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Article

Accommodative Response in Children


with Visual Impairment
Catherine L. Heyman, OD, FAAO, FCOVD
Assistant Professor, Southern California College of Optometry

ABSTRACT an accommodative response that was the most similar


Purpose: The purpose of this pilot study was to to a normal accommodative response. The positive
objectively evaluate the accommodative response in slope lag sub-type (one subject), showed a large lag
children with visual impairment caused by macular of accommodation initially and much more accurate
pathology. accommodative response as the demand increased.
Methods: Ten children, ages 5-14, were enrolled And lastly, the fixed lead sub-type (two subjects),
into the study with previously diagnosed Stargardts, initially showed marked over-accommodation that
ocular albinism, macular hypoplasia, or rod/cone or decreased as the demand increased.
cone/rod dystrophy. Visual acuity ranged from 20/80- Conclusions: Although further investigation
20/250. Each subjects accommodative response was is needed the results of this study suggest that
measured by the Grand Seiko WV500 autorefractor accommodation in pediatric patients with macular
at demand distances of 33cm, 25cm and 20cm. pathology can be variable and unpredictable and
The targets were vertical, high contrast, square-wave clinicians should not expect a normal accommodative
gratings that were one octave above threshold acuity. response. Therefore, clinicians managing these types
As the test distance decreased the grating size was of patients should consider using near retinoscopy to
decreased accordingly to ensure maintenance of a one assess each patients accommodative response prior to
octave above threshold target. This response was then prescribing near addition lenses.
converted to an amplitude response to determine
the accommodative lead or lag. All testing was done Keywords: accommodation, albinism, macula,
through the subjects best distance refraction. pediatrics, Stargardts, visual impairment
Results: The subjects had five sub-types of
accommodative response. The negative slope lag Introduction
sub-type (one subject) showed increasing lags as the Providing appropriate near devices for children
demand increased. The fixed lag sub-type (five with visual impairment is critical for optimal
subjects) showed a tendency to under accommodate educational outcomes. Many school-aged children
a consistent amount regardless of the demand. The with visual impairment can read typical size print
fixed accurate sub-type (one subject), demonstrated by bringing the print to a close working distance,
thereby utilizing relative distance magnification. As
Correspondence regarding this article should be emailed to
the target is brought closer, a high accommodative
cheyman@scco.edu or sent to Dr. Catherine L. Heyman at Southern demand results, and pediatric low vision patients are
California College of Optometry, 2575 Yorba Linda Boulevard, Fullerton, often prescribed near addition lenses to meet the high
CA 92831-1699. All statements are the authors personal opinions and may accommodative demand.1-3 Very few textbooks discuss
not reflect the opinions of the College of Optometrists in Vision Development,
Optometry & Vision Development or any institution or organization to
this issue; although they do address accommodation
which the author may be affiliated. Permission to use reprints of this article in visually impaired children, there is an assumption
must be obtained from the editor. Copyright 2011 College of Optometrists of near normal accommodative amplitudes and
in Vision Development. OVD is indexed in the Directory of Open Access accuracy and no discussion of the means of measuring
Journals. Online access is available at http://www.covd.org.
accommodative response is addressed.1-3 To date there
Heyman C. Accommodative response in children with visual have been only a few studies that have investigated
impairment. Optom Vis Dev 2011;42(1):10-16. accommodative responses in children with visual
10 Optometry & Vision Development
impairments. Determining the ability and accuracy Table 1: Patient characteristics
of accommodation in pediatric patients with visual Subjects
Age Visual Acuity/ Ocular
Refractive Error Diagnosis
(years) Preferred eye* Findings
impairment is a critical factor when prescribing
1 12 20/250 OD No OD PL-250 X 180 Rod/Cone
optical devices. 20/250 OS* strabismus Dystrophy
The accommodative response to a specific near 2 10 20/250 OD* Nystagmus OD -11.00-2.00 X 180 Ocular
demand has been extensively studied in the visually 20/280 OS LET
LHYPT
OS -10.50-2.00 X 180 albinism

