Graefes Arch Clin Exp Ophthalmol (2011) 249:925935
DOI 10.1007/s00417-010-1570-z
PEDIATRICS
Contact lenses vs spectacles in myopes: is there any
difference in accommodative and binocular function?
Raimundo Jimnez & Loreto Martnez-Almeida &
Carlos Salas & Carolina Ortz
Received: 21 May 2010 / Revised: 18 October 2010 / Accepted: 3 November 2010 / Published online: 23 November 2010
# Springer-Verlag 2010
Abstract
Background Theoretically, the accommodative and ver-
gence demands are different between single-vision contact
lenses and spectacle lenses. The aim of the present study
was to determine whether these differences exist when
these two correction methods are used in clinical practice.
For this, different visual parameters that characterize the
accommodative (accommodation amplitude, accommoda-
tive facility, and accommodative response) and binocular
function (near and distance horizontal and vertical dissoci-
ated phorias, near and vertical associated phorias, near and
distance negative and positive fusional vergence, vergence
facility, near point of convergence, negative and positive
relative accommodation, stimulus AC:A ratio and stereoa-
cuity) were evaluated in a student population when their
myopia was corrected with either spectacles or soft contact
lenses (SCL).
Methods All parameters were measured on two separate
occasions in 30 myopic habitual contact lens and spectacle
wearers of mean age 192.4 years. Some parameters such
as accommodation amplitude, accommodative response,
and stimulus AC:A ratio were measured using two
measurement methods which are commonly used in clinical
practice. Three measurements were taken for each param-
eter and averaged. For the comparative statistical analysis,
we used the Students t-test (p value<0.05).
Results The following statistically significant differences
were found with the use of SCL in comparison to
spectacles: higher accommodative lags, higher negative
relative accommodation, more esophoric near horizontal
R. Jimnez (*) : L. Martnez-Almeida : C. Salas : C. Ortz
Departamento de ptica, Facultad de Ciencias, C/ Campus
Fuentenueva, Universidad de Granada,
18071, Granada, Spain
e-mail: raimundo@ugr.es
dissociated phoria, and lower negative fusional vergence in
near vision.
Conclusions The results found in this study show a definite
trend towards poorer accommodative and vergence function
with the use of contact lenses in comparison to glasses.
This downward trend, though not statistically significant in
accommodative function (lower PRA values and less lens
amplitude of accommodation) might suggest that temporal
insufficiency in the accommodation process could be
occurring while contact lenses are used, thereby possibly
creating a lag in accommodation to reduce associated
overconvergence. This would be manifested in more
esophoric values being found in the vergence function.
The higher accommodative lags found in this study with
SCL could indicate that prolonged use of SCL in near tasks
may provoke a continuous hyperopic retinal defocus, a risk
factor for the onset and progression of myopia, as indicated
in numerous studies.
Keywords Myopia . Contact lenses . Spectacles .
Accommodation . Convergence . Phoria
Introduction
Currently, many myopic subjects from the age of adoles-
cence choose to correct their myopia with soft contact
lenses (SCL) [14]. Contact lenses, if fitted correctly, often
provide cosmetic and optical advantages over spectacles.
However, there is no consensus in the literature consulted
as to whether their use leads to a greater or more rapid
progression of myopia. Some studies [57] have established
a greater progression in subjects who wear SCL than in
those who wear glasses, but other studies [810] have not
found faster myopic progression using SCL in comparison
926
to spectacles. A more recent work by Marsh-Tootle et al.
(2009) [11] has established that children switching from
glasses to SCL experienced a small statistically significant
but clinically inconsequential increase in myopia progression.
From theoretical optical calculations, we know that
accommodation and vergence demands vary for ametropes
depending on whether their refractive error is corrected
with single-vision contact lenses or spectacle lenses [12
14]. In fact, it is widely known that some myopes have
difficulty with near vision when they change from
spectacles to contact lenses [15, 16]. The general effect is
as if the near vision task was moved slightly closer to the
eye, since increased accommodation and greater conver-
gence effort are required when wearing contact lenses.
The search for a relationship between accommodative
amplitude and myopia has offered inconsistent results. The
amplitude of accommodation in myopes has been found to
be reduced [1719], increased [2022], or unaffected by the
refractive error [2326]. Allen and OLeary [27] suggested
that the two key accommodative functions that are related
to myopia progression are accommodative facility and lag
of accommodation. However, it is not clear, due to the
nature of the study design, whether the various accommo-
dation anomalies are independently linked to myopic
progression or whether they are causal. Accommodation
inaccuracy during prolonged near work may cause an
increase in the accommodative lag, and the resulting
hyperopic retinal defocus may then contribute to myopic
progression [2833]. Conversely, Mutti et al. [34] suggest
that accommodative lag is a result of the myopia rather than
a cause.
The ocular parameters normally used for characterizing the
accommodative and vergence system are: accommodation
amplitude, accommodative facility, accommodative response,
near and distance horizontal and vertical phorias, near and
distance negative and positive fusional vergence, vergence
facility, and near point of convergence (NPC). Other param-
eters, such as negative relative accommodation (NRA),
positive relative accommodation (PRA), binocular accommo-
dative facility, stimulus AC:A ratio, and stereoacuity, are used
to evaluate the interaction between the vergence and accom-
modative systems. Even though it is well-known that
accommodation and vergence demands depend on the type
of optical correction, only a few studies [13, 3537] examine
the clinical differences between these parameters in myopes
when contact lenses are used as opposed to spectacles. In
addition, all of these studies were carried out many years ago,
when the material, design, and technical characteristics of
SCL were different from those currently available.
The aim of the present study is to determine whether the
clinical measurements of these ocular parameters differ in
the same subjects when wearing either soft contact lens
(SCL) or spectacle corrections, and whether these values
Graefes Arch Clin Exp Ophthalmol (2011) 249:925935
correspond to those which would be predicted from optical
calculations. This clinical trial could also provide useful
information concerning the changes caused in accommoda-
tion and convergence when SCL are used, and whether
these changes could be significant factors in the onset or
progression of myopia, as suggested by Fulk et al. [7].
Material and methods
Study population
Data were recorded from 30 myopic subjects (they
indifferently used contact lenses and spectacles daily), all
optometry students at the University of Granada, Spain.
