retina when active
accommodation

Buffer Area - is the area of tolerance in the brain.

• Exophoria – buffer area for convergence pattern

• Hyperopia – buffer area for accommodative pattern
• The buffer area in accommodative pattern is
called hyperopia (farsightedness).
• The buffer area in the convergence pattern is
called exophoria. → measure in the amount of BI prism
• Hyperopia is thus a relationship between the patterns of
accommodation and convergence to protect the integrity
Probe Bodies – composed of lenses and prisms used to
investigate the relationship of visual pattern (accommodation
and convergence).
1. Lenses – used for specific effect upon accommodative
pattern → spherical lenses
2. Prism – used for specific effect upon convergence
pattern → BI or BO
4 Basic Changes Using Lenses and Prism
Accommodation
1. Convex Lens – Inhibit or relaxes accommodation
• The induced change is as if the object is moved away
from the plane of regard.
• The size changed observed is that the target appears
bigger.
• Hyperopia → corrective + lens → associated with
esophoria
o Hyperope = active accommodation → eyes
converge → to relax use plus lens
2. Concave Lens – activate or stimulates accommodation
• The induced change is as if the object is moved closer to
the observer.
• The size changed observed is that the target appears
smaller.
• Myopia → corrective - lens → associated with exophoria
o Myope = relax accommodation → eyes diverge →
to activate use minus lens
Convergence
3. Base-In Prism – inhibit or relaxes convergence
• The induced change is as if the object is moved away
from the plane of regard.
• The size changed observed is that the target appears
bigger.
4. Base-Out Prism – stimulates or activates convergence
• The induced change is as if the object is moved closer to
the observer.
• The size changed observed is that the target appears
smaller.
PHOROMETRIC TEST (or also known as 21 steps)
Phorometric test – test which deals with the determination of
the power of accommodation and convergence particularly with
the action of the two with each other.
• Different techniques for performing the phorometric tests
was introduced in order to assess the visual function of
an individual.
• The Optometric Extension Program (OEP) create a series
of test procedures that will give comparable results for
the same patient.
• It is said that optometric tests are psychological in nature
and the visual system is complex, it is better that the
situation must be controlled if reliable results are to be
obtained.
• OEP developed a method where same testing procedure
is done but of different spatial direction and are
compared with one another.
• It is also important that testing procedure be done
smoothly and rapidly from one test to another, in order to
get reliable and accurate result.
Visual Tests
Visual tests are composed of series of test procedures to
assess the condition of the patient. It includes standard
procedures for objective and subjective examination as well as
binocular vision tests.
Objective tests include: Optometric Extension Programs
• Ophthalmoscopy (VT #1),
• Keratometry (VT #2),
o 1 and 2 are not part of binocular vision test, but
included in the OEP (21 steps)
• Retinoscopy (VT #4-6)
o Static 4
o Dynamic 5 and 6
• VT #7 for subjective refraction
Binocular vision test includes test for accommodation and
convergence.
Common visual disorders are usually caused by binocular vision
anomalies that causes patient to experience headache, eye
strain, blurred vision, and double vision.
The examiner performs different binocular vision tests to confirm
or rule out differential diagnosis so that the examiner will have a
better understanding on the patient's problem.
HABITUAL TEST – performing procedures using the habitual or
old prescription of the patient
INDUCED TEST – the lenses in place or used is based on the
result of the refraction either by subjective or objective findings
→ commonly used the subjective test findings (test #7)
Optometric Extension Program (21 Steps)
A. Test inducing an alteration of stimulus of convergence
1. Phoria test at Far and Near
a. Lateral phoria at far (#3 habitual test, #8 induced
test)
b. Vertical phoria at far and near (#12 - far, #18 -
near) → no habitual test → not affected by the
accommodation → used the lenses in the test #7
c. Lateral phoria at near (#13A - HT, 13B - IT, 15A,
15B)
 • 15A and 15B is the induced phoria based
on the near subjective refraction → uses the
findings from the test #7 at near
2. Duction and Vergence at Far and Near
FAR
a. True adduction or Advergence at Far (#9)
b. Convergence at Far (#10)
c. Abduction or Abvergence at Far (#11)
FAR AND NEAR
d. Vertical Duction at Far and Near (#12, 18) – 5 test
findings or recordings → for phoria and duction
test
NEAR
e. Positive Relative Convergence at Near (#16A)
f. Positive Fusional Reserve at Near (#16B)
g. Negative Relative Convergence at Near (#17A)
h. Negative Fusional Reserve at Near (#17B)
B. Test Inducing an Alteration of Stimulus to
Accommodation → help to get the probable correction at
near point
1. Test of indefinite response
a. Dissociated Crossed Cylinder (#14A)
b. Binocular Crossed Cylinder (#14B)
2. Test of definite response
a. Amplitude of accommodation (#19)
b. Positive Relative Accommodation (#20)
c. Negative Relative Accommodation (#21)
Note: 21 steps have Total of 27 steps
Action of Prism
1. An eye looking through a prism is turned towards the
apex
2. Rays of light passing through a prism deviate towards the
base.
3. An object seen through a prism is displace towards the
apex
General Use of Phoria Test
• Designate primarily to indicate the position of rest of the
eyes when fusional convergence is relaxed.
Phoria Measurement
• A vertical dissociating prism is used for the measurement
of a lateral phoria. → eso and exo
• A horizontal dissociating prism is used for the
measurement of a vertical phoria. → hypo and hyper
• Phorias are measured at distances of 20ft (6M) and 16”
(40cm)
• At 16 inches the stimulus or activates to accommodation
is 2.50D and the stimulus to convergence is 15 prisms (if
PD is approximately 64mm)
Distance Phoria
• Most people are orthophoric at distance or nearly so, and
this is thought to be due to a “fusion adaptation theory”
which tends to cause the two visual axes to become (and
remain) parallel.
• According to this theory, if the individual is found to have
a significant distance phoria, it is because he does not
possess or has deficient adaptation process.
o Compensated phoria – reserve is twice the
demand
Near Phoria
• The norm or expected value at near is about 3 to 5XOP
(6XOP commonly used).
• The tendency for asymptomatic individuals to have a
moderate amount of exophoria is demonstrated using
terms as physiological exophoria. →1/2XOP far and
6XOP near
o Physiological astigmatism = -0.50cx90
• The amount of convergence required at 40cm is 15prism
Von Graefe method – method used in phoria measurement
where dissociating prism is placed in front of one eye and a
measuring prism in front of the other eye.
lateral phoria
• 12 prism base-in is placed in front of the right eye →
measuring prism
o Image is displaced temporally
• 6 prism base-up is placed in front of the left eye →
dissociating prism
o Image is displaced downward
Vertical phoria
• 12 prism base-in is placed in front of the right eye →
dissociating prism
o Image is displaced temporally
• 6 prism base-up is placed in front of the left eye →
measuring prism
o Image is displaced downward
Base in/out prism → prism 0 mark is located at 90degrees
Base up/down prism → prism 0 mark is located at 180degrees
Note: will see unfused diplopia seeing one image above and one
image below. Also, rotation should be smooth transition when
changing prism for more accurate response
Appearance of the test target 2. Break point – represents the point when patient, using all
vergence source can no longer maintain single vision. →
2nd to happen
3. Recovery point – indicates that the induced retinal
disparity has been decreased to the point that the patient
can access the vergence system and regain single vision
Horizontal deviation → vertical alignment

Instrumentation:

Phoropter Head Test Chart

Vertical deviation → horizontal alignment

The following are test procedures for determining the lateral

muscular imbalance at far and near.

Note: First test done in phorometric test is TEST #3 → habitual

Vertical Phoria phoria at far

• Occur as a result of toxic conditions

• Also found when patient has a severe cold, sinus infection
or other debilitating condition but it will disappear when
the patient’s health returns to normal.
• In older patients, this may occur as a result of cerebral
vascular accident or stroke
Fusional vergence reserves/ Reflex vergence
• Distance – Base-in vergences are tested before base-
out vergences because base-out is a stimulating test and
there may be aftereffects that would interfere with the
results of the base-in test.
o #16A, #9, #10 – uses base out prism – stimulates
o #17A, #17B, #11 – uses base in prism – relax
• Presence of base-in blur at distance indicates that the
subjective finding is in error in the direction of insufficient
plus, or excessive minus power and the subjective
endpoint should be rechecked.
• Near – blur point is expected because 2.50D of
accommodation is stimulated when near findings are
taken.
Habitual Phoria at Far (VT #3)
Requirements: habitual correction, illumination (20ft. candle) of
Snellen chart, phoropter, and prism
Habitual phoria at far is the first test for binocular vision under
the OEP technique. It is done with the habitual correction in
place (if there's any) worn by the patient at far. The patient is
asked to fixate on the smallest readable target at far with his old
correction.
Measuring and dissociating prism is placed before the
patient's eye. 12 prism base-in is placed over the right eye and 6
prism base-up on the left eye, this will create an uncrossed
diplopia. The patient is then asked to fixate on the lower target
on the right (left of Px) and to inform the examiner as soon as
the target becomes vertically as the examiner starts to reduce
the measuring prism. → alignment method
Significance:
Test No. 3: determine the lateral muscular imbalance at far.
Procedure:

Vertical Vergence Findings/ Vertical Fusional Reserves

Habitual Phoria at Far (VT #3)
• Vertical vergence differs from base-in and base-out
reserves in a way that prism power is introduced in front
Test distance 20ft or 6M (3m new set up)
of only one eye at the time rather than in front of both
eyes
• No blur point because vertical prism has no effect on the Test target Smallest readable target → VA
accommodative mechanism
o Base out → exophoria → crossed diplopia → Lenses in place Habitual correction at far (if no
converging → blur point → #9 correction: Plano)
o Base in → esophoria → uncrossed diplopia →
diverging → no blur point → #11
Prisms in place OD: 12-15ΔBI
OS: 6ΔBU
Horizontal Vergence at Distance

• To measure through the application of prism, the patient’s

Illumination 20 ft. candle
ability to use horizontal vergence to maintain binocular
vision
• When testing in BI and BO vergences, the examiner is Phoropter Far PD
looking for 3 subtests findings. adjustment

These includes:
Endpoint Vertical alignment
1. Blur point – represents the point when the patient can no
longer compensate for the prism induced retinal disparity
while maintaining stable accommodation. → 1st to happen Significance: determine the lateral muscular imbalance at far
 Test target Smallest readable

Lenses in place Hab. Correction at near

Appearance of the Test Target (initial)

Prisms in place OD: 12-15ΔBI OS 6ΔBU

Illumination 20 ft. candle

Endpoint: Vertical Alignment
Ask the patient to look at the lower left target → stationary or not Phoropter adjustment Near PD
moving target → then adjust until reach the endpoint.
If the endpoint is reached → occlude one or both eyes (to avoid
uncertainty and move or swinging of target) Endpoint Vertical Alignment

Any remaining prism towards:

OD: 12-15ΔBI → measuring prism → not easily to converge or
fuse → maintaining the position of the target
OS: 6ΔBU → dissociating prism
Note: The amount of phoria can be measure in NPC
• Base-in direction - Exophoria (e.g. 6BI – 2xop)
• Exactly at 0 - Orthophoria (e.g. 0 – ortho)
• Base- out direction - Esophoria (e.g. 2BI – 1 sop)

Induced Phoria at Far (VT #8)

