IJO Spring 2006.qxp - Indiana University School of Optometry

Spring 2006 

Volume 9, Number 1 

FACULTY PROFILE: 

T. Rowan Candy 

FEATURED REVIEW: Infants and Toddlers: 

How w to Examine Them 

and What t to Expect 

CLINICAL THEORY: Use of Dynamic RetinoscopR 

etinoscopy y to Determine 

Changes in Accommodati 

tive e Response R 

with Varying 

Amounts of Plus 

Add 

BOOK REVIEW: Phantoms in the Brain: 

Probing the Mysteries of the 

Human Mind 

REVIEW: Recent Studies on Conver 

ergence ence Insufficienc 

iciency Treatments 

and Associations 

LETTER TO THE EDITOR 

AND AUTHORS’ 

REPLIES

In This Issue 

The Indiana University faculty member whose profile is featured in this issue is T. Rowan 

Candy, who joined the faculty at IU in 2000. She and a former student and resident 

whom she helped to train, Christy Hohenbary, team to present information on the 

examination of infants and toddlers. They discuss appropriate tests and the types of 

conditions that are likely to be found in that age group. 

Also in this issue there is an article addressing clinical theory surrounding 

accommodative response to plus lens adds and the use of dynamic retinoscopy in 

nearpoint problems. Indiana University alumnus Craig Andrews contributed a review of 

a book about the brain and perception that he has found to be particularly enlightening. 

A short literature review discusses some interesting recent studies on the treatment of 

convergence insufficiency and on an apparent association of convergence insufficiency 

with ADHD. Lastly, a letter to the editor expands upon some of the material published in 

our last issue. 

David A. Goss 

Editor 

ERRATUM: 

On page 39 of the Fall, 2005 issue, the authorship for the photoessay on Terson’s Syndrome should have been 

listed as: Ali A. Bodla, M.D., and Arvind K. Singh, F.R.C.S., F.R.C.Ophth., Ophthalmology Department, The Ayr 

Hospital, Dalmellington Road, Ayr, Scotland. The authorship was listed correctly in the table of contents for the 

issue, but not on page 39. 

Correspondence and manuscripts submitted for publication should be sent to the Editor: David A. 

Goss, School of Optometry, Indiana University, Bloomington, IN 47405 USA (or 

dgoss@indiana.edu). Business correspondence should be addressed to the Production Manager: 

J. Craig Combs, School of Optometry, Indiana University, Bloomington, IN 47405 USA (or jocombs 

@indiana.edu). Address changes or subscription requests should be sent to Sue Gilmore, School 

of Optometry, Indiana University, Bloomington, IN 47405 USA (or sgilmore@indiana.edu). 

Our appreciation is extended to Essilor of America for 

financial support of this publication. 

Varilux® is a registered trademark of Essilor International, S.A

Spring 2006 

Volume 9, Number 1 

Table of Contents 

Indiana University School of Optometry 

Administration: 

Gerald E. Lowther, O.D., Ph.D., 

Dean 

Clifford W. Brooks, O.D., 

Director, 

Optician/Technician Program 

Daniel R. Gerstman, O.D., M.S., 

Executive Associate Dean for 

Budgetary Planning and 

Administration 

Joseph A. Bonanno, Ph.D., 

Associate Dean for Research 

Steven A. Hitzeman, O.D., 

Director of Clinics 

Edwin C. Marshall, O.D., M.S., 

M.P.H., Associate Dean for 

Academic Affairs 

Graeme Wilson, O.D., Ph.D., 

Associate Dean for 

Graduate Programs 

Sandra L. Pickel, B.G.S., A.S., 

Opt.T.R., Associate Director, 

Optician/Technician Program 

Cindy Vance, 

Director of Student Administration 

CONTENTS 

FACULTY PROFILE: T. Rowan Candy 

by Don W. Lyon ................................................................................................... 2 

FEATURED REVIEW: 

Infants and Toddlers: How to Examine Them and What to Expect 

by T. Rowan Candy and Christy C. Hohenbary .............................................. 3 

CLINICAL THEORY: 

Use of Dynamic Retinoscopy to Determine Changes in 

Accommodative Response with Varying Amounts of Plus Add 

by David A. Goss and Danielle F. Warren ...................................................... 9 

BOOK REVIEW: 

Phantoms in the Brain: Probing the Mysteries of the Human Mind 

Reviewed by Craig Andrews ............................................................................. 15 

REVIEW: 

Recent Studies on Convergence Insufficiency 

Treatments and Associations 

by David A. Goss ................................................................................................ 16 

LETTER TO THE EDITOR AND AUTHORS’ REPLIES: 

by Steven F. Sampson, Ali A. Bodla, and Elli J. Kollbaum .......................... 20 

Indiana Journal of Optometry 

Editor: 

David A. Goss, O.D., Ph.D. 

