Vergence, accommodation, and visual tracking in children and adolescents evaluated in a multidisciplinary concussion clinic.
2021; 184: 30?36
Effectiveness of vergence/accommodative therapy for accommodative dysfunction in children with convergence insufficiency.
Ophthalmic & physiological optics : the journal of the British College of Ophthalmic Opticians (Optometrists)
Many patients with concussion experience visual symptoms following injury that lead to a diagnosis of convergence insufficiency, accommodative insufficiency, or saccadic dysfunction. However, these diagnostic categories are based on aggregates of clinical tests developed from a non-concussed population and therefore may not accurately describe visual deficits in the concussed population. Thus, we sought to understand individual metrics of visual dysfunction in chronically symptomatic post-concussion patients. This retrospective cross-sectional study included patients examined at the multidisciplinary concussion clinic (MDCC) at Boston Children's Hospital over four years. Patients aged 5-21years who had a complete assessment of eye alignment, vergence, accommodation, and visual tracking, and had visual acuity better than or equal to 20/30 in each eye were included. Patients with history of amblyopia, strabismus, or ocular pathology were excluded. Chart review yielded 116 patients who met inclusion criteria (median age 15years, 64% female). The majority of patients (52%) experienced a single concussion and most were sports-related (50%). Clinical data show vergence, accommodation, or visual tracking deficits in 95% of patients. A receded near point of convergence (NPC, 70/116) and reduced accommodative amplitude (63/116) were the most common deficits. Both NPC and accommodative amplitude were significantly correlated with one another (r=-0.5) and with measures of visual tracking (r=-0.34). Patients with chronic post-concussion symptoms show deficits in individual metrics of vergence, accommodation and visual tracking. The high incidence of these deficits, specifically NPC and accommodative amplitude, highlights the need for a detailed sensorimotor evaluation to guide personalized treatment following concussion.
View details for DOI 10.1016/j.visres.2021.03.002
View details for PubMedID 33838503
Impact of Visual Cues on the Magnitude and Variability of the Accommodative Response in Children With Emmetropia and Uncorrected Hyperopia and Adults.
Investigative ophthalmology & visual science
2019; 60 (5): 1527?37
To determine the effectiveness of office-based vergence/accommodative therapy for improving accommodative amplitude and accommodative facility in children with symptomatic convergence insufficiency and accommodative dysfunction.We report changes in accommodative function following therapy among participants in the Convergence Insufficiency Treatment Trial - Attention and Reading Trial with decreased accommodative amplitude (115 participants in vergence/accommodative therapy; 65 in placebo therapy) or decreased accommodative facility (71 participants in vergence/accommodative therapy; 37 in placebo therapy) at baseline. The primary analysis compared mean change in amplitude and facility between the vergence/accommodative and placebo therapy groups using analyses of variance models after 4, 8, 12 and 16 weeks of treatment. The proportions of participants with normal amplitude and facility at each time point were calculated. The average rate of change in amplitude and facility from baseline to week 4, and from weeks 4 to 16, were determined in the vergence/accommodative therapy group.From baseline to 16 weeks, the mean improvement in amplitude was 8.6 dioptres (D) and 5.2 D in the vergence/accommodative and placebo therapy groups, respectively (mean difference = 3.5 D, 95% confidence interval (CI): 1.5 to 5.5 D; p = 0.01). The mean improvement in facility was 13.5 cycles per minute (cpm) and 7.6 cpm in the vergence/accommodative and placebo therapy groups, respectively (mean difference = 5.8 cpm, 95% CI: 3.8 to 7.9 cpm; p < 0.0001). Significantly greater proportions of participants treated with vergence/accommodative therapy achieved a normal amplitude (69% vs. 32%, difference = 37%, 95% CI: 22 to 51%; p < 0.0001) and facility (85% vs. 49%, difference = 36%, 95% CI: 18 to 55%; p < 0.0001) than those who received placebo therapy. In the vergence/accommodative therapy group, amplitude increased at an average rate of 1.5 D per week during the first 4 weeks (p < 0.0001), then slowed to 0.2 D per week (p = 0.002) from weeks 4 to 16. Similarly, facility increased at an average rate of 1.5 cpm per week during the first 4 weeks (p < 0.0001), then slowed to 0.6 cpm per week from weeks 4 to 16 (p < 0.0001).Office-based vergence/accommodative therapy is effective for improving accommodative function in children with symptomatic convergence insufficiency and coexisting accommodative dysfunction.