normal population.4-9 At forty centimeters, Rouse et 3 13 20/160 OD Nystagmus OD -5.00-0.75 X 180 Cone
al10 measured the accommodative response of 100 20/126 OS* CAXT OS -5.50-0.75 X 180 Dystrophy

children from kindergarten through 12th grade and 4 14 20/200 OD


20/200 OS*
No
strabismus
OD +0.25-0.75 X 015
OS +0.25-0.75 X 010
Stargardts
disease
found a mean lag of +0.33D ( 0.35) and +0.35D No correction worn
( 0.34) for the right and left eyes respectively. 5 15 20/200 OD Nystagmus OD +3.00-4.00 X 010 Rod
20/200 OS* OS + 4.00-4.00 X 170 Monochromat
Jackson et al11 reported that both eyes have a mean Nystagmus
6 15 20/126 OD OD PI-3.50 X 005 Ocular
lag of +0.23D ( 0.29) when measurements were 20/100 OS* IAXT OS PI-3.25 X 180 Albinism
gathered from pediatric patients age 7.9 to 15.9 years. 7 8 20/80 OD* No OD -0.50-1.00 X 180 Cone
20/80 OS strabismus OS -1.50-1.50 X 180 Dystrophy
The research demonstrates that the accommodative
8 5 20/240 OD Nystagmus OD +3.50-1.50 X 180 Cone
lag found in children without visual impairment is 20/200 OS* CRXT OS +2.75-0.75 X 165 Dystrophy
approximately one third of a diopter. In contrast, 9 5 20/160 OD Nystagmus OD -6.00DS Aniridia
IAXT
studies of patients with systemic impairments such 20/160 OS* OS -6.00DS
10 5 20/105 OD Nystagmus OD +1.00-1.00 X 180 Aniridia
as Down syndrome12,13 and cerebral palsy14,15 as well 20/80 OS* OS +1.00-1.00 X 180
as studies of patients with visual impairment such as
amblyopia16-22 found lags that were significantly larger. target demands, but increasing lags with increasing
White and Wick23 evaluated six subjects with target demand. They also suggested that reduced
juvenile macular degeneration, ranging in age from visual acuity is not a sufficient explanation for the
19 to 34 years of age who had acuities ranging from reduced accommodative accuracy.
20/120 to 20/240. The accommodative response was The purpose of the present study was to explore
measured under three different conditions: Badal the accommodative responses of pediatric subjects
condition, monocular condition and binocular diagnosed with significant visual acuity loss (10/40-
condition. Accommodative responses were measured 10/125) from various macular disorders (e.g. cone
using the SRI servo-controlled infrared optometer dystrophy, Stargardts disease, ocular albinism.) Unlike
over demands ranging from 0-5 diopters. The subjects prior research this study used only young children
demonstrated poor accommodative accuracy at near and a completely objective method of measuring
viewing distances. White and Wick23 concluded that accommodative response. Use of an autorefractor
because of this poor accommodative ability and close allowed us to achieve objective measurements
working distance, these patients would experience and standardization between investigators. The
the effects of presbyopia at younger ages and require autorefractor was an open field design which allowed
a reading lens of higher power than normally-sighted for more natural viewing conditions to be used.
patients.
Leat and Mohr24 evaluated 21 subjects with Methods
conditions including: albinism, rubella, Peters Ten children, 5-15 years, with congenital macular
anomaly, retinitis pigmentosa, congenital nystag disorders and moderate to severe visual impairment
mus, homonymous hemianopia and refractive (20/80- 20/250) were enrolled in the study. Subjects
amblyopia. Subjects ranged in age from 5-34 years were recruited from the patient base of the Southern
of age and had acuities ranging from 20/25 to California College of Optometry, Eye Care Center
20/320. Accommodative response was measured and the Blind Childrens Learning Center. The study
with dynamic retinoscopy, using a modified Nott followed the tenets of the Declaration of Helsinki,
technique at 4, 6, 8, and 10 diopters. They found informed consent was obtained from the parent, and
that the deficits of accommodation worsened with a child assent form was completed where appropriate
increasing accommodative demand in patients with after an explanation of the nature and possible
ocular albinism. In contrast to the White and Wick23 consequences of the study. The study was reviewed
study, they found more accurate responses at lower
Volume 42/Number 1/2011 11
Figure 1: Subject during testing with the Grand Seiko WV500. All Figure 2: Subjects view of sine wave grating pattern used during
subjects lenses were clear, reflection from the autorefractor screen at close measurements.
distance gives impression that the lenses were tinted.