Editorial Board: 

Arthur Bradley, Ph.D. 

Clifford W. Brooks, O.D. 

Daniel R. Gerstman, O.D., M.S. 

Victor E. Malinovsky, O.D. 

Neil A. Pence, O.D. 

Production and Layout 

J. Craig Combs, M.H.A. 

Statement of Purpose: The Indiana Journal of Optometry is published by the Indiana University 

School of Optometry to provide members of the Indiana Optometric Association, Alumni of the 

Indiana University School of Optometry, and other interested persons with information on the 

research and clinical expertise at the Indiana University School of Optometry, and on new 

developments in optometry/vision care. 

The Indiana Journal of Optometry and Indiana University are not responsible for the opinions and 

statements of the contributors to this journal. The authors and Indiana University have taken care 

that the information and recommendations contained herein are accurate and compatible with the 

standards generally accepted at the time of publication. Nevertheless, it is impossible to ensure that 

all the information given is entirely applicable for all circumstances. Indiana University disclaims 

any liability, loss, or damage incurred as a consequence, directly or indirectly, of the use and 

application of any of the contents of this journal. This journal is also available on the world wide 

web at: http://www.opt.indiana.edu/IndJOpt/home.html

Faculty Profile: T. Rowan Candy, Ph.D. 

by Don W. Lyon, O.D. 

Rowan Candy joined the faculty of the Indiana 

University School of Optometry in 2000. Her main 

interest is the development of the visual system and 

visual function. She spent her optometry, Ph.D., and 

post-doctoral training gaining the skills and experience to 

work with the infant population after her 

interest was stimulated by a single 

lecture early in her undergraduate 

optometry training in Wales. She was 

struck by the fact that visual experience 

could define the development of the 

brain, and that optical abnormality could 

completely restructure synaptic 

connections in the visual cortex of 

animal models. Management of infants’ 

neural development through optical correction leapt out 

as an opportunity to make a significant contribution using 

the existing strengths of optometry. 

She spent her spare time during optometry school at 

the University of Wales getting additional training in 

clinical techniques for assessing visual development, 

plus learning how to change diapers, find particularly 

colorful and noisy toys, and make assorted animal 

noises – all which are critical components of infant 

vision examinations. 

By the end of her optometry training, Rowan was 

frustrated by problems of determining which infants 

needed optical correction and predicting which infants 

were going to develop strabismus or amblyopia if left 

uncorrected. Studies suggested that infants were to be 

left uncorrected to encourage emmetropization, while 

other studies promoted optical correction to prevent 

refractive strabismus and amblyopia. After two years of 

primary care optometry practice in Great Britain, Rowan 

was still driven by these issues and looked for an 

opportunity to gain further understanding and training. 

She was accepted into the Ph.D. program in Vision 

Science at University of California Berkeley, and 

completed her degree in 1997. There she worked with 

Marty Banks learning the subtleties of the development 

of visual function. Her Ph.D. thesis work included 

computational analyses of retinal function in infancy and 

an EEG based analysis of the optical performance of the 

infant eye. This work helped provide further insight into 

the way in which information is processed by and 

passed through the developing visual system. Rowan 

then went to work as a research associate at the Smith 

Kettlewell Eye Research Institute in San Francisco. She 

spent three years there working with Tony Norcia 

recording visual-evoked potentials from infants and 

adults with various developmental visual abnormalities 

focusing on understanding the development of the visual 

cortex. 

The offer of a job at Indiana University was an 

exciting opportunity, as Rowan was now able to stop 

spending all day commuting and spend the time she 

saved interacting with the optics experts at the school, 

particularly Larry Thibos and Arthur Bradley. She could 

complement her training and knowledge in the 

development of the neural visual system with their visual 

optics expertise. 

