Functional optometry ii

Opt 462
Case Analysis and Classification
Several analytical approaches are presented in the optometric literature. Each
has its own unique characteristics, advantages, and disadvantages. Each of
these systems also has shortcomings that are significant enough to have
prevented wide acceptance of any one approach by the profession. Rather, it is
common for optometrists, during their early years of practice, to develop their
own personal approach to case analysis that is often a combination of the
various systems they have been taught during their education.
The four approaches that are most widely discussed in our literature are
graphical analysis, the Optometric Extension Program (OEP) analytical
analysis approach, Morgan’s system of normative analysis, and fixation
disparity analysis. This chapter briefly describes these four case analysis
approaches. This discussion leads directly to a detailed presentation of the
case analysis approach that is used throughout this text.

Review of Currently Available Analytical Approaches

GRAPHICAL ANALYSIS
Graphical analysis is a method of plotting clinical accommodation and
binocular findings to determine whether a patient can be expected to have
clear, single, and comfortable binocular vision. The test findings that are
commonly plotted include the dissociated phoria; base-in to blur, break, and
recovery; base-out to blur, break, and recovery; negative relative
accommodation (NRA); positive relative accommodation (PRA); amplitude of
accommodation; and near point of convergence.

Advantages
The primary advantage of the graphical analysis system is that it allows one to
visualize the relationship among several optometric findings and is, therefore,
an excellent system to introduce the concepts of case analysis. The width of
the zone of clear, single, binocular vision; the relationship between the phoria
and fusional vergence; the accommodative convergence to accommodation
(AC/A) ratio; and the relationship of the NRA and PRA findings to fusional
vergence and/or accommodation are all clearly portrayed on the graph. For
the student learning about accommodation and binocular vision for the first
time, the ability to view a visual representation can be a very powerful
learning tool. Over the years, graphical analysis has become a standard
teaching approach in many optometric curricula.
Graphical analysis also facilitates identification of erroneous findings. When
data are plotted on the graph, a characteristic pattern becomes evident. If an
individual finding deviates from this typical pattern, it may indicate that it is
erroneous and unreliable.
Although the primary purpose of graphical analysis is simply the visual
representation of accommodative and binocular data, various guidelines for
analyzing these findings have developed over the years. The most popular of
these guidelines has been Sheard’s criterion. Sheard postulated that for an
individual to be comfortable, the fusional reserve should be twice the demand
(phoria). For example, in the case of a 10 Δ exophoria, the positive fusional
convergence should be 20 Δ to meet Sheard’s criterion. This postulate can
also be used to determine the amount of prism necessary to make the patient
comfortable or to determine whether lenses or vision therapy would be
appropriate.
 Disadvantages
The system does have shortcomings, however, which, for the most part, have
relegated graphical analysis to the classroom.