Alignment method – both eye is open, then ask the patient to
Induced Phoria at Far is performed in the same manner as
look at the lower left target, then ask if the two targets are
induced phoria at far (VT#3). The patient is again asked to fixate
aligned. → used in clinic
at smallest readable target with the result of the subjective
Flash method – OD containing the measuring prism is refraction in place. The target is again dissociated with 12 prism
occluded, then adjust the prism, then ask if the target is closer, base-in on the right eye and 6 prism base-up over the left eye
repeat until it is aligned creating an uncrossed diplopia. The examiner then reduced the
amount of measuring prism until the endpoint is reached and the
Overshooting → once reached the endpoint, the clinician will
finding is recorded.
try to still move forward, then if the patient sad its double, the
clinician will go back. And compare if the measurement is the Significance:
same. (not done, patient is tired)
Test No. 8: Determine the lateral muscular imbalance at far as
influenced by test #7. → about lens effect on the phoria
Clinical Finding and Interpretation: Procedure:
Test result: 2ΔBI
Induced Phoria at Far (VT #8)
Interpretation: 2XOP (used in recordings)
Recording:
• Any remaining prism towards: Test distance 20 ft/6M (3m new set up)
o Base-In direction – exophoria (2ΔBI – 2XOP)
o Exactly at 0 – Orthophoria (0 – ortho)
Test target Smallest readable (best VA)
o Base – out direction – Esophoria (1ΔBO – 1SOP)

Note:
Lenses in place Test No. 7
• High exophoria – increase base-in prism
• High hyperphoria – increase base-up prism Prisms in place OD: 12-15ΔBI OS 6ΔBU
• Suppression – increase the amount of dissociating prism
or place a red glass before the suppressed eye
Illumination 20 ft. candle

Habitual Phoria at Near (VT #13A)

Phoropter adjustment Far PD
Habitual Phoria at Near is done in the same manner as VT#3
with the fixation distance changed from 20ft/6M to a near-point
Endpoint Vertical Alignment
distance of 16 inches or 40cm. The test is performed through
the patient's habitual correction at near (if there's any),
otherwise the test is done through plano. Clinical Finding and Interpretation
Significance: Any remaining prism towards:
• Base-in direction – Exophoria (4BI – 4XOP)
• Exactly at 0 – Orthophoria (0 – ortho)
Test No. 13A: determine the lateral muscular imbalance at near. • Base- out direction – Esophoria (2 BI – 2SOP)

Procedure:

Habitual Phoria at Near (VT #13A)

Appearance of the Endpoint: Vertical Alignment

Test distance 16”/40cm
Test Target (initial)
Induced Phoria at Near (VT #13B) Example: phorometric test

Induced Phoria at Near has the same procedure with VT #13A Old Rx = +0.50 add +2.00
with the only exception that the test is performed with the result
#3 = +0.50 (LP)
of subjective refraction.
#13A = +2.50 (TRA)
Significance:
Test No. 13B: determine the lateral muscular imbalance at near
as influenced by test #7. Example: phorometric test
Procedure: Old Rx = -0.50 add +1.00
Induced Phoria at Near (VT #13B)
#3 = -0.50 – 2XOP

Test distance 16”/40cm #13A = +0.50 – 5XOP

#7 OU = -1.00
Test target Smallest readable
#8 = -1.00 → Ortho

#13B = -1.00 → 3XOP

Lenses in place Test No. 7

Prisms in place OD: 12-15ΔBI OS: 6ΔBU Accommodative convergence/ accommodation (AC/A Ratio)

• Measurement of convergence induced by accommodation

Illumination 20 ft. candle per diopter of convergence
• Indicates the relationship between the amount of
Phoropter adjustment Near PD convergence produced by a stimulus to accommodate and
the amount of accommodation which produces that
convergence
Endpoint Vertical Alignment • Ratio of accommodative convergence expressed in prism
diopter to the stimulus to accommodation expressed in
Clinical Finding and Interoperation: diopter
• 4 Δ BI – 4XOP Accommodative convergence is the degree of convergence
• 0 – ortho induced by accommodation.
• 2ΔBO – 2SOP
Accommodative Convergence/Accommodation – Is clinically
defined as the ratio of accommodative convergence expressed
Example: phorometric test in prism diopters, to the stimulus to accommodation expressed
in diopters.
Old Rx = -0.50 constant wear (far and near)
• The AC/A ratio can be determined or measured by either
#3 = -0.50 → 20/30 – 2XOP the Gradient Method or Calculated Method.
#13A = -0.50 → 20/25 – 5XOP • Gradient method involves taking more than lateral phoria at
40cm through different stimuli to accommodation. → repeat
#7 = -1.00 → more minus (exophoria) – more stimulated the #13B → #13B gradient (add auxiliary lens = + or – 1.00
accommodation – more convergence lens over control lens)
#8 = -1.00 → 20/20 – 1XOP • Calculated method involves taking phoria at 6m and 40cm
→ use the result of test #8 and #13B
#13B = -1.00 → 20/20 → 3XOP

Purpose: to determine the changes in accommodative

Example: phorometric test
convergence that occurs when the patient accommodates or
Old Rx = relaxes accommodation at a given amount (Catherine heyman,
OD, 2012)
#3 = Plano – 1SOP
Significance: helpful when the examiner is considering the
#13A = Plano – 1XOP
possibility of altering the spherical component of the patients’
#7 OU = +1.00 → relax accommodation – less convergence spectacle correction to reduce a phoria by stimulating or
#8 = +1.00 → 2XOP relaxing accommodation and accommodative convergence.

#13B = +1.00 → 3XOP 4 components of convergence

1. Tonic convergence – the amount of convergence in effect

when fixating a distant object with accommodation and
Example: phorometric test fusional impulse absent (no fusional and accommodation
Old Rx = Plano convergence since looking at far)
2. Proximal convergence – stimulated by awareness of
#3 = Plano – 1SOP nearness of fixed object.
#13A = Plano – 1XOP 3. Accommodative convergence – amount of convergence in
action due to innervation from accommodation.
#8 = Plano → 1SOP/ ortho (relax accommodation in #7)
4. Fusional convergence – amount of convergence that must
#13B = Plano → 1XOP be added or needed to accommodative convergence in order
to bring the foci upon the two-fovea needed to insure single
binocular vision
Determination of AC/A Ratio
1. Gradient Method – A phoria is taken at the near point
working distance (16 inches/40cm) with the subjective in
place, and upon alignment of the target, a known amount of
minus or plus lens is placed before the eyes and the
changed phoria values represents the change in
convergence to the known change in accommodation
stimulus.
• If a plus lens power is added and the exophoria is
increase or esophoria is decreased, the gradient is
positive. If oppositely affected, it is negative.
o Repeated 3 times, if still negative = negative gradient
• If minus lens is added, the phoria are affected oppositely
and the values of the esophoria and exophoria are
reversed.
• If the sized and the distance of the target are constant,
the response is more reliable.
• The addition of minus is considered to give more
reliable results normally than does the addition of plus. →
looking at near stimulated accommodation → making the
addition of minus lens will give more a smooth result of
stimulating the accommodation
• Dissociating prism is placed in front of the patient’s eye
and a known amount of minus or plus lens is placed
before the patient’s eye. The phoria is again measured
and the change in convergence to the known change in
accommodative stimulus is measured.
• Auxiliary lens = +/- 1.00D (constant)
#13B (-4.00) = 1SOP
#13BG w/ +1.00 (-3.00) = 4XOP
AC/A = 5:1
#13B (-4.00) = 3XOP
#13BG w/ -1.00 (-5.00) = 1XOP
AC/A = 2:1
2. Calculated Method – involves taking the induced lateral
phoria at far (20ft #8) and near (40cm #13B) → use the
induced result of test #8 and #13B
Formula: AC = 15 – Physiological Exophoria (PEX)
A 2.50
15 = constant value → equivalent of every 2.50D of
accommodation there is a 15 prism of convergence.
2.50 = constant value → when look at near (40cm) equivalent to
2.50D of accommodation → 100/40 = 2.50D
Physiological exophoria = Near phoria (#13B) – Distance phoria (#8)
• ½ far → normal expected values
• 6 near → greater value since eyes are converging
where: PEX = Near Phoria – Distance Phoria
Note: EXO = (+) value
ESO = (-) value
Example

Distance phoria = 2XOP PEX = 8 - (+2) = 6

Near Phoria = 8XOP
Significance: determine the ACA ratio
AC = 15 – PEX
#13B Gradient A 2.50
= 15 - 6
Test distance 16”/40cm 2.50
AC = 9
Test target Smallest readable A 2.50

AC/A = 3.6Δ/1.00D
Lenses in place Test No. 7 with +/- 1.00D Note: always indicate if it’s a minus or negative

Prisms in place OD: 12-15ΔBI OS: 6ΔBU Example:

Test number Case 1 Case 2
Illumination 20 ft. candle #3 ortho 1XP
#7 +1.25 -2.75
#8 1XP 2XP
Phoropter adjustment Near PD #13A 2XP 3XP
#13B 3XP 1XP
#13B gradient 7XP w/ +1.00 4SP w/ -1.00
Endpoint Vertical Alignment
Gradient method
Case 1:
If same direction of phoria = minus #13B = 3XP
#13BG (w/ +1.00) (+2.25) = 7XP
If different direction of phoria = plus
AC/A = 4:1
Normal AC/A ratio = min – 4:1 (commonly used), ave. – 5:1, max Case 2:
– 6:1 #13B = 1XP
#13BG (w/ -1.00) (-3.75) = 4SP
Example:
AC/A = 5:1
#13B = 3XOP
#13BG w/ +1.00 = 8XOP Calculated method
AC/A = 5Δ:1D Case 1:
#13B = 3XOP AC = 15 – (3XP – 1XP)
#13BG w/ -1.00 = 1SOP A 2.50
AC/A = 4:1 = 15 - 2
2.50
#13B = 5XOP AC = 13
#13BG with +1.00 = 8XOP A 2.50
AC/A = 3:1 AC/A = 5.2Δ/1.00D
Case 2: Recording or findings:

AC = 15 – (1XP – 2XP) Add the remaining prism to the 2 rotary prism (left and right)
A 2.50
= 15 – (-1)
2.50 Note: at far 20ft or 6m
AC = 16
A 2.50 • Base out prism → produces crossed diplopia → looking at
AC/A = 6.4Δ/1.00D far → cause blur, break, and recovery point (test #9 and #10)
→ due to stimulating accommodation
• Base in prism → produces uncrossed diplopia (diverge) →
Note: If comparing the gradient and calculated AC/A. it is said
when looking at far accommodation is not stimulated →
that both gradient and calculated ratios.
causing for test #11 to have no blur point, just break and
Gradient method – Determine the amount of accommodative recovery point
convergence associated with each diopter of accommodation
but there is slight difference in terms of the amount of AC/A both
Note: at near 40cm
for gradient and calculated method. Because under gradient
AC/A this one is taken at the distance of 40 centimeters (#13B • Base out prism or Base in prism → stimulating
and #13B gradient), the only difference that we tend to add accommodation → looking at near → cause blur, break, and
either a plus one or negative one to your control lens. Therefore, recovery point
whatever proximal convergence your accommodation is
operating at 40cm would be expected to affect both phoria
findings equally.
True adduction at Far #9
However, under calculated AC/A the test is taken at 20 feet
(#8) and 40cm (#13B), so in other words proximal convergence
is operating when one of the phoria is taken but not when the Test distance 20 ft/6M
other is taken.ken is
Test target Smallest readable

Horizontal Vergence at Far (VT #9)

Lenses in place Test No. 7
True adduction at far (VT #9) is the first fused prism test in 21
steps. This test is followed by Convergence at Far (VT
Auxillary lens +0.25S (blur)
#10). The two procedures utilize prism base-out and is done
one after the other in order determine the blur point, break point
and the recovery point. Prisms in place OU ready to turn Base Out

