Decreased accommodation during decompensation of distance exotropia

Objective. Disparity cues can be a major drive to accommodation via the CA/C (convergence accommodation to convergence) linkage but, on decompensation of exotropia, disparity cues are extinguished by suppression, so this drive is lost. This study investigated accommodation and vergence responses to disparity, blur and proximal cues in a group of distance exotropes aged between 4-11 years both during decompensation and when exotropic. Methods. 19 participants with distance exotropia were tested using a PlusoptiXSO4 photorefractor set in a remote haploscopic device which assessed simultaneous vergence and accommodation to a range of targets incorporating different combinations of blur, disparity and proximal cues at four fixation distances between 2m and 33cm. Responses on decompensation were compared to those from the same children when their deviation was controlled. Results. Manifest exotropia was more common in the more impoverished cue conditions. When decompensated for near, mean accommodation gain for the all-cue (naturalistic) target reduced significantly (p<0.0001), with resultant mean under-accommodation of 2.33D at 33cm. The profile of near cues usage changed after decompensation, with blur and proximity driving residual responses, but these remaining cues did not compensate for loss of accommodation caused by the removal of disparity. Conclusions. Accommodation often reduces on decompensation of distance exotropia as the drive from convergence is extinguished, providing a further reason to try to prevent decompensation for near.

Evidence that convergence rather than accommodation controls intermittent distance exotropia

Purpose. This study considered whether vergence drives accommodation or accommodation drives vergence during the control of distance exotropia for near fixation. High accommodative convergence to accommodation (AC/A) ratios are often used to explain this control, but the role of convergence to drive accommodation (the CA/C relationship) is rarely considered. Atypical CA/C characteristics could equally, or better, explain common clinical findings. Methods. 19 distance exotropes, aged 4-11 years, were compared while controlling their deviation with 27 non-exotropic controls aged 5-9 years. Simultaneous vergence and accommodation responses were measured to a range of targets incorporating different combinations of blur, disparity and looming cues at four fixation distances between 2m and 33cm. Stimulus and response AC/A and CA/C ratios were calculated. Results. Accommodation responses for near targets (p=0.017) response gains (p=0.026) were greater in the exotropes than the controls. Despite higher clinical stimulus AC/A ratios, the distance exotropes showed lower laboratory response AC/A ratios (p=0.02), but significantly higher CA/C ratios (p=0.02). All the exotropes, whether the angle changed most with lenses (“controlled by accommodation”) or on occlusion (“controlled by fusion”), used binocular disparity not blur as their main cue to target distance. Conclusions. Increased vergence demand to control intermittent distance exotropia for near also drives significantly more accommodation. Minus lens therapy is more likely to act by correcting over-accommodation driven by controlling convergence, rather than by inducing blur-driven vergence. The use of convergence as a major drive to accommodation explains many clinical characteristics of distance exotropia, including apparently high near stimulus AC/A ratios.

The use of cues to convergence and accommodation in naive, uninstructed participants

A remote haploscopic video refractor was used to assess vergence and accommodation responses in a group of 32 emmetropic, orthophoric, symptom free, young adults naïve to vision experiments in a minimally instructed setting. Picture targets were presented at four positions between 2 m and 33 cm. Blur, disparity and looming cues were presented in combination or separately to asses their contributions to the total near response in a within-subjects design. Response gain for both vergence and accommodation reduced markedly whenever disparity was excluded, with much smaller effects when blur and proximity were excluded. Despite the clinical homogeneity of the participant group there were also some individual differences.

Accommodation and vergence response gains to different near cues characterize specific esotropias

Aim. To describe preliminary findings of how the profile of the use of blur, disparity and proximal cues varies between non-strabismic groups and those with different types of esotropia. Design. Case control study Methodology. A remote haploscopic photorefractor measured simultaneous convergence and accommodation to a range of targets containing all combinations of binocular disparity, blur and proximal (looming) cues. 13 constant esotropes, 16 fully accommodative esotropes, and 8 convergence excess esotropes were compared with age and refractive error matched controls, and 27 young adult emmetropic controls. All wore full refractive correction if not emmetropic. Response AC/A and CA/C ratios were also assessed. Results. Cue use differed between the groups. Even esotropes with constant suppression and no binocular vision (BV) responded to disparity in cues. The constant esotropes with weak BV showed trends for more stable responses and better vergence and accommodation than those without any BV. The accommodative esotropes made less use of disparity cues to drive accommodation (p=0.04) and more use of blur to drive vergence (p=0.008) than controls. All esotropic groups failed to show the strong bias for better responses to disparity cues found in the controls, with convergence excess esotropes favoring blur cues. AC/A and CA/C ratios existed in an inverse relationship in the different groups. Accommodative lag of >1.0D at 33cm was common (46%) in the pooled esotropia groups compared with 11% in typical children (p=0.05). Conclusion. Esotropic children use near cues differently from matched non-esotropic children in ways characteristic to their deviations. Relatively higher weighting for blur cues was found in accommodative esotropia compared to matched controls.