Sample graphical analysis worksheet showing the test findings that are
commonly plotted: (A) The dissociated phoria, (B) base-in to blur, (C) base-in
to break, (D) base-out to blur, (E) base-out to break, (F) negative relative
accommodation, (G) positive relative accommodation, (H) amplitude of
accommodation, and (I) near point of convergence.
 The graphical system fails to identify some binocular vision,
accommodation, and oculomotor problems. When using the graphical
analysis approach, important data such as accommodative facility, fusion
facility, fixation disparity, and monocular estimation method (MEM)
retinoscopy findings are not included in the analysis. This is significant
because of the 15 most common accommodative, ocular motor, and
binocular vision anomalies (e.g., accommodative excess, accommodative
infacility, ill-sustained accommodation, fusional vergence dysfunction, and
ocular motor dysfunction) cannot be identified using graphical analysis. For
example, an individual with a condition called accommodative infacility may
have a normal amplitude of accommodation, NRA, and PRA. When the data
are plotted according to established graphical analysis guidelines and
analyzed according to Sheard’s criterion, the result is a normal graph and
failure to identify a problem. Accommodative infacility can only be
 diagnosed when facility testing is performed and analyzed. This type of
information, however, is not part of the routine in the graphical system. A
condition such as accommodative infacility would, therefore, not be
diagnosed using a traditional graphical analysis approach.
 Graphical analysis relies heavily upon criteria—such as those by
Sheard3,4 and by Percival5—to determine whether a problem exists. These
criteria, however, can only be considered guidelines. Although Sheard’s
criterion has been readily accepted by optometry since its introduction,
there has been little research evidence, until recently, to support its validity.
A study by Dalziel6 found that a vision therapy program that was effective in
improving fusional vergence to meet Sheard’s criterion was effective in
relieving symptoms. Sheedy and Saladin7,8 studied the relationship between
asthenopia and various clinical analysis measures of oculomotor balance.
The objective was to determine which measures would best discriminate
symptomatic from asymptomatic patients. Sheard’s criterion was found to
be the best for the entire population and exophoria, but the slope of the
fixation disparity curve was found to be best for esophores. Worrell et
al9 evaluated patient acceptance of prism prescribed by Sheard’s criterion.
They prescribed two pairs of glasses for each subject. The glasses were
identical in every way, except that one contained a prism based on Sheard’s
criterion. The results of this study showed that patients with esophoria
preferred the glasses with the prism, whereas those with exophoria
preferred the glasses without the prism. Although these studies are
somewhat supportive of Sheard’s criterion, there are certainly suggestions
that, in some cases, it fails to identify patients who are symptomatic and may
not always be the most effective method for determining appropriate
management.
 Another shortcoming of graphical analysis is that it may be too precise a
method for clinical purposes and is cumbersome to use. Although most
optometry students begin their study of case analysis with a presentation of
graphical analysis, few continue to graph data throughout their careers. The
actual mechanics of plotting the data are cumbersome and time-consuming.
An experienced clinician rarely needs to actually plot optometric data to
reach a decision about diagnosis and management.

ANALYTICAL ANALYSIS
The second case analysis approach is referred to as the analytical analysis
system. Developed by the OEP, this approach has several rigid requirements
and steps:
 Administration of a 21-point examination using precise instructional sets
 Checking (comparison of data to a table of expected findings)
 Chaining (grouping the data)
 Case typing (identifying the condition)
In the analytical analysis approach, the specific 21 tests (points), as described
by the OEP, must be used and the instructional sets must be precisely
followed. Any deviation from the suggested routine invalidates the results and
the analytical system.
Results of the examination must then be compared with a table of expected
values developed by the OEP (table bleow). This is followed by a procedure
referred to as chaining, or grouping of the data. Chaining simply means that
those findings found to be high are entered above a horizontal line, whereas
data that are low are placed below the horizontal line. The data are also
grouped together according to specific rules. The following illustrates an
example of chaining:

The results of this chaining or grouping of all the high and low data are then
analyzed. This process is referred to as case typing. Two basic types or
classifications exist in the OEP system: the B-type (accommodative problem)
and the C-type (convergence problem). The B-type case is further divided into
seven stages or subtypes.

Advantages
Analytical analysis incorporates several unique concepts into its system that
are derived from the underlying philosophy of vision of the OEP. Two
examples are described next.

OPTOMETRIC EXTENTION PROGRAMME EXPECTED FINDINGS

Distance lateral phoria Ortho -0.5 exophoria

Near lateral phoria 6.0 exophoria

 Base-out (distance) Blur: 7

Break: 19

Recovery: 10

Base-in (distance) Break: 9

Recovery: 5

Base-out (near) Blur: 15

Break: 21

Recovery: 15

Base-in (near) Blur: 14

Break: 22

Recovery: 18

Negative relative accommodation +2.00

Positive relative accommodation -2.25

Fused cross-cylinder +0.50

 Concept 1: The status of the visual system can deteriorate over
time. The OEP stresses the concept that vision problems develop over time
and that the deterioration occurs as an adaptation to a stressful condition
(e.g., excessive reading or near work). Analytical analysis allows one to
evaluate the current stage or deterioration of the vision problem, and the
therapy prescribed depends on this determination. If this treatment using
lenses or vision therapy is not instituted, continued reading can be expected
to result in adaptations that take the form of fusional vergence and
accommodative problems, refractive error, and strabismus. This concept is
dramatically different from traditional thinking, which suggests that vision
disorders occur as random variations or as a failure in development.
 Concept 2: Vision problems can be prevented. OEP philosophy postulates
that vision problems develop as an adaptation to near point
demands. Because analysis of the data can indicate the current stage of
development of a vision problem, subtle changes can be detected early. With
appropriate intervention using lenses, prism, and vision therapy, many
vision problems can be prevented, according to OEP philosophy.