When testing for both BI and BO vergences, the examiner is

looking for 3 sub-tests findings which includes: Illumination 20 ft. candle

• Blur point – represents the point when the patient can no

longer compensate for the prism induced retinal disparity Phoropter adjustment Far PD
while maintaining stable accommodation.
• Break point – represents the point when patient, using all Endpoint Blur (same as +0.25S)
vergence source can no longer maintain single vision. →
diplopia
• Recovery point – indicates that the induced retinal disparity
has been decreased to the point that the patient can access Significance:
the vergence system and regain single vision. → fusion Test No. 9: blur point indicates the limit of available fusional
Note: blur point, break point and recovery point happen due to convergence in reserve.
the prisms (90 degrees at 0 mark to turn BI – relaxes
convergence or BO – stimulates convergence) in placed in front
Auxillary lens of +0.25Sph is added over test #7 to produce
of the patient’s eye, in a primary position → added a prism BI →
blur point → will experience slight blurring of target when
causing image to displaced temporally → fovea will try to follow
binocular subjective reduction is done (getting the maximum
the image point → resulting fusional convergence to maintain
plus, least minus)
the target single → if still increase the amount of prism (activates
action of accommodation to assist the convergence → causing Note: if it does not create a blur after adding the auxillary lens →
of blurring of vision – due to presence of accommodation) → indicates insufficient plus in the test #7 → the practitioner did
fovea cannot follow the image point → causing doubling of not follow the maximum plus and least minus
vision → if reports diplopia → decrease the amount of stimulus
→ to have the recovery point or regain the fusion
#9 True adduction at Far
Note: test #9 - #11 is the buffer for distance phoria for test #8
and #13B • Lenses in place: subjective findings
• Auxillary lens: +0.25S (blur)
• In some cases, fusion is not regained right away → use
opposite direction of stimulus → regain fusion → negative Example:
value
+1.25 → 20/20 – with difficulty
• Break point has bigger value than blur point
• Recovery point can be lower than the blur point +1.00 → 20/20 – W/O difficulty + (+0.25S) = +1.25S → slight
• The movement of rotary prism is the same in both eyes → blur (ask the patient to what the appearance of the test target is
continuous and same speed in #9 and #10
and to remember the same blurriness because it will serve as Recovery point (R) = 1BO + 1BI = -2
the basis or baseline)
Recording = 10/16/-2
If blurriness is remembered by the patient → remove the
auxiliary lens, then proceed to test #9 → then add the prism BO
→ increase until the patient reports blurring of vision (the same Example: no blur point
with the auxiliary lens) -1.00 + (+0.25S) = -0.75 – SB
+1.00 → clear → add prism BO → until reach the same slightly -1.00 → adding prism BO
blur
Note: if no blur point, direct to break point it indicates
Blur point = OD: 4BO + OS: 6BO = 10prism BO convergence mechanism is not fully developed

BP = no blur
Recording: Break point (BR) = 10 + 10 = 20
BP = 4 + 6 = 10 Recovery point (R) = 3 + 3 = 6

Note: binocularly will always get higher plus → no need to refine
because there are still follow up tests
Trial framing (used) or test #7A (not included in books) – can
refine
Recording = X/20/6
Note: if the patient reports moving target and not breaking of
image → it indicates suppression → must identify which eye
causes the image to move to identify which eye is suppressed.

• In patient’s reference → clock orientation → #9 and #10

• If the target moves to right side = indicates right eye is
Convergence at Far #10 suppressed
• If the target moves to left side = indicates left eye is
Test distance 20 ft/6M suppressed
• Inform the patient to report as soon as there’s a movement in
the target to the right or to the left eye → if movement is
Test target Smallest readable reported → stop and record → Add the amount in both
rotaries → serves as test result
Lenses in place Test No. 7

Recording: suppression in eye

Prisms in place OU ready to turn Base Out
Movement of target = 9 x 2 = 18prism BO – starts to move to
right – OD eye (suppressed eye OD)
Illumination 20 ft. candle
Or 10 + 8 = 18prism BO – starts to move to left – OS eye
(suppressed eye OS)
Phoropter adjustment Far PD

Endpoint Break/ recovery Abduction at Far (VT #11)

The test utilizes base-in prism to create break and recovery

Significance:
period. The procedure is the same with Adduction at Far, it
Test No. 10: Breakpoint represents the reserve of the total differs only on the direction of the stimulus applied where base-
positive convergence at far. in prism is used.

Recovery represents the limit of fusional field in that direction.

If blurriness is remembered by the patient → remove the
auxiliary lens, then proceed to test #9 → then add the prism BO
→ increase until the patient reports blurring of vision (the same
with the auxiliary lens) → continue to increase the amount of
prism BO → until first seen double or split image or break point
(report right away) → and then decrease the amount → until
patient reports single vision
Significance:
Test No. 11: Breakpoint indicates the negative fusional
convergence or divergence in reserve. Recovery represents
the limit of fusional field in that direction.
Procedure: True Adduction at Far / Convergence at
Far/Abduction at Far

Recording: (continuation of #9) #9 True #10 #11 Abduction

adduction Convergence at at Far
BP = 4 + 6 = 10
at Far Far
Break point (BR) = 8 + 8 = 16

Recovery point (R) = 1 + 1 = 2 Test 20 ft/6M 20 ft/6M 20 ft/6M

distance
Recording = 10/16/2

Test target Smallest Smallest Smallest

Example: different direction of recovery readable readable readable

BP = 4 + 6 = 10
Lenses in Test No. 7 Test No. 7 Test No. 7
Break point (BR) = 8 + 8 = 16 place
 Test No. 18: Phoria determines the amount of vertical
Auxillary +0.25S None None imbalance at near.
lens Duction determines the reserve used at far in order to
compensate for muscular imbalance existing at near.
Prisms in OU ready OU ready to OU ready to
place to turn turn BO turn BI
BO Procedure: Vertical Phoria

Illumination 20 ft. 20 ft. candle 20 ft. candle #12 Vertical #18 Vertical Phoria
candle Phoria and and Duction at Near
Duction at Far

Phoropter Far PD Far PD Far PD

adjustment Test distance 20 ft/6M 16”/40cm

Endpoint Blur Break/Recovery Break/Recovery Test target Smallest readable Smallest readable
(same as
+0.25)
Lenses in place Test No. 7 Test No. 7
Clinical Finding: (subjective findings)
• BO Prism: 9/18/8
• BI Prism: X/ 20/8 Prisms in place OD: 12-15ΔBI OD: 12-15ΔBI
OS: 6ΔBU OS: 6ΔBU
Recording: #11 abduction at far

• If the target moves to right side = indicates left eye is Illumination 20 ft. candle 20 ft. candle
suppressed
• If the target moves to left side = indicates right eye is
suppressed Phoropter Far PD Near PD
adjustment

Vertical Phoria and Duction at Far (#12) and Near (#18)

The technique consists of two parts, the vertical phoria and
duction test both at far and near. The general procedure is the
same with lateral phoria measurement but this technique, the
measuring device is the 6-prism base-up and the dissociating
device is the 12-prism base-in. The test is performed both far
and near using the result of subjective refraction as the control
lens. The patient is asked to fixate on the smallest readable
target and to inform the examiner as the target becomes
horizontally aligned.
Appearance of the Test Target Vertical deviation
Vertical phoria
• Occur as a result of toxic conditions
• Also found when patient has a severe cold, sinus infection or
the debilitating condition but it will disappear when the
patient’s health returns to normal.
• In older patients, this may occur as a result of cerebral
vascular accident or stroke
Duction Test involves using prism ready to turn up or down
until diplopia occurred (break point) and recovery point as the
examiner reduces the amount of prism base-up or down. As the
endpoint is reached, the finding is recorded and interpreted for
any amount of correcting prism needed by the patient.
Significance:
Test No. 12: Phoria determines the amount of vertical
imbalance at far.
Duction determines the reserve used at far in order to
compensate muscular imbalance existing at far.
5 test findings → 1 in vertical phoria and 4 in duction findings for
far and near
Endpoint Horizontal Horizontal Alignment
Alignment
Lower target will move
Upper right target will be the fixating target
Recording:
Ask the patient to look at the upper right target (stationary
target) → reduce the amount of the measuring prism → until
patient reports horizontal alignment of the test target
Vertical Phoria:
• Base-up prism – Right hyperphoria or Left hypophoria
• O – Orthophoria (no vertical phoria)
• Base-down prism – Left hyperphoria or Right hypophoria
o Note: in cover uncover test → Determine the type of
phoria → in vertical phoria indicated which eye has
phoria
Sample:
• 2ΔBU – 2 right hyperphoria
• 1ΔBD – 1 left hyperphoria
Vertical Duction
• Right Supraduction – Break: 5; Recovery: 2 (5/2)
• Right Infraduction – Break: 4; Recovery: 1 (4/1)
• Left Supraduction – Break: 4; Recovery: 1 (4/1)
• Left Infraduction – Break: 4; Recovery: 1 (4/1)
o Uses BD or BU to break the and recover the test target
o Supraduction → Prism downward → or towards down
o Infraduction → Prism Upward → or towards Up
o If opposite recovery → 5/-1 → recorded as negative value
o Usually, same value in supra and infra if no vertical
deviation
o Repeat the same procedure on the other eye if there are
deviation or differences in values → or if the same the OD
infra will be used as the value in OS supra, while OD
supra will be used as the value in OS infra → due to
common orthophoria at far in patients and to avoid
tiresome to patient
 Vertical Duction Test Program (OEP) or test #19 which is commonly used in a clinical
setting. This utilizes the addition of minus or plus lenses.
#12 Vertical Phoria #18 Vertical Phoria Techniques used in preliminary test to measure amplitude of
and Duction at Far and Duction at Near accommodation → donder’s table, Hofstetter method and NPA
using push-up amplitude method
Test distance 20 ft/6M 16”/40cm

Push-up amplitude method

Test target Smallest readable Smallest readable
• Ask the patient to read the smallest readable target

• Move slowly the target until blurred → NPA (cm) to get the
Lenses in place Test No. 7 Test No. 7
AA (D) → compute using the D = 1/f or 100/cm

• If with habitual correction, → ask the patient to wear it

Prisms in place Prism Ready to Prism Ready to turn
turn BU and BD (0 BU and BD o Minus the habitual correction to the value of NPA
mark is aligned to
the 0 and 180) o As much as possible, if the patient can still read a target in
the reduced Snellen without correction, do it without
correction to avoid confusion
Illumination 20 ft. candle 20 ft. candle
Raf rule – instrument used to measure NPA and NPC

Phoropter Far PD Near PD Myope → late presbyope

adjustment
Test #5 and #6 → objective method to determine the amount of
lens needed in near point → counterpart in subjective test is the
Endpoint Break and Break and Recovery cross-cylinder test #14B a part of accommodation test.
Recovery

Note: both eyes are open → to produce diplopia Amplitude of Accommodation

Clinical Finding:
• AA is one important test in eye examination
Vertical Phoria:
Any remaining prism towards the: • Helps the practitioner to detect accommodative insufficiency
• Base-up prism – Right hyperphoria or Left hypophoria especially if the amount is below the expected for the
patient’s age
• O – Orthophoria
• Base-down prism – Left hyperphoria or Right hypophoria • Useful in calculating the amount of near correction needed by
the patient
Duction Test • Absolute AA or negative AA
• Right Supraduction – Break: 4; Recovery: 1 (4/1)
• Right Infraduction – Break: 4; Recovery: 1 (4/1)
Significance
To determine the amplitude of accommodation of the patient.
TEST NO. 19: AMPLITUDE OF ACCOMMODATION
Accommodation is defined as the dioptric adjustment of the
Instrumentation
crystalline lens of the eyes to obtain clear vision at different
distances either at far or near. • Phoropter Head
• Reduced Snellen chart → in paragraph form → target (.62
• Sclerotic → lens became rigid and not flexible → AA EM type)
decrease as we age
• Reading Rod

Accommodation test Procedure:

• Dissociated cross-cylinder test (#14A)
• Binocular cross-cylinder test (#14B)
• Amplitude of accommodation (#19)
• Positive relative accommodation (#20)
• Negative relative accommodation (#21)
The amplitude of Accommodation is the maximum amount of
accommodation that the visual and ocular system can produce
expressed in diopters. → no sign, unless absolute AA or 0 or
negative AA
Measurement of the amplitude of accommodation is one
important test in the eye examination. This helps the practitioner
to detect accommodative insufficiency especially if the amount
is below the expected for the patient’s age. It is also useful in
calculating the amount of near correction needed by the patient.
There are different techniques to measure the amplitude of
accommodation, such as Push-Up Amplitude, the Hofstetter
technique, and the one used in the Optometric Extension
The target (.62 EM type) is placed on the midline 40cm away in
front of the patient’s eye. The test target should be properly
illuminated using a 20foot candle. Pupillary distance is set for
patients near PD. The lens is placed in the power obtained in
subjective refraction and the patient is asked if the target is
readable or not readable. Additional lenses are added in the
quarter diopter as the patient is instructed to read the
paragraph aloud (repeatedly). If the target is readable sufficient
amount of minus lenses are in the quarter diopter until the target
becomes totally blurred. On the other hand, if the target is not
readable additional plus lenses are added in the quarter diopter
until the patient reads the target with difficulty (1st readable). The
amount obtained will serve as Gross #19.
Computation of net finding is based on the amount of minus
or plus lens added to subjective finding (test no. 7) which is then
combined to 2.50D.
• The amount of minus lenses added above the subjective
finding is added to 2.50 diopters to the binocular amplitude
of accommodation.
 • The amount of plus lenses added above the subjective Example 3:
finding is deducted to 2.50 diopters to get the amplitude of
Gross #19 = -6.50S = -0.50cx 90
accommodation. Test No. 7 = -0.50S = -0.50cx 90
= 6.00 = -0.50cx 90
To get the AA = add 6.00 from 2.50
#19 Amplitude of Accommodation
Net #19 = 2.50 + 6.00 = 8.50D

Test distance 13” or 40cm (AA = 2.50D) or 16” Note: in AA no cylinder

Test target 0.62Em Type Example 4:

Gross #19 = -5.50S
Lenses in place Test No. 7 Test No. 7 = -0.75S
= 4.75
Presbyope: plus lenses added until
clear (1st readable) Net #19 = 2.50 + 4.75 = 7.25D
Non-presbyope: minus lenses added until
print becomes difficult to read
Example 5:
Gross #19 = +3.00S
Illumination 20 ft. candle Test No. 7 = +1.25S
= 1.75
Phoropter Near PD Net #19 = 2.50 – 1.70 = 0.75D
adjustment

Example 6:
Endpoint 1st readable (presbyope)
Print difficult to read (non presbyope) Gross #19 = -6.00S
Test No. 7 = Plano
= -6.00
Presbyope: not all presbyope has blurry vision → do not add
Net #19 = 2.50 + 6.00 = 8.50D
plus if still readable even blurry → instead add minus until
totally blurred and remains blurred Example 7:

Non-presbyope: minus lenses added until print becomes Gross #19 = +1.00S
difficult to read Test No. 7 = -0.50S
= 1.50
Note: if huge gap in VA of both eyes, get AA monocularly
Net #19 = 2.50 – 1.50 = 1.00D
Procedure:

• Prepare and adjust all the requirements needed Note: the amount of AA can be used to compute for the reading
• Ask the patient regarding the clarity of the test target correction.

o If readable: add minus lens in 0.25D until the target Reading Add (RA) = WD – ½ (AA)
becomes totally blurred and remains blurred
▪ The added amount of minus lens in the control lens Example: tentative reading add via AA method
(#7) is deducted to #19G then added to the 2.50 to get
the AA → AA = 2.50 + (?) #7 = +0.50 AA = 1D

o If not readable: add plus lens in 0.25D until the target
becomes readable (1st readable) with difficulty
▪ The added amount of plus lens in the control lens (#7)
is deducted to #19G then subtracted to the 2.50 to get
the AA → AA = 2.50 - (?)
WD = 40cm → D= 100/40 = 2.50D
RA = 2.50D – ½ (1D) → 2.50D – 0.50D = 2.00D
RA = 2.00D
Final Rx = OU: +0.50 add +2.00

• Unlike signs → ADD

Interpretation of Finding
• Like signs → DEDUCT
• If the amount of AA is 5.00D or more, it means that the
patient has no difficulty in near point
Example 1: non-presbyope • If the amount of AA is below 5.00D it means amplitude of
accommodation starts to recede and the patient may
Gross #19 = -7.00Sph → added lens
experience difficulty seeing at a near point.
Test No. 7 = +0.50Sph → control lens
7.50 → disregard sign
To get the AA = add 2.50 to 7.50
Test no. 7 → subjective refraction at far
Net #19 = 2.50 + 7.50 = 10.00D
Test no. 14A Subjective refraction at Near
Test no. 4 → static retinoscopy or Objective refraction at far
Example 2: presbyope
Test no. 5 (40cm) and 6 (20cm) → dynamic retinoscopy or
Gross #19 = +2.00 Sph
objective refraction at near → can determine lag of
Test No. 7 = +0.50 Sph
= 1.50 accommodation if patient accept more plus lens at near than at
far
To get the AA = deduct 1.50 from 2.50
Net #19 = 2.50 – 1.50 = 1.00D
Cross-Cylinder Test (Test 14A and 14B)
Crossed-Cylinder Test is a procedure to determine the amount
of near correction through subjective
means

• Cross cylinder – trial case (auxiliary) accessory used for

checking the cylinder axis and power in test no. 7 → also
used as one component in near subjective refraction in test
no. 14A and 14B → as it is used to relax accommodation

• For patient who is not a presbyope, the crossed-cylinder

findings provide information concerning the lag of
accommodation.
• For presbyopic patients, the binocular crossed cylinder
finding provides a rapid and convenient method of
determining the tentative addition.
• In some cases, the cross cylinder findings identify patient
who have latent hyperopia or who could benefit by the
prescription of the additional plus lens power for near or
bifocal lenses.

The target is dissociated with the use of 3ΔBD over the OD eye
and 3ΔBU over the OS left and a crossed cylinder (with a red
Note: sometimes patient won’t see vertically aligned targets –
dot at 90⁰) will serve as an auxiliary lens. The patient is directed
leave it as is → displacement due to phoria
to fixate at the cross grid placed 40cm away from the patient.
With the result of the subjective test in place, the patient is 1st part of #14A: no cross cylinder – but set prior to test →
asked about the appearance of the grid (composed of five normal illumination
horizontal and vertical lines). If the horizontal lines are clearer
Procedure: Test #14A: Dissociated Cross-Cylinder Test
additional plus is used until the vertical lines become clearer. On
the hand, if the vertical lines appear to be clearer minus lenses
1st Part: Horizontal or Vertical – add +0.25S and -0.25C with
are added until equality is established. The amount of lens that axis at 90 to the darkest lines
equalizes both the horizontal and vertical lines represent the
gross finding. • Horizontal = represents axis 90
• Vertical = represents axis 180

Note: both eyes open → even done monocularly

#14A Dissociated Cross-Cylinder Test
• Instruct patient that will see two targets with grid lines
crossing
Test distance 16” or 40cm
• Ask the patient to look first at the upper target → If the lines
are equally clear, dark or blur → proceed to the lower
Test target Cross-grid target
• Lower target → if equally clear, black, blur → proceed to
2nd part
Lenses in place Test No. 7 • If not equally clear lines (H or V) → add +0.25S to the
spherical component, → ask again the patient with the
appearance of the target
Prisms in place OD: 3ΔBD o If equally clear → proceed to the lower target
OS: 3ΔBU • If still not equally clear → add -0.25C with axis at 90 to the
darkest lines (original axis)
o If vertical is clear with original axis 180 (SAME) → add
Auxillary device cross-cylinder (-0.50D) with red dot -0.25C → increase cylinder power
at 90⁰ o If vertical is clear with original axis of 90 (different) →
reduce -0.25C → decrease cylinder power
o If horizontal is clear with original axis 180 (different) →
Illumination 20ft. Candle (1st part) or Dim (2ft. Candle) reduce -0.25C → decrease cylinder power
illumination (2nd part) o If horizontal is clear with original axis 90 (SAME) →
Add -0.25C → increase cylinder power
Phoropter Near PD o If equal clear → proceed to the lower target
adjustment • If still not clear after adding add +0.25S and -0.25C with axis
at 90 to the darkest lines → repeat the procedure 3 times →
if still not clear leave the target as is (+0.25S with -0.25C)
Endpoint Equality (highest plus) → or point of
reversal • Minimum and maximum power is +0.25S with -0.25C → to
avoid total changing of distance correction value
• If oblique astigmatism → only the sphere portion can be
Cross grid → has 5 horizontal and vertical lines used to
changed, cylinder cannot be added
determine if the patient accepts more plus or less minus
• ATR or WTR → sphere and cylinder adding is applicable
Phoropter cross cylinder → -0.50D common

• +0.25 = -0.25

• +1.37 = -1.37 2nd Part: dim illumination and addition of cross cylinder to relax
accommodation
• -0.50 = +0.50
Note: ask the patient which target to fixate (upper or lower)
Note: increase with the same amount of prism in both eyes to
increase the distance of the target if appeared close Lens in place: gross in 1st part
Non-presbyope • lower target: VERTICAL lines clearer → add +0.25 to
SPHERE
• Horizontal lines darker – add plus (+) lenses → until reach o OS: -0.75S = -1.00C X 90 → V. C. → reduce +0.25C
the highest equality and point of reversal (due to OG axis is 90 and chooses vertical axis or 180)
• Vertical lines darker – add minus (–) lenses → until reach o OS: -0.75S = -0.75C X 90 → E.C. → Proceed to Part 2
the highest equality and point of reversal → common for
non-presbyope Part 2:
• Equally clear (V and H) – add + lenses → until reach the
highest equality and point of reversal Fixation target: either upper or lower target patient’s preference
• Equality impossible – leave vertical lines clearer Lens in Place:
• Pattern → usually HEV (common), EV, VHEV, HVH,
• OD -0.75S = -1.00C X 90
sometimes no equality look for reversal • OS -0.75S = -0.75C X 90
Early or presbyope
Patient’s Response:
• Horizontal lines darker – add plus (+) lenses → until reach
VERTICAL lines clear – increase minus decrease plus until
the highest equality and point of reversal → common for
equality
non-presbyope
• Vertical lines darker – add plus (+) lenses → until reach
• OD: -0.75S = -1.00C X 90 → V.L. clearer
the highest equality and point of reversal → distance
correction is insufficient for reading, adding plus lens to • OS: -0.75S = -0.75C X 90
suffice • OD -1.00S = -1.00C X 90 → V.L. clearer
• Equally clear (V and H) – add + lenses → until reach the • OS -1.00S = -0.75C X 90
highest equality and point of reversal • OD -1.25S = -1.00C X 90 → E.C. → STOP → GROSS 14A
• OS -1.25S = -0.75C X 90
• Equality impossible – leave vertical lines clearer → VL are
more plus Note: ONLY change in sphere
Note: only change on the SPHERE In minus lens and vertical → 1st equality is the stopping point →
highest plus

Example 1:

Test No. 7: OU -1.00S

#15A Induced Phoria Through unfused
Cross-Cylinder Test
1st Part Patient’s Response:

• Patient reported that the horizontal and vertical lines on the Test distance 16” or 40cm
upper target are equally clear → Proceed to lower target
• Patient reported that the horizontal and vertical lines on the
lower target are equally clear → Proceed to 2nd part of the Test target Cross-grid
test

Note: remind the patient to NOT compare the upper and lower Lenses in place Gross No. 14A
target → focus only on one target
Prisms in place OD: 12-15ΔBI (measuring device)
OS: 6ΔBU (dissociating device)
2nd Part: dim illumination then add cross cylinder red dot at 90

Ask which target to fixate Auxillary device cross-cylinder (-0.50D) with red dot

Lens in Place: Test No. 7: OU: -1.00S → Equally clear in part 1 at 90⁰

Note: REDUCE MINUS/ INCREASE PLUS UNTIL EQUALITY Illumination 20 ft. candle (normal)
Patient’s Response: looking at 1 target with dim and cross cyl
Phoropter Near PD
• OU: -1.00S → Horizontal → add +0.25 adjustment
• OU: -0.75S → Horizontal → add +0.25
• OU: -0.50S → Equal → add +0.25
• OU: -0.25S → Vertical → add -0.25 (point of reversal) Endpoint Vertical alignment