These included 13 males and 17 females, with a mean age
of 192.4 years. Inclusion criteria were: at least 0.50 D of
myopia in both principal meridians of both eyes, 0.75 D
and <2.00 D of astigmatism (to be able to correct the
astigmatism with disposable toric SCL), and a best-
corrected Snellen distance visual acuity6/6 in each eye.
Exclusion criteria were: anisometropia >2.00 D, stereoa-
cuity value>60 sec. of arc, accommodative and binocular
dysfunction defined according to the criteria of Scheiman
and Wick [38], and ocular pathology. The study was
explained to the subjects, and informed consent was
obtained in accordance with the Helsinki Declaration.
All subjects were examined by two optometrists expe-
rienced in clinical practice. Each subject received a full
optometric examination which included an objective re-
fraction in which the refractive error was measured with an
auto-kerato refractometer (Topcon RM-8000B: Topcon
Corporation, Tokyo, Japan), and three readings were taken
in each eye and averaged. In addition, a second objective
refraction was measured with non-cycloplegic retinoscopy
while the subject maintained a fixed gaze on a distant (6 m)
non-accommodative target; and finally each subject under-
went a full monocular and binocular subjective refraction,
using an endpoint criterion of maximum plus consistent
with best vision. The Topcon RM-8000B was also used to
measure central corneal curvature in the flattest and steepest
meridians, and three readings were taken of each eye and
averaged. Soft contact lenses were fitted, taking into
account the health of the eye, keratometric reading and
exact refraction compensated for vertex distance. Contact
lenses were spherical or toric disposable soft contact lenses
(HEMA and Ocufilcon D respectively, 55% water content)
supplied by Servilens Contact Lens Company. When the
myopia was combined with astigmatism<0.75 D, lenses
with appropriate spherical equivalent were selected. A
contact lens over refraction was performed, and the lens
fitting and follow-up care were given by the subjects own
vision-care providers.
Graefes Arch Clin Exp Ophthalmol (2011) 249:925935
For measurements made with a spectacle correction, each
subject wore the correction in a simple trial frame or
phoropter (vertex distance = 12 mm), adjusted for the
subjects interpupillary distance and pupil height to avoid
prismatic effects during distance and near visual examina-
tion. In the spectacles, the lenses were centred was realized
using plane lenses with cross hairs for both distance and near
vision. In the phoropter, we introduced the interpupillary
distance for far vision, measured with a digital interpupill-
ometer. We controlled near interpupillary distance with the
vergence levers.
Test procedures
The parameters measured in the study were: accommodation
amplitude, accommodative facility, accommodative response,
near and distance horizontal and vertical dissociated phorias,
near horizontal and vertical associated phorias (aligning
prism), near and distance negative and positive fusional
vergence, vergence facility, near point of convergence
(NPC), negative relative accommodation (NRA), positive
relative accommodation (PRA), stimulus AC:A ratio, and
stereo acuity.
The measurements of all parameters were made follow-
ing the recommendations of Scheiman and Wick [38]. First
of all, the stereoacuity was tested using the Randot test (a
vectograph test to identify shapes from random-dot back-
grounds) to detect possible strabismus or suppression. This
test provides three variations to facilitate testing of
individuals at different comprehension levels, although,
because of the age of the subjects examined, we used the
maximum level: the Graded Circle Test. The subjects were
asked to identify geometric shapes during testing (40020 s
of arc). Random dot patterns require the binocular
individual to isolate figures from a background in such a
way as to eliminate any influence the distance between
them might have on judgement. The test figures can be
identified only with polarized 3-D viewing glasses
(included). There were ten presentations of three circles
each in the RANDOT. In each presentation, the subject
was asked to indicate the circle that could be seen three-
dimensionally (appeared closest), and we recorded the
last level that was successfully passed.
Both binocular as well as monocular accommodative
amplitudes were measured by two different methods:
Donders push-up method and the minus-lens method. In
the first method, a 20/30 single letter on the fixation stick
was used as the target. The target was moved closer from
approximately 50 cm from the subject toward the subject at
about 5 cm/sec until the subject reported when the target
begins to blur. We stopped when the first sustained blur was
reported. This was considered the endpoint, and then we
measured the distance from the spectacle plane to the near
927
point of accommodation. We converted this distance to the
dioptric (D) equivalent, and recorded the results. In the
minus-lens method, a near target (one line of letters larger
than the patients near visual acuity) at 40 cm was used as
minus lenses were added in 0.25 increments until the
subject could not distinguish the letter (sustained blur). The
minus lenses added plus working distance (2.50 D) is the
accommodative amplitude measurement. All measurements
of accommodation amplitude (testing lenses) were cor-
rected for effectiveness of the spectacle lenses and referred
to the cornea (ocular accommodation), as indicated by
Atchison and Smith [39].
The measurement of binocular accommodative facility
with antisuppression control, was achieved using Bernell
test no. 9 with the letter size 20/30 (Bernell VTP,
Mishiwaka, IN, USA) at a distance of 40 cm, using
polarized glasses and 2.00 flippers. For the monocular
measurement, the test was administered without polarized
glasses and with the non-viewing eye occluded. We placed
the +2.00 in front of the subjects eye and asked the subject
to try to see the letters clearly and singly as quickly as
possible, and when the letters were reported to be clear, the
patient was to press the flipper quickly to the minus side.
Again, the subject was instructed to read the letters and
report when the letters appeared clear or disappeared. We
recorded the cycles per minute, in both monocular and
binocular testing.
The monocular and binocular accommodative response
(accommodative lag or lead) were measured by monocular
estimate method (MEM) retinoscopy and the cross-cylinder
subjective method at a distance of 40 cm. The MEM
retinoscopy was carried out by very briefly interposing, in
front of one eye at a time, convergent or divergent lenses
(with motion or against motion, respectively) until neutral-
izing the reflex found in the horizontal meridian, while the
subject read a test close-up with 20/30 letters. For the cross-
cylinder subjective method, we used a cross target consist-
ing of four to five vertical and horizontal lines presented to
the subject at 40 cm. The cross-cylinder lenses (0.50 DC)
were placed in front of the eyes (phoropter), and the patient
was asked to indicate which group of lines was darker, the
vertical or horizontal. The end point of this test was
equality of blackness or clarity of the horizontal and
vertical lines. To achieve this, we added minus lenses or
plus lenses in 0.25 D increments until equality was reached.