In addition to teaching a course in pediatric 

optometry, Rowan was given the task to start infant 

vision clinics at the Atwater and the Indianapolis Eye 

Care Centers. These clinics were designed to examine 

children from birth to three years of age by providing the 

necessary tools and instructions to fourth year 

optometry interns on how to appropriately care for this 

young population. Through these clinics, the school has 

been able to promote infant vision care to parents and to 

professionals who work with children on a daily basis. 

In 2003, Rowan was awarded a four year grant by the 

National Eye Institute examining the role of 

accommodation and defocus in infants’ visual 

performance and development. She has an active 

laboratory that studies the typical development of 

infants’ refractive error, accommodation, retinal image 

quality, and neural function. They gear their studies and 

the equipment they have developed towards defining 

the relationship between the optical and neural 

characteristics required for normal development. They 

also bring older children with high hyperopia, 

strabismus, and amblyopia to the lab to understand how 

their visual systems have developed. 

Rowan is excited about the potential to prevent 

developmental visual abnormalities such as strabismus 

and amblyopia through her research, through training 

optometry and technician students about infants in both 

clinical and classroom settings, and through providing 

ODs with continuing education. In addition to her 

research and other responsibilities at the school, Rowan 

was appointed as a topical editor for Optometry and 

Vision Science, a member of the American Academy of 

Optometry’s research committee, and a member of the 

Association for Research in Vision and Ophthalmology 

program committee that assembles the scientific 

program for its annual meeting. 

Don W. Lyon is Clinical Assistant Professor of 

Optometry and Chief of the Pediatrics/Binocular 

Vision Clinic at Indiana University. He graduated 

from Indiana University School of Optometry in 

1999, and completed a Residency in Binocular 

Vision/Pediatrics at IU in 1999/2000. 

Page 2 ... Vol. 9, No. 1 ... Spring 2006 ... Indiana Journal of Optometry ..............................................................................

Infants and Toddlers: How to Examine 

Them and What to Expect 

by T. Rowan Candy, Ph.D., and Christy C. Hohenbary, O.D. 

In recent years we have gained a deeper 

understanding of the importance of postnatal 

visual experience in the development of the visual 

system, both in terms of synaptic refinement in the 

visual cortex and control of refractive error during 

growth of the eye. We are now exploring 

strategies for intervention at earlier and earlier 

ages to prevent clinical conditions such as 

refractive esotropia, amblyopia and myopia. As a 

result, we need to focus our efforts on younger and 

younger patients. Hopefully, we can prevent these 

conditions rather than merely treat them when the 

child has failed a vision screening. The goal of this 

piece is to review the procedures and expectations 

for testing very young patients for practitioners who 

might be considering examining this age group. 

We include suggestions to help make these exams 

a positive experience for the patient, parent and 

doctor. 

At What Age Should an Infant Have an Eye 

Examination and How do Infants of Differnt 

Ages Behave? 

The American Optometric Association currently 

suggests that infants should have their first eye 

examination at around six months of age, and then 

be examined again at three years and five years if 

there are no clinical concerns. It so happens that 

six months, three years and five years are typically 

easy times to interact with a child, but parents will 

obviously book an exam at any time if they are 

concerned. Before moving into techniques and 

expectations for the eye examination, we therefore 

want to provide general predictions for how infants 

of different ages will behave and concerns that 

bring them to a primary care office (although not 

included in this list, ocular disease can obviously 

bring them in at any age). 

i) Infants less than 3 months of age typically do 

little more than eat and sleep, with periods of calm 

quiet looking around or crying. If they are crying, 

they are typically hungry, tired or uncomfortable 

and need to be moved around. Parents are often 

worried about a naso-lacrimal duct obstruction 

(NLDO), red eyes, or ‘odd-looking’ eye movements 

at this age. 

ii) Infants become more alert and adventurous 

between 3 and 8 months of age. They are still 

relatively easy to test, however, as they typically sit 

still and want to look at, and reach for, objects. 

They are starting to smile and attend to people. 

Ideally (and typically) they will sit and smile at you. 

Parents bringing an infant of this age have often 

heard that their child should be examined at 6 

months or are worried about NLDO or an ‘eye 

turn’. 

iii) At 8 months things start to get much harder. 

Infants of this age are focused on moving. 

Language is not interesting to them at this point, 

and they just want to move around to explore. 

Holding them in one place is usually not popular. 