Figure 3: Provides a visual illustration of the sub-types as determined by data analysis. The mean accommodative error across the 3-5D range.
p values and correlation coefficient ( r ) findings are listed by subject.

and approved by the appropriate institutional review Accommodative response was measured using the
board (IRB). (See Table 1 for patient characteristics) Grand Seiko WV500 Autorefractor at distances of
A review of the subjects prior history and medical 33cm (3D), 25cm (4D) and 20cm (5D) (see Figure
records was performed to determine diagnosis and 1) using a vertically oriented, high contrast, square-
visual acuity for study eligibility. At the study visit, wave grating pattern that was one octave above each
non-cycloplegic retinoscopy was used to determine patients threshold visual acuity (see Figure 2). The
whether the subjects habitual distance correction room illumination was full. At each test distance
was within 1D sphere, -0.50D cylinder and within the grating size was maintained at one octave above
5 degrees in axis. Any refractive findings outside of threshold by decreasing the size of the grating.
the above criteria were placed in a trial frame for Measurements were taken through the subjects
use during the study measurements. No subjects distance correction. Five readings were taken from
required a change from their habitual correction. The the patients preferred eye with the non-preferred
subjects monocular threshold distance visual acuity eye occluded. The preferred eye was determined by
was measured using either the Bailey-Lovie chart or subject report or by the eye with the best acuity if the
Lea symbols distance chart, depending on age and patient did not identify a preferred eye. The median
comprehension ability. Acuity was measured at 10 reading was then converted to a spherical equivalent
feet with high illumination directed at the chart. and subtracted from the accommodative demand to
Near visual acuity was measured at 25 cm, a common determine the accommodative response.
habitual distance for children, using the Lighthouse
single letter acuity card or Lea symbols near card.
12 Optometry & Vision Development
Figure 4: Box plot of overall results. The line in each boxplot represents
the median value of each group and the shaded portion represents the
inter-quartile range at each demand.

Figure 6: Accommodative response of the negative slope lag sub-type


(one subject) who had a mean accommodative error (lag) of 4.39D over
the 3-5D range.

the null hypothesis of zero accommodative error.


Because these tests were performed separately on
each subject, the Bonferroni correction was used to
correct for family-wise error rate. Figure 3 provides a
visual illustration of the sub-types.