In the same way as accommodation amplitude measure-
ments, the measurements of accommodative responses
(testing lenses) were corrected for effectiveness of the
spectacle lenses and referred to the cornea.
Negative relative accommodation (NRA) and positive
relative accommodation (PRA) values were determined by
adding lenses in front of the patients eyes (plus and minus
lenses, respectively). The objective of the test was to keep
928
the letters as clear and single as possible and to indicate
when the letters were blurry or double. The NRA
measurement was made before the PRA, as recommended
by Scheiman and Wick [38]. These measurements (testing
lenses) were corrected for effectiveness of the spectacle
lenses and referred to the cornea. The amplitude of
accommodation by the minus-lens method could then be
calculated as the sum of the added negative powers over
subjective refraction plus 2.50 D, which corresponds to the
accommodative effort needed to view the target clearly at a
working distance of 40 cm.
Near and distance horizontal and vertical phoria were
measured by Thoringtons method, as recommended by
several authors [38, 4042] for its simplicity, control over
accommodation, and high reliability and repeatability. For
the distance horizontal phoria, the subject, situated at 5 m
from the point test, held the Maddox bar horizontally in
front of his/her own right eye and was asked to indicate at
what point of the horizontal axis of the Maddox cross the
red vertical line was situated. Afterwards, the vertical
phoria was measured in the same way, by rotating the
Maddox bar vertically, while the subject indicated at what
point of the vertical axis of the Maddox cross the horizontal
line was situated. These were the distance values in
prismatic dioptres of the horizontal and vertical phoria
respectively. If the value of the phoria lay outside the axes
of the Maddox cross, an additional rotating prism was used,
the phoria value being the sum of the prism and the test.
For the near horizontal phoria, the subject, situated at 40 cm
from the Bernell muscle imbalance measure (MIM) test,
was requested to gaze at a point of light (LED) and to
indicate at what point on the horizontal axis of the test the
vertical red line was situated (in the case of horizontal
phoria), or at what point on the vertical axis of the test the
horizontal red line was situated (in the case of vertical
phoria). These were the values in prism diopters for the
near horizontal and vertical phoria. If the red line was
outside the axes, an additional prism was used, as described
above.
Near horizontal and vertical associated phorias (aligning
prism) were measured by near Mallet unit (Optec Interna-
tional Ltd, London, UK). The near Mallett unit is an
instrument used widely in optometric practice in the UK.
This unit includes a test for aligning prism, consisting of
two small monocular markers (one seen for each eye when
viewing through a polarised filter), a central reference
target, and paramacular as well as peripheral fusion detail.
The relative position of these markers with respect to the
central reference indicates whether any fixation disparity is
present and whether it is confined to one eye or is present in
both. The prism aligning the markers was recorded.
Near and distance negative and positive vergence ampli-
tude (blur, break, and recovery values) were measured. For
Graefes Arch Clin Exp Ophthalmol (2011) 249:925935
both near and distance, the negative fusional vergence was
measured first to avoid affecting the value for vergence
recovery because of excessive stimulation of convergence
[38, 43]. A gradually increasing horizontal Risley prism was
introduced in both eyes while the patient fixated on a
line of the Snellen optotype E, corresponding to the
highest visual acuity at 40 cm and 6 m fixation
respectively. When the added prism (base-in and base-
out prism for negative and positive fusional vergence
respectively) caused the patient to experience blurred
vision, we recorded the amount of prism. We continued
to add prism until the patient reported double vision
(recorded as the break point). The prism power was then
reduced until the double images could be fused again to
determine the recovery point.
Near point of convergence was evaluated by the push-up
technique using an accommodative target [38, 44]. A 20/30
single letter on the fixation stick was used as the target. The
target was moved closer until the subject experienced
constant diplopia on the stick. This was considered to be
the break point, and we measured the distance from the eye
to the stick. This distance expressed in centimetres was the
measurement of the break point. Then we asked the patient
to move it away from the eye until single vision was
achieved (recovery point).
For the measurement of vergence facility, a suppression
control was carried out with the target generally used in a
binocular accommodative facility testing: the Bernell No. 9
vectogram. This is a Polaroid target that has one line seen
by the right eye (row No. 4), one by the left (row No. 6),
and one by both (row No. 5). These rows were of 20/30
Snellen letters. With the two eyes open, the subject was
instructed to pay attention to the presence of the two
rows (4 and 6 that control suppression), which should
not disappear or be seen double throughout the session.
The number of changes in the position of the flipper of 3
D base-in/12 D base-out completed in 1 min was
recorded [45].
The stimulus AC:A ratio was established by two
methods: gradient method and calculated method [46]. For
the gradient method, following the measurement of the near
horizontal phoria, the flipper with +1.00 lenses was placed
in front of the Maddox bar and the new phoria value was
noted: this was then repeated with 1.00 D lenses. These
values were used for calculating the relationship between
the accommodative convergence (AC) and accommodation
(A). By the alternative calculated method, the AC:A ratio
was determined from the values of far and near phoria
values.
Each test was administered consistently by the same
optometrist to avoid variability between examiners. The tests
in the two sessions were undertaken by the same examiner.
Three measurements were taken for each parameter and
Graefes Arch Clin Exp Ophthalmol (2011) 249:925935 929

averaged. The accommodation demand (i.e., the amount of
accommodation required to focus clearly to an object) is
different if referred to the spectacle plane (spectacle
accommodation) or corneal vertex (ocular accommoda-
tion). Values of spectacle accommodation were converted
into ocular accommodation [39] to compare with the
ocular accommodation achieved with contact lenses. In a
later session (usually the next day), the subjects were
given an appointment to take the same measurements after
wearing SCL for 30 min before the optometric examina-
tion. As with the spectacles, three measurements were
taken of each parameter and averaged. The illumination of
the distance vision tests was controlled in such a way that
the mean luminance levels were within photopic ranges
(103 cd/m2), close to the mean of the range recommended
by the CIE (85 cd/m2), providing retinal illumination
conditions in which visual acuity stabilized. For the near
vision tests, the mean luminance was 129 cd/m2, measured
by a Topcon spectroradiometer (Model SR-1; Topcon
Corporation,Tokyo, Japan).
