Strabismus, 16:6569, 2008 Copyright c 2008 Informa Healthcare USA, Inc.

ISSN: 0927-3972 print / 1744-5132 online DOI: 10.1080/09273970802039763

ORIGINAL PAPER

Accommodation Insufciency in Children: Are Exercises Better than Reading Glasses?

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Rune Brautaset, BSc (Optom), MPhil, PhD, Marika Wahlberg, BSc (Optom), Saber Abdi, BSc, MSc (Orthop), PhD, and Tony Pansell, BSc (Optom), PhD Unit of Optometry, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden

ABSTRACT Purpose: The aim of the present study was to investigate which mode of therapy, plus lens (+1.00D) reading addition (PLRA) or spherical ipper (1.50D), is the most effective in the treatment of accommodative insufciency (AI). Methods: Initially, 24 subjects (mean age 10.3 years, 2.5 SD) with AI were included in the study. Ten subjects completed 8 weeks of PRLA treatment whereas 9, out of 14, subjects completed 8 weeks of spherical ipper treatment. Results: There was a statistically signicant improvement in the accommodative amplitude with both regimes of treatment [F(1, 17) = 18.84, p = 0.0004). Spherical ipper treatment was found to have an overall larger effect on accommodative function as compared with PLRA treatment. However, accommodation did not reach normal values after only 8 weeks of treatment. Discussion: The results indicate that both methods improve the accommodative amplitude, but that overall accommodative function reaches higher levels of improvement with spherical ipper as compared with PLRA treatment. However, the accommodative function did not gain normal values in 8 weeks of treatment with either regime.
KEYWORDS Accommodative insufciency; treatment; asthenopia; children; spherical
ipper treatment; reading glasses

INTRODUCTION
The normal accommodative system is often described as exible and resistant to fatigue; despite this, accommodative dysfunction is a relatively common visual anomaly in children and young adults. The prevalence of accommodative dysfunction not associated with presbyopia probably affects at least 23% of the population (Rutstein & Daum, 1998). Accommodative dysfunction often results in symptoms such as blur, headaches and asthenopia; these symptoms generally occur in association with near visual work (Daum, 1983a; Daum, 1984). One of the most commonly seen accommodative dysfunctions is accommodative insufciency (AI). AI is a condition in which the amplitude of accommodation as measured with push-up accommodative stimuli is chronically below the lower limit of the expected amplitude for the patients age (Mein & Trimbel, 1994; Benjamin, 1998). AI subjects also demonstrate a reduced accommodation facility (Scheiman & Wick, 1994) and sometimes an increased lag
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Received 5 November 2007; Accepted 4 March 2008 Correspondence: Marika Wahlberg, Unit of Optometry, Department of Clinical Neuroscience, Karolinska Institute, Box 8056, S-104 20 Stockholm, Sweden. Fax: +468 672 38 46. E-mail: marika.wahlberg@ste.ki.se

of accommodation (Rutstein & Daum, 1998; Scheiman & Wick, 1994). Subjects with AI usually suffer from blur, headache and asthenopia associated with near work (Daum, 1983b; Chrousos et al., 1988). AI is one of the most frequently diagnosed binocular vision anomalies (Daum, 1983b; Rouse, 1987), and it has been reported to be the most common cause of asthenopia in schoolchildren between 8 and 15 years of age (Borsting et al., 2003). Vision therapy has for many years been an important mode of therapy for both children and adults who manifest a range of non-strabismic accommodative and vergence disorders (Abdi et al., 2006). The cure rates for accommodative disorders generally range from 80% to 100% (Daum, 1983b; AOA, 1998). Visual therapy involves purposeful and controlled manipulations of target blur, disparity and proximity, with the aim of normalizing the accommodative system, the vergence system, and mutual interactions (Grifn & Grisham, 1995; Rutstein & Daum, 1998). The two most important vision therapy regimes for AI are plus lens reading additions (PLRA) and orthoptic exercises such as spherical ippers (Daum, 1983b; Mazow et al., 1989; Rutstein & Daum, 1998), however, the two regimes of therapy are fundamentally different. PLRA is a relatively passive mode of therapy in which the accommodative system is given a helping hand in getting a clear retinal image. The amount of blur on the retina when wearing the PLRA is less than while not wearing the plus addition. The role of the PLRA is therefore to reduce blur to such an extent that the remaining blur is recognized and within the subjects accommodative capacity. The subjects task is to recognise the remaining image blur and to clear the image. However, by being able to clear the image, the blur-driven sensors and the adaptive mechanism within the accommodative system will start to regain normal capacity (Ciuffreda, 2002). With spherical ippers, the initial amount of blur is not reduced; however, a controlled amount of additional blur (with the negative side of the ipper) and a controlled amount of reduction in blur (with the positive side of the ipper) is induced each time the ipper is twisted between the negative lens side and the positive side. The subjects task is to recognise the change in defocus of the image and to try to respond by obtaining a clear image. By being able to recognise and respond to the blurred image, the blur-driven sensors and the adaptive mechanism within the accommodative system will start to regain normal capacity (Ciuffreda, 2002).
R. Brautaset et al.

