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Citation information: Leon AA, Medrano SM & Rosenfield M. A comparison of the reliability of dynamic retinoscopy and subjective measurements of amplitude of accommodation. Ophthalmic Physiol Opt 2012, 32, 133141. doi: 10.1111/j.1475-1313.2012.00891.x
Abstract
Purpose: Dynamic retinoscopy (DR) is an objective technique for assessing maximum accommodative responsivity. The present study examined the test-retest
reliability of this procedure when measuring the amplitude of accommodation
(AA).
Methods: In the first trial, the within-session repeatability of the AA was
measured in 79 subjects between 18 and 30 years of age using DR and two
subjective procedures, namely the modified push-down (MPD) and minus
lens (ML) techniques. Data were collected by two different examiners. In a
second trial, the inter-session repeatability of the AA was assessed in 76 subjects by a single evaluator with a time interval of 7 days between the first
and second sessions. The repeatability, reproducibility and agreement between
the methods were determined using the mean difference, 95% limits of agreement, intraclass correlation coefficient and concordance correlation coefficient.
Results: DR showed the lowest mean value of AA in each trial (average for the
two trials = 7.44 D) while the equivalent mean values for the MPD and ML
techniques were 9.84 and 9.43 D, respectively. Further, DR showed the best
repeatability in both the repeatability trials and poorer inter-examiner
agreement was observed for the MPD and ML procedures. The concordance
correlation coefficient for DR)MPD, DR)ML and MPD)ML procedures were
0.32, 0.33 and 0.62, respectively for the within-session trial and 0.31, 0.36 and
0.76, respectively for the inter-session trial.
Conclusion: The DR technique provides a more veridical measurement of the
AA because it avoids the overestimation resulting from the depth-of-field.
Moreover, the DR technique exhibited higher reproducibility, when compared
with subjective methods. These differences may be important when evaluating
accommodative dysfunctions or monitoring accommodative therapy. The fact
that the DR procedure can be performed using standard clinical equipment
makes this a valuable technique both for vision screening programs and routine
eye care.
Introduction
The normal values for the amplitude of accommodation
(AA), i.e., maximum accommodative ability as a function
of age were determined by Donders towards the end of
Ophthalmic & Physiological Optics 32 (2012) 133141 2012 The College of Optometrists
133
Leon AA et al.
Ophthalmic & Physiological Optics 32 (2012) 133141 2012 The College of Optometrists
Leon AA et al.
similar conditions) and reproducibility (comparing measurements obtained by multiple examiners)15 of objectively obtained measurements of AA determined using
DR. Accordingly, the aim of the present investigation was
to examine the test-retest reliability (both within and
across sessions) of the DR technique for measuring the
AA and compare the values with those obtained using
subjective procedures.
Materials and methods
In order to assess the within-session repeatability, measurements of the AA were obtained from 79 subjects, all
of whom were optometry students at the Fundacion Universitaria del Area Andina in Pereira. All had visual acuity
of 0.2 logMAR or better (at both distance and near) when
measured using an ETDRS 2000 series chart (http://
www.richmondproducts.com/shop/index.php?route=product/
product&product_id=47). Subjects wore a full refractive
correction and had no ocular pathology. Any subject with
a refractive error greater than 2.00 D (sphere or cylinder), accommodative dysfunction (i.e., a lag of accommodation outside a range of 0.250.75 D and/or binocular
accommodative facility using 2.00 D flippers of <8
cycles min)1) strabismus, aphakia or amblyopia was
excluded. The protocol followed the tenets of the Declaration of Helsinki and Decree 8430 (1993) of the Ministry
of Social Protection in Colombia. Following a full explanation of the experimental protocol, the objectives of the
investigation and having been given an opportunity to
ask questions of the experimenters, all subjects signed a
written consent form prior to participation.
Data were obtained by two optometrists, each with a
minimum of 10 years experience in carrying out the test
procedures. They were assisted by a third year optometry student. Results were recorded by the student assistant who did not provide this information to the
evaluators in order to minimize the possibility of bias.
Initially, a pilot study was conducted on 10 subjects to
evaluate the variability of the data and to allow a population size calculation to be conducted. From this pilot
trial, taking a minimum correlation coefficient of 0.90
with a standard deviation of 0.03 and a two-tail error
type of 0.01, a required sample size of 74 subjects was
calculated.16
Before recording AA measurements, the refractive error
of each subject was determined using static retinoscopy
and subjective refraction (Jackson crossed cylinder). The
measured refractive correction was worn for all trials. AA
was assessed using two subjective and one objective
method as described below. To assess the within-session
reliability, the three procedures were repeated by a second
evaluator 30 min later using the same protocol. The order
Ophthalmic & Physiological Optics 32 (2012) 133141 2012 The College of Optometrists
135
Leon AA et al.
Table 1. Mean and range of values for age, visual acuity, objective (static retinoscopy) and subjective refraction for both the within-session
repeatability (WSR) (N = 79) and inter-session repeatability (ISR) (N = 76) trials. The p values indicate the level of significance between the findings
for the WSR and ISR trials. Figures in parentheses show 1 S.D.
Mean
Age (years)
Visual acuity (logMAR)
Static retinoscopy (D)
Subjective refraction (D)
136
Range
WSR
ISR
WSR
ISR
20.4 (2.8)
)0.06 (0.09)
+0.18 (0.41)
)0.08 (0.24)
20.4 (2.4)
)0.03 (0.11)
+0.17 (0.75)
)0.01 (0.61)
1829
)0.3 to 0.12
)1.25 to +1.00
)1.25 to +0.25
1827
)0.2 to 0.2
)2.00 to +2.00
)2.00 to +1.75
1.00
0.07
0.92
0.35
Ophthalmic & Physiological Optics 32 (2012) 133141 2012 The College of Optometrists
Leon AA et al.