The data were analysed by the statistical package SPSS
9.0 (SPSS, Chicago, IL, USA). In the overall sample, all
variables displayed a normal Gaussian distribution after the
SmirnovKolmogorov goodness-of-fit test was applied in
each case, indicating that the sample is homogeneous and
useful for the purposes of the study.
Results
All subjects (N = 30) completed the study. Spherical
refractive errors were between 0.50 D and 6.00 D, with
a mean value of 2.591.65 S.D. The means (and standard
deviations) of all the measured parameters were calculated
for each correction method, and are given in Tables 1 and 2.
The values for the parameters in the two groups were then
compared. For this, a two-sample paired t-test was applied
at a confidence level of 95%. There was no statistically
significant difference in accommodation amplitude by
either method, or in accommodative facility (Table 1).
However accommodative lag was significantly higher when
wearing SCL.
The mean values by different methods in the measure-
ment of accommodation amplitude (push-up and minus
lenses methods) and the accommodative lag (MEM and
cross cylinder methods) were compared (Students t-test).
In both cases, statistically significant differences were
found (p<0.05) on using different methodology, both with
the use of spectacles and SCL.
Near horizontal dissociated phoria showed more esophoric
values with SCL than spectacles; near negative fusional
vergence (blur, break, and recovery) was lower when wearing
SCL, but the negative relative accommodation showed the
highest values when correction was made with SCL, with the
difference being about 0.25 D (Table 2).
All other parameters such as stereoacuity, distance
horizontal and vertical dissociated phoria, near vertical
dissociated phoria, near horizontal and vertical aligning
prism, near point of convergence, distance negative and
positive fusional vergence, near positive fusional vergence,
vergence facility and ratio AC:A no showed no significant
differences when wearing SCL compared to spectacles.
Table 3 shows the linear-correlation indices between the
different accommodative and binocular parameters. The
most significant correlation coefficients (p<0.01) were
found between NRA and near negative fusional vergence
(break point) and between near negative fusional vergence
(break point) and near horizontal dissociated phoria.

Table 1 Accommodative-
system parameters evaluated Method Spectacles Soft contact lenses P-value
according to the measurement
method (mean SD) and optical Amplitude (D) push-up technique R.E. 10.992.15 11.112.27 0.78
compensation method used. L.E. 11.041.95 11.052.21 0.72
Statistically significant Binocular 11.711.73 11.472.10 0.76
differences with Students t-test
(p<0.05). (R.E., right eye; L.E:, minus lens R.E. 10.092.42 9.002.11 0.08
left eye) L.E. 10.452.32 9.292.59 0.07
Binocular 8.512.03 7.771.90 0.15
Facility (cpm) Flippers 2.00 D R.E. 16.104.66 15.555.20 0.47
L.E. 16.464.82 16.925.88 0.56
Binocular 14.494.60 13.034.29 0.06
Lag (D) M.E.M. R.E. 0.420.38 0.960.63 p<0.01
L.E. 0.410.35 1.020.64 p<0.01
Binocular 0.320.30 0.850.47 p<0.01
Cylinder cross (40 cm) R.E. 0.030.42 0.370.63 p<0.01
L.E. 0.030.46 0.470.56 p<0.01
Binocular 0.110.32 0.490.58 p<0.05
930 Graefes Arch Clin Exp Ophthalmol (2011) 249:925935

Table 2 Binocular system parameters evaluated according to the (negative values in dissociated and aligning prism indicate exodevia-
measurement method (mean SD) and optical compensation method tions and positive values indicate esodeviations)
used. Statistically significant differences with Students t-test (p<0.05)

Parameters Method or type of value Spectacles Soft contact lenses P-value

Stereoacuity (second of arc) 29.1712.80 29.8313.68 0.74

Distance horizontal dissociated phoria () Thorington -0.082.48 0.292.31 0.07
Distance vertical dissociated phoria () Thorington -0.120.33 -0.090.36 0.44
Near horizontal dissociated phoria () Thorington -0.154.36 2.203.94 p<0.05
Near vertical dissociated phoria () Thorington 0.130.57 -0.090.32 0.06
Near horizontal aligning prism () -0.180.70 00 0.16
Near vertical aligning prism () 00 00 -
Near point of convergence (cm) Break value 5.221.86 5.352.11 0.46
Recovery value 7.303.40 7.843.97 0.08
Distance negative fusional vergence () Blur value 6.530.62 8.423.80 0.15
Break value 9.972.95 9.272.57 0.33
Recovery value 5.192.73 4.471.97 0.24
Distance positive fusional vergence () Blur value 16.705.65 15.424.86 0.56
Break value 24.458.01 24.078.03 0.84
Recovery value 14.416.23 14.876.81 0.79
Near negative fusional vergence () Blur value 16.535.60 14.076.55 p<0.05
Break value 18.865.99 15.786.29 p<0.01
Recovery value 12.305.28 8.844.98 p<0.01
Near positive fusional vergence () Blur value 23.553.26 21.5010.12 0.67
Break value 29.758.36 29.747.93 0.99
Recovery value 19.477.58 19.738.15 0.84
Vergence facility () 15.205.08 16.074.34 0.29
Positive relative accommodation 6.012.03 5.261.90 0.07
Negative relative accommodation (D) 2.770.45 3.210.56 p<0.01
Ratio AC/A Calculated method 5.631.52 5.481.10 0.44
Gradient method 1.713.17 2.301.83 0.49

Discussion accommodative demand can significantly differ between a

As we indicated above in the Material and method section,
the subjects of this study indifferently used contact lenses
and spectacles daily and, on making the optometric
examinations with glasses and contact lenses on different
days, we expected no influence of subjectivity or learning
of some measurements over others. We should add that the
subjects were students of optometry, and therefore clearly
understood the instructions on methodology.