View details for DOI 10.1111/opo.12747
View details for PubMedID 33119180
A Randomized Clinical Trial of Immediate versus Delayed Glasses for Moderate Hyperopia in 1- and 2-Year-Olds.
We investigated the effect of blur and disparity cues on accommodative accuracy (lag) and variability (time [RMS] and frequency domain [LFC]) in the developing visual system.A total of 59 children (3-9 years, spherical equivalent refractive error [RE] = -0.3- +4.91 diopters [D]) and 10 adults (23-31 years, RE = -0.37-+1.15D) participated. Accommodation was measured in the right eye for 1 minute at 100 and 33 cm using photorefraction (25 Hz) for three conditions: blur + disparity (binocular, 20/50 optotypes), blur-only (monocular, 20/50 optotypes), disparity-only (binocular, difference-of-Gaussian stimulus). The effect blur and disparity cues have on accommodative accuracy, RMS, and LFC was assessed.Lag, RMS, and LFC increased (P < 0.001) from 100 to 33 cm for each condition in children and adults. In children, accommodation was most accurate and stable when blur and disparity cues remained in the stimulus and became significantly less accurate and more variable (P < 0.001) when blur or disparity cues were removed at 33 cm. In adults, accommodation was significantly less accurate and more variable only when blur was removed from the stimulus (P < 0.022). Children with RE matched to adults had less accurate and more variable accommodative responses at near than adults when cues were removed (P ? 0.02).In children and adults, an increase in RMS and LFC is related to an increase in accommodative lag. Children's accommodative systems do not compensate as efficiently as adults when blur and disparity cues are removed, suggesting children <10 years old do not have a mature afferent visual pathway.
View details for PubMedID 30994863
Reliabilityand Validity of Gaze-Dependent Functional Vision Space: A Novel Metric Quantifying Visual Function in Infantile Nystagmus Syndrome
INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE
2018; 59 (5): 1760?68
Two strategies were compared for managing moderate hyperopia without manifest strabismus among 1- and 2-year-old children: (1) immediate prescription of glasses versus (2) observation without glasses unless reduced distance visual acuity (VA), reduced stereoacuity, or manifest strabismus.Prospective randomized clinical trial.A total of 130 children aged 1 to 2 years with hyperopia between +3.00 diopters (D) and +6.00 D spherical equivalent (SE) in at least 1 eye, anisometropia ?1.50 D SE, and astigmatism ?1.50 D based on cycloplegic refraction and no manifest strabismus.Participants were randomly assigned to glasses (1.00 D less than full cycloplegic hyperopia) versus observation and followed every 6 months for 3 years. Glasses were prescribed to those assigned to observation if they met prespecified deterioration criteria of distance VA or near stereoacuity below age norms, or development of manifest strabismus.At the 3-year primary outcome examination, participants were classified as failing the randomized management regimen if distance VA or stereoacuity was below age norms or manifest strabismus was observed (each with and without correction in trial frames, confirmed by masked retest, irrespective of whether deterioration had occurred previously), or if strabismus surgery had been performed.Of the 106 participants (82%) completing the 3-year primary outcome examination, failure occurred in 11 (21%) of 53 in the glasses group and 18 (34%) of 53 in the observation group (difference = -13%; 95% confidence interval [CI], -31 to 4; P = 0.14). Sixty-two percent (95% CI, 49-74) in the observation group and 34% (95% CI, 23-48) in the glasses group met deterioration criteria (requiring glasses if not wearing).For 1- and 2-year-olds with uncorrected moderate hyperopia (+3.00 D to +6.00 D SE), our estimates of failure, after 3 years of 6-month follow-ups, are inconclusive and consistent with a small to moderate benefit or no benefit of immediate prescription of glasses compared with careful observation (with glasses only if deteriorated).
View details for PubMedID 30615896
Blur Detection, Depth of Field, and Accommodation in Emmetropic and Hyperopic Children
OPTOMETRY AND VISION SCIENCE
2018; 95 (3): 212?22
This study presents test-retest reliability of optotype visual acuity (OVA) across 60° of horizontal gaze position in patients with infantile nystagmus syndrome (INS). Also, the validity of the metric gaze-dependent functional vision space (GDFVS) is shown in patients with INS.In experiment 1, OVA was measured twice in seven horizontal gaze positions from 30° left to right in 10° steps in 20 subjects with INS and 14 without INS. Test-retest reliability was assessed using intraclass correlation coefficient (ICC) in each gaze. OVA area under the curve (AUC) was calculated with horizontal eye position on the x-axis, and logMAR visual acuity on the y-axis and then converted to GDFVS. In experiment 2, validity of GDFVS was determined over 40° horizontal gaze by applying the 95% limits of agreement from experiment 1 to pre- and post-treatment GDFVS values from 85 patients with INS.In experiment 1, test-retest reliability for OVA was high (ICC ? 0.88) as the difference in test-retest was on average less than 0.1 logMAR in each gaze position. In experiment 2, as a group, INS subjects had a significant increase (P < 0.001) in the size of their GDFVS that exceeded the 95% limits of agreement found during test-retest.OVA is a reliable measure in INS patients across 60° of horizontal gaze position. GDFVS is a valid clinical method to be used to quantify OVA as a function of eye position in INS patients. This method captures the dynamic nature of OVA in INS patients and may be a valuable measure to quantify visual function patients with INS, particularly in quantifying change as part of clinical studies.