From the literature, it is not clear whether PLRA or orthoptic exercises are equally effective or whether one method is more effective than the other. The aim of the present study was to clarify this issue.

MATERIALS AND METHODS

This study was partly blind. Subjects seen by the rst examiner (E1) who met the inclusion criteria were asked consecutively to participate in the study. If the subject met the inclusion criteria, the subject was seen by a second examiner (E2) who, without knowing the results of the inclusion examination, performed measurements of the study variables. The subject was then seen by a third examiner (E3) who, according to a randomization list and without knowing the results obtained by E1 and E2, assigned the subjects to either ipper or PLRA treatment. After eight weeks of treatment, all subjects were re-examined by the second examiner (E2), without the examiner knowing the kind of treatment that the subjects had received. If the subject, after eight weeks of treatment, still had AI, he/she was referred back to the rst examiner (E1) for further treatment and follow up. Initially, 24 subjects (mean age 10.3 years, 2.5 SD) with AI were included in the study. All subjects participated with their parents written consent and the study adhered to the declaration of Helsinki. In order to be included as an AI subject the following criteria had to be met (measurements were performed by E1 as part of the inclusion examination): (1) symptoms, according to the history, revealing uncomfortable vision, blur and/or headache; (2) refractive error less than 1.00D of hypermetropia and less than 0.50D of myopia, and/or astigmatism less than 0.50D measured in cycloplegia; (3) distance heterophoria between 2 of exophoria and 2 of esophoria and near (40 cm) heterophoria between 6 of exophoria and 4 of esophoria; (4) near point of convergence of 10 cm or better on the RAF (Royal Air Force) rule; (5) fusional reserve at least twice the near phoria; (6) near point of accommodation worse than (100/(15D-(0.4 age))) on the RAFrule; (7) distance Snellen visual acuity of 0.8 or better
This calculation of the minimum accommodative amplitude is based on Hofstetters (1944) comparison of Duanes and Donders table of the amplitude of accommodation. Hofstetter calculated that the minimum normal accommodative amplitude should be regarded as (100/(15D (0.25age))); this formula yields an accommodative amplitude in cm. In this study, we used the formula (100/(15 (0.4age))) in order not to include subjects with normal but low accommodative amplitude.

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both monocularly and binocularly; (8) normal ocular motility; (9) full stereo vision on the Lang II test; (10) no ocular pathology; (11) no history of ophthalmologic treatment; and (12) not taking any drugs with a known effect on visual acuity and/or binocular function and accommodation. After having been included, the subjects were seen by E2 for measurements of the study variables: (1) the near point of accommodation on the RAF-rule (three repeated measurements both monocularly and binocularly); (2) accommodative facility at 40 cm with a 2.00D ipper while xating a vertical row of letters equivalent to 6/9 visual acuity (measured binocularly and in the dominant eye; dominance was tested with the Miles test (Michaels, 1975)); (3) lead/lag of accommodation as measured with Nott dynamic retinoscopy while xating a vertical row of letters equivalent to 6/9 visual acuity at 40 cm; and (4) subjective grading of the degree of asthenopia on a Visual Analogue Scale (VAS). The question asked with the VAS was If 0 equals no problem when doing near work and 10 equals the worst degree of problems, what number would you grade your problems at near work to be now? These four measures were repeated after the 8 weeks treatment period. The treatment received was either ipper treatment with a 1.50D ipper or +1.00 plus lens reading addition (PLRA). The power of the ipper (1.50D) used for treatment and the power of the PLRA (+1.00D) were chosen based on previous experience (Abdi et al., 2006, 2007) with ipper and PLRA treatment in emmetropic children with AI. For the ipper treatment the subjects were instructed to do two sessions of nine minutes each day. The sessions were to be done at times when the subjects were not feeling tired or experiencing asthenopia. The ipper was to be done at 40 cm. The subjects did as many ips as possible for one minute. This was followed by another one-minute trial of ipping and a one-minute break. This sequence was repeated until

the subject had done a total of ve minutes of ipping. Each subject was also given a xation target (vertical row of letters equivalent to 6/9 visual acuity at 40 cm). For the PLRA treatment the subjects were encouraged to use the glasses as much as possible for all types of near visual work. Initially, 10 subjects (average age 10.3 years 2.74) were given plus lens addition treatment and 14 were given ipper lens treatment (average age 10.3 years 2.41). After the treatment period, 19 subjects showed up for re-examination. All ve dropouts were from the group treated with ipper.

Statistical Methods
The effect of treatment (before vs. after), the type of therapy regime (ipper vs. PLRA) and the interaction effect between them were analysed using multivariate analysis of variance. The data were further analysed by Bonferroni post-hoc analysis and by planned comparison. A Wilcoxon matched pair test was used for analysis of the VAS score and the within-group results in Table 1. A signicance level of 0.05 was considered signicant. Dropouts have not been included in the analysis.

