General Binocular Dysfunction In An Urban Optometry Clinic

General binocular dysfunctions in an

urban optometry clinic

lence of accommodative insuffi­ ciency in a small group (n = 13) of normal children, while Hoffman s found clinically abnonnal accom­ Abstract: The prevalence oj modation in 44% of twenty-five general binocular dysfunction non-learning disabled children. Nei­ with asthenopia was deter­ ther study reported on associated mined for non-presbyopes aJ. asthenopia. Hennessey et al 6 had a an urban optometry clinic serv­ 23.3% prevalence rate for sympto­ ing municipal workers and matic accommodative infacility their dependents. Of the sam:" among sixty randomly selected chil­ pIe of 119 patients. 42.9% had dren who had previously passed a jobs wilh heavy desk work de­ comprehensive visual screening. mands (primarily secretarial Morgan's' normative data predicts and clerical) and 39.5% were of non-pres­ about twelve percent studertls. De prevalence ot byopes will have significant near s 'm tomatic en 7 bmocu­ esophoria (>2 prism diopters), but 'S untion was 21.0 o. Ac­ prevalence of symptomatic near commodative ysJunctions esophoria has not been reported. were the most commonly' en­ Presented here are prevalence countered condition aC 16.8%. figures for symptomatic general bi­ . SJ'mplomatic near esophoria nocular dysfunctions (near es0­ was found in 5.9% ofpaJients phoria, convergence insufficiency, and convergence insufficiency accommodative insufficiency, ac­ in 4.2%. Both vergence dys­ commodative infacility, and accom­ funci ions overlapped. with ac­ modative spasm) among non-pres­ commodative dysfuncliQns. byopic clinic patients at an urban optometry clinic for municipal Key words: prevalence, gen­

workers and their dependents. eral binocular ·dysfunction.

esophoria, convergence insuf

Method jiciency. accommodative dys­

funelion. asthenopia

Clinic records were reviewed for pa­ tients seen by the author between September, 1981, and March, 1982, at a municipal workers' union op­ (ntroduction tometry clinic serving union mem­ Although general binocular dys­ bers and their dependents in New functions (non-strabismic or am­ York City, New York. The author blyopic) are a popuJar topic in the saw patients on a part-time basis and examined approximately 390 ophthalmic literature,' very little patients. An estimated 4000 pa­ prevalence data is available. 2 For the tients were seen at the clinic during one condition that has been fre­ this period. Only records for pa­ quently reported on, convergence i nsu fficiency, a wide range of prev­ tients aged thirty-five years and younger were reviewed in order to alence rates are seen, although most are between one and ten percent. 2,) minimize overlap of accommoda­ tive dysfunctions with presbyopic Accommodative dysfunctions are changes. also commonly discussed; but prevalence data is sparse,l General binocular dysfunction patients had both abnonnal clinical Robinson" found a 14.4% preva'­ Steven C. Hokoda, 0.0.

560

Journal of the American Optometric Association

findings and associated asthenopic symptoms which would not be ad­ dressed by correction of the refrac­ tive error alone. They had healthy eyes and no strabismus or ambly­ opia. Patients with abnormal clini­ cal findings but who were asymp­ tomatic were excluded and counted as normals, as were those patients with asthenopia but whose accom­ modative-convergence findings were normaL Dysfunctions were di­ vided into vergence dysfunctions (near esophoria and convergence in­ sufficiency) and accommodative dysfunctions (insufficiency, infaciJ­ ity, and spasm). Table 1 lists criteria for inclusion within each dysfunc­ tion group. Qinical norms were de­ rived from Morgan's norms' and Pacific University College of Op­ tometry norms,' and generally rep­ resent at least one standard devia­ tion from the mean finding for that measure..

Results One hundred and nineteen non­ presbyope records were reviewed. Errors in recordkeeping probably account for about a ten percent un­ selected undercount of patients ex­ amined. Mean age for the &roup was 22.9 ± 9.0 years, with the youngest be.ing four years of age (one girl and one boy). Table 2 presents the general binocular dysfunction data. Overall. 21.0% showed abnormal clinical findings and associated asthenopia. Mean age of dysfunction patients, 22.7 ± 8.3 years (youngest, a six year old girl), was not significantly differ­ ent from the mean age ofall patients (t = 0.83, p> 0.20). Female to male ratio for general binocular dysfunc­ tion patients, 68.0%/32.0%, did not differ significantly from the ratio for non-dysfunction patients, 67.0%/ 33.0% (x 2 = 0.02, p> 0.20).

