Accommodation and intraocular pressure

The relationship between accommodation and intraocular pressure (lOP) has not been addressed as a research question for over 20 years, when measurement of both of these parameters was less advanced than today. Hence the central aim of this thesis was to evaluate the effects of accommodation on lOP. The instrument of choice throughout this thesis was the Pulsair EasyEye non-contact tonometer (NCT) due principally to its slim-line design which allowed the measurement of lOP in one eye and simultaneous stimulation of accommodation in the other eye. A second reason for using the Pulsair EasyEye NCT was that through collaboration with the manufacturers (Keeler, UK) the instrument's operational technology was made accessible. Hence, the principle components underpinning non-contact lOP measures of 0.1mmHg resolution (an order of magnitude greater than other methods) were made available. The relationship between the pressure-output and corneal response has been termed the pressure-response relationship, aspects of which have been shown to be related to ocular biometric parameters. Further, analysis of the components of the pressure-response relationship together with high-speed photography of the cornea during tonometry has enhanced our understanding of the derivation of an lOP measure with the Pulsair EasyEye NCT. The NCT samples the corneal response to the pressure pulse over a 19 ms cycle photoelectronically, but computes the subject's lOP using the data collected in the first 2.34 ms. The relatively instantaneous nature of the lOP measurement renders the measures susceptible to variations in the steady-state lOP caused by the respiratory and cardiac cycles. As such, the variance associated with these cycles was minimised by synchronising the lOP measures with the cardiac trace and maintaining a constant pace respiratory cycle at 15 breathes/minute. It is apparent that synchronising the lOP measures with the peak, middle or trough of the cardiac trace significantly reduced the spread of consecutive measures. Of the 3 locations investigated, synchronisation with the middle location demonstrated the least variance (coeflicient of variation = 9.1%) and a strong correlation (r = 0.90, p = <0.001) with lOP values obtained with Goldmann contact tonometry (n = 50). Accordingly lOP measures synchronised with the middle location of the cardiac cycle were taken in the RE while the LE fixated low (L; zero D), intermediate (I; 1.50 D) and high (H; 4 D) accommodation targets, Quasi-continuous measures of accommodation responses were obtained during the lOP measurement period using the portable infrared Grand Seiko FR-5000 autorefractor. The lOP reduced between L and I accommodative levels by approximately 0.61 mmHg (p <0.00 I). No significant reduction in IOP between L and H accommodation levels was elicited (p = 0.65) (n = 40). The relationship between accommodation and lOP was characterised by substantial inter-subject variations. Myopes demonstrated a tendency to show a reduction in IOP with accommodation which was significant only with I accommodation levels when measured with the NCT (r = 0.50, p = 0.01). However, the relationship between myopia and lOP change with accommodation reached significance for both I (r = 0.61, p= 0.003) and H (r = 0.531, p= 0.0 1) accommodation levels when measured with the Ocular blood Flow Analyser (OBFA). Investigation of the effects of accommodation on the parameters measured by the OBFA demonstrated that with H accommodation levels the pulse amplitude (PA) and pulse rate (PR) responses differed between myopes and emmetropes (PA: p = 0.03; PR: p = 0.004). As thc axial length increased there was a tendency for the pulsatile ocular blood flow (POBF) to reduce with accommodation, which was significant only with H accommodation levels (r = 0.38, p = 0.02). It is proposed that emmetropes arc able to regulate the POBF responses to changes in ocular perfusion pressure caused by changes in lOP with I (r = 0.77, p <0.001) and H (r = 0.73, p = 0.001) accommodation levels. However, thc relationship between lOP and POBF changes in the myopes was not correlated for both I (r = 0.33, p = 0.20) and H (r = 0.05, p = 0.85) accommodation levels. The thesis presents new data on the relationships between accommodation, lOP and parameters of the OBFA,: and provides evidence for possible lOP and choroidal blood flow regulatory mechanisms. Further the data highlight possible deficits in the vascular regulation of the myopic eye during accommodation, which may play a putative role in the aetiology of myopia development.