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RESULTS Accommodative Amplitude and Accommodative Facility

The analysis of accommodative function showed a signicant interaction between the study variables and the treatment [F(2,34) = 6.97, p = 0.003]. The post hoc analysis showed a signicant change in accommodative amplitude [F(1,17) = 18.84, p < 0.001]. The improvement was 1.6D in the PLRA group and 3.6D in the ipper group. Accommodative facility increased by 1.25 cpm on average for the PLRA group and by 1.51 cpm in the ipper group, which was close to

TABLE 1 Average values (SD) of the study variables before and after treatment. [Acc amp, accommodative amplitude with the RAF-rule;
Acc fac, accommodative facility with a 2.00 ipper; Lag, lag of accommodation; VAS, Visual Analogue Scale results]

PLRA (n = 10) Variables Acc amp (DS) Acc fac (cpm) Lag (D) VAS
=

Flipper (n = 9) Diff 1.58 1.25 0.04 4.7 Before 4.25 1.83 4.66 2.42 0.32 0.44 8.11 0.78 After 7.82 4.51 6.17 3.54 0.34 0.51 1.77 1.30 Diff 3.57 1.51 0.02 6.34

Before 3.58 0.81 5.55 3.22 0.34 0.33 7.3 0.95

After 5.16 2.15 6.80 2.42 0.30 0.41 2.6 0.52

Wilcoxon matched pair test = p 0.05; = p 0.01.

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Accommodative Insufciency Treatment

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FIGURE 1 Slope of the improvement in accommodative amplitude before and after treatment in the two treatment groups. Effect of the treatment for both regimes. Current effect: F(2, 34) = 1.1763, p = 0.32064.

signicant [F(1,17) = 3.96, p = 0.06]. The accommodative response did not change [F(1,17) = 0.006, p = 0.937]. For details, see Table 1 and Figure 1.

Flipper vs. PLRA

The analysis did not reveal any statistically signicant difference between the two therapy regimes [F(1,17) = 0.31, p = 0.58]. With the accommodative response excluded, the difference was still not signicant [F(1,17) = 2.06, p = 0.17].

VAS
Both the ipper group and the PLRA group experienced a reduced level of asthenopic symptoms after treatment as indicated by the reduced VAS score. The average VAS score for the PLRA group was 4.7 units lower after treatment [Z(n = 10) = 2.80; p = 0.005] and for the ipper group was 6.3 units lower after treatment [Z(n = 9) = 2.66; p = 0.008]. For details, see Table 1.

DISCUSSION
Visual therapy in accommodative insufciency involves purposeful and controlled manipulations of target blur, disparity and proximity with the aim of normalizing the accommodative system (Grifn & Grisham, 1995; Rutstein & Daum, 1998). The two most commonly used regimes of therapy for AI are fundamentally different, in that PLRA is a much more passive type
R. Brautaset et al.

of treatment as compared with ipper treatment. However, in both regimes, the aim is to improve the response of the blur-driven sensors and the adaptive mechanisms within the accommodative system so that they can regain normal capacity (Ciuffreda, 2002). The purpose of the present study was to evaluate which mode of therapy, PLRA or spherical ipper, is more effective in the treatment of accommodative insufciency. Expected values for accommodative amplitude in the age range tested in this study are between 14.0 and 16.5D (Rutstein & Daum, 1998). The results of the present study show that both methods improve accommodative amplitude. The improvement with PLRA was from 3.58D to 4.25D. This is less than the improvement found by Abdi et al. (2007) over a 12-week treatment period with the same +1.00D reading addition and less than that found by Daum (1983b). However, in the results reported by Daum (1983b), the subjects were seen more frequently by the examiner, which is likely to improve compliance. With the ipper treatment, accommodative amplitude improved from 5.16D to 7.82D. Again, this improvement is less than that reported by Daum (1983a); however, the subjects in Daums study were seen more frequently and did a total of at least 30 minutes of treatment each day. On the other hand, the results of the present study are similar to those reported by Sterner et al. (2001). In that study, the amount of treatment and the treatment time were comparable to the treatment regime used in this study.
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The expected binocular values for accommodative facility are between 6 and 10 cpm (Rutstein & Daum, 1998). Before treatment, all subjects performed worse on accommodative facility. After treatment, all subjects reached values just within the normal range, irrespective of the treatment regime. Despite this, the improvement was small and not statistically signicant (p = 0.06). VAS scores used to grade ocular pain or discomfort in children without any ocular pathology have shown that a grading of 2 or less can be regarded as normal (Abdi et al., 2006). Before treatment, all subjects included had a grading of much more than 2 (7.3 and 8.1 on average in the PLRA and ipper groups, respectively). The reduction in VAS score was signicant in both groups, but only in the ipper group was an average VAS score below 2 achieved. We therefore believe that treatment of AI, with a treatment regime like the one used in the present study, should be continued much longer than 8 weeks. The higher level of improvement in accommodative amplitude and the lower VAS score after treatment in the ipper treatment group indicates that the treatment time needed will be shorter with this type of treatment as compared with PLRA. On the other hand, the fact that dropout only occurred in the ipper treatment group indicates that it may be more difcult to motivate subjects to do orthoptic exercises as compared to wearing reading glasses.

REFERENCES
Abdi S, Brautaset R, Rydberg A, Pansell T. The inuence of accommodative insufciency on reading. Clin Exp Optom. 2007;90:36 43.

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