Disadvantages
The analytical approach is mainly used by members of the OEP and has not
gained widespread use for several reasons.
 A major problem with this system is that the student or practitioner must be
familiar with specific OEP testing protocols. Unless these protocols are
precisely followed, the system becomes unusable. Because most schools of
optometry do not teach this system of testing, students are generally
unfamiliar with the instructional sets.
 An understanding and acceptance of OEP philosophy is a basic requirement.
The OEP is primarily a postgraduate education organization. Students at the
various schools and colleges of optometry generally receive only
introductory information about the OEP. It is not difficult to understand,
therefore, why so few students feel comfortable with this approach.
 The OEP literature is written using a basic language that is often very
different from the classic optometric language taught in optometry schools.
Basic definitions of terms such as accommodation, convergence, blur, break,
recovery, and phoria are all significantly different. For example, Manas
defines exophoria as “[a] developmental relationship within the visual
behavior pattern, between areas of that pattern, operationally active to
preserve the integrity of performance of the convergence pattern.” If an
optometrist wants to use analytical analysis, it requires a period of time
 learning this new language. For a student or practitioner who has just spent
several years learning one optometric language, the additional effort
required is an obstacle that must be overcome before involvement with the
OEP analysis system is possible.

MORGAN’S SYSTEM OF CLINICAL ANALYSIS (NORMATIVE ANALYSIS)

Morgan’s system is based on his 1944 study, in which he presented the
concept that it is important to analyze the results of groups of data. In
Morgan’s approach, little significance is attributed to variation from the norm
on any one given test. Morgan found that he was able to divide all data into
groups based on the direction in which the tests tend to vary. To analyze
optometric data using Morgan’s analytical approach, one must first compare
the findings with Morgan’s table of expected findings (Table 2.2) and then
look for a trend in the group A and group B findings (Table 2.3). The
important concept in this system is that no single finding is considered
significant by itself. However, when a group as a whole varies in a given
direction, it is considered clinically significant. If the group A findings are high
and the group B data are low, a convergence problem is present. If the group B
data are high and the group A findings are low, an accommodative fatigue
problem is indicated. The data in group C are used to suggest whether lenses,
prism, or vision therapy should be recommended as treatment.
Morgan’s approach, therefore, is an attempt to present an analytical system
that is easily applied and that does not go beyond the exactness and
significance of the data involved.

Advantages
 The primary advantage of this approach is the concept that it is important to
look at groups of findings rather than individual data. Morgan stresses that if
one finding falls outside the “normal range,” it does not necessarily indicate
that the patient has a problem. He states that “statistical data applies to
populations and not necessarily to individuals.”
 Another advantage of this system is its flexibility and ease of use, compared
with the complexity and rigidity associated with graphical and analytical
analyses.

MORGANS TABLE OF EXPECTED FINDINGS

 Test Expected Standard
Finding Deviation

Distance lateral phoria 1 exophoria ±2 Δ

Near lateral phoria 3 exophoria ±3 Δ

AC/A ratio 4:1 ±2 Δ

Base-out (distance) Blur: 9 ±4 Δ

Break: 19 ±8 Δ

Recovery: 10 ±4 Δ

Base-in (distance) Break: 7 ±3 Δ

Recovery: 4 ±2 Δ

Base-out (near) Blur: 17 ±5 Δ

Break: 21 ±6 Δ

Recovery: 11 ±7 Δ

Base-in (near) Blur: 13 ±4 Δ

Break: 21 ±4 Δ

Recovery: 13 ±5 Δ
 Amplitude of accommodation

Push-up 18 – 1/3 age ±2.00 D

Fused cross-cylinder +0.50 ±0.50 D

Negative relative +2.00 ±0.50 D

accommodation

Positive relative -2.37 ±1.00 D

accommodation

AC/A, accommodative convergence to accommodation.