Note: choose the highest plus least minus Note: ask to fixate on the lower target (stationary target)
Recording: #14A gross = -0.50S Recording:

• BI = exo

• BO = eso
Example 2:
• If increase more plus at near → expect increase in phoria
Test No. 7: OU -1.00S = -1.00C X 90
• If increase more minus at near
1st Part Patient’s Response:
o if exo → decrease in phoria
• Upper target: HORIZONTAL lines clearer → add +0.25S to o if ortho → get more eso
SPHERE
o OD: -0.75S = -1.00C X 90 → E.C → Proceed to lower o if eso → increase in phoria
target
Sample recording 2nd Part Patient’s Response: dim illumination then add cross
cylinder red dot at 90 → fixating at 1 target
#14A = OD -1.25S = -1.00C X 90
Lens in Place: Test No. 7:
OS -1.25S = -0.75C X 90
• OD: +0.75S = -0.25C x 90 → E.C → add +0.25S
#15A = 5 XOP (5ΔBI) • OS: +1.00S
o OD: +1.00S = -0.25C x 90 → E.C → add +0.25S
o OS: +1.25S
o OD: +1.25S = -0.25C x 90 → V.C → add -0.25S
Significance (#14A and 15A) o OS: +1.50S

• Indicates the lag of accommodation under dissociated Note: choose the highest plus least minus
condition.
• Determines the influence of #14A lenses on lateral muscular Recording:
imbalance at near.
#14A gross

o OD: +1.00S = -0.25C x 90 → E.C → add +0.25S

Example 1: o OS: +1.25S

Test No. 7: (antimetropia)

Proceed now to get the phoria #15A Induced Phoria
• OD: +0.75S
Through unfused Cross-Cylinder Test
• OS: -0.50S = -0.75C x180
Procedure:
1st Part Patient’s Response:
Place the OD: 12-15ΔBI and OS: 6ΔBU then measure the
• Upper target: phoria by reducing the measuring prism until vertically align
o OD: +0.75 → V.C → add +0.25S
o OD: +1.00 → V.C → add -0.25C After that proceed to #14B binocular cross cylinder → no
o OD: +1.00S = -0.25C x 180 → E.C → proceed to lower prism just cross cylinder in dim illumination
target
Note: only see 1 target → compare horizontal and vertical line
• Lower target:
o OS: -0.50S = -0.75C x180 → H.C → add +0.25S Procedure:
o OS: -0.25S = -0.75C x180 → H.C → reduce -0.25C
o OS: -0.25S = -0.50C x180 → E.C → proceed to 2nd part • OD: +1.00S = -0.25C x 90 → V.C → add -0.25S
• OS: +1.25S

o OD: +0.75S = -0.25C x 90 → V.C → add -0.25S

2nd Part Patient’s Response: dim illumination then add cross o OS: +1.00S
cylinder red dot at 90 o OD: +0.50S = -0.25C x 90 → E.C
o OS: +0.75S
Lens in Place: Test No. 7:

• OD: +1.00S = -0.25C x 180 → E.C → add +0.25S

• OS: -0.25S = -0.50C x180 Recording: #14B
o OD: +1.25S = -0.25C x 180 → V.C → add -0.25S
o OS: PL = -0.50C x180 • OD: +0.50S = -0.25C x 90 → E.C
o OD: +1.00S = -0.25C x 180 → E.C • OS: +0.75S
o OS: -0.25S = -0.50C x180

Note: choose the highest plus least minus

Example 3:
Recording:
Test No. 7: OU: Plano
#14A gross
1st Part Patient’s Response:
o OD: +1.00S = -0.25C x 180
o OS: -0.25S = -0.50C x180
• Upper target:
o OD: Plano → E.C → proceed to lower target
• Lower target:
o OS: Plano → H.C → add +0.25S
Example 2: o OS: +0.25 → E.C → proceed to 2nd part
Test No. 7:

• OD: +0.50S 2nd Part Patient’s Response: dim illumination then add cross
• OS: +0.75S cylinder red dot at 90

1st Part Patient’s Response: Lens in Place: Test No. 7:

• Upper target: • OD: Plano → H.C → add +0.25

o OD: +0.50S → H.C → add +0.25S • OS: +0.25
o OD: +0.75S → H.C → add -0.25C o OD: +0.25S → H.C → add +0.25S
o OD: +0.75S = -0.25C x 90 → E.C → proceed to lower o OS: +0.50
target o OD: +0.50S → H.C → add +0.25S
• Lower target: o OS: +0.75
o OS: +0.75 → V.C → add +0.25S o OD: +0.75S → E.C → add +0.25S
o OS: +1.00 → E.C → proceed to 2nd part o OS: +1.00
o OD: +1.00S → E.C → add +0.25S
 o OS: +1.25 Significance:
o OD: +1.25S → E.C → add +0.25S → gross
o OS: +1.50 • Test No. 14A: Indicates the lag of accommodation under
o OD: +1.50S → V.C → add -0.25S dissociated conditions.
o OS: +1.75
• Test No. 15A: Determines the influence of #14A lenses on
lateral muscular imbalance at near.

Then proceed to #15A Induced Phoria Through unfused Cross-

Cylinder Test #14B fused or binocular Cross-cylinder Test

Procedure: add cross cylinder with OD: 12-15ΔBI OS: 6ΔBU,

still the target is the cross grid → look at lower target → say stop #14B fused binocular Cross-
if vertically aligned → get the measurement cylinder Test

Recording: 5ΔBI = 5EXO

Test distance 16” or 40cm

Then proceed to #14B binocular cross cylinder or fused

Test target Cross-grid
binocular cross cylinder → uses cross cylinder but no prism
Procedure:
Lenses in place Gross No. 14A
Lens in place: #14A gross → looking at the cross grid (target)

o OD: +1.25S → E.C → add +0.25S → gross Prisms in place None

o OS: +1.50

Tell the patient, you will only see 1 target and ask which line is Auxillary device cross-cylinder (-0.50D) with red
clearer horizontal or vertical lines dot at 90⁰

o OD: +1.25S → H.C → add +0.25S

o OS: +1.50 Illumination 2 ft. Candle or Dim illum.
o OD: +1.50S → H.C → add +0.25S
o OS: +1.75
o OD: +1.75S → V.C → add -0.25S Phoropter adjustment Near PD
o OS: +2.00
o OD: +1.50S → H.C → add +0.25S
o OS: +1.75 Endpoint Equality (highest plus)

In #14B leave the Horizontal clearer → no need for more plus

Dissociated Cross-cylinder Test and Induced Phoria

through Unfused Cross-cylinder Test

#14A Dissociated #15A Induced

Cross-cylinder Test Phoria through
Unfused Cross-
cylinder Test

Test distance 16”/40cm 16”/40cm

Procedure: #14B

Test target Cross-grid Cross-grid • Horizontal lines darker – add + lenses

• Vertical lines darker – add – lenses
• Equally clear (V and H) – add + lenses
Lenses in Test No. 7 Gross No. 14A • Equality impossible – leave horizontal lines clearer
place
Significance

Prisms in place OD: 3ΔBD OD: 12-15ΔBI • Indicates the lag of accommodation under dissociated
OS: 3ΔBU OS: 6ΔBU condition.

Example 1:
Auxillary cross-cyl (-0.50D) cross-cyl (-0.50D)
device with red dot at 90⁰ with red dot at 90⁰ Lens in Place: 14A Gross: -0.50S

Patient’s Response:
Illumination 20 ft. Candle/Dim 20 ft. candle
illum. • OU: -0.50S → Horizontal → Add +0.25
• OU: -0.25S → Horizontal → Add +0.25
• OU: 0.00 → Equal → Add +0.25
Phoropter Near PD Near PD
• OU: +0.25S → Equal → Add +0.25
adjustment
• OU: +0.50S → Vertical → add -0.25 → STOP

Endpoint Equality (highest Vertical alignment Recording: Gross #14B: OU = +0.25S

plus)
Example 2: Binocular Cross-cylinder Test/Induced Phoria through
Fused Cross-cylinder Test
Lenses in Place: Gross #14A

• OD -1.25S = -1.00C X 90 #14B Binocular Cross- #15B Induced

• OS -1.25S = -0.75C X 90 cylinder Test Phoria through
Fused Cross-
Patient’s Response: HORIZONTAL lines clear – DECREASE cylinder Test
minus /INCREASE plus until equality

• OD -1.00S = -1.00C X 90 → H.C → Add +0.25 Test distance 16” or 40cm 16” or 40cm
• OS -1.00S = -0.75C X 90
• OD -0.75S = -1.00C X 90 → H.C → Add +0.25
• OS -0.75S = -0.75C X 90 Test target Cross-grid Reduced Snellen
• OD -0.50S = -1.00C X 90 → E.C → Add +0.25
• OS -0.50S = -0.75C X 90
• OD -0.25S = -1.00C X 90 → V.C → Add -0.25 → stop Lenses in Gross No. 14A Gross No. 14B
• OS -0.25S = -0.75C X 90 place

Prisms in None OD: 12-15ΔBI

After doing Test #14A or Test #14B, continue the test place
procedure by determining the amount of induced phoria at near OS: 6ΔBU
and the result of Dissociated and Fused Crossed-Cylinder
Test as a control lens. Determine the amount of phoria at soon Auxiliary cross-cylinder (-0.50D) None
as the target becomes vertically aligned. Record the finding. device with red dot at 90⁰
Instrumentation:
• Vision Tester Illumination 20 ft. Candle/Dim illum. 20 ft. candle
• Reduced Snellen/Cross Grid
• Reading Rod Phoropter Near PD Near PD
• Cross-Cylinder Lens adjustment

Endpoint Equality (highest plus) Vertical alignment

#15B Induced Phoria through Fused
Cross-cylinder Test Significance:
• Test No. 14B: Indicates the lag of accommodation under
Test distance 16” or 40cm fused conditions.
• Test No. 15B: Determines the influence of #14B lenses on
Test target Reduced Snellen lateral muscular imbalance at near.

Lenses in place Gross No. 14B

Phorometric Test – application of the application of principles
in the steps procedures.
Prisms in place OD: 12-15ΔBI
Note: pseudo myope → accepts plus lens but should use minus
OS: 6ΔBU
lens

Auxiliary device None Objective test no. 4 followed by subjective test no. 7, then
objective test no, 5 followed by subjective test no. 14A and 14B

Illumination 20 ft. candle (normal) Lag – to determine the amount of inhibition to accommodation
due to the cross–cylinder, dim illumination and plus sphere, the
inhibition to accommodation due to presence of exophoria
Phoropter Near PD should be corrected. This correction factor for the influence of
adjustment convergence upon accommodation is termed as lag.