Near esophoria had a 5.9% prevalence rate, with 71.4% of these patients showing an accommoda­ tive dysfunction (57.1 % with insuf­ ficiency and 14.3% with infacility). Convergence insufficiency occurred in 4.2% of patients, with 40.0% also having an accommodative dysfunc­ tion (20.0% with insufficiency and 20.0% with infacility). The most prevalent conditions were accom­ modative dysfunctions, with a 16.8% occurrence rate. The most common accommodative dysfunc­ tion was insufliciency. 9.2% (36.4% of these patients had near esophoria and 9.1 % had convergence insuffi­ ciency), followed by infacility, 5.1 % (16.7% with esophoria), and spasm. 2.5% (33.3% with convergence in­ sufficiency), Table J provides a

Table. 1:

Discussion

breakdown of the accommodative dysfunction data.

The population sample reviewed here showed overall strabismus and amblyopia prevalence rates similar to previously reported general pop­ ulation figures (5.9% strabismus prevalence versus a general popula­ tion prevalence of about six per­ cent,l and 20/40 or worse best spec­ tacle corrected amblyopia preva­ lence of 2.5% versus a general pop­ ulation figure of about three percent l . IO ). Further, the 4.2% con­ vergence insufficiency occurrence rate was consistent with previously reported prevalence rates. 2•3 These similarities allow one to look at the esophoria and accommodative dys­ function occurrence rates, as well as the overall 21.0% general binocular

As for near visual demands, 48.0% (n = 12) of dysfunction pa­ tients had primarily desk work re­ lated jobs (largely secretarial and clerical): 40.0% (0 = 10) were stu­ dents; and 12.0% (n = 3) had min­ imal near visual demands. For non­ dysfunction patients, 41.5% (n = 37) had jobs primarily near work oriented (again largely secretarial and clerical); 39.4% (n = 34) were students; and 19.1% (n = 18) had minimal near visual demands. A chi-square comparison of dysfunc­ tion patients and non-dysfunction patients showed no significant dif­ ference io these visual demand dis­ tributions (x 2 = 0.77. p> 0.20).

~Jassification criteria for: general binoc~lar dysfuri
Vergence Dysfunctions

Esophoria

. Patient must show both:

1. Near fj:SOphoOa >2 prism diopters. ' . '. 2. Symptoms with vergence testing sUnitar to those wfth habCtuaI use of the eyes. 8.r'd/or ~~..CXX'!lfort with COflY8X laos adds

redodng the eso de~tion. In additioo. patient must have either. 1. Decreased refative ~«geoc:e. ::s9/17/8.

. .

.'

.. '

.

tor ~ur. diplopia. and fusion recovery (at least one finding 1oW). 2. Eso~ation disparity at near (rnooocuIaI1y seen fiduciary lines wfth 8 3.6 degree round first fu~ con~.

Convorgence Insuftidency

PatHiKlt must show:

1. Symptoms associated with V6f"genc6 tosting similar to symptoms habituaftv Olq...A1enoed wtth near visual demands. In addition, patient must have ettner: . . .' . 1. Convergence nearpoklt equal to or ou~ 5"[7" for bss and re<::oYe(y Of fuston. aoo/Of' excesstve, s~ to maintain fusion It or outside 8"'. . • . . . .

one

2. Decreased ~tive convergence. :s 12/15/4. for bkK, diplopia, and fusion reco "'1 (at least w,,<.. Aoc;ommodative Dysfunctions . In6ufflc;iency Patient must show: 1. Symptoms with aocommodative testing sit"nKar toflatlftual ~ye ~; and/or i\cr8ased comfort wtth c:onvex lens adds.

In addition, patient must ha\<e either: '.' . :

1. Decreased positive reCative accommodation, :51.250. . . . 2. Push-up accommodative ampfitude at least two diopters be40w Hofstette('s calculation for minimum ega apprOjlOate ampItude: 15 - .25 x age In years.' " .' . InfadIity Patient must have ooth; . . , 1. 8rur end/Of" ast:h8nopic symptoms with habitual near tasks simRar to symptoms generated by accommodativ~ t~. eM/« increased comfort with convex lens a d d s . ' . ; 2. Normal positive refaUve accommodatioo and accommodatfve arnpfitude (pustHJp amplitude not routinely measured).

In addftion, patient must have eCther:

1. Deaeesec1 accommodative -rocks.- :515 cydes/minute with -2.000 add over the subjective refraction ~ 20/20 !:;:ttera el 40cm. . .' ' . 2. Increased aocommodatfve lags: binocular cross cyiinder add, <1.250; M~M retinoscopy lag. C!!O.750; and/CK low neutral retinOscopy add. ~1.500. Aft referenced to the subjective re~ (both retlnoscopytecflnlques had the patient 0f8Ity read 201 100 letters at 40 em.). . I)pasm

Patient must have:

1. History of variable acufty. asthenopia, end/Of symptoms from accommodative testing similar to habitual symptoms. 2. A difference of at least one diopter (ffiO(e p4us or leSs minus measured) between stali<; retinoscopy and the subjoctive refraction with varia~ subjective responses. . Variable visual acuity at distance without change of lenses.