Disadvantages
The primary limitation of Morgan’s approach is that the groups developed by
Morgan in the 1940s have not been updated to include some of the more
recent optometric tests that have been shown to be important clinical
findings. As a result, it fails to identify some binocular vision, accommodation,
and oculomotor problems. When using Morgan’s analysis, important data,
such as accommodative facility, fusion facility, fixation disparity, MEM
retinoscopy, and ocular motility findings, are not included in the analysis.

MORGANS THREE GROUPS

 Group A data

Negative fusional vergence at distance—break

Negative fusional vergence at near—blur
Negative fusional vergence at near—break
Positive relative accommodation
Amplitude

Group B data

Positive fusional vergence at distance—blur and break

Positive fusional vergence at distance—blur and break
Binocular cross-cylinder
Monocular cross-cylinder
Near retinoscopy
Negative relative accommodation

Group C data

Phoria
AC/A ratio

AC/A, accommodative convergence to

accommodation.

FIXATION DISPARITY ANALYSIS

 Fixation disparity is a small misalignment of the eyes under binocular
conditions This misalignment from exact bifoveal fixation is very small, with a
magnitude of only a few minutes of arc. Several clinical methods have been
developed to evaluate fixation disparity at near, including the Mallett unit, the
Bernell lantern slide, the Wesson card, and the Borish card. For fixation
disparity testing at distance, the Mallett unit (distance unit) and the American
Optical vectographic slide were the only primary commercially available
instruments for many years. Today, many of the computer-based visual acuity
(VA) testing instruments include a distance fixation disparity target. The
associated phoria, or the amount of prism necessary to neutralize the fixation
disparity, is determined using the Mallett unit, the American Optical
vectographic slide, the Bernell lantern slide, the Borish card, and computer-
based VA testing instruments. The Wesson card permits a more complete
analysis of the fixation disparity. Using this instrument, a fixation disparity
curve can be generated and four diagnostic characteristics of the curve can be
analyzed. These four characteristics are the type, slope, x-intercept, and y-
intercept.
The use of fixation disparity data has been suggested as a useful method for
the analysis and diagnosis of problems of the oculomotor system. The primary
advantage of fixation disparity analysis is that the assessment takes place
under binocular and, therefore, more natural conditions. Studies have
indicated that analyzing binocular vision using fixation disparity is useful in
determining those patients who are likely to have symptoms. Some
authors have suggested that fixation disparity data may be the most effective
method for determining the amount of prism to prescribe for binocular vision
disorders.

Advantages
 The primary advantage of fixation disparity analysis is that the data are
gathered under binocular vision conditions. Other analytical systems
depend on phoria vergence testing performed under dissociated conditions
that may not truly reflect the way the system operates under binocular
conditions. For example, in about one-third of patients, a condition referred
to as paradoxical fixation disparity is present. This is a condition in which the
fixation disparity is in the direction opposite to the phoria.
 Studies have shown that fixation disparity provides the most effective
method of determining the amount of prism necessary for the treatment of
certain binocular vision disorders.
 Disadvantages
 Fixation disparity testing is a technique for evaluating binocular vision and
does not provide direct information about accommodation or ocular motor
disorders.
All of the systems described earlier have failed to gain widespread acceptance
by the profession because of the limitations described. The rest of this chapter
is devoted to the presentation of the case analysis system that is utilized
throughout this text. This approach draws from the major contributions of the
four systems described, while it attempts to eliminate most of their
disadvantages. Its use allows the optometrist to operate with much more
flexibility than available with strict adherence to any of the other approaches.

INTEGRATIVE ANALYSIS APPROACH

The integrative analysis approach is an analysis system that attempts to make

use of the most positive aspects of other case analysis approaches while
avoiding the problems associated with them.
It requires three distinct steps:
 1. Comparing the individual tests to a table of expected findings
 2. Grouping the findings that deviate from expected findings
 3. Identifying the syndrome based on steps 1 and 2.
This format uses the concepts of the OEP analytical analysis system: checking,
chaining, and typing. However, the primary disadvantages of analytical
analysis—that is, the rigidity of the 21-point examination and the OEP
language problems—are avoided. The integrative analysis approach also
makes use of the following important characteristics of other systems:
 Some of the unique concepts of the OEP system are utilized, including the
following:
 The status of the visual system can deteriorate over time.
 Vision problems can be prevented.
 Morgan’s suggestion that it is important to look at groups of findings rather
than individual data is a key element in the integrative analysis approach.
 Fixation disparity data performed under binocular conditions are included.
 The integrative analysis approach includes an analysis of ocular motor,
accommodative facility, vergence facility, MEM retinoscopy, and fixation
disparity data. No other analysis system makes use of all of these data.
 Specifics