• Knew the patient has lag of accommodation when accepts

Endpoint Vertical alignment more plus at near than at far
• Lead of accommodation accepts more minus at near than
at far
Sample recording • Lag is converted into diopter to use in getting the #14A net
#14B = OD -0.50S = -1.00C X 90

OS -0.50S = -0.75C X 90 Dissociated Crossed-Cylinder Test (#14A)

#15B = 7 XOP (7ΔBI) The relationship between direct and conditioned
accommodation and convergence at the normal 16” or 40cm
Significance test distance is 2.50D of Accommodation and 15D of
convergence or 6D of convergence are associated with 1D of
• Test #14B – Indicates the lag of accommodation under fused accommodation.
condition.
• Test #15B – Determines the influence of #14B lenses on To convert the phoria to exophoria into accommodative effect,
lateral muscular imbalance at near. divide the prism diopter by 6.
 • 40/16 = 2.50D (max allowable lag in #14A) → if more than Formula: 14A Net = 14A gross – lag
2.50D of lag it cannot be used. Instead use the 2.50D
= +0.50 – 2/6
• 15/2.50 = 6D

• 2.50/2.50 = 1D = +0.50 – (0.33)

Amount of phoria 15𝐴 14A Net = 0.17Sph or +0.25

𝐿𝑎𝑔 =
6 Note: if there is cylinder power it is indicated or connected at the
end.
Fused Crossed-Cylinder (#14B)

2/3 of convergence is stimulated by accommodation

Example (#14A Net)
• 15D of convergence = to 2/3 X 2.50D of accommodation =
1.67 or 1.75D → maximum allowable lag in #14B
Given
• 15ΔD / 1.75 = 8.57 or 9D (15B/9)
• #7 = +0.50D
Amount of phoria 15𝐵
𝐿𝑎𝑔 = • #14A Gross = +2.50D
9 • #15A = 2 XOP
• #19 Net = 4.00D

Formula: 14A Net = 14A gross – lag (AA/5)

Test #14A: Binocular Cross-Cylinder Test
= +2.50 – (2/6 X 4/5)
Computation (#14A Net)
= +2.50 – (0.33 X 0.8)
Formula: 14A Net = 14A gross – lag (15A/6)
= +2.50 - 0.26
Remember:
14A Net = +2.24 or +2.25S
• If test #19 net is less than 5.00D, modify the AA using the
formula MD = AA/5 or AA X 0.2
• M.L. = Lag X MD
o 14A Net = 14A gross – lag x (AA/5) Example (#14A Net)
• If test #15A is Orthophoria or SOP, lag = 0
• The maximum lag for 14A = 2.50D Given

• #7 = +0.50D
• #14A Gross = +1.75D
Example (#14A Net) • #15A = 2 XOP
• #19 Net = 4.00D
Given
Formula: 14A Net = 14A gross – lag (AA/5)
• #7 = +1.00D
• #14A Gross = +2.00D = +1.75 – (2/6 X 4/5)
• #15A = 6 XOP
• #19 Net = 7.00D = +1.75 – (0.33 X 0.8)

Formula: 14A Net = 14A gross – lag = +1.75 - 0.26

= +2.00 – 6/6 14A Net = +1.49 or +1.50S

= +2.00 – 1.00 Reading add = #7 – #14A

= +0.50 - +1.50 = +1.00D
14A Net = +1.00 Sph → serves as total lens in place
(TRA) not the actual add Rx: +0.50S Add +1.00 → presbyopic stage

Reading add = #7 – #14A

= +0.75 - +1.00 = +0.25D
Computation (#14B Net)
Assessment: +0.75S for distance only as it has greater AA
value and near vision can be still compensated. Formula: 14B Net = 14B gross – lag (15B/9)

Note: check for the net or gross value → net no sign Remember:

To get the actual reading add → #7 – #14A = Reading add →
this will serve as the amount of accepted near power
• Reading add available in the market starts only in +1.00
to +3.00 for finished lens and +3.50 for processed lens
• If test #19 net is less than 5.00D, modify the AA using the
formula MD = AA/5 or AA X 0.2
• M.L. Lag X MD
o 14A Net = 14A gross – lag x (AA/5)
• If test #15B is Orthophoria or SOP, lag = 0
• The maximum lag for 14B = 1.75D

Note: the value of lag is always positive

Example (#14A Net): MYOPE

Given
Example (#14B Net)
• #7 = -1.00D
• #14A Gross = +0.50D Given
• #15A = 2 XOP
• #7 = +1.00D
• #19 Net = 7.00D
• #14B Gross = +2.25D
 • #15B = 9 XOP • #14B = OU -2.25
• #19 Net = 7.00D • #15B = 4XOP
• #19G = -2.25S
Formula: 14B Net = 14B gross- lag
#19G = -2.25S
= +2.25 – 9/9
#7 = -3.25S
= +2.25 – 1.00
1.00
14B Net = +1.25Sph
#19N = 2.50 - 1.00 = 1.50D

#14AN = 14A G - ML
Example (#14B Net)
= -2.00 - (5/6 X 1.5/5)
Given
= -2.00 - (0.83 X .3)
• #7 = -1.00D
• #14B Gross = +0.25D = -2.00 - (+.25)
• #15B = 1 XOP
• #19 Net = 7.00D #14A N = -2.25

Formula: 14B Net = 14B gross – lag #14B N = 14BG - ML

= +0.25 – 1/9 = -2.25 - (4/9 X 1.5/5)

= +0.25 – 0.11 = -2.25 - (0.44X .3)

14B Net = +0.14 Sph +0.25Sph = -2.25 - (.13)

#14B N = -2.38S or -2.50S

Example (#14B Net)

Given Exercise No. 2

• #7 = +0.50D Given:
• #14B Gross = +3.00D
• #15B = 6XOP • Hab. Rx = OU -2.25S
• #19 Net = 4.00D • #7 = OU -3.25S
• #14A Gross = OU -2.00S
Formula: 14A Net = 14A gross – lag (AA/5) • #15A = 5 XOP
• #14B = OU -2.25
= +2.50 – (6/9 X 4/5) • #15B = 4XOP
• #19G = -4.25S
= +2.50 – (0.67 X 0.8)
#19G = -4.25S
= +2.50 - 0.54
#7 = -3.25S
14A Net = +1.96 or +2.00S
1.00

#19N = 2.50 + 1.00 = 3.50D

Example (#14B Net)
#14AN = 14AG – ML
Given
= -2.00 - (5/6 X 3.50/5)
• #7 = +0.75D
• #14B Gross = +2.75D = -2.00 - (0.83 X .70)
• #15B = 6XOP
• #19 Net = 4.00D = -2.00 - (+0.58)

Formula: 14A Net = 14A gross – lag (AA/5) #14A N = -2.58 or -2.50S

= +2.75 – (6/9 X 4/5)

= +2.75 – (0.67 X 0.8) #14B N = 14BG - ML

= +2.75 - 0.54 = -2.25 - (4/9 X 3.50/5)

14A Net = +2.21 or +2.25S = -2.25 - (0.44X 0.70)

= -2.25 - (0.30)

Exercise No. 1 #14B N = -2.55S or -2.50S

Given:
FRx: -3.25 – distance correction #7
• Hab. Rx = OU -2.25S
• #7 = OU -3.25S X-cy: -2.50 – Cross cylinder #14A and #14B
• #14A Gross = OU -2.00S
= +0.75 – reading add
• #15A = 5 XOP
Note: starting power of reading add available is +1.00 to +3.00 Reading add trial start at +1.75 to +2.25 (where patient is
(finished lens) if +3.50 (processed lens) comfortable) sometimes more than +2.25 depends on patient
needs
Assessment: -3.25S Add +1.00 or since the patient is myope,
ask the patient to remove the distance correction but take
consideration to the working distance or working environment of
Pseudo myope – complain muscle spasm → gives plus lens
the patient.
but instruct the patient to try until adapt.

Exercise No. 3 Horizontal Vergence at Near (Test No. 16A – 16B and Test
No. 17A – 17B)
Given:
Horizontal Vergence at Near is composed of:
• Hab. Rx = none
• Positive Relative Convergence (Test No. 16A)
• #7 = OD +1.00S OS +1.50S
• #14A Gross = OD +3.00S OS +3.50S • Positive Fusional Reserve (Test No.16B)
• #15A = 7 XOP • Negative Relative Convergence (Test No. 17A)
• #14B = OD +3.50S OS +4.00S
• Negative Fusional Reserve (Test No. 17B)
• #15B = 9 XOP
• #19G = OD +2.50S OS + 3.00S

OD OS Positive Relative Convergence and Positive Fusional

#19G = +2.50S
#7 = +1.00S
1.50
#19N = 2.50 - 1.50 = 1.00D
#14A N = 14A G - ML
= -2.00 - (5/6 X 1.5/5)
= -2.00 - (0.83 X .3)
= -2.00 - (+.25)
#14A N = -2.25
OD
#14A N = 14A G - ML #14A N = 14A G - ML
= +3.00 - (7/6 X 1.0/5)
Reserve
+3.00
It is a near test that utilizes a base-out prism that results in a
+1.50 near-point base-out to blur out the test. The control lens use
depends on the refractive condition of the patient. If the patient
1.50 is a non-presbyope hyperope or emmetrope the test is
performed using the result of subjective refraction (test no.7). In
#19N = 2.50 - 1.50 = 1.00D the case of myopic non-presbyope the test is performed through
the habitual near correction worn by the patient. The prism is
positioned before the patient so that it can be rotated towards
the base-out direction. Once all the necessary requirements are
set, the patient is directed to look at the smallest target placed at
40cm and advised to take note as soon as the target becomes
blurred as the examiner turns the prism towards the base-out
direction. After the blur point, the examiner continues to
increase the base-out prism binocularly until the target becomes
double. After noting the amount of prism for both blur and
breakpoint, the amount of prism base-out is slowly reduced until
the target becomes single and that will serve as the recovery
OS
point.
Note: according to sheard’s, the patient will experience comfort
if the reserve is more than twice than the demand
= +3.50 - (7/6 X 1.0/5)

= +3.00 - (1.17 X .2) = +3.50 - (1.17 X .2)

= +3.00 - (+.234) = +3.50 - (+.234) #16A Positive Relative Convergence

#14A N = +2.77S #14A N = +3.27S

Test distance 16” or 40cm
or +2.75S or +3.25S

Test target Smallest readable (reduced snellen)

OD
#14B N = 14B G - ML
= +3.50 - (9/9 X 1.0/5)
OS
Lenses in place Non presbyope: test #7 (H or E)
#14B N = 14B G - ML
Myope: habitual minus at near
= +4.00 - (9/9X 1.0/5) Presbyope: 14B Net

= +3.50 - (1.0 X .2) = +4.00 - (1.0 X .2)

Prisms in place OU is ready to turn BO (0 at axis 90)
= +3.50 - (0.20) = +4.00 - (0.20)

#14B N = +3.30S #14B N = +3.80S Illumination 20 ft. candle

or +3.25S or +3.75S
Phoropter Near PD
adjustment

OD OS
Endpoint Blur-out
#7 +1.00S +1.50S
Note: if lenses are used for distance only, use PLANO if not,
14A Net +2.75S +3.25S (+1.75) use what is applicable

14B Net +3.25S +3.75S (+2.25) Continuation of #16A is #16B

 Note: #16A and #16B is done the same as #9 and #10 →
#16B Positive Fusional Reserve continuously done from blur to break to recover period

• In suppression → #16A and #16B it creates cross diplopia

Test distance 16”/40cm • If the target moves to right side = indicates right eye is
suppressed
Test target Smallest readable (reduced snellen) • If the target moves to left side = indicates left eye is
suppressed
• Inform the patient to report as soon as there’s a movement in
Lenses in place Non-presbyope: test #7
(H or E) the target to the right or to the left eye → if movement is
reported → stop and record → Add the amount in both
Myope: hab. minus at near
rotaries → serves as test result
Presbyope: 14B Net

Prisms in place OU is ready to turn BO Negative Relative Convergence and Negative Fusional
Reserve

Illumination 20 ft. candle This is a complete base-in-blur-out test. The procedure is the
same with the Positive Relative Convergence and Positive
Fusional Reserve except that the stimulus applied is a base-in
Phoropter adjustment Near PD prism.