Theoretical differences in accommodation and vergence
demands when wearing single vision SCL compared to
spectacle lenses have been established with the support of
clinical results [13, 14, 16, 35]. For the sake of convention,
accommodation is usually considered to take place at the
spectacle plane. However, because it represents a change in
ocular refraction, accommodation usually takes place at the
first principal plane of the eye, and therefore this must be
considered when one determines the amount of accommo-
dation necessary for a corrected ametrope, since the
contact lens wearer and a spectacle wearer. This difference
increases with greater ametropia, and reaches maximum
significance in the pre-presbyopic and presbyopic years
[14]. This change in accommodative demand means there is
also a change in the amount of accommodative conver-
gence present for close work, which causes a change in the
amount of fusional convergence required for fusion., As
indicated by Fannin & Grosvenor [14], most contact lens
wearers have refractive errors ranging from 1.00 to5.00 D
(the refractive errors of our population were between 0.50
to 6.00 D), with the result that the change in accommo-
dative convergence required with contact lenses is not
often a problem. However, in the present work comparing
the use of SCL in comparison to spectacles (Table 1), we
found significance differences in accommodative parame-
ters such as accommodative lag and NRA value (both
referring to the cornea).
More accommodation is required by myopes when they
change from spectacles to contact lenses, and this should
Graefes Arch Clin Exp Ophthalmol (2011) 249:925935
Table 3 Linear correlation (p<0.05) between different parameters with the use of spectacles (grey cells) and contact lenses (white cells)
Spectacles Binocular
Accommodative
response
Soft Contact Lenses
(MEM)
Binocular
Accommodative Lag
- 0.44*
(MEM)
Negative relative
accommodation 0.63**
Near horizontal
dissociated phoria 0.04
Near negative
fusional vergence 0.09
(break point)
* p<0.05. ** p<0.001
imply lower accommodation amplitudes. As a general
theoretical rule [14], for a reading distance of 40 cm, the
amount of decreased accommodation reaches 0.25 D for
about 3.00 D of myopia. Fong [19] stated that eyes with
lower accommodation amplitudes must use more of their
accommodative reserve for near work, and myopia may be
an adaptation that develops or progresses in eyes with
reduced accommodative amplitudes. In our work, we found
no significant differences in the mean values of accommo-
dation amplitude when either compensation method was
used. This contrasts with the results of previous studies [13,
36, 47]. Various causes could explain this difference. The
methodology used in the fitting of contact lenses has varied
enormously in recent years in relation to the work
performed in the 1970s. That is, some studies used SCL
and others rigid contact lenses, the interval studied in the
refractive error differed (1.50 to 10.00 D) from ours, and
the population sizes were much smaller than in our study.
Also, the short period of SCL wearing in our study did not
allow adaptational changes in accommodative amplitude,
and perhaps after several hours or days of SCL wear the
results might be different. Nevertheless, in the analysis of
the mean values of the mean accommodation amplitude
with negative spectacles (Table 1) and the mean PRA
values (Table 2) with the use of spectacles in comparison to
SCL, we find that these values are lower by approximately
0.75 D when contact lenses were used; and therefore it can
931
Negative Near Near
relative horizontal negative
accommodation dissociated fusional
phoria vergence
0.08 -0.27
- 0.15 -0.32
-0.06 - -0.45*
0.66** -0.66** -
be considered that clinically significant differences
existed. However, the values of accommodative lag
found were higher with the SCL than with spectacles
(by about 0.250.50 D), and statistically different as
shown in Table 1. These higher lag values, found after
just 30 min of SCL wear, could be an early sign of a
subsequent reduction in the accommodation amplitude
when SCL are used for long periods of time. Birnbaum
[48] suggested that accommodative insufficiency occurs as
a result of inhibition of accommodative function, thereby
creating a lag of accommodation to reduced associated
overconvergence, and his lag of accommodation reflects
the reduced accommodative effort, and reduces over-
convergence without inducing blur. Therefore, a larger
lag of accommodation that exceeds the magnitude of the
depth of focus of the eye will produce blur, but may still
be preferable to diplopia. An inhibited accommodation
induces a poor response to clinical testing, which requires
the location of accommodation closer than convergence,
and consequently, low PRA findings may result. When
this inhibition becomes sufficiently conditioned, the blur
response following the introduction of minus lenses will
be poor even during monocular testing, and hence the
accommodation amplitude of the minus lens [49] will also
be reduced [50]. This would agree with the lower
amplitude values and PRA values found in this work,
although this point needs further study.
932
Also, if an accommodative lag exists during near-point
viewing, the near-point target is conjugate with a point
behind the retina, and an increased rate of axial elongation
of eye could occur [2831, 33, 51]. As proposed by Goss
and Zhai [29], an individual who does a great deal of near
work, and whose accommodation lags more than normal, is
prone to develop or to progress in myopia. This finding
(higher lag with SCL wear) may be particularly important
in increasing the risk of myopia progression. As indicated
by Allen and OLeary [27], the lag of accommodation and
accommodative facility are the two key accommodative
parameters that differentiate participants who have a stable
refractive error and those who do not have. In this work, we
found no statistically significant differences in the average
value of binocular accommodative facility when spectacle
wear was compared to SCL (p=0.06), although this value
was lower when SCL was worn (Table 1). Perhaps after
several hours or days of SCL wear, this difference would be
significant, and our results could be useful to establish a
link between SCL wearing and myopia progression.
When a myope wearing spectacle lenses that are centred
for his/her pupillary distance fixates on a near object, the
amount of convergence required is not only a function of
the interpupillary distance and the distance of the object,
but also could be a function of the refracting power of the
spectacle lenses. It would be expected that if a myope
(when the spectacle lenses are centred only for distance
vision, and are also used for near tasks) converges to bi-
fixate on a near object, his visual axis departs from the
centre of his spectacle lenses and he would encounter
increasing amounts of prismatic effect. Theoretically, this
reduces the convergence requirement, as compared to the
naked eye or the wearing of contact lenses. Therefore, the
myope who discards his spectacle lenses in favour of
contact lenses must converge more to bi-fixate on a given
near object. In our work the prismatic effects were
eliminated, and therefore the values of the near point of
convergence (break and recovery point) do not differ with
use of either contact lenses or spectacles (Table 2).