To utilize this case analysis system, the optometrist must be knowledgeable

about the following:
 Expected findings for each optometric test administered
 The relationship of one finding to another or how to group the data that are
gathered
 A classification system that categorizes the most commonly encountered
vision problems or syndromes.

Grouping Optometric Data

The concept of the importance of looking for trends comes from both the OEP
analysis and Morgan’s system. The integrative analysis approach is simply an
expansion of this concept and divides optometric data into six groups, rather
than the three proposed by Morgan . Tests or data are placed in a group if they
directly or indirectly evaluate the same function.

TESTS EVALUATING POSITIVE FUSIONAL VERGENCE

 Positive fusional vergence (PFV)—smooth vergence testing
 PFV—step vergence testing
 PFV—vergence facility testing
 NRA
 Binocular accommodative facility (BAF) with plus lenses
 Near point of convergence
 MEM retinoscopy and fused cross-cylinder

TESTS EVALUATING NEGATIVE FUSIONAL VERGENCE

 Negative fusional vergence (NFV)—smooth vergence testing
 NFV—step vergence testing
 NFV—vergence facility testing
 PRA
 BAF with minus lenses
 MEM retinoscopy and fused cross-cylinder

TESTS EVALUATING THE ACCOMMODATIVE SYSTEM

 Monocular accommodative amplitude
 Monocular accommodative facility with plus and minus lenses
 MEM retinoscopy
 Fused cross-cylinder
 NRA/PRA
 BAF testing
 Binocular accommodative amplitude

TESTS EVALUATING VERTICAL FUSIONAL VERGENCE

 Supravergence and infravergence
 Fixation disparity

TESTS EVALUATING THE OCULAR MOTOR SYSTEM

 Fixation status
 Subjective assessment of saccades using grading scales
 Developmental eye movement (DEM) test
 Visagraph
 Subjective assessment of pursuits using grading scales

MOTOR ALIGNMENT AND INTERACTION TESTS

 Cover test at distance
 Cover test at near
 Phoria at distance
 Phoria at near
 Fixation disparity
 AC/A ratio
 CA/C ratio

Classification System of Common Accommodative and Nonstrabismic

Binocular Vision Problems
Once the test findings are grouped and a trend is identified, the specific
syndrome can be selected from the list of the 15 common accommodative,
ocular motility, and binocular vision problems. This classification is a
modification of the well-known Duane-White classification suggested by Wick.

BINOCULAR ANOMALIES

Heterophoria with Low AC/A Ratio

 Orthophoria at distance and exophoria at near—convergence insufficiency
 Exophoria at distance, greater exophoria at near—convergence insufficiency
 Esophoria at distance, orthophoria at near—divergence insufficiency
 Heterophoria with Normal AC/A Ratio
 Orthophoria at distance, orthophoria at near—fusional vergence
dysfunction
 Esophoria at distance, same degree of esophoria at near—basic esophoria
 Exophoria at distance, same degree of exophoria at near—basic exophoria

Heterophoria with High AC/A Ratio

 Orthophoria at distance and esophoria at near—convergence excess
 Esophoria at distance, greater esophoria at near—convergence excess
 Exophoria at distance, less exophoria at near—divergence excess

Vertical Heterophoria
 Right or left hyperphoria

Accommodative Anomalies
 Accommodative insufficiency
 Ill-sustained accommodation
 Accommodative excess
 Accommodative infacility

Ocular Motor Problems

 Ocular motor dysfunction

Analysis of Specific Groups

POSITIVE FUSIONAL VERGENCE GROUP DATA
Optometric data that can be used to determine the status of a patient’s PFV
are included in this category. These include all data that directly or indirectly
assess PFV at both distance and near.