Endpoint Break and Recovery

#17A Negative Relative
Convergence

Positive Relative Convergence and Positive Fusional

Reserve Test distance 16” or 40cm

#16A Positive #16B Positive Test target Smallest readable (reduced Snellen)
Relative Fusional Reserve
Convergence
Lenses in place Non-presbyope: test #7 (H or E)
Myope: hab. minus at near
Test 16”/40cm 16”/40cm
distance Presbyope: 14B Net

Test target Smallest readable Smallest readable Prisms in place OU ready to turn BI (0 at axis 90)

Lenses in Non presbyope: Non-presbyope: Illumination 20 ft. candle

place test #7 (H or E)
test #7
Myope: hab. (H or E) Phoropter adjustment Near PD
minus at near
Myope: hab.
Presbyope: 14B minus at near
Endpoint Blur–out
Net
Presbyope: 14B Net
Continue to do the #17B after #17A
Prisms in OU is ready to OU is ready to turn
place turn BO BO #17B Negative Fusional Reserve

Illumination 20 ft. candle 20 ft. candle Test distance 16”/40cm

Phoropter Near PD Near PD Test target Smallest readable (reduced Snellen)

adjustment

Lenses in place Non-presbyope: test #7 (H or E)

Endpoint Blur-out Break/Recovery
Myope: hab. minus at near
Significance: Presbyope: 14B Net

Test No. 16A: Blur point indicates the amount of positive

fusional innervation in reserve available at that fixation distance. Prisms in place OU ready to turn BI

Test No. 16B: Breakpoint indicates the accommodative

convergence in reserve that can be utilized at the fixation Illumination 20 ft. candle
distance.
Recovery indicates the limit of the fusion field in that direction. Phoropter adjustment Near PD

Endpoint Break and Recovery

Recording (16A – 16B) = 9/18/17

After this done for vergence test in getting the reserved value
Note: accommodation may not have been completely relaxed in the
subjective refraction and should repeat the binocular
Positive = medial rectus
subjective end point.
Negative = lateral rectus
Relative accommodation is maybe positive or negative. This
measures the total amount of accommodation that can be
Negative Relative Convergence and Negative Fusional exerted while the convergence of the eye is fixed. This can be
Reserve achieved by either stimulating or stimulating accommodation
with the use of either a positive or negative lens while
maintaining clear and single binocular vision.
#17A Negative #17B Negative
Relative Fusional Reserve According to Scheiman and Wick, Negative Relative
Convergence Accommodation (NRA) can be measured before Positive
Relative Accommodation (PRA) in order to avoid the influence
Test distance 16”/40cm 16”/40cm of accommodation on the measurements. This technique can
also be used to calculate the amount of near correction needed
by the patient
Test target Smallest readable Smallest readable
Assessment of relative accommodation (NRA and PRA) will
guide the examiner to determine accommodative problems
Lenses in Lenses in place Lenses in place
place which may affect the visual clarity. This will serve as an indicator
Non-presbyope: test Non-presbyope: test that may influence the state of binocular vision (e.g.,
#7 (H or E) #7 (H or E) accommodation and vergence).
Myope: hab. minus Myope: hab. minus
at near at near
Presbyope: 14B Net Presbyope: 14B Net
#20 Positive Relative Accommodation

Prisms in OU ready to turn BI OU ready to turn BI Test distance 16” or 40cm

place

Test target Smallest readable (reduced Snellen)

Illumination 20 ft. candle 20 ft. candle
Lenses in place Non-presbyope: test #7 (H or E)
Phoropter Near PD Near PD
adjustment Myope: habitual minus at near
Presbyope: 14B Net

Endpoint Blur -out Break /Recovery

Illumination 20 ft. candle

Significance:
Test No. 17A: Blur point indicates the amount of negative Phoropter adjustment Near PD
fusional convergence or measures the amount of convergence
relaxable at that fixation distance. Endpoint Blur – out

Test No. 17B: Breakpoint indicates the amount of

accommodative convergence which the relaxation of
accommodation can inhibit.
Recovery indicates the limit of fusion field in that direction
Recording (17A–17B) = 10/21/8
Note: utilize a minus lens until blur or difficult to read
Procedure test #20: Minus lens added (in -0.25D) until patient
cannot read the 20/20 reduced Snellen placed at 40cm. This
measures the maximum amount of accommodation that can be
stimulated.

Note: #17A and #17B creates uncrossed diplopia → has blur Sample recording: #20G = -5.50S
point (due to stimulating the accommodation by placing the
Significance Test No. 20: Indicates the extent to which
target at 40cm)
accommodation would be stimulated while fixation is maintained
• In suppression → uncrossed diplopia at 16 inches.
• If the target moves to right side = indicates left eye is
Computation of NET #20:
suppressed
• If the target moves to left side = indicates right eye is #20 𝑛𝑒𝑡 = #20 𝑔𝑟𝑜𝑠𝑠 − 𝑙𝑒𝑛𝑠𝑒𝑠 𝑖𝑛 𝑝𝑙𝑎𝑐𝑒
suppressed
Note: the value in front is always the one to find not the given
• Inform the patient to report as soon as there’s a movement in
the target to the right or to the left eye → if movement is Example: Non-presbyope (hyperope)
reported → stop and record → Add the amount in both
#20G = -2.25S
rotaries → serves as test result
#7 = +0.25S
#20N = -2.50D
Positive and Negative Relative Accommodation

• 2.50D of accommodation is stimulated at 40cm testing

distance, so the maximum amount of accommodation that will Example: presbyope
be expected to relax at 40cm would be 2.50D. #20G = -2.75S
• Therefore, the negative relative accommodation finding, plus
to blur should not be expected greater than +2.50D. if greater #7 = -0.50S
than that amount the examiner should suspect that #20N = -2.25D
 #21 Negative Relative Phoropter Near PD Near PD
Accommodation adjustment

Test distance 16” or 40cm Endpoint Blur -out Blur-out

Test target Smallest readable (reduced Snellen) Procedure:

Test No. 20: Minus lenses added until the patient cannot read
Lenses in place Non-presbyope: test #7 (H or E) the 20/20 reduced snellen. This measures the maximum amount
Myope: habitual Minus at near of accommodation that can be stimulated.
Presbyope: 14B Net
Test No. 21: Plus, lenses added until the patient cannot read
the 20/20 reduced Snellen.
Illumination 20 ft. candle

Phoropter adjustment Near PD

Significance:

Endpoint Blur-out Test No. 20: Indicates the extent to which accommodation
would be stimulated while fixation is maintained at 16 inches.
Note: remove the added minus lens in #20 then proceed to #21
Test No. 21: Indicates the extent to which accommodation
then use a plus lens until blur or difficult to read
could be inhibited while fixation is maintained at 16 inches.
Procedure Test No. 21: Plus lenses added until the patient
cannot read the 20/20 reduced Snellen.
Note: net findings can be used to determine the probable
Significance Test No. 21: Indicates the extent to which
reading correction of the presbyopic patient
accommodation could be inhibited while fixation is maintained at
16 inches. If non-presbyope, #21 net findings are low or high it signifies
problem with accommodation or anomalies of accommodation
Sample recording: #21G = +2.50S
→ other supplemental test procedures are done to determine
Computation of NET #21: the anomalies of accommodation (flipper lens – cycle per minute
→used for rehab)
#21 𝑛𝑒𝑡 = #21 𝑔𝑟𝑜𝑠𝑠 − 𝑙𝑒𝑛𝑠𝑒𝑠 𝑖𝑛 𝑝𝑙𝑎𝑐𝑒

Note: the value in front is always the one to find not the given
Heterophoria
Example: Non-presbyope (hyperope)
Heterophoria or latent squint is a condition in which the eyes
#21G = +3.50S
deviate from parallelism.
#7 = +1.00S
The eye may deviate laterally such as:
#21N = +2.50D
• Inward deviation (esophoria),
• Outward deviation (exophoria), → ideal condition (buffer)
Example: presbyope
Vertically such as:
#21G = +3.75S
• Upward deviation (hyperphoria) and
#7 = +1.25S • Downward deviation (hypophoria) in the absence of
#21N = +2.50D fusion.

On the other hand, orthophoria is a condition when the eyes

are straight when relaxed and not fusing.
Positive Relative Accommodation and Negative Relative
Accommodation
Symptoms of Heterophoria:
#20 Positive #21 Negative
Relative Relative • Headache
Accommodation Accommodation
• Eyestrain
Test distance 16”/40cm 16”/40cm
• Difficult change focus from near to distant

Test target Smallest readable Smallest readable • Blurring of vision

• Diplopia
Lenses in Lenses in place Lenses in place
place • Difficulty to judge distance and position
Non-presbyope: test Non-presbyope: test
#7 (H or E) #7 (H or E) • Interpupillary distance
Myope: hab. minus Myope: hab. Minus
• Structure of extra-ocular muscles
at near at near
Presbyope: 14B Net Presbyope: 14B Net • Dissociation factor

Normal expected value of phoria: ½ far and 6 at near

Illumination 20 ft. candle 20 ft. candle A. Classification of Heterophoria

1. Static – due to structural factors of the muscles.
• Orbital asymmetry
 • Interpupillary distance Near = #13B XOP #16A blur → if no finding get break
• Size and shape of globe
= #13B SOP #17A blur → if no finding get break
• Structure of extra-ocular muscles
Note:
Example: #3 habitual = 16 XOP
ΔBO → XOP → #9 at far and #16A at near
#7 subjective = -4.50Sph
ΔBI → SOP → #11 at far and #17A at near
#8 induced = 14 XOP
Note: cannot be improved phoria → usually high amount of
phoria and can be still reduced → feasible progress Example:
2. Kinetic – due to the effects of accommodation upon Induced phoria at far #8 = 2SOP → minimum reserve is 4
convergence → uncorrected refractive condition
• Age Induced phoria at near #13B = 4SOP → minimum reserve is 8
• Convergence ΔBO at far = 11/17/8
• Accommodation
• Dissociation factor ΔBI at far = x/20/6 → reserved is much
ΔBO at near = 12/21/6
Example: #3 = 3 XOP
ΔBI at near = 11/22/4 → reserved is much
#7 = -2.25Sph
Far: comfort
#8 = 1 XOP
Near: comfort
Note: phoria of patient is not usually high → over stimulate or
relaxation → check if need modification Analysis: the patient will experience comfort at far and at near
3. Neurogenic – due to weakness, hyper-excitation, or and the phoria is compensated according to sheard’s criteria as
incoordination of neuro-musculature. the patient has more reserved than the demand
• Sometimes combination of static and kinetic

Example: #3 = 18XOP Example:

#7 = -4.50Sph Induced phoria at far #8 = 1XOP
#8 = 18XOP Induced phoria at near #13B = 8XOP
Note: amount of phoria is usually high with no progress ΔBO at far = 12/27/8
ΔBI at far = x/20/6
Case analysis: ΔBO at near = 12/21/6 → not enough
The symptoms are dependent on the symptoms of the patient ΔBI at near = 11/22/4
and may be divided into compensated and decompensated.
Far: comfort
• Decompensated heterophoria – patient experienced some
Near: discomfort
difficulties when the fusion amplitudes are not enough to
control deviation. Analysis: the patient will experience comfort at far and difficulty
• Compensated heterophoria – the patient does not exhibit at near according to sheard’s criteria as the patient has more
any associated symptoms. reserved than the demand at far while at near is insufficient

Analysis: Kinetic #3 = 3XOP

Old Rx = +1.00S #7 = +1.50S → relaxes more XOP

#3 = 4XOP #8 = 5XOP

#7 = +2.50S → relaxes more XOP ΔBO = 10/19/6

#8 = 8XOP ΔBI = 12/21/8

• Don’t give test #7 (+2.50)

• Amount of exophoria increases because of the effect of plus Note: sometimes even the patient has high reserve of fusion if
lens that causes relaxation of accommodation and the classification of heterophoria is affected → the prescription
convergence. should be adjusted since it affects the phoria

Analyze the case after all the test procedure is done

This correlates to Sheard’s Criteria which states that: If doing the 21 steps → analyze after the 21 steps
• The patient will experience comfort if the fusional reserve is If case to case basis or segment by segment → you can
twice or more than twice than the fusional demand. → goes analyze or alter right away
with test #8 (induced)

