Effect of heterophoria measurement technique on the clinical accommodative convergence to accommodation ratio

Measurement of the stimulus accommodative convergence to accommodation (AC/A) ratio is a standard procedure in clinical optometric practice. Typically, heterophoria is assessed at several accommodative stimulus levels, and the gradient of the vergence to accommodation function computed. A number of procedures are available for the subjective measurement of heterophoria, but it is unclear whether the use of different vergence measurement techniques will alter the obtained AC/A value. Accordingly, the current study compared AC/A ratios measured using 3 clinical subjective heterophoria tests, namely the von Graefe (VG), Maddox Rod (MR), and Modified Thorington (MT) procedures.

The AC/A ratio was measured in 60 visually normal subjects between 20 and 25 years of age using each of the 3 procedures listed above. The accommodative stimulus was varied by the introduction of +/-1.00 diopter (D) spherical lenses over the distance refractive correction while subjects viewed a target at a viewing distance of 40 cm. To examine the repeatability of each procedure, the AC/A ratio was measured on 2 separate occasions for each measurement technique, with the 2 sessions being separated by at least 24 hours.

Mean values of stimulus AC/A ratio measured using the VG, MR, and MT procedures were 3.47, 2.99, and 2.46Delta/D, respectively. These differences were significant (p=0.0001). In addition, the coefficient of repeatability for the 3 techniques was 2.22, 1.99, and 1.20 Delta/D, respectively.

Ratios obtained using the Modified Thorington technique with +/-1.00 D lenses showed the best repeatability, whereas the poorest repeatability was found with the von Graefe technique when only +1.00 D lenses were used to vary the accommodative stimulus. Accordingly, we recommend that that Modified Thorington procedure with +/-1.00 D lenses be used to quantify heterophoria during clinical measurement of the stimulus AC/A ratio.