Positive Fusional Vergence:

Smooth Vergence Testing

As base-out prism is added, the patient is instructed to keep the target single
and clear as long as possible and to report when the target blurs or becomes
double. This requires the patient to converge to maintain bifoveal fixation and
maintain accommodation at a given level (either distance or near). It is also
important to realize that as prism is added and the patient converges, the
accommodative response gradually increases because of increased vergence
accommodation. The amount of vergence accommodation stimulated depends
on the convergence accommodation to convergence (CA/C) ratio. The patient
must relax accommodation to counterbalance this increased vergence
accommodation. When the patient can no longer do this, a blur occurs. As
more base-out prism is added beyond the blur limit, diplopia occurs when
fusion is no longer possible.
An important aspect of this test is that the prism is added in a slow, gradual
manner. Because the technique requires the patient to maintain
accommodation at a given level, accommodative convergence cannot be used
to assist convergence. The patient must, therefore, use PFV. If the patient
attempts to use accommodative convergence, he or she will report a blur.

Positive Fusional Vergence: Step Vergence Testing

Step vergence testing is similar to the smooth vergence testing described
earlier, except that it is performed outside the phoropter with a prism bar.
Because a prism bar is used instead of Risley prisms, the actual prismatic
demand is presented in a steplike manner. This is in contrast to the smooth
demand introduced using Risley prism. Studies have determined that the
expected findings for this test are different from smooth fusional vergence
testing for children.

Positive Fusional Vergence: Vergence Facility Testing

The patient is instructed to keep a vertical line of 20/30 letters single and
clear as base-out prism is suddenly introduced (12 base-out and 3 base-in). To
accomplish this, the patient must maintain his or her accommodative level at
2.50 D, using 12 Δ of PFV to restore bifoveal fixation. Because of the lag of
accommodation, the actual accommodative response will generally be less
than 2.50 D. The usual accommodative response for a 2.50 D accommodative
stimulus is about 1.75 to 2.00 D. If sufficient fusional vergence is available, the
response will be a single clear image. A report of diplopia indicates that the
patient cannot restore binocularity using PFV. Another possible response is a
single but blurred target, suggesting the use of accommodative convergence to
compensate for the inability to use the fusional vergence mechanism to
restore bifoveal fixation.
The important differentiation between vergence facility testing and standard
testing of PFV is that prism is introduced in large increments and over a
longer period of time. A patient is forced to make rapid changes in fusional
vergence to sustain these changes over time. A patient having adequate
smooth fusional vergence ranges may experience difficulty on the vergence
facility test.
Negative Relative Accommodation
This test evaluates PFV in an indirect manner. The NRA is comparable to the
assessment of smooth fusional vergence ranges, because lenses are
introduced in a slow, gradual manner. However, with the NRA, the patient is
being asked to maintain convergence at a particular level while changing the
accommodative response. As plus lenses are added in +0.25 D increments, the
patient is instructed to keep the target single and clear. To accomplish this, he
or she must relax accommodation. However, any relaxation of accommodation
is accompanied by a decrease in accommodative convergence. The amount of
accommodative convergence change depends on the AC/A ratio.
If the patient allows his or her eyes to diverge as accommodation is relaxed,
he or she will report diplopia. To counteract this decrease in accommodative
convergence, the patient must use an appropriate amount of PFV. Thus, the
result obtained during the NRA test can depend on the status of the PFV
system. Of course, the endpoint in the NRA can also be limited by the patient’s
ability to relax accommodation as plus lenses are introduced.
To determine which factor—accommodation or PFV—is causing the blur, the
patient’s accommodative status can be tested monocularly. If he or she can
clear +2.50 monocularly but only +1.50 binocularly, PFV is the causative
factor. Another way to differentiate is simply to cover one eye after the patient
reports blur on the NRA test. If the target clears under monocular conditions,
the fusional vergence system is at fault.