Modelling the human accommodation system using finite element analysis

The human accommodation system has been extensively examined for over a century, with a particular focus on trying to understand the mechanisms that lead to the loss of accommodative ability with age (Presbyopia). The accommodative process, along with the potential causes of presbyopia, are disputed; hindering efforts to develop methods of restoring accommodation in the presbyopic eye. One method that can be used to provide insight into this complex area is Finite Element Analysis (FEA). The effectiveness of FEA in modelling the accommodative process has been illustrated by a number of accommodative FEA models developed to date. However, there have been limitations to these previous models; principally due to the variation in data on the geometry of the accommodative components, combined with sparse measurements of their material properties. Despite advances in available data, continued oversimplification has occurred in the modelling of the crystalline lens structure and the zonular fibres that surround the lens. A new accommodation model was proposed by the author that aims to eliminate these limitations. A novel representation of the zonular structure was developed, combined with updated lens and capsule modelling methods. The model has been designed to be adaptable so that a range of different age accommodation systems can be modelled, allowing the age related changes that occur to be simulated. The new modelling methods were validated by comparing the changes induced within the model to available in vivo data, leading to the definition of three different age models. These were used in an extended sensitivity study on age related changes, where individual parameters were altered to investigate their effect on the accommodative process. The material properties were found to have the largest impact on the decline in accommodative ability, in particular compared to changes in ciliary body movement or zonular structure. Novel data on the importance of the capsule stiffness and thickness was also established. The new model detailed within this thesis provides further insight into the accommodation mechanism, as well as a foundation for future, more detailed investigations into accommodation, presbyopia and accommodative restoration techniques.

Dynamic measurement of accommodation and pupil size using the portable Grand Seiko FR-5000 autorefractor

PURPOSE. The purpose of this study was to evaluate the potential of the portable Grand Seiko FR-5000 autorefractor to allow objective, continuous, open-field measurement of accommodation and pupil size for the investigation of the visual response to real-world environments and changes in the optical components of the eye. METHODS. The FR-5000 projects a pair of infrared horizontal and vertical lines on either side of fixation, analyzing the separation of the bars in the reflected image. The measurement bars were turned on permanently and the video output of the FR-5000 fed into a PC for real-time analysis. The calibration between infrared bar separation and the refractive error was assessed over a range of 10.0 D with a model eye. Tolerance to longitudinal instrument head shift was investigated over a ±15 mm range and to eye alignment away from the visual axis over eccentricities up to 25.0°. The minimum pupil size for measurement was determined with a model eye. RESULTS. The separation of the measurement bars changed linearly (r = 0.99), allowing continuous online analysis of the refractive state at 60 Hz temporal and approximately 0.01 D system resolution with pupils >2 mm. The pupil edge could be analyzed on the diagonal axes at the same rate with a system resolution of approximately 0.05 mm. The measurement of accommodation and pupil size were affected by eccentricity of viewing and instrument focusing inaccuracies. CONCLUSIONS. The small size of the instrument together with its resolution and temporal properties and ability to measure through a 2 mm pupil make it useful for the measurement of dynamic accommodation and pupil responses in confined environments, although good eye alignment is important. Copyright © 2006 American Academy of Optometry.

Simultaneous continuous recording of accommodation and pupil size using the modified Shin-Nippon SRW-5000 autorefractor

The internal optics of the recent models of the Shin-Nippon SRW-5000 autorefractor (also marketed as the Grand Seiko WV-500) have been modified by the manufacturer so that the infrared measurement ring has been replaced by pairs of horizontal and vertical infrared bars, on either side of fixation. The binocular, open field-of-view, allowing the accommodative state to be objectively monitored while a natural environment is viewed, has made the SRW-5000 a valuable tool in further understanding the nature of the oculomotor response. It is shown that the root-mean-square of model eye measures was least (0.017 ± 0.002D) when the separation of the horizontal measurement bars were averaged twice. The separation of the horizontal bars changes by 3.59 pixels/dioptre (r2 = 0.99), allowing continuous on-line analysis of the refractive state at up to 60 Hz temporal resolution to an accuracy of <0.001D, with pupils >3 mm. The pupil edge is not obscured in the diagonal axis by the measurement bars, unlike the ring of the original optics, so in the newer model pupil size can be measured simultaneously at the same rate with a resolution of <0.001 mm. The measurements of accommodation and pupil size are relatively unaffected by eccentricity of viewing up to ±10° from the visual axis and instrument focusing inaccuracies over a range of 10 mm towards the eye and 5 mm away from the eye. The resolution and temporal properties of the analysis are therefore ideal for the simultaneous measurement of dynamic accommodation and pupil responses. © 2004 The College of Optometrists.