Results
Figure 4 displays the median accommodative
responses at 33cm (3D), 25cm (4D) and 20cm (5D)
of all ten subjects. The line in each boxplot represents
the median value of each group and the shaded portion
Figure 5: Illustrates the accommodative response that was found in represents the inter-quartile range at each demand.
selected studies from the literature of children with normal accommodation Although there is a statistically significant difference
for approximately the same age and across the same accommodative
demands as the present study. among the medians (P=0.002) the boxplot shows that
the data are skewed and asymmetrical with extreme
Data Analysis outliers and unequal upper and lower whiskers.
Due to the small number of subjects we had to Figure 5 illustrates the accommodative response
use a more descriptive type of statistical analysis. On that was found in selected studies from the literature
initial visual inspection, there appeared to be distinct of children with normal accommodation for
differences in the patterns of accommodative response approximately the same age and across the same
in children with visual impairment. Post-hoc single- accommodative demands as the present study. Figures
case statistics were used to explore these observations. 6-10 illustrate the accommodative response versus the
To test for a stimulusresponse slope significantly stimulus of the ten subjects.
different from zero, a linear correlation was performed Figure 6 shows the response of what we term
to obtain the correlation coefficient (r). To test for the negative slope lag sub-type (one subject) who
significant leads or lags of accommodation at the had a mean accommodative response of 4.39 D over
three stimulus levels, a t-test was performed with the three to five diopter range. This subject showed
Volume 42/Number 1/2011 13
Figure 9: Accommodative response of the positive slope lag sub-type
(one subject), with a mean accommodative error of 1.34D over the 3-5D
Figure 7: Accommodative response of the fixed lag sub-type (five range.
subjects) who demonstrated a mean accommodative error (lag) of 2.08D
over the 3-5D range.
decreased (lag increased). The fixed lag sub-type (five
subjects) who demonstrated a mean accommodative
lag of 2.08D over the three to five diopter range
and showed a tendency to under accommodate a
consistent amount regardless of the demand (see Fig.
7). Figure 8 shows what we term the fixed accurate
sub-type (one subject), with a mean accommodative
response of 1.50D over the three to five diopter
range, demonstrating an accommodative response
that was the most similar to a normal accommodative
response. Figure 9, the positive slope lag sub-
type (one subject), with a mean accommodative
response of 1.34D over the three to five diopter
range, shows a large lag of accommodation initially
and much more accurate accommodative response
as the demand increased. Figure 10, the fixed lead
sub-type (two subjects), shows over accommodation
with a mean lead of 4.57D over the three to five
diopter range. These subjects initially showed marked
over accommodation that decreased as the demand
increased. Both subjects were moderate to high
Figure 8: Accommodative response of the fixed accurate sub-type (one
subject), with a mean accommodative error (lag) of 1.50D over the 3-5D myopes who habitually removed their glasses for near
range. tasks. In general, the acuity, refractive errors, and
ocular diagnosis did not appear to be predictive of the
increasing lags as the demand increased. As the target subjects accommodative response.
was moved closer and the accommodative demand
increased, the subjects accommodative response
14 Optometry & Vision Development
adult patients whose accommodative system may
respond differently than that of a child.
Leat and Mohr24 evaluated several subjects that
would not have been included in the present study as
low vision, for example, those subjects with refractive
amblyopia. When only considering the subjects
with low vision, they found that there were two
sub-types. Those that demonstrated a near normal
accommodative response and those that demonstrated
increased lag with increased demand. These results
are very similar to those of our fixed accurate and
negative slope lag sub-types.
Clinicians should not expect a normal
accommodative response in children with visual
impairment. Therefore, clinical methods relying on,
or assuming, a normal response should be modified
and accommodative response should be measured
in this population by whatever method is clinically
available prior to prescribing near reading corrections.
By measuring the accommodative accuracy of these
Figure 10: Accommodative response of the fixed lead sub-type (two patients the clinician can base prescribing decisions
subjects), who showed over accommodation with a mean accommodative
error (lead) of 4.57D over the 3-5D range. on objective data rather than general assumptions.
Accommodative response should be measured in this
population by whatever method clinically available
Discussion prior to prescribing near reading corrections.
The results of this study confirm previous Several limitations of this study should be noted.
findings that accommodative response in pediatric First the small sample size, this limitation did not
patients with visual impairment is considerably less allow for consideration or analysis of accommodative
accurate than normally sighted children.12-15, 23-24 response related to specific disease condition or other
The accommodative response of children with visual demographic variables such as ethnicity. Additionally,
impairment showed larger variability and was more some sub-types had very few members, future studies
complex than the expected accommodative response with a larger sample size may reveal additional types
relative to that of children without visual impairment. or determine that larger groups are more appropriate.
Similar to the findings of White and Wick23 Therefore, caution should be taken in inferring too
and Leat and Mohr24 our data suggested that the much about the sub-types due to the small sample
majority of visually impaired subjects show a larger size. Additionally, the sample was collected from
than normal lag of accommodation. As in the present patients at two clinics and so the ability to generalize
study, White and Wick23 found that the subjects the findings might have been better through a multi-
were divided into sub-types. One sub-type showed center design. Second, due to the cross-sectional
a minimal accommodative response with high lag of design, these findings do not consider a view of
accommodation and the other group showed a lead accommodation over time. Future studies could re-
of accommodation. When more visual cues, such as examine the accommodative response on follow-up
target proximity and binocular viewing were allowed, visits to determine repeatability. Lastly, the physical
the accommodative response improved and more limitations of the open field autorefractor only
closely resembled that of a normally-sighted patient. allowed measurements up to 5D and many children
White and Wick23 evaluated accommodative responses with visual impairment habitually adopt a working
up to four diopters; however, the working distance for distance of 10 centimeters or closer. Despite these
children with visual impairment is often much closer limitations, the present findings offer important
which requires higher levels of accommodation.1 implications for clinical low vision management of
Another issue is that White and Wick23 evaluated children with macular diseases. Clinicians should
Volume 42/Number 1/2011 15
use clinically available methods, such as MEM 13. Woodhouse JM, Pakeman VH, Saunders KJ, Parker M, Fraser WI, Lobo S,
et al. Visual acuity and accommodation in infants and young children with
or other near retinoscopy techniques, to evaluate Downs syndrome. J Intellect Disabil Res. 1996;40(Pt 1):49-55.
accommodative response in this population prior to 14. McClelland JF, Parkes J, Hill N, Jackson AJ, Saunders KJ. Accommodative
prescribing near corrections. dysfunction in children with cerebral palsy: a population-based study. Invest
Ophthalmol Vis Sci. 2006;47(5):1824-30.
Further research in this area is necessary to
15. Leat SJ. Reduced accommodation in children with cerebral palsy.
provide clinicians with a better understanding Ophthalmic Physiol Opt 1996;16(5):385-390.
of the accommodative response in children with 16. Hokoda SC, Ciuffreda KJ. Measurement of accommodative amplitude in
congenital macular disorders. Suggestions for future amblyopia. Ophthalmic Physiol Opt. 1982;2(3):205-12.