Convergence accommodation trumps accommodative convergence

Purpose. This symposium contribution presents research that shows that disparity cues within a near stimulus drive not only vergence but also most of the accommodation. Be-cause blur is a weaker cue, accommodative convergence is therefore only of minor significance for most individuals. Methods. The Infant Vision Laboratory at the University of Reading uses a Power Ref II photorefractor to collect simultaneous accommodation and convergence data from participants fixating targets moving in depth. By manipulating target characteristics, we have been able to test how blur, disparity and proximal cues each contribute to driving responses. Results. Results from a series of studies over the past 12 years have contributed to a coherent body of evidence suggesting that disparity cues override blur and proximity cues in most individuals. Some strabismic patients do use blur as a more strongly weighted cue, and this strategy could contribute to their symptoms, clinical characteristics and response to treatment. Conclusion. Although convergence accommodation is extremely difficult to measure clinically, clinicians should be aware of its importance in binocular vision and strabismus. Although CA/C relationships typically seem more important than AC/A, bo th only partly explain the interplay between convergence and accommodation.

Change in convergence and accommodation after two weeks of eye exercises in typical young adults

Abstract: Introduction Although eye exercises appear to help heterophoria, convergence insufficiency and intermittent strabismus, true treatment effects can be confounded by placebo, practice and encouragement factors. This study assessed objective changes in vergence and accommodation responses in typical naïve young adults after two weeks of exercises compared to control conditions to assess the extent of treatment effects occur above other factors. Methods 156 asymptomatic young adults were randomly assigned to 6 exercise groups or 2 no-treatment groups. Treatment targeted i) accommodation, ii)vergence, iii) both, iv) convergence>accommodation, v)accommodation>convergence, or vi) a placebo. All were re-tested under identical conditions, except for the second control group who were additionally encouraged during testing. Objective accommodation and vergence were assessed to a range of targets moving in depth containing combinations of blur, disparity and proximity/looming cues. Results Response gain improved more for less naturalistic targets where more improvement was possible. Convergence exercises improved vergence for near across all targets (P=.035). Mean accommodation changed similarly,but non-significantly. No other treatment group differed significantly from the non-encouraged control group, while encouraging effort produced significantly increased vergence (P=.004) and accommodation (P=.005) gains in the other control group. Conclusions True treatment effects were small, only significantly better after vergence exercises to a non-accommodative target, and were rarely related to response they were designed to improve. Exercising accommodation without convergence made no difference to accommodation to cues containing detail. Additional effort improved objective responses the most, so should be controlled carefully in research, and considered when auditing treatment.

Disparity-driven vs blur-driven models of accommodation and convergence in binocular vision and intermittent strabismus

Background. Current models of concomitant, intermittent strabismus, heterophoria, convergence and accommodation anomalies are either theoretically complex or incomplete. We propose an alternative and more practical way to conceptualize clinical patterns. Methods. In each of three hypothetical scenarios (normal; high AC/A and low CA/C ratios; low AC/A and high CA/C ratios) there can be a disparity-biased or blur-biased “style”, despite identical ratios. We calculated a disparity bias index (DBI) to reflect these biases. We suggest how clinical patterns fit these scenarios and provide early objective data from small illustrative clinical groups. Results. Normal adults and children showed disparity bias (adult DBI 0.43 (95%CI 0.50-0.36), child DBI 0.20 (95%CI 0.31-0.07) (p=0.001). Accommodative esotropes showed less disparity-bias (DBI 0.03). In the high AC/A and low CA/C scenario, early presbyopes had mean DBI of 0.17 (95%CI 0.28-0.06), compared to DBI of -0.31 in convergence excess esotropes. In the low AC/A and high CA/C scenario near exotropes had mean DBI of 0.27, while we predict that non-strabismic, non-amblyopic hyperopes with good vision without spectacles will show lower DBIs. Disparity bias ranged between 1.25 and -1.67. Conclusions. Establishing disparity or blur bias, together with knowing whether convergence to target demand exceeds accommodation or vice versa explains clinical patterns more effectively than AC/A and CA/C ratios alone. Excessive bias or inflexibility in near-cue use increases risk of clinical problems. We suggest clinicians look carefully at details of accommodation and convergence changes induced by lenses, dissociation and prisms and use these to plan treatment in relation to the model.