View details for DOI 10.1167/iovs.17-23229
View details for Web of Science ID 000429088400009
View details for PubMedID 29610862
View details for PubMedCentralID PMC5886028
Impact of Cognitive Demand during Sustained Near Tasks in Children and Adults
OPTOMETRY AND VISION SCIENCE
2018; 95 (3): 223?33
Our results demonstrate that blur detection thresholds are elevated in young children compared with adults, and poorer blur detection thresholds are significantly correlated with the magnitude of accommodative microfluctuations. Given that accommodative microfluctuations are greater with greater accommodative responses, these findings may have implications for young uncorrected hyperopes.This study investigated the association between subjective blur detection thresholds and accommodative microfluctuations in children 3 years to younger than 10 years old and adults.Blur detection thresholds were determined in 49 children with habitually uncorrected refractive error (+0.06 to +4.91 diopters [D] spherical equivalent) and 10 habitually uncorrected adults (+0.08 to +1.51 D spherical equivalent) using a custom blur chart with 1° sized optotypes at 33 cm. Letters were blurred by convolution using a Gaussian kernel (SDs of 0.71 to 11.31 arc minutes in ?2 steps). Subjective depth of field was determined in subjects 6 years or older and adults. Accommodative microfluctuations, pupils, and lag were measured using infrared photorefraction (25 Hz).Children had greater blur detection thresholds (P < .001), accommodative microfluctuations (P = .001), and depth of field (P < .001) than adults. In children, increased blur detection thresholds were associated with increased accommodative microfluctuations (P < .001), increased uncorrected hyperopia (P = .01), decreased age (P < .001), and decreased pupil size (P = .01). In a multiple linear regression analysis, blur detection thresholds were associated with accommodative microfluctuations (P < .001) and age (P < .001). Increased accommodative microfluctuations were associated with increased uncorrected hyperopia (P = .004) and decreased pupil size (P = .003) and independently associated with uncorrected hyperopia (P = .001) and pupil size (P = .003) when controlling for age and lag.Children did not have adult-like blur detection thresholds or depth of field. Increased accommodative microfluctuations and decreased age were independently associated with greater blur detection thresholds in children 3 years to younger than 10 years. Larger amounts of uncorrected hyperopia in children appear to increase blur detection thresholds because the greater accommodative demand and resulting response increase accommodative microfluctuations.
View details for DOI 10.1097/OPX.0000000000001177
View details for Web of Science ID 000426554100007
View details for PubMedID 29401180
View details for PubMedCentralID PMC5821572
Accommodative Gain in Relation to Perceived Target Clarity
OPTOMETRY AND VISION SCIENCE
2015; 92 (11): 1092?1102
These results demonstrate that accommodation in children is more accurate and less variable when performing a sustained near task with increased cognitive demand. In addition, children with increased uncorrected hyperopia have less stable accommodative responses, which may have visual implications during sustained near tasks.This study investigated accommodative accuracy (lag) and variability during sustained viewing for passive and active tasks in children and adults with emmetropia and uncorrected hyperopia.Lag and variability (root mean square [RMS] and low-frequency component) were measured in 54 children aged 3 to younger than 10 years with mean spherical equivalent of +1.31 ± 1.05 diopters (D) (range, -0.37 to +4.58 D) and 8 adults aged 22 to 32 years with mean spherical equivalent +0.65 ± 0.62 D (range, -0.13 to +1.15 D). Subjects viewed 20/50 stimuli at 33 cm during both a 10-minute passive and active task. Group 1 (<6 years or nonreaders) viewed shapes; group 2 (?6 years and reading) and adults read passages.Groups 1 and 2 had larger lags, RMS, and low-frequency component for passive versus active tasks (P < .001). Lag and RMS did not differ between tasks in adults (P > .05), but low-frequency component was larger during passive viewing (P = .04). Group 1 had significantly higher RMS and low-frequency component than group 2 and the adults in the passive condition had greater low-frequency component in the active condition. In children, hyperopia was independently associated with RMS and low-frequency component under passive (RMS 95% confidence interval [CI], 0.04 to 0.15; low-frequency component 95% CI, 0.00011 to 0.00065) and active (RMS 95% CI, 0.001 to 0.06; 95% CI, 0.000014 to 0.00023) viewing.Accommodation is more accurate and less variable when children are engaged in the task. Children also have more variable accommodation than adults. In addition, children with greater hyperopia have more variable accommodation during sustained near tasks.