Sympathetic control of accommodation:evidence for inter-subject variation

Autonomic innervation of ciliary smooth muscle is mediated principally by the parasympathetic nervous system and is supplemented by the sympathetic nervous system. Previous drug and nerve stimulation experiments on humans and animals have demonstrated that sympathetic innervation is inhibitory (via β-2 adrenoceptors), relatively small, slow and augmented by concurrent levels of background parasympathetic activity. These characteristics are pertinent to the sympathetic system having a specific role in our ability to adapt successfully to sustained near vision tasks and, given the clear association between near vision and the onset and development of myopia, to a putative aetiological role in myopia development in pre-disposed individuals. A fifth characteristic, namely the variation between individuals in access to an inhibitory sympathetic facility is therefore of particular interest. A novel method for continuous recording of accommodation, currently employed in a large sample longitudinal study of myopia in young adults, was used following topical instillation of non-selective (timolol) and selective (betaxolol) sympathetic β-adrenoceptor antagonists. Measures of post-task accommodative hysteresis were taken with reference to the time-course of regression of accommodation when open-loop (Difference of Gaussian) conditions were immediately imposed following short (10 s) and long (3 min) duration far (0D) and near (3D above tonic level) tasks viewed through a Badal system. Data confirm earlier informal experimental observations that only one in three individuals are likely to have access to a sympathetic inhibitory facility during sustained near vision. © 2002 The College of Optometrists.

Continuous recording of accommodation and pupil size using the Shin-Nippon SRW-5000 autorefractor

A newly released commercial autorefractor, the Shin-Nippon SRW-5000 (Japan), has been found to be valid compared to subjective refraction and repeatable over a wide prescription range. Its binocular open field-of-view allows the accommodative state to be monitored while a natural environment is viewed. In conventional static mode, the device can take up to 45 readings in 1min using digital image analysis of the reflected retinal image of a measurement ring. Continuous on-line analysis of the ring provides high (up to 60Hz) temporal resolution of the refractive state to an accuracy of <0.001D. Pupil size can also be analysed to a resolution of <0.001mm. The measurement of accommodation and pupil size was relatively unaffected by eccentricity of viewing up to ±10° and instrument focusing inaccuracies of ±5mm. The resolution properties of the analysis are shown to be ideal for measurement of dynamic accommodation and pupil responses. Copyright © 2001 The College of Optometrists.

Green@CU:an environmental game for residential accommodation

The importance of using games for supporting behavioural and attitudinal change has been explored in the literature, most recently the games for change movement has promulgated the use of games for supporting altruistic changes that have a positive impact upon the environment. This paper presents a Serious Game designed for University students and its main aim is to educate them about environmental issues. In particular, the focus lies in the importance of saving energy. A user study with 42 participants assessed the feeling of presence of the whole virtual learning experience.

