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Diagnostic Validity of Accommodative Tests for Screening Suspected Accommodative Excess in Adolescents
Esther Mármol-Errasti1,2, José Miguel Cárdenas-Rebollo3, Antonio Rodán3,4
1Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Boadilla del Monte, Spain. emarmol@ceu.es.
Purpose:
Accommodative excess (AE) is characterised by an excessive accommodative response (lead) and impaired ability to relax accommodation, typically accompanied by asthenopic symptoms and reduced visual comfort during near tasks. Although AE is frequently observed in clinical practice, its definition and diagnostic criteria remain inconsistent, and the diagnostic performance of commonly used clinical tests is not well established. This study examined the diagnostic validity of tests evaluating the accommodative response and relaxation to detect suspected AE in a non-clinical adolescent population, using monocular accommodative facility (MAF) as the reference clinical sign.
Methods:
In this prospective observational study, 159 participants aged 13-14 years underwent comprehensive vision examinations including anamnesis, refraction, binocular vision assessment and measurement of accommodative variables (negative relative accommodation (NRA), fused cross cylinder (FCC), binocular accommodative facility (BAF) and monocular estimate method retinoscopy (MEM)). After exclusions, 142 participants were analysed. MAF served as the reference clinical sign. For each test, diagnostic ability (area under the receiver operating characteristic (ROC) curve), sensitivity, specificity and likelihood ratios were calculated.
Results:
Areas under the ROC curve were: BAF = 0.97, FCC = 0.79, MEM = 0.62, NRA = 0.62. Sensitivity and specificity were high for BAF (0.88, 0.97), very good and good for FCC (0.90, 0.79), very low and very high for MEM (0.22, 0.96) and low and very high for NRA (0.32, 0.97). Positive and negative likelihood ratios were: BAF = 29.33/0.12, FCC = 4.28/0.12, MEM = 5.5/0.81, NRA = 5.33/0.72.
Conclusions:
BAF and FCC show the highest sensitivity for identifying suspected AE in school-aged populations. MEM retinoscopy and NRA exhibited low sensitivity relative to the reference clinical sign and may fail to detect AE when included as required signs in multimodal diagnostic protocols. Their results should therefore be interpreted cautiously and alongside more sensitive accommodative tests and clinical symptoms.