View details for DOI 10.1097/OPX.0000000000001186
View details for Web of Science ID 000426554100008
View details for PubMedID 29461410
View details for PubMedCentralID PMC5875985
Intraobserver reliability of contact pachymetry in children
JOURNAL OF AAPOS
2013; 17 (2): 144?48
The purpose of this study is to determine the relationship between target clarity and the magnitude of accommodative lag using the metric accommodative gain (AG).Monocular accommodative responses were measured with Grand Seiko autorefraction using both proximal and minus lens techniques in 139 subjects aged 5 to 35 years. Subjects viewed a 1.5-mm letter at 13 discrete distances (range, 40 to 3.33 cm) for the proximal technique and fixed at 33 cm through minus lenses of increasing power for the lens technique. Subjects were instructed to keep the target clear and report when it blurred. The AG was calculated (accommodative response/accommodative demand) for the four greatest consecutive demands perceived clear (termed conditions 1 to 4) and the first demand perceived blurry (termed condition 5).Multivariate planned contrast, including age as a predictor, revealed that mean AG was significantly larger when the target was clear (range, 0.71 to 0.77 for conditions 1 to 4 across techniques) versus blurry (0.59 and 0.68 for condition 5 across techniques) (p < 0.001 for proximal and p < 0.036 for lens). Age was only a contributing factor for the proximal technique, with the youngest subjects having the largest decrease in AG when the target changed from clear to blurry (p = 0.017).These data suggest that across age and technique, the AG is relatively constant when the target is perceived clear but drops below approximately 70%, on average, once the target is perceived as blurry for subjects aged 5 to 35 years. The AG may be a useful metric to compare accommodative responses across a range of demands and to identify accommodative responses that may not be sufficient to perceive a clear target.
View details for DOI 10.1097/OPX.0000000000000711
View details for Web of Science ID 000364200600009
View details for PubMedID 26421684
View details for PubMedCentralID PMC4812439
Vision Specific Quality of Life of Pediatric Contact Lens Wearers
OPTOMETRY AND VISION SCIENCE
2010; 87 (8): 560?66
Central corneal thickness (CCT) is an important measurement in the treatment and management of pediatric glaucoma and potentially of refractive error, but data regarding reliability of CCT measurement in children are limited. The purpose of this study was to evaluate the reliability of CCT measurement with the use of handheld contact pachymetry in children.We conducted a multicenter intraobserver test-retest reliability study of more than 3,400 healthy eyes in children aged from newborn to 17 years by using a handheld contact pachymeter (Pachmate DGH55; DGH Technology Inc, Exton, PA) in 2 clinical settings--with the use of topical anesthesia in the office and with the patient under general anesthesia in a surgical facility.The overall standard error of measurement, including only measurements with standard deviation ?5 ?m, was 8 ?m; the corresponding coefficient of repeatability, or limits within which 95% of test-retest differences fell, was ±22.3 ?m. However, standard error of measurement increased as CCT increased, from 6.8 ?m for CCT less than 525 ?m, to 12.9 ?m for CCT 625 ?m and greater. The standard error of measurement including measurements with standard deviation >5 ?m was 10.5 ?m. Age, sex, race/ethnicity group, and examination setting did not influence the magnitude of test-retest differences.CCT measurement reliability in children via the Pachmate DGH55 handheld contact pachymeter is similar to that reported for adults. Because thicker CCT measurements are less reliable than thinner measurements, a second measure may be helpful when the first exceeds 575 ?m. Reliability is also improved by disregarding measurements with instrument-reported standard deviations >5 ?m.