Clinically, reduced accommodation is frequently associ-
ated with exophoria in near, and excessive accommodation
with near-point esophoria [38, 52]. However, some studies
have found reduced accommodation to be associated with
near esophoria [32, 53]. We observed that subjects
experienced a change in the near-point phoria in the
convergent direction (about +2.40 ), when wearing SCL
compared to spectacles. This finding contrasts with the
results of Fulk et al. [7], who reported a change in
exophoric values to near-point phoria with the use of
contact lenses, although in their study the sample included
only myopic adolescents initially with near esophoria. A
few studies have reported that accommodative lag is
associated with greater esophoria [32, 53, 54] suggesting
Graefes Arch Clin Exp Ophthalmol (2011) 249:925935
that an esophoric child must relax accommodation to
reduce accommodative convergence and thus maintain
single binocular vision. The reduction in accommodation
may prompt hyperopic defocus during near work, which
could lead to the onset of myopia or progression of existing
myopia [29]. Perhaps the presence of a higher accommo-
dative lag, and esophoria to near-vision targets, in contact
lens wearers encourages the development of myopia.
In addition to knowledge of the phoria size, the
magnitude of the relevant fusional reserves is useful in
assessing a patients binocular status. Patients with esopho-
ria in near vision use part of the negative fusional vergence
to correct the deviation at this distance. Our results indicate
that SCL encourage a greater use of negative fusional
vergences for near work; indeed, lower values are found
than with spectacles (Table 2), and there is a stronger
relationship (Table 3) between near negative fusional
vergence and the near horizontal dissociated phoria with
contact lenses (r=0.66, p<0.01) compared to spectacles
(r=0.45, p<0.05). Consequently, as indicated by Goss
[54], a lower PRA value is often associated with higher
esophoria value, and children who develop juvenile onset
myopia tend to have lower PRA findings, more plus on the
binocular cross-cylinder test, and more esophoric or less
exophoric near-point phoria than children who remain
emmetropic. In our study, the mean values of accommoda-
tion amplitude (monocular and binocular) measured with
the minus lens method and PRA values with SCL are lower
than with spectacles (Table 1). Although these results are
not statistically significant, they are from a clinical
standpoint. This could imply that the myopia could be
accelerated more rapidly with the use of contact lenses.
Reduced accommodation tends to be associated with
elevated AC:A ratios [51, 55]. Although apparently the
AC:A ratio when wearing SCL should be affected because
of more esophoric values found in near-horizontal disso-
ciated phoria, in the present study the AC:A ratio value
remained relatively unchanged when switching from
spectacles to contact lenses. These results agree with
those of Westheimer [56], Stone [57] and Robertson et al.
[13]. If, after 30 min of contact-lens use, we find more
esophoric values in near vision, and a higher accommo-
dative lag, we may suspect that after prolonged periods of
SCL use (especially in near vision) accommodative
convergence is affected and, therefore, the accommodation
and AC:A ratio as well. This could exacerbate the
development of myopia; as indicated by Gwiazda et al.
[55], the significantly higher AC:A ratios in the children
who became myopic are a result of significantly reduced
accommodation. Poor accommodation and high AC:A
ratios are simply an offshoot of the hypothesised structural
growth of the eye slightly before as well as during myopia
progression, as shown by Flitcroft [58].
Graefes Arch Clin Exp Ophthalmol (2011) 249:925935
Anomalous results of NRA have not been clearly
associated with any binocular dysfunction in particular
[59]. In fact, some authors do not use relative accommo-
dation for diagnosing general binocular disorders [6063],
whereas other authors use low values of relative accom-
modations as diagnostic signs in some accommodative and
vergence dysfunctions [6468], or as tests associated with
the visual function [69]. In our work, we have found high
NRA values, these values being higher with SCL use than
with spectacles and statistically different (Table 2). Al-
though high values of NRA have been reported [70], in no
study cited above are high values of relative accommoda-
tion considered a sign for diagnosing general binocular
disorders. As indicated by Garca et al. [59], the high NRA
values can be associated with disorders such as accommo-
dative insufficiency and convergence excess, although their
use should be complementary to other binocular tests when
diagnosing general binocular disorders. The only clear
relationships seem to be between a high NRA value and
under-corrected hyperopia or over-corrected myopia [71].
However, this does not apply in our case, given that an
over-refraction and the optical correction was made with
standard subjective refraction, using an endpoint criterion
of maximum plus consistent with best vision, and taking
into account the compensated exact refraction in power
compared to the spectacle lenses for vertex distance. Higher
values found for NRA with contact lens use than with
spectacles appear to be related more to the accommodative
function than to binocular function. These results, together
with the higher values of accommodative lag and lower
PRA values and accommodative amplitude (not with
statistical but with clinical significance) found in subjects
wearing SCL, could indicate the presence of an accom-
modative insufficiency with the use of SCL. In addition,
with the use of contact lenses statistically significant
correlations exist between NRA with accommodative lag
(Table 3; r=0.63, p<0.01). Higher esophoric values in near
vision and greater accommodative lags with the use of SCL
could also indicate a trend towards excess convergence in
near tasks, although the normal AC:A ratio found here rules
out this possibility [38]. A higher value of NRA, as
indicated by Garca et al. [59], could be associated with a
disorder such as accommodative insufficiency or conver-
gence excess; however, in this same work, given that no
differences were found in the NRA value in these two
anomalies with respect to the others such as convergence
excess plus accommodation excess, or between accommoda-
tion insufficiency and convergence insufficiency plus accom-
modation excess, we cannot be sure that a high NRA value is
related only to accommodative insufficiency or convergence
excess. A higher NRA value with the use of SCL in the
present work could indicate that the two methods of refractive
correction were not exactly equivalent in their ability to relax
933
accommodation or to exert positive and negative fusional
vergence. More research is needed to find the exact role of
these differences, and their possible influence on the origin
and progression of myopia.
Acknowledgements We thank the Servilens Fit & Covers for the
donation of the contact lens supplies used in this study and David
Nesbitt (translator) for translating the text into English.