Accommodation in young adults wearing multifocal soft contact lenses under long- and short- wavelength lighting

Purpose: Several studies have suggested accommodative lags may serve as a stimulus for myopic growth, and while a blurred foveal image is believed to the main stimulus for accommodation, spectral composition of the retinal image is also believed to influence accommodative accuracy. Of particular interest is how altering spectral lighting conditions influences accommodation in the presence of soft multifocal contact lenses, which are currently being used off-label for myopia control. Methods: Accommodative responses were assessed using a Grand Seiko WAM-5500 autorefractor for four target distances: 25, 33, 50, and 100cm for 30 young adult subjects (14 myopic, 16 emmetropic; mean refractive errors (±SD, D) -4.22±2.04 and -0.15±0.67 respectively). Measurements were obtained with four different soft contact lenses, Single vision distance (SVD), Single vision near (SVN), Centre-Near (CN) and Centre-Distance (CD) (+1.50 add), and three different lighting conditions: red (peak λ 632nm), blue (peak λ 460nm), and white (peak λ 560nm). Corrections for chromatic differences in refraction were made prior to calculating accommodative errors. Results: The size of accommodative errors was significantly affected by lens design (p<0.001), lighting (p=0.027), and target distance (p=0.009). Mean accommodative errors were significantly larger with the SV lenses compared to the CD and CN designs (p<0.001). Errors were also significantly larger under blue light compared to white (p=0.004) and a significant interaction noted between lens design and lighting (p<0.001). Blue light generally decreased accommodative lags and increased accommodative leads relative to white and red light, the opposite was true of red light (p≤0.001). Lens design also significantly influenced direction of accommodative error (i.e. lag or lead) (p<0.001). Interactions with or between refractive groups were not found to be statistically significant for either the magnitude or direction of accommodative error (p>0.05 for all). Conclusions: Accuracy of accommodation is affected by both lens design and by wavelength of lighting. These accommodative lag data lend some support to recent speculation about the potential therapeutic value of lighting with a spectral bias towards blue during near work for myopia, although such treatment effects are likely to be more subtle under broad compared to the narrow spectrum lighting conditions used here.

The relationship between CA/C ratio and individual differences in dynamic accommodative responses while viewing stereoscopic images

The oculomotor synergy as expressed by the CA/C and AC/A ratios was investigated to examine its influence on our previous observation that whereas convergence responses to stereoscopic images are generally stable, some individuals exhibit significant accommodative overshoot. Using a modified video refraction unit while viewing a stereoscopic LCD, accommodative and convergence responses to balanced and unbalanced vergence and focal stimuli (BVFS and UBVFS) were measured. Accommodative overshoot of at least 0.3 D was found in 3 out of 8 subjects for UBVFS. The accommodative response differential (RD) was taken to be the difference between the initial response and the subsequent mean static steady-state response. Without overshoot, RD was quantified by finding the initial response component. A mean RD of 0.11 +/- 0.27 D was found for the 1.0 D step UBVFS condition. The mean RD for the BVFS was 0.00 +/- 0.17 D. There was a significant positive correlation between CA/C ratio and RD (r = +0.75, n = 8, p <0.05) for only UBVFS. We propose that inter-subject variation in RD is influenced by the CA/C ratio as follows: an initial convergence response, induced by disparity of the image, generates convergence-driven accommodation commensurate with the CA/C ratio; the associated transient defocus subsequently decays to a balanced position between defocus-induced and convergence-induced accommodations.

A method for profiling biometric changes during disaccommodation

PURPOSE: To demonstrate the application of low-coherence reflectometry to the study of biometric changes during disaccommodation responses in human eyes after cessation of a near task and to evaluate the effect of contact lenses on low-coherence reflectometry biometric measurements. METHODS: Ocular biometric parameters of crystalline lens thickness (LT) and anterior chamber depth (ACD) were measured with the LenStar device during and immediately after a 5 D accommodative task in 10 participants. In a separate trial, accommodation responses were recorded with a Shin-Nippon WAM-5500 optometer in a subset of two participants. Biometric data were interleaved to form a profile of post-task anterior segment changes. In a further experiment, the effect of soft contact lenses on LenStar measurements was evaluated in 15 participants. RESULTS: In 10 adult participants, increased LT and reduced ACD was seen during the 5 D task. Post-task, during fixation of a 0 D target, a profile of the change in LT and ACD against time was observed. In the two participants with accommodation data (one a sufferer of nearwork-induced transient myopia and other a non-sufferer), the post-task changes in refraction compared favorably with the interleaved LenStar biometry data. The insertion of soft contact lenses did not have a significant effect on LenStar measures of ACD or LT (mean change: -0.007 mm, p = 0.265 and + 0.001 mm, p = 0.875, respectively). CONCLUSIONS: With the addition of a relatively simple stimulus modification, the LenStar instrument can be used to produce a profile of post-task changes in LT and ACD. The spatial and temporal resolution of the system is sufficient for the investigation of nearwork-induced transient myopia from a biometric viewpoint. LenStar measurements of ACD and LT remain valid after the fitting of soft contact lenses.

