CONVERGENCE

University of Gondar
Department of Optometry
by Nebiyat Feleke

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 Outline

Definitions

Measures of convergence:
Relative Convergence

Maddox components of convergence

Clinical assessment of convergence

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 Convergence
• Definition :

The change in the relative position of the visual

axes when we change fixation from distance
object to near

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 Voluntary and reflex convergence

• Convergence is essentially a reflex adjustment

to give single binocular near vision, but it may
be produced voluntarily.
• With practice many people can converge in
the absence of a physical stimulus as if they
were viewing a near object.
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 Reflex convergence – midbrain, change in
convergence in pursuit of single binocular
vision
 Voluntary convergence – front, area 8

We can voluntarily turn our eyes in, but not out.

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 The Stimulus to Convergence
• Analysis of physiological diplopia – tells us how much we
need to change our convergence to eliminate this diplopia.
• We need to change our convergence when we look from
far to near.
• Convergence of the eyes is measured in terms of the prism
dioptre

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 Example
• If a Px has a PD of 6cm and converges to the midline
to fixate a point at distance of 1m, each eye will turn
inward 3∆ (displacement of 3cm at a distance of 1m)
= a total of 6∆ of convergence for both eyes.
• For distances other than 1m, convergence (in prism
dioptres) = displacement x reciprocal of the testing
distance in metres
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 Measures of convergence

a. Far point of convergence

Presumed to be infinity
b. Near point of convergence, NPC

Measured in cm
Normal ~ 10 cm

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 Measures …

c. Range of convergence
• aka linear convergence
• Difference between far and near points of convergence.
• This is difficult to measure unless the Px has a finite far
point (v. rare).
• Outside this range they squint

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 Measures …
d. Relative Convergence
• That amount of convergence which can be exerted while
accommodation remains unchanged. It is measured to
the limits of blur, but single binocular vision. Beyond
this limit accommodation changes.
• If we put base out prisms in front of two eyes, the eyes
will have to turn in more to avoid diplopia.
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I. Positive relative convergence
By adding base out prisms, how much can we
make the Px turn their eyes IN before we drag
their accommodation? If it starts to blur, we
have got to the limit.

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II. Negative relative convergence
How much can we make the Px turn their eyes
OUT?

e. Amplitude of relative convergence

Add +ve and –ve relative convergence

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 Maddox Components Of Convergence

• In 1893, Maddox provided the first description

and classification of vergence movements of
the eyes.
o Tonic convergence
o Accommodative convergence
o Proximal convergence
o Fusional convergence
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 Tonic convergence

• Due to the tonus of the muscles, and is largely

fixed.
• If all innervations to the ocular muscles were to
cease (as in death) the eyes would take up the
anatomical position of rest = large divergence

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 Accommodative convergence

• The convergence that is associated with accommodation.

• How much convergence does accommodation produce?

For example: 3 increase in convergence for every 1 D of

accommodation.

• Accommodative convergence may be brought into play

by stimulating accommodation, either by the use of a
near-testing distance or by the use of minus lenses.
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 Proximal convergence

- Also known as voluntary convergence

- The convergence that takes place due to the

knowledge that an object is nearby.

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 Fusional convergence (reflex)
– Convergence compensating for any excess or deficit
in tonic convergence.
– Retinal disparity is the stimulus.
– The component of convergence that keeps a person
from seeing double.
– The component of convergence which is induced by
fusional stimuli or which is available in excess of that
required to overcome hetero phoria.
– Without the stimulus to fusion, the eyes take up their
phoria position.

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 CLINICAL ASSESSMENT OF CONVERGENCE

Near point of convergence (NPC) using RAF rule

The closest point in the median plane to which

the eyes can converge is the near point of
convergence - NPC
NPC can vary from 2cm – 50cm
Normal values range from 4cm – 16cm
> 16cm, likely to have symptoms
Between 10cm – 16cm, may have symptoms
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 CLINICAL ASSESSMENT OF CONVERGENCE

Only applicable to measure for binocular patients and

is particularly important for symptomatic exophores

It is important to choose appropriate target

either the dot and line on the RAF rule, or a near 6/9
vertical letters

Most accurately measured with RAF rule. Use in

depressed position (45 degrees)
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 Assessment of NPC ….
Start at about 20 cm and slowly move target forwards.

Watch the Px’s eyes, and also ask them to report when they see

diplopia

Both eyes should turn in smoothly and the pupils contract.

At some point, they can no longer converge and their non-dominant

eye gives up.

Their accommodation also gives up at ~ 10 cm and their pupils dilate

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SUBJECTIVE AND OBJECTIVE NPC

Subjective - Px tells you when they see double.

Objective – watch the Px’s eyes – observer
notices one or both eyes diverge

Values recorded ----------Break /Recovery

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Both break and recovery are measured to the
nearest half centimetre
In order to check for fatigue, it should be measured
3 times near the beginning of the assessment and
twice at the end
An NPC with a break greater than 10 cm is
considered to be the most consistent finding in
subjects with convergence insufficiency. 24
Fatigue needs to be assessed as a subject may be
able to produce one good result with the RAF rule,
but the NPC may increase with further testing.
Many subjects report the occurrence of symptoms
only after several minutes of near task
performance

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 NPC can increase with age (old – 15cm, middle
aged – 10cm)
 If measure on presbyopes – have presbyopic Rx in
place.
 There is no systemic decrease in amplitude of
convergence with increasing age (as in
accommodation).

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 Some Px manage to maintain good powers of
convergence into advanced age, while others do
not.
 It may reduce through lack of use and to loss of
accommodative convergence

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 Jump Convergence

o Patient is asked to fixate in turn on distant and

near targets and to report any diplopia.
o Activates voluntary convergence
o For example, get Px to look at 6/6 letter and hold
pencil outside NPC. Get Px to look at distance
letter on chart and then the pencil.

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 Jump con….
o A normal Px can do this easily – both eyes move
smoothly and symmetrically
o With poor convergence – eyes makes several
movements to converge. Often Px moves head
back to increase distance.
o This is a more difficult task than NPC test.

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Thank you

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