References
1. Lee YC, Lim CW, Sam SM, Koh D (2000) The prevalence and
pattern of contact lens use in a Singapore community. CLAO J
26:2125
2. Uedaganka S (2001) Contact lens use among high-school
students. Ophthalmol Jpn 43:293297
3. Colleen R, Robin LC (2005) Survey of contact lens wearing
habits and attitudes towards methods of refractive correction:
2002 versus 2004. Optom Vis Sci 82:555561
4. Morgan PB, Woods CA, Tranoudis IG, Efron N, Knajian R,
Grupcheva CN, Jones D, Tan K-O, Pesinova A, Ravn O,
Santodomingo J, Vodnyanszky E, Erdinest N, Hreinsson HI,
Montani G, Itoi M, Bendoriene J, van der Worp E, Helland M,
Phillips G, Gonzalez-Meijome JM, Radu S, Belousov V, Silih MS,
Nichols J (2010) Internacional contact lens prescribing in 2008.
Contact Lens Spectr 26(2):3036
5. Nizam A, Waring GO, Lynn MJ, Ward MA, Asbell PA, Balyeat
HD, Cohen E, Culbertson W, Doughman DJ, Fecko P, The PERK
Study Group (1992) Stability of refraction and visual acuity
during 5 years in eyes with simple myopia. J Refract Corneal Surg
8:439447
6. Nizam A, Waring GO, Lynn MJ, the PERK Study Group (1996)
Stability of refraction during 11 years in eyes with simple myopia.
Invest Ophthalmol Vis Sci 37:S1004
7. Fulk GW, Cyert LA, Parker DE, West RW (2003) The effect of
changing from glasses to soft contact lenses on myopia progres-
sion in adolescents. Ophthal Physiol Opt 23:7177
8. Andreo LK (1990) Long-term effects of hydrophilic contact lenses
on myopia. Ann Ophthalmol 22:224229
9. Horner DG, Soni PS, Salmon TO, Schroeder T (1999) Myopia
progression in adolescent wearers of soft contact lenses and
spectacles. Optom Vis Sci 76:474479
10. Walline JJ, Jones LA, Sinnot I, Manny RE, Gaume A, Marjorie JR,
Chitkara M, Stacy L, The ACHIEVE Study Group (2008) A
randomized trial of the effect of soft contact lenses on myopia
progression in children. Invest Ophthalmol Vis Sci 49(11):47024706
11. Marsh-Tootle WL, Wendy L, Dong LM, Hyman L, Gwiazda J,
Weise K, Dias L, Fern KD, The COMET Group (2009) Myopia
progression in children wearing spectacles vs switching to contact
lenses. Optom Vis Sci 86(6):741747
12. Alpern M (1949) Accommodation and convergence with contact
lenses. Am J Optom 26:379387
13. Robertson DM, Ogle JA, Dyer JA (1967) Influence of contact
lenses on accommodation. Theoretic considerations and clinical
study. Am J Ophthalmol 64:860871
14. Fannin TE, Grosvenor T (1996) Clinical optics, 2nd edn. Butterworth
Heinemann, New York
15. Bennet ES, Weissman BA (2005) Clinical contact lens practice.
Lippincott Williams & Wilkins, Philadelphia
16. Hunt OA, Wolffsohn JS, Garca-Resa C (2006) Ocular motor
triad with single vision contact lenses compared to spectacle
lenses. Cont Lens Anterior Eye 29:239245
934
17. Duang CM (1985) The relation among ametropia, age and
amplitude of accommodation. Chin J Ophthalmol 21:216221
18. Zhai HF, Guan ZS (1988) Observation of accommodation in
juvenile myopia. Yan Ke Xue Bao 4:228231
19. Fong DS (1997) Is myopia related to amplitude of accommoda-
tion? Am J Ophthalmol 123:416418
20. Fledelius HC (1981) Accommodation and juvenile myopia. Doc
Ophthalmol 28:103108
21. Maddock RJ, Millodot M, Leat S, Johnson CA (1981) Accom-
modation responses and refractive error. Invest Ophthalmol Vis
Sci 20(3):387391
22. Mc Brien NA, Millodot M (1986) Amplitude of accommodation
and refractive error. Invest Ophthalmol Vis Sci 27(7):11871190
23. Gawron VJ (1981) Differences among myopes, emtropes and
hyperopes. Am J Optom Physiol Opt 58(9):753760
24. Wold RM (1967) The spectacle amplitude of accommodation of
children aged six to ten. Am J Optom Arch Am Acad Optom 44
(10):642664
25. Fisher SK, Ciuffreda KJ, Levine S (1987) Tonic accommodation,
accommodative hysteresis, and refractive error. Am J Optom
Physiol Opt 64(11):799809
26. Mantyjarvi MI (1987) Accommodation in hyperopic and
myopic schoolchildren. J Pediatric Ophthalmol Strabismus 24
(1):3741
27. Allen PM, OLeary DJ (2006) Accommodation functions: Co-
dependency and relationship to refractive error. Vis Res 46:491
505
28. Gwiazda J, Bauer J, Thorn F, Held R (1993) Myopic children
show insufficient accommodative response to blur. Invest Oph-
thalmol Vis Sci 34:690694
29. Goss DA, Zhai H (1994) Clinical and laboratory investigations
of the relationship of accommodation and convergence function
with refractive error: a literature review. Doc Ophthalmol
86:349380
30. Jiang BC (1995) Parameters of accommodative and vergence
system and the development of late-onset myopia. Invest
Ophthalmol Vis Sci 36(8):17371742
31. Abbott ML, Schmid KL, Strang NC (1998) Differences in the
accommodation stimulus response curves of adult myopes and
emmetropes. Ophthal Physiol Opt 18:1320
32. Gwiazda J, Thorn F, Held R, Grice K, Bauer J (1996) Myopic
children with esophoria underaccommodate at near. Invest
Ophthalmol Vis Sci 37:s687
33. Norton TT, Gamlin PD (1999) The near response, emetropa and
myopia. Ophthal Physiol Opt 19(2):7980
34. Mutti DO, Mitchell GL, Hayes JR, Jones LA, Moeschberger ML,
Cotter SA, Kleinstein RN, Manny RE, Twelker JD, Zadnik K
(2006) Accommodative lag before and after the onset of myopia.