The effect of ageing on in vivo human ciliary muscle morphology and contractility

Purpose. To assess the effect of ageing on in vivo human ciliary muscle morphology and contractility during accommodation. Methods. Seventy-nine subjects, aged 19–70 years were recruited. High-resolution images were acquired of nasal and temporal ciliary muscle in the relaxed state, and at stimulus vergence levels of -4 and -8 D, using anterior segment optical coherence tomography (AS-OCT). Objective refractions and axial lengths were also recorded. Linear regression analysis was performed to determine the effect of age on nasal and temporal ciliary muscle morphologic characteristics. Results. Ciliary muscle anterior length decreased significantly with age both nasally (R = 0.461, P = 0.001) and temporally (R = 0.619, P < 0.001) in emmetropic eyes. In a subset of 37 participants, ciliary muscle maximum width increased significantly with age, by 2.8 µm/year nasally (R = 0.54, P < 0.001) and 3.0 µm/year temporally (R = 0.44, P = 0.007), while the distance from the inner apex of the ciliary muscle to the scleral spur decreased significantly with age on both the nasal and temporal aspects (R = 0.47; P = 0.004 and R = 0.43; P = 0.009, respectively). During accommodation, changes to ciliary muscle thickness and length remained constant throughout life. Conclusions. The human ciliary muscle undergoes age-dependent changes in morphology that suggest an antero-inwards displacement of muscle mass, particularly in emmetropic eyes. However, the morphologic changes observed appear not to affect the ability of the muscle to contract during accommodation, even in established presbyopes, thus supporting a lenticular model of presbyopia development.

Accommodating intraocular lenses:a review of design concepts, usage and assessment methods

The correction of presbyopia and restoration of true accommodative function to the ageing eye is the focus of much ongoing research and clinical work. A range of accommodating intraocular lenses (AIOLs) implanted during cataract surgery has been developed and they are designed to change either their position or shape in response to ciliary muscle contraction to generate an increase in dioptric power. Two main design concepts exist. First, axial shift concepts rely on anterior axial movement of one or two optics creating accommodative ability. Second, curvature change designs are designed to provide significant amplitudes of accommodation with little physical displacement. Single-optic devices have been used most widely, although the true accommodative ability provided by forward shift of the optic appears limited and recent findings indicate that alternative factors such as flexing of the optic to alter ocular aberrations may be responsible for the enhanced near vision reported in published studies. Techniques for analysing the performance of AIOLs have not been standardised and clinical studies have reported findings using a wide range of both subjective and objective methods, making it difficult to gauge the success of these implants. There is a need for longitudinal studies using objective methods to assess long-term performance of AIOLs and to determine if true accommodation is restored by the designs available. While dual-optic and curvature change IOLs are designed to provide greater amplitudes of accommodation than is possible with single-optic devices, several of these implants are in the early stages of development and require significant further work before human use is possible. A number of challenges remain and must be addressed before the ultimate goal of restoring youthful levels of accommodation to the presbyopic eye can be achieved.