Fusional demand Fusional reserve

Far = #8 XOP #9 blur → if no finding get #10 break

= #8 SOP #11 Break
#7 Subjective Refraction
Subjective Refraction is a technique used for determining the
refractive error of the eye that involves the patient’s response.
The starting point may be the Retinoscopy or A/R result, and
to some extent, the previous prescription, and is performed
monocular at first, then binocular.
The method described in the discussion is a proven method, but
just one of many possible methods of subjective refraction.
Methodology
A systematic method is recommended on the process of
performing the subjective refraction:
a. Determining the Sphere: Fogging method
b. Determining the Cylinder: with the use of Jackson Cross
Cylinder method
c. Binocular Balance: Dissociation by vertical prism
d. Final Check of Binocular Sphere, and Comfort
e. The Prescription: The Final Rx
Determining the Sphere
The idea is to initially create a blur or ‘fog’, to relax the patient’s
accommodation. The most suitable level of fog is addition of
+1.50D (@ 20/125 Snellen chart). This simulates the resting
focus of the eye (tonic accommodation).
• Lenses in Place (LIP): Objective result (A/R, Retinoscopy
findings or previous rx) —- net findings This done
MONOCULARLY, make sure to occlude left and start with the
right eye.
• Fog by adding +1.50D: expected VA is 20/200
• If vision is better than 20/100, fog is insufficient, add by
+0.25D increments until vision is reduced to 20/200
• If vision is worse than 20/200, this implies that the LIP
was over plus or less minus; start to remove fog in 0.25D
increments
• Remove fog in steps of 0.25D: that is, add -0.25D per step.
Theoretically, each 0.25D reduction of fog should improve
vision by 1 line.
• Continue to remove fog until you reach 20/20 line: stop
when vision does not improve further
• Return to the sphere that gives the most plus (least minus):
this is the best sphere at this stage.
Duochrome Test
The Duochrome Test may be used to check the spherical
correction. The patient is asked to look at the chart and compare
the letters/numbers on the red and green background. You may
ask “on which side do the letters appear blacker and clearer?...
Or do they appear equally black on both sides?”
• If the patient sees the characters more clearly on the red
background, → overplus → add -0.25D
• If the patient sees the characters more clearly on the green
background, → over minus → add +0.25D
• If the patient sees the characters as equally clear on the red
and green backgrounds, the central point focus is positioned
on the retina and the patient is properly focused for this test
distance
Example: Subjective refraction #7
Lens in place: net #4 = -0.75S
Fogging: -0.75 → add +1.50 → +0.75S
Defog: +0.75 → -0.25 until → -0.50 → 20/20
Ideal fog: +0.50
Plano → sphere (-0.50) with ideal fog (+0.50)
Duochrome: red is clearer → add -0.25
Plano → red → add -0.25
-0.25 → red → add -0.25
-0.50 → red → add -0.25 → more plus
-0.75 → green → add +0.25
Determining the Cylinder
After determining the sphere, the next step is to determine the
cylinder axis and power. Cylinder axis is checked first, followed
by the cylinder power.
The method used for this is the Jackson Cross Cylinder:
• Lenses in Place (LIP): Objective result (A/R, Retinoscopy
findings or previous rx)
o If no objective result, tentative axis can be determined
with fan dial / astigmatic dial.
o If no fan dial / astigmatic dial, you can do bracketing /
fishing method.
• Test Target: Cluster of round dots (honeycomb – no
doubling of dots) / 20/30 line / Fan dial / Astigmatic Dial
1. Determining the cylinder axis:
a. Position the HANDLE along the axis: this is the
position 1 of the cross cylinder
b. Twist the cross cylinder quickly: this is to show
position 2 of the cross cylinder. Ask the patient to indicate
which of the two positions offers clearer vision.
c. Change the axis of the (minus) corrective cylinder by
5 degrees: turning it towards the location of the preferred
minus cross cylinder position. → until 15 degrees
d. Repeat steps a to c until the patient can see no
difference or almost no difference between the two
positions: this is now the cylinder axis of the patient
Example:
Target: fan dial → darker line is 180 = axis 90 (lightest)
LIP (#4): -0.75S = -0.25cx 90 (handle is at 90) → position 1 →
move to where the red one is
Note: move until equally clear = refined axis

Example:
Tentative axis: lighter vertical = axis 90
Refine axis: handle is at 90 → flip → position 1 (red) → 95
Axis 95 → flip → position 1 → 100
Axis 100 → flip → Equal
2. Determining the cylinder Power:
a. Position the negative axis of the cross cylinder along
the axis of the (minus) corrective cylinder: this is
position 1
b. Twist the cross cylinder quickly: this is to show
position 2 of the cross cylinder. Ask the patient to indicate
which of the two positions offers clearer vision.
c. If the patient prefers: position 1(minus axis along the
corrective axis), it indicates patient prefers more minus
cylinder, so increase by -0.25D. If position 2 is preferred,
remove -0.25D
d. Repeat steps a to c until the patient can see no
difference or almost no difference between the two
positions: this is now the cylinder power of the patient
As a rule of thumb, to maintain the spherical equivalent,
remember to adjust the sphere power by +0.25D for every extra
-0.50D cylinder added, and by -0.25D for every extra -0.50D
cylinder removed.
If hesitating between two-cylinder powers, prescribe lesser
(minus) cylinder power.
Finalizing the Sphere
3. Remove ideal fog (+0.50sph)
4. Final Check of Sphere: to ensure that maximum plus is
given (20/20)
a. Add an extra +0.25D sphere, expected vision should be
slightly reduced; if it’s not, add the +0.25D and repeat the
checking of the sphere
b. With an extra -0.25D sphere, vision should remain the
same
Example:
Lens in place: net #4 OS = -2.00S
Fogging: -2.00 → add +1.50 → -0.50S → 20/200
Defog: -0.50 → -0.25 until → -2.00 → 20/20
Ideal fog: -2.00 → +0.50 fog → -1.50 → 20/25
-1.50 → sphere (-2.00) with ideal fog (+0.50)
Check cylinder axis and power:
Tentative axis: darker between 0 to 90 = axis 145
Refine axis: handle is at 145 → flip → position 1 (red) → 150
Axis 150 → flip → position 2 → 145
Axis 145 → flip → Equal
Cylinder power: ask if position 1 or equal → if position 1 → add
-0.25 if equal no cylinder or as is
Defog: -1.50S = -0.25cx 90 → add -0.25 → -2.00S = -0.25cx 90
Then do duochrome
Binocular Balance
After determining the monocular refractions of the right and left
eyes, it is important that the accommodative effort of the two
eyes are equal. Note that we will only perform this test only if the
eyes can reach 20/20 monocularly.
The method used for this is Dissociation with vertical prisms:
• Lenses in Place (LIP): Subjective refraction
• Test Target: 20/30 line
1. Dissociate the two eyes:
• OD 3BU; OS 3BD
• Upper target — left
• Lower target —- right
• OD 3BD: OS 3BU
• Upper target: lower target
2. Fogging: Add +0.50D
3. Ask patient if targets are equally clear or blurred
4. Add +0.25 to the eye that see more clear (if both eyes never
see equally, leave dominant eye clearer)
5. Defog: Remove +0.50D from both eyes – target 20/20 line
Final Check of Binocular Sphere and Comfort TRIAL
FRAMING
After getting the refraction of each eye separately and balanced
one with the other, the sphere must be confirmed binocularly.
This should be done in a trial frame. And this is being done
after performing all the other Visual Tests.
This is to simulate natural environment as opposed to sitting
behind the phoropter. For this reason, when judging for the
binocular sphere and comfort, it is preferable to have the patient
look outside, at the horizon.
Remember to take into account in the final prescription the fact
that the subjective refraction has been performed at a finite
distance and not at optical infinity.
Take note that the conventional test distance is not equal to
optical infinity and subjective refraction performed using a chart
at 20 feet gives rise to an error of 3.2ft/20ft. = +0.16D. Although
this error is lesser than a prescribing increment of 0.25D, it’s still
potentially significant. We should consider adjusting final
prescription by -0.25D binocularly.
Final Check of Binocular Sphere and Comfort
1. Place the subjective refraction result in the trial frame
2. Place an extra +0.25D in front of both eyes: ask patient if
vision is better, worse, or no different.
• If vision is worse, the refraction result in the trial frame is
correct. Do not add the +0.25D. Proceed to step 3.
• If there is no change, The refraction result is over-minuses
or under-plussed; Add the +0.25D binocularly and repeat
step 2.
• If there is no change, The refraction result is over-minuses
or under-plussed; Add the +0.25D binocularly and repeat
step 2. If >+0.50D needs to be added, redo the refraction.
3. Place -0.25D in front of both eyes: ask patient if vision is
better, worse, or no different.
a. If vision is worse: The refraction result in the trial frame is
now correct. This is your final prescription.
b. If there is no change: The refraction result in the trial frame
is correct or slightly over-minuses. Make a judgement
whether to add or not.
c. If vision is better: The refraction is over-plussed or under-
minus: add-0.25D and repeat step 3. If >-0.50D needs to
be added, redo the refraction.
In summary, the response that we seek during binocular
verification is that there should be a reduction in clarity and
comfort with the an extra +0.25D and absence of real change
Test Name
observed with an extra -0.25D. #

1 Ophthalmoscopy
The Prescription (Final RX)
The refraction as determined by the method discussed is not 2 keratometry
always what is finally prescribed: this is where the “art” of
3 Habitual phoria at far
prescribing comes into play, following the “science” of refraction.
Below are some factors to consider in deciding the final 4 Static retinoscopy
prescription to give.
• Consider the change between the new and previous 5 Dynamic retinoscopy at 20”
prescriptions. >0.75D sphere, >0.50D cylinder, >10deg axis,
6 Dynamic retinoscopy at 40”
or >+0.75D add. Patient should be forewarned of the
“learning process” with their new prescription (it is easier to
7 Subjective refraction
learn in smaller steps)
• Spectacle lenses are manufactured in 0.25D steps but the 7A Subjective refraction at near
eye is a biological organ that does not conform so; give
maximum visual acuity by considering maximum plus/less 8 Induced phoria at far
minus principle.
• For Myopia, young patient tends to accept over-correction 9 True adduction at far
due to the greater contrast that it gives. However, too much
over-correction should be avoided for reasons of visual 10 Convergence at far
comfort, and in some cases, progression of myopia.
• For young hyperopic patients, take note and be careful in 11 Abduction at far
prescribing the full correction since they still have
12 Vertical phoria and duction at far
considerable amount of accommodation that they use. On the
other hand, they are also sensitive to over-correction, and 13A Habitual phoria at near
asthenopia may be induced if under-corrected. Again, best to
give maximum plus prescription that will not worsen distance 13B Induced phoria at near
vision.
• Remember to take into account the test distance at which the 14A Dissociated/ monocular or unfused cross-cylinder test
subjective refraction was performed and adjust thereafter for at near
optical infinity. (D=1/f)
• For the cylinder correction, it is preferable to give least 14B Associated/ binocular or fused cross-cylinder test at
near
amount giving the best vision.
• For presbyopia, distance vision must be accurate since they
15A Induced phoria test through 14A
no longer have accommodation and any error in the distance
prescription may be wrongly compensated by increasing or 15B Induced phoria test through 14B
decreasing the add.
• For near vision correction, prescribe the minimal near 16A Positive relative convergence
addition required and never over prescribe. Remember that
the patient will prefer stronger add due to magnification 16B Positive fusional convergence
effect, but it will affect the overall performance of the lens,
one of which is peripheral deformation. 17A Negative relative convergence
• As a general rule, if a choice must be made, give priority to
visual comfort over visual acuity. Remember acuity is just one 17B Negative fusional convergence
element of vision and the only one considered in subjective
18 Vertical phoria and duction at near
refraction. Other factors, such as peripheral perception of
forms and movement, also contribute to the visual
19 Amplitude of accommodation
experience. At the end of the examination, always test the
correction in a ‘real life’ situation. 20 Positive relative accommodation

21 Negative relative accommodation