View details for DOI 10.1016/j.jaapos.2012.11.005
View details for Web of Science ID 000319027700006
View details for PubMedID 23622447
View details for PubMedCentralID PMC3639436
Randomized Trial of the Effect of Contact Lens Wear on Self-Perception in Children
OPTOMETRY AND VISION SCIENCE
2009; 86 (3): 222?32
Several studies have shown that children are capable of wearing and caring for contact lenses, but it is not known whether the benefits outweigh the risks associated with contact lens wear. The purpose of this article is to compare the vision-related quality of life benefits of children randomized to wear spectacles or contact lenses for 3 years using the Pediatric Refractive Error Profile.The Pediatric Refractive Error Profile was administered to 484 children who wore glasses at baseline. The children were then randomly assigned to wear contact lenses (n = 247) or spectacles (n = 237) for 3 years. The survey was administered at the baseline examination, at 1 month, and every 6 months for 3 years.During 3 years, the overall quality of life improved 14.2 +/- 18.1 units for contact lens wearers and 2.1 +/- 14.6 units for spectacle wearers (p < 0.001). In all scales except the visual performance scales (Distance Vision, Near Vision, and Overall Vision), the quality of life improved more for older subjects than younger subjects. The three scales with the largest improvement in quality of life for contact lens wearers were Activities, Appearance, and Satisfaction with Correction.Myopic children younger than 12 years of age report better vision-related quality of life when they are fit with contact lenses than when they wear glasses. Older children, children who participate in recreational activities, children who are motivated to wear contact lenses, and children who do not like their appearance in glasses will benefit most.
View details for DOI 10.1097/OPX.0b013e3181e6a1c8
View details for Web of Science ID 000280551000006
View details for PubMedID 20562669
A Randomized Trial of the Effect of Soft Contact Lenses on Myopia Progression in Children
INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE
2008; 49 (11): 4702?6
To determine whether contact lens wear affects children's self-perceptions.The Adolescent and Child Health Initiative to Encourage Vision Empowerment Study was a randomized, single-masked trial conducted at five clinical centers in the United States. Subjects were 8- to 11-year-old myopic children randomly assigned to wear spectacles (n = 237) or soft contact lenses (n = 247) for 3 years. The primary endpoint was the Self-Perception Profile for Children Global Self-Worth scale. Secondary outcomes included the Physical Appearance, Athletic Competence, Scholastic Competence, Behavioral Conduct, and Social Acceptance Self-Perception Profile for Children scales.Global self-worth was not affected by contact lens wear [analysis of variance (ANOVA), difference = 0.06; 95% CI, -0.004 to 0.117]. Physical appearance (ANOVA, difference = 0.15; 95% CI, 0.07 to 0.22), athletic competence (ANOVA, difference = 0.08; 95% CI, 0.01 to 0.15), and social acceptance (ANOVA, difference = 0.10; 95% CI, 0.03 to 0.17) were all greater for contact lens wearers.Although contact lens wear does not affect global self-perceptions of 8- to 11-year-old myopic children their physical appearance, athletic competence, and social acceptance self-perceptions are likely to improve with contact lens wear. Eye care practitioners should consider the social and visual benefits of contact lens wear when choosing the most appropriate vision correction modality for children as young as 8 years of age.
View details for DOI 10.1097/OPX.0b013e3181971985
View details for Web of Science ID 000264004400008
View details for PubMedID 19214129
Soft contact lenses have been reported to increase the progression of myopia. The purpose of this study was to determine whether soft contact lenses affect the progression of myopia in children.Children between the ages of 8 and 11 years with -1.00 to -6.00 D myopia and less than 1.00 D astigmatism were randomly assigned to wear soft contact lenses (n = 247) or spectacles (n = 237) for 3 years. Refractive error and corneal curvatures were measured annually by cycloplegic autorefraction, and axial length was measured annually by A-scan ultrasound. Multilevel modeling was used to compare the rate of change of refractive error, corneal curvature, and axial length between spectacle and contact lens wearers.There was a statistically significant interaction between time and treatment for myopia progression (P = 0.002); the average rate of change was 0.06 D per year greater for contact lens wearers than spectacle wearers. After 3 years, the adjusted difference between contact lens wearers and spectacle wearers was not statistically significant (95% confidence interval [CI] = -0.46 to 0.02). There was no difference between the two treatment groups with respect to change in axial length (ANCOVA, P = 0.37) or change in the steepest corneal curvature (ANCOVA, P = 0.72).These data provide reassurance to eye care practitioners concerned with the phenomenon of "myopic creep." Soft contact lens wear by children does not cause a clinically relevant increase in axial length, corneal curvature, or myopia relative to spectacle lens wear. (ClinicalTrials.gov, NCT00522288.).
View details for DOI 10.1167/iovs.08-2067
View details for Web of Science ID 000260502200002
View details for PubMedID 18566461