To make things worse they are also starting to 

become anxious about strangers and may not let 

you near them. These parents may be concerned 

about NLDO or an eye turn again. 

iv) The nervous wriggling continues until around 

18 months of age, when toddlers start to become 

interested in language. They start to want to sit 

still and listen to people. The examination 

becomes easier again. At this age, parents are 

starting to notice refractive esotropia, or are often 

worried that their child is stumbling or sitting too 

close to the TV. 

v) The average two- to five-year-old is very verbal 

and fun to play with, but developing a will. It is 

important to gently and calmly win them over 

before trying to work with them at this age. They 

may be having an eye examination because they 

have failed a vision screening, or because 

somebody had noticed an eye turn. 

As we start the eye examination we find the 

following general approaches useful: 

i) We will often ask parents if they have a 

photograph of the child showing the eye turn that 

they are concerned about. 

ii) If the concern is that the child gets too close to 

the TV, we ask if the child seems to see things in 

the distance in other environments. 

iii) We hide brightly colored plastic toys in the 

exam room so that we can bring them out as 

something new and exciting whenever necessary 

(and be able to clean plastic after the exam). 

iv) We try to not keep wrigglers waiting before the 

exam as they become harder to test if they are 

bored. 

v) We advise parents that it is just fine if infants 

fall asleep while they are dilating. After gently 

touching the sleeping infant’s head and eyelid, it 

becomes easy to lift the eyelid and complete a 

retinoscopy and fundus examination while the 

infant stays asleep. 

vi) Retinoscopy and a fundus examination may 

also be performed while the infant is eating. A 

bottle is a useful tool to keep the child’s hands 

occupied. 

............................................................ Indiana Journal of Optometry ... Spring 2006 ... Vol. 9, No. 1... page 3

Performing the Eye Examination 

The following section describes the core 

components of the eye examination: binocularity, 

visual acuity, refractive error, and ocular health. 

We will lay out the tests in the order that we 

typically do them and provide the expected results 

as a function of age. 

One of the most important parts of the 

examination is to spend a minute or two at the 

beginning gently talking to/with the child. This 

gives a sense of how comfortable the child is in the 

exam room environment. Holding out a toy will 

reveal how close they are willing to let a stranger 

get - their ‘comfort zone’. Most children will be 

fine, but some become anxious as the toy 

approaches. These children will often not tolerate 

a cover test until late in the exam when they have 

become more relaxed and comfortable. 

History 

Typical infants will probably only be calm and 

cooperative for 10 to 20 minutes, if they are the 

center of attention. The history must therefore be 

gathered briefly, during the exam, or through a 

survey completed by the parent in the waiting 

room. If the parent has a concern, we most often 

hear histories that describe infantile esotropia, 

refractive/accommodative esotropia, intermittent 

exotropia, or incomitant strabismus. In our 

environment it appears that most significant 

pathology presents to the pediatrician, although we 

are always careful to be aware of the occasional 

history of leucocoria in photographs. 

Motility 

Before three months of age infants typically 

have poor smooth pursuit eye movements. They 

will track a bunch of keys with a series of moderate 

amplitude saccades. This is normal. They should 

be able to move their eyes into all positions of 

gaze, however, although their vergence responses 

may appear slow. 

By three to four months infants should produce 

coarsely adult-looking version movements. At a 

year of age it may be hard to get them to track a 

toy on a penlight – they are much more interested 

in watching the examiner’s face than moving to the 

peripheral gaze positions. If necessary, we move 

our faces along with the target to keep their 

attention. It is not uncommon to find incomitant 

strabismus for the first time in toddlers, and so 

versions should be performed on all of these 

patients. It is a good first test, for two reasons: i) 

The child is still a little nervous and so will watch 

the examiner’s every move intently. ii) Versions 

can be made into a fun game that does not 

threaten the child’s spatial comfort zone – it is a 

test that does not require approaching the child. 