Knowledge management applied to enterprise risk management

Risk and knowledge are two concepts and components of business management which have so far been studied almost independently. This is especially true where risk management (RM) is conceived mainly in financial terms, as for example, in the financial institutions sector. Financial institutions are affected by internal and external changes with the consequent accommodation to new business models, new regulations and new global competition that includes new big players. These changes induce financial institutions to develop different methodologies for managing risk, such as the enterprise risk management (ERM) approach, in order to adopt a holistic view of risk management and, consequently, to deal with different types of risk, levels of risk appetite, and policies in risk management. However, the methodologies for analysing risk do not explicitly include knowledge management (KM). This research examines the potential relationships between KM and two RM concepts: perceived quality of risk control and perceived value of ERM. To fulfill the objective of identifying how KM concepts can have a positive influence on some RM concepts, a literature review of KM and its processes and RM and its processes was performed. From this literature review eight hypotheses were analysed using a classification into people, process and technology variables. The data for this research was gathered from a survey applied to risk management employees in financial institutions and 121 answers were analysed. The analysis of the data was based on multivariate techniques, more specifically stepwise regression analysis. The results showed that the perceived quality of risk control is significantly associated with the variables: perceived quality of risk knowledge sharing, perceived quality of communication among people, web channel functionality, and risk management information system functionality. However, the relationships of the KM variables to the perceived value of ERM are not identified because of the low performance of the models describing these relationships. The analysis reveals important insights into the potential KM support to RM such as: the better adoption of KM people and technology actions, the better the perceived quality of risk control. Equally, the results suggest that the quality of risk control and the benefits of ERM follow different patterns given that there is no correlation between both concepts and the distinct influence of the KM variables in each concept. The ERM scenario is different from that of risk control because ERM, as an answer to RM failures and adaptation to new regulation in financial institutions, has led organizations to adopt new processes, technologies, and governance models. Thus, the search for factors influencing the perceived value of ERM implementation needs additional analysis because what is improved in RM processes individually is not having the same effect on the perceived value of ERM. Based on these model results and the literature review the basis of the ERKMAS (Enterprise Risk Knowledge Management System) is presented.

Dynamic measurement of accommodative responses while viewing stereoscopic images

Using video refraction accommodative and convergence dynamic responses were measured to stepped changes in convergence stimuli with unchanged accommodative stimuli (conflicting stereoscopic image) and compared with responses to non-conflicting target stimuli. Three targets were used that varied in their spatial frequency components. An accommodative transient overshoot was evident in four out of seven subjects for only conflicting stimuli. One showed accommodative and convergence oscillation probably due to difficulty in fusing the stereoscopic target when it had a higher spatial component, however, this oscillation diminished when the target was spatial low-pass filtered. We hypothesise that transient responses to step stimuli is initiated by convergence-driven accommodation and subsequently followed by slower fine-control of accommodation modulated by the amount of blur. Inter-subject differences in convergence-driven accommodation may also be a factor to consider. For stereoscopic stimuli, it is proposed that the increase in blur immediately after the onset of the accommodative response inhibits cessation of the response.

Accommodative amplitude required for sustained near work

Purpose: Many practitioners base the prescription of near vision additions on the assertion that only one half or two-thirds of an individual’s amplitude of accommodation is sustainable for a prolonged period. To better understand how much eye focus needs to be restored for presbyopic corrections to be adequate, this study investigated the robustness of the pre-presbyopic human accommodative system during a sustained and intensive near vision task. Methods: Twenty-one pre-presbyopic volunteers (aged 26.1 ± 4.7 years) participated in the study. Binocular subjective amplitude of accommodation was measured before and after a prolonged reading exercise, using the RAF rule. During the 30 min reading task, the subject’s closest comfortable eye-to-text distance and pupil size was monitored. Accommodative accuracy to 0.2, 1.0, 2.0, 3.0 and 4.0 D stimuli was determined objectively using a validated binocular open-view autorefractor immediately before, and after the reading task. Results: Amplitude of accommodation (p = 0.09) and accommodative accuracy (p > 0.05) were statistically unchanged following the intensive near task. The mean proportion of accommodation exerted throughout the near exercise was 80.6% (range 45.3 ± 3.7 to 96.6 ± 4.3%), which increased as the task progressed (F = 2.24, p = 0.02). The mean percentage of accommodation utilised increased with subject age (r = 0.517, p = 0.016). Conclusion: The pre-presbyopic human accommodative system is robust to fatigue during intense and prolonged near work. A greater proportion of one’s amplitude of accommodation may be continuously exerted than previously suggested.