Volume 56, Number 7, 7/85

561

References

Table 2:

Prevalence of general binOCular dysfunctions .

Frequency of 'OCCUITeoce 1,7 % (2 females)

Esophoria Esophoria with accommooative dys­ function Convergence insufficiency Convergence in$uffldency with ac­ commodative dysfunction . Accommodative dysfunction Totcl

Table 3:

4.~/o

2.50/0 (2

10.9°10 (9 female.s. 4 21.0~9

Spasm

55.0 (9 females. 2 males) 30.0 (4 females, 2 males) 15.0 (3 males) 100.0 (13 females. 7

males)

dysfunction prevalence. with an eye toward wider application of these figures for the general population. Purcell et alII provide an indirect comparison figure for symptomatic binocular dysfunctions. They re­ viewed patient charts (n = 125) at an optometry colJege clinic for twenty-five to thirty-five year oids without strabismus. amblyopia. eye pathology. or current contact lens wear. and found that 30.8% of pa­ tients received treatment other than or in addition to the subjective re­ fraction for symptoms associated with the use of the eyes. The high occurrence of general binocular dysfunctions with associ­ ated asthenopia justifies the atten­ tion given to these problems in the

562

m~s)

(17 females, 8 mates)

Pen:eot with i



Cooy«-gence

EsophoOa

dystunctions

Total

rnaJe)

maler'

Accommodative dysfunctions

~tfve

Infacility

femaJes~:l

1.7% (1 female, 1

Percentot

Insufficiency

(3 females,. 2 maJe~)

Jnsufftdency

36.4 (2

9.1 (1 ,female)

females, 2 males) 16.7(1 temale)

0

0 25.0 (3 femaJe~,

2

33.3 (1 male) '10.0 (1 ferT}8Je, . ,1'~$l'

males)

ophthalmic Ijterature. As many of these dysfunctions can be ad9ressed to the benefit of the patient with proper lens, prism, and/or orthoptic therapY,I2-15 conscientious opto­ metric care should include ade· quate case history probes and ac­ com modative-con vergence testi ng to identify and treat these common problems. ••

Submitted for publication 10/84 Revised 2/85 Group Health Cooperative of Puget Sound Central Speciality Center Wing G-Eye Clinic 200 15th Avenue East Seattle, Wa 98112

Journal of the American O~t'lmetric Association

I. Griffin JR. Binocular Anomalies: Pro­ cedures for Vision Therapy. 2nd ed. Chi­ cago: Professional Press. J982. 2. Bennett RG. Blondin M. Ruskicwicl J. Incidence and prevalence of selected visual conditions. J Am Oplom Assoc 1982:53:647-56. 3. Cooper J. Duckman R. Convergence in­ sufficiency: incidence, diagnosis. and treatment. J Am Oplom Assoc 1978: 49:673-80. 4. Robinson BN. A study of visual function in institutionalized juveniles who are demonstrated underachieving readers. Am J Optom Arch Am Acad Optom 1973:50: 113-6. 5. Hoffman LG. Incidence of vision diffi­ culties in children with learning disabili­ ties. J Am Optom Assoc 1980;51:447­ 51.

6. Hennessey D. losue RA. Rouse MW. Relation of symptoms to accommoda­ tive infacility of school-aged children. Am J Oplom Physiol Opt 1984:61: 177­ 83. 7. Morgan MW. The clinical aspects of ac­ commodation and convergence. Am J Optom Arch Am Acad Optom 1944; 21:301-13. 8. Haynes HM. Monograph on elementary visual training case analysis: clinical norms. Forest Grove. Oregon: Lc:arning Resource Center. Pacific University Col­ lege of Optometry, 1970. 9. Barish 1M. Clinical Refraction. 3rd ed. Chicago: Professional Press. 1975: 170. 10. Shapero M. Amblyopia. Philadelphia: Chilton Book Co, J97 J:56-66. 'I. Purcell lR. Nuffer JS, Gements SO, Gausen LR. Schuman DO, Yoltan RL The cost effectiveness of selected opto­ metric procedures. J Am Optom Assoc 1983;54:643-7. 12. Haynes HM. Brattis NJ, Egger MJ. Ef­

fects of bifocals and reading &Jasscss on

near point visual complaints and fixation

disparity in myopes with hypoposturing

accommodative perfonnance. Tran­

scripts of the OEP Skeffington Sympo­

sium on Visual Training. 1980; Leban­

non. Oregon: Caryl Croisanl.

13. Daum KM. Accommodative dysfunc­ tion. Doc Ophth 1983;55: 177-98. '4. Daum KM. Convergence insufficiency. Am J Optom Physiol Opt 1984;61: 22. 15. Shttdy JE. Actual mea.,,>uremenl of fixa­ tion disparity and its usc in diagnosis and treatment. J Am Optom Assoc 1980; 51: 1079-84.

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