Table 2. Mean (1 SD) and range of AA values using the three methods of measurement (DR, Dynamic Retinoscopy; MPD, Modified push down;
ML, Minus lens). (a) shows the findings for each examiner in the Within-session repeatability trial. (b) shows the findings for each session in the
Inter-session repeatability trial
DR
MPD
Examiner 1
(a) Within-session repeatability
Mean
7.73 1.06
Range
5.3511.01
Session 1
(b) Inter-session repeatability
Mean
7.12 1.18
Range
3.889.18
ML
Examiner 2
Examiner 1
Examiner 2
Examiner 1
Examiner 2
7.75 1.00
5.5910.25
9.77 1.49
5.9714.37
9.94 1.42
6.714.37
9.47 1.66
6.3315.91
9.53 1.79
6.0015.33
Session 2
Session 1
Session 2
Session 1
Session 2
7.14 1.21
3.609.18
9.75 1.65
6.1713.14
9.89 1.75
6.2414.37
9.41 2.22
4.5814.91
9.32 1.92
4.4214.10
DR-ML
MPD-ML
)1.76 (1.21)
<0.001
0.33
0.68
0.49
0.35 (1.31)
0.39
0.62
0.65
0.96
)2.24 (1.26)
<0.001
0.36
0.80
0.45
0.46 (1.31)
0.04
0.76
0.79
0.95
Ophthalmic & Physiological Optics 32 (2012) 133141 2012 The College of Optometrists
137
Leon AA et al.
MPD
ML
0.07 1.03
2.01
0.82 (0.740.88)
0.10 1.18
2.30
0.84 (0.760.90)
limits of agreement were again estimated using a regression approach.22 (Equivalent figures showing the 95%
limits of agreement for the inter-session findings have not
been included as they were broadly similar to those
shown in Figures 13).
The mean and standard deviation of the differences,
together with the reproducibility between examiners and
sessions as assessed by the coefficient of reproducibility
(COR) and intraclass correlation coefficient (ICC) for the
three measurement techniques are shown in Table 4. For
the within-session trials (Table 4a), the DR showed the
lowest mean difference and COR, indicating that its reproducibility is higher than the other two techniques. The
high ICC values in both trials confirm that all three techniques had excellent reliability with DR again having the
best reproducibility. The DR COR was lower in the intersession trial compared with the within-session findings,
whereas increases in COR were observed for the MPD and
particularly the ML procedures in the inter-session trials.
Discussion
Figure 3. Difference between the minus lens (ML) and dynamic retinoscopy (DR) values of AA (N = 79) plotted as a function of the mean
of these measurements as assessed in the within-session trial. The
value for each method is the average from examiner 1 and 2. The
solid diagonal lines represent the 95% limits of agreement while the
diagonal dashed line indicates the mean difference. Since the difference between the findings varied significantly with the mean values
(p = 0.00), the limits of agreement were estimated using a regression
approach where the upper limit = )1.04 + 0.55A, and the lower
limit = )4.96 + 0.55A. (with A = mean AA for both procedures).
Ophthalmic & Physiological Optics 32 (2012) 133141 2012 The College of Optometrists
Leon AA et al.
a bias-correction factor (accuracy) and Pearson correlation coefficient (precision). Since the Pearson correlation
coefficient does not consider inaccuracy, the CCC can
segregate inaccuracy from imprecision, which the ICC
does not.17 Accordingly, we used the CCC to assess the
agreement between the methods to measure the AA. This
parameter showed low agreement in both the within-session and inter-session trials between the subjective and
objective procedures (MPD-DR: CCC = 0.315; ML-DR:
CCC = 0.357) because of low accuracy (bias-correction
factor <0.50). This indicates a significant discrepancy
between these techniques. The agreement between the
two subjective techniques was also poor (CCC = 0.69)
with moderate precision (r = 0.72) but high accuracy
(bias-correction factor = 0.96). Both methods tend to
obtain results clustered around a similar mean value, but
with a broad spread of findings. In contrast, the objective
DR technique shows high test-retest reliability (reproducibility ICC = 0.94, COR = 0.80), presumably because it
combines two reliable techniques, i.e., push up7 and Nott
retinoscopy.32 Nott retinoscopy was used in the present
investigation rather than the Monocular Estimate Method
(MEM) firstly because the addition of supplementary plus
lenses may influence the accommodative response and
secondly because attempting to insert the lenses for a period shorter than the typical accommodative response
(approximately 350 ms) is practically impossible.23
Further, the 95% limits of agreement between the various techniques found in this study are similar to those
reported by Winn-Hall et al.,14 who used both a Hartinger coincidence optometer (HCR) and an open field WR
5100K Grand Seiko optometer with minus lens-stimulated
accommodation to evaluate the accommodative response
at the point of maximum accommodative effort. When
comparing the objective push-up findings with the ML
results, the mean difference and 95% limits of agreement
(LoA) were 0.03 and 1.26 D, respectively. In the present
investigation, we assessed the reproducibility of DR using
the ICC and obtained a very high value (0.96); therefore
measurements obtained are likely to be similar across
observers. These results demonstrate that findings
obtained using DR are significantly more reliable that
those obtained using subjective procedures. Accordingly,
it is advisable for future research studies into the AA to
adopt this objective method of measurement, since the
reduced variability will allow for a smaller sample size.
With regard to the repeatability of the subjective techniques, Antona et al.,13 reported a coefficient of repeatability for AA with the ML and push-up techniques of
2.52 and 4.00 D, respectively. However, no clear explanation for these differences was provided. These authors
also evaluated the agreement between the two tests,
obtaining a coefficient of agreement of 4.51, which is
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