Binocular Accommodative Facility with Plus Lenses

This test is similar to the NRA, because it requires maintenance of
convergence at a specific level while the accommodative response changes. As
+2.00 lenses are introduced binocularly, the patient is instructed to maintain
single and clear binocular vision. To accomplish this, the patient must relax
about 2.00 D of accommodation to keep the target clear (the actual
accommodative response will be about 10% less than the stimulus). The
relaxation of 2.00 D of accommodation, however, causes a reflex decrease in
accommodative convergence. The amount of divergence will be directly
related to the AC/A ratio. Assuming a 5:1 AC/A ratio, if the patient relaxes
2.00 D of accommodation, his or her eyes will tend to diverge by 10 Δ. If this
occurs, the patient will see two images.
Because the instructions require the patient to maintain single clear vision, he
or she must use 10 Δ of PFV to compensate for the decrease in
accommodative convergence. The endpoint of this test can be caused by one
of two factors. Either the patient has inadequate PFV or is unable to relax his
or her accommodative system (ACC). To differentiate, one simply needs to
cover one eye. If the print clears under monocular conditions, the limiting
factor is the fusional vergence system.

Near Point of Convergence

The patient is asked to maintain single vision as a target is moved toward his
or her nose. To accomplish this, the patient can use a combination of various
types of convergence, including accommodative convergence, PFV, and
proximal convergence. If PFV is deficient, it may affect the patient’s ability to
achieve the expected finding on this test. A receded near point of convergence
is, therefore, an indirect measure of PFV.

Monocular Estimation Method Retinoscopy and Fused Cross-cylinder

Both tests are performed under binocular conditions and are designed to
assess the accommodative response. The normal finding is approximately
+0.25 to +0.50 for MEM retinoscopy and +0.50 to +0.75 for the fused cross-
cylinder test. However, when a patient presents with exophoria and low PFV
group findings, the MEM and fused cross-cylinder tests often yield less plus
than expected.
Decreased plus on these tests is interpreted as overaccommodation for the
particular stimulus. This is a common response in a patient with exophoria
and reduced PFV. The individual is substituting accommodative convergence
for the lack of PFV. By overaccommodating, the patient has additional
accommodative convergence available to help overcome the exophoria.

SUMMARY
These seven tests constitute the PFV group. In the presence of exophoria and
symptoms, the data in the PFV group will generally be lower than expected,
and the MEM and the fused cross-cylinder tests will tend to show
overaccommodation (less plus than expected). All of the findings in this group
provide information about the patient’s PFV system and the ability to
compensate for exophoria. Occasionally only the facility findings will be low,
whereas the amplitude findings are normal. This would be the type of
situation missed with the graphical analysis approach.

NEGATIVE FUSIONAL VERGENCE GROUP DATA

This group includes optometric data that reflect the status of a patient’s NFV.
It includes tests that directly or indirectly assess NFV at both distance and
near.

Negative Fusional Vergence: Smooth Vergence Testing

As base-in prism is gradually added, the patient is instructed to keep the
target single and clear as long as possible and to report if the target blurs or
becomes double. The test requires the patient to diverge to maintain bifoveal
fixation and maintain accommodation at a given level. It is also important to
realize that as prism is added and the patient diverges, the accommodative
response gradually decreases as a result of decreased vergence
accommodation. The amount of decrease in vergence accommodation
depends on the CA/C ratio. The patient must stimulate accommodation to
counterbalance this decreased vergence accommodation. When the patient
can no longer do this, a blur occurs. By requiring clarity, we are forcing the
patient to use NFV to compensate for the base-in prism.
An important aspect of this test is that the prism is added in a slow, gradual
manner.

Negative Fusional Vergence: Step Vergence Testing

Although the introduction of the prism demand is different from smooth
vergence testing, the instructional set and the explanation of the requirements
of the test are similar to that described for smooth vergence testing.

Negative Fusional Vergence: Vergence Facility Testing

The patient is instructed to keep a vertical line of 20/30
letters single and clear as 12 Δ base-out and 3 Δ base-in prism is abruptly
introduced. To accomplish this, the patient must maintain his or her
accommodative level at 2.50, while using 3 Δ of NFV to restore bifoveal
fixation. If sufficient fusional vergence is available, the response will be a
single clear image. A report of diplopia would indicate that the patient could
not restore binocularity using NFV. A report of a single blurred target
indicates the use of a decrease in accommodative convergence to aid the
fusional vergence mechanism.