Convergence and accommodation development is pre-programmed in premature infants

Purpose This study investigated whether vergence and accommodation development in pre-term infants is pre-programmed or is driven by experience. Methods 32 healthy infants, born at mean 34 weeks gestation (range 31.2-36 weeks) were compared with 45 healthy full-term infants (mean 40.0 weeks) over a 6 month period, starting at 4-6 weeks post-natally. Simultaneous accommodation and convergence to a detailed target were measured using a Plusoptix PowerRefII infra-red photorefractor as a target moved between 0.33m and 2m. Stimulus/response gains and responses at 0.33m and 2m were compared by both corrected (gestational) age and chronological (post-natal) age. Results When compared by their corrected age, pre-term and full-term infants showed few significant differences in vergence and accommodation responses after 6-7 weeks of age. However, when compared by chronological age, pre-term infants’ responses were more variable, with significantly reduced vergence gains, reduced vergence response at 0.33m, reduced accommodation gain, and increased accommodation at 2m, compared to full-term infants between 8-13 weeks after birth. Conclusions When matched by corrected age, vergence and accommodation in pre-term infants show few differences from full-term infants’ responses. Maturation appears pre-programmed and is not advanced by visual experience. Longer periods of immature visual responses might leave pre-term infants more at risk of development of oculomotor deficits such as strabismus.  

Convergence accommodation in orthoptic practice

Aims. Orthoptists are familiar with AC/A ratios and the concept that accommodation drives convergence, but the reverse relationship, that of the accommodation associated with convergence, is rarely considered. Methods. This article reviews published evidence from our laboratory which has investigated the drives to both vergence and accommodation. All studies involved a method by which accommodation and vergence were measured concurrently and objectively to a range of visual stimuli which manipulate blur, disparity and proximal/looming cues in different combinations. Results Results are summarised for both typical and atypical participants, and over development between birth and adulthood. Conclusions For the majority of typical children and adults, as well as patients with most heterophorias and intermittent exotropia, disparity is the main cue to both vergence and accommodation. Thus the convergence→accommodation relationship is more influential than that of accommodative vergence. Differences in “style” of near cue use may be a more useful way to think about responses to stimuli moving in depth, and their consequences for orthoptic patients, than either AC/A or CA/C ratios. The implications of a strong role for vergence accommodation in orthoptic practice are considered.

Defining the domain of corporate social responsibility (CSR) in tourism organisations : a preliminary view from stakeholders in Thailand's accommodation sector

This paper aims to define the domain of Corporate Social Responsibility (CSR) for hotel and accommodation organizations in Thailand. It seeks to integrate the diverse components of CSR as defined within the general business/management, tourism and stakeholder literatures. A review of existing literature, codes of practice and standards, identify three broad CSR components – economic issues, social/ethical issues and environmental – although each of the standards varied in terms of the definition and emphasis applied. The components were ‘aggregated’ within each of the broad management and tourism literature, these two sets of groupings were then aggregated into one overarching set of CSR issues. Semi-structured interviews were then undertaken with 38 key informants from hotel and resort businesses in Thailand to identify their views toward the applicability of these over-arching components to hotel and accommodation organisations.

The results of the aggregation of standards suggest that CRS approaches within general business tend to be more socially/ethically orientated whereas within the tourism area approaches tend to be more environmentally orientated. Key respondents’ views were generally consistent with the three broad issues of the integrated CSR domain, although some issues were identified as more salient to hotel and accommodation organisations than others. The paper suggests that there is a need to develop CSR measures and indicators applicable and reflective of the different environmental, legal, cultural and local setting.

Understanding cross-cultural negotiation : A model integrating affective events theory and communication accommodation theory

Business interactions are increasingly crossing boundaries. Boundary crossing is a process of joining or parting people. Negotiation is the media of this process. This paper is an attempt to bridge the boundaries of strategic business negotiation, communication and emotion in a cross-cultural context. In particular, we argue that miscommunications are ‘boundary crossing mishaps’. Such mishaps are affected by negotiators’ understanding of the respective cultures of the parties, negotiation skill, affective cultural background of the parties, cultural differences, emotional awareness and regulation, negative affect and discrepancy in convergence divergence between the interactants. When too many of these hassles or mishaps occur, negotiation breaks down. In this way, it is the accumulation of many little things, many little misunderstandings, that break negotiation.