Invest Ophthalmol Vis Sci 47:837846
35. Hermann JS, Johnson R (1969) The accommodation requeriment
in myopia: a comparison of contact lenses and spectacles. Arch
Ophthalmol 76:4751
36. Carney LG, Woo GC (1977) Comparison of accommodation with
rigid and flexible contact lenses. Am J Optom Physiol Opt
54:595597
37. Matthews JF, Moore S, Cohen RL (1981) Clinical evaluation of
the changes that occur when shifting from glasses to contact
lenses. Am Orth J 31:95102
38. Scheiman M, Wick B (2008) Clinical management of binocular
vision: heterophoric, accommodative and eye movement disor-
ders, Chap. 1. Lippincott Willians & Wilkins, Philadelphia, pp 3
52
39. Atchison DA, Smith G (2000) Optics of the human eye.
ButterworthHeinemann, Oxford
40. Hirsch MJ, Alpern M, Schultz HL (1948) The variation of phoria
with age. Am J Optom Arch Am Acad Optom 25:535541
Graefes Arch Clin Exp Ophthalmol (2011) 249:925935
41. Schroeder TL, Rainey BB, Goss DA, Grosvenor TP (1996)
Reliability of and comparisons among methods of measuring
dissociated phoria. Optom Vis Sci 73:389397
42. Rainey BB, Schroeder TL, Goss DA, Grosvenor TP (1998) Inter-
examiner repeatability of heterophoria tests. Optom Vis Sci
75:719726
43. Rosenfield M, Ciuffreda KJ, Ong E, Super S (1995) Vergence
adaptation and the order of clinical vergence range testing. Optom
Vis Sci 72:219223
44. Scheiman M, Gallaway M, Frantz KA, Peters RJ, Hatch S, Cuff
M, Mitchell L (2003) Nearpoint of convergence: test procedure,
target selection, and normative data. Optom Vis Sc 80:214225
45. Gall R, Wick B, Bedell H (1998) Vergence facility: establishing
clinical utility. Optom Vis Sci 75:731742
46. Rutstein RP, Daum KM (1998) Anomalies of binocular vision:
diagnosis and management. Mosby, St Louis, Chap. 3: pp 6194,
Chap. 6: pp 147188
47. Yago K, Kato K (1975) Changes in near points of accommodation
when wearing soft contact lenses. Contac Intraocul Lens Med J 1
(12):6068
48. Birnbaum MH (1985) Nearpoint visual stress: clinical implica-
tions. J Am Optom Assoc 56:480490
49. Rosenfield M (1997) Accommodation. In: Zadnick K (Ed) The ocular
examination. Measurement and findings. Saunders, Philadelphia, pp
87-121
50. Birnbaum MH (1993) Optometric management of nearpoint
vision disorders. ButterworthHeinemann, Oxford
51. Gwiazda J, Grice K, Thorn F (1999) Response AC/A ratios are
elevated in myopic children. Ophthal Physiol Opt 19(2):173179
52. Morse J (1999) Oculomotor function after virtual reality use
differentiates symptomatic from asymptomatic individuals. Optom
Vis Sci 76(9):641
53. Goss DA (1991) Clinical accommodation and heterophoria findings
preceeding juvenile on-set of myopia. Optom Vis Sci 68:110116
54. Goss DA, Rainey BB (1999) The relationship of accommodative
response and near-point phoria in a sample of myopic children.
Optom Vis Sci 76:292294
55. Gwiazda J, Thorn F, Held R (2005) Accommodation, accommo-
dative convergence, and response AC/A ratios before and at the
onset of myopia in children. Optom Vis Sci 82(4):273278
56. Westheimer G (1955) The relationship between accommodation
and accommodative-convergence. Am J Optom Physiol Opt
32:206
57. Stone J (1967) Near vision difficulties in non-presbyopic corneal
lens wearers. Contact Lens 1:1425
58. Flitcroft FI (1998) A model of the contribution of oculomotor and
optical factors to emmetropization and myopia. Vis Res 38:2869
2879
59. Garca A, Cacho P, Lara F (2002) Evaluating relative accom-
modations in general binocular dysfunctions. Optom Vis Sci 79
(12):779787
60. Daum KM (1983) Accommodative dysfunction. Doc Ophthalmol
55:177198
61. Matsuo T, Ohtsuki H (1992) Follow-up results of a combination
of accommodation and convergence insufficiency in school-age
children and adolescents. Graefes Arch Clin Exp Ophthalmol
230:166170
62. Russell GE, Wick B (1993) A prospective study of treatment of
accommodative insufficiency. Optom Vis Sci 70:131135
63. Dwyer P, Wick B (1995) The influence of refractive correction
upon disorders of vergence and accommodation. Optom Vis Sci
72:224232
64. Hokoda SC (1985) General binocular dysfunctions in an urban
optometry clinic. J Am Optom Assoc 56:560562
65. Scheiman M, Gallaway M, Coulter R, Reinstein F, Ciner E,
Herzberg C, Parisi M (1996) Prevalence of vision and ocular
Graefes Arch Clin Exp Ophthalmol (2011) 249:925935
disease conditions in a clinical pediatric population. J Am Optom
Assoc 67:193202
66. Porcar E, Martinez-Palomera A (1997) Prevalence of general
binocular dysfunctions in a population of university students.
Optom Vis Sci 74:111113
67. Garcia A, Cacho P, Lara F, Megias R (2000) The relation between
accommodative facility and general binocular dysfunction. Oph-
thalmic Physiol Opt 20:98104
68. Lara F, Cacho P, Garcia A, Megias R (2001) General binocular
disorders: prevalence in a clinic population. Ophthalmic Physiol
Opt 21:7074
935
69. Atchison DA, Schmid KL, Edwards KP, Muller SM, Robotham J
(2001) The effect of under and over refractive correction on visual
performance and spectacle lens acceptance. Ophthalmic Physiol
Opt 21:255261
70. Jackson TW, Goss DA (1991) Variation and correlation of clinical
tests of accommodative function in a sample of school-age
children. J Am Optom Assoc 62:857866
71. Newman JM (1998) Analysis, interpretation and prescription for
the ametropias and heterophorias. In: Benjamin WJ, Borish IM
(eds) Borish's clinical refraction. Saunders, Philadelphia, pp 776
822
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