studies include measurement of accommodative 17. Ciuffreda KJ, Hokoda SC. Spatial frequency dependence of accommodative
responses in amblyopic eyes. Vision Res. 1983;23(12):1585-94.
response both monocularly and binocularly, and
18. Abraham SV. Accommodation in the amblyopic eye. Am J Ophthalmol.
comparison to standardize clinical measured of 1961;52:197-200.
accommodative accuracy. Binocular viewing may 19. Kirschen DG, Kendall JH, Riesen KS. An evaluation of accommodation
improve accommodative response as demonstrated response in amblyopic eyes. Am J Optom Physiol Opt. 1981;58(7):597-
602.
in the White and Wick study.23 Use of targets with
20. Ciuffreda KJ, Rumpf D. Contrast and accommodation in amblyopia.
more accommodative detail may also improve the Vision Res. 1985;25(10):1445-57.
accommodative response. A more natural target may 21. Ciuffreda KJ, Hokoda SC, Hung GK, Semmlow JL, Selenow A. Static
aid in achieving better attention and therefore better aspects of accommodation in human amblyopia. Am J Optom Physiol Opt.
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accommodative response.25
22. Hung GK, Ciuffreda KJ, Semmlow JL, Hokoda SC. Model of static
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Acknowledgements: The authors wish to 1983; 30(10):665-72.
dedicate this paper to Dr. Michael W. Rouse, who was 23. White JM, Wick B. Accommodation in humans with juvenile macular
degeneration. Vision Research 1995;35(6):873-880.
instrumental in the inspiration and conception of this
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paper. Additional thanks to Dr. Jerry Paugh and Dr. impairment and its clinical implications. Invest Ophthalmol Vis Sci.
Lawrence Stark for their assistance with the paper. 2007;48(8):3888-96.
25. Ciuffreda KJ. The Glenn A. Fry invited lecture. Accommodation to gratings
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16 Optometry & Vision Development

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