Hirschberg & Cover Test 

After completing versions, it is easy to take a 

toy off a penlight and use the penlight to assess 

eye alignment with the Hirschberg test. The first 

Purkinje image reflecting from the cornea should 

be symmetrically positioned in the two eyes, and if 

anything centered 0.5 mm nasally from the center 

of each pupil (due to angle lambda). If the 

reflection is relatively centered in one eye and 

displaced in the other eye the strabismus can be 

estimated using a conversion of 1mm 

displacement to approximately 22 prism diopters of 

deviation. 1 Although it is very hard to detect a 

strabismus of less than 10 prism diopters with this 

test, it is extremely helpful in confirming a 

pseudostrabismus due to epicanthal folds and a 

number of parents are able to understand this 

demonstration that their child’s eyes are fixating 

symmetrically. An estimate of a real strabismus 

can be found by determining how much prism is 

required to move the reflection from its deviated 

location back to the fixating position (0.5 mm 

nasally from pupil center). The prism is placed 

over the eye that is fixating. This is known as the 

Krimsky method. 

The Hirschberg assessment can be confirmed 

with a cover test for children who are comfortable 

with the examiner approaching them. There is 

usually no problem with this, and we find it easiest 

if we introduce a game of ‘peekaboo’. Children are 

comfortable with this word and have an 

expectation that eyes are going to be covered. We 

find that covering and uncovering one of our eyes 

and saying ‘peekaboo’ works wonders. We are 

typically able to calmly approach the infant/child 

and do the same thing. 

A toy on a penlight usually works well for a 

near target, and an assessment at distance can be 

attempted with a flashing light across the room or 

by attracting the child’s attention to a toy over 

there. Some children will do well watching a video 

across a room. Using the video can result in 

problems with getting their attention on to a 

different task for the rest of the exam though. We 

recommend covering the eyes with a hand or a 

thumb rather than a cover paddle, as it is more 

natural and less distracting. 

It is often difficult to assess an infant’s phoria 

with a cover test, but the most important piece is to 

exclude the presence of strabismus. An 

intermittent strabismus before 3 months of age 

may reflect normal infants’ poor control of their eye 

movements. It may only require monitoring if there 

is no sign of significant hyperopia and refractive 

esotropia. Intermittent strabismus at a later age 

needs further work-up. Every child with a history of 

or evidence of intermittent esotropia needs to have 

a cycloplegic refraction. Refractive esotropia 

typically has an onset at around 18 months of age, 

but can appear from around 4 months until 3 or 4 

Page 4 ... Vol 9, No. 2 ... Spring 2006 ... Indiana Journal of Optometry ..............................................................

years of age. It is usually intermittent for a few 

months and then decompensates to a constant 

deviation. Prescribing glasses during the 

intermittent period is typically all that is needed to 

straighten the eyes. The parents do have to be 

warned, however, that the child is still likely to have 

a deviation with the glasses off - the focusing effort 

is reintroduced and linked to convergence. 

A child’s refractive error needs to be greater 

than around +2.50D in order for glasses to be likely 

to have a significant effect on intermittent 

esotropia. Hyperopia of less than this amount is 

typically not a good explanation for the strabismus. 

Some people advocate prescribing the full 

hyperopic refractive error to reduce the 

accommodative demand, while others recommend 

a partial correction to encourage emmetropization. 

The critical point is that children with an intermittent 

deviation must be given enough of their hyperopic 

correction to straighten their eyes completely, and 

prevent a constant deviation. Moderate to high 

hyperopes with an intermittent esotropia usually 

adapt to their glasses in a matter of days at any 

age. They happily wear them full-time. 

Cooperation with full-time wear can be much 

harder if the child has decompensated into a 

constant strabismus. 

While an intermittent esotrope needs 

immediate management because they will 

decompensate rapidly to a constant deviation and 

develop amblyopia, the intermittent exotrope can 

continue for years with their intermittent condition. 

Intermittent exotropia can have an onset in the first 

year of life, and actually be hard to elicit in an 

examination if the infant is controlling it well. The 

reassuring point with these patients is that, if the 

child is straight most of the time, the strabismus 

should not be leading to a loss of binocularity and 

amblyopia. Management of these exotropes, 

therefore, consists of helping them control their 

deviation for as long as possible so that there are 

no consequences for the neural visual system. 

Many of the very young ones can merely be 

monitored until they are old enough to perform 

vision therapy. A constant exotropia before one 

year of age, however, is associated with a higher 

incidence of other neurological conditions and is 

therefore worth referring for further examination 

(especially if there is any question of a pupil 

defect). 2 

Near Point of Convergence 

Telling a toddler that the toy on the penlight is 

going to kiss their nose usually relaxes them and 

allows the examiner to test the near point of 

convergence (NPC). The convergence should look 

responsive and smooth by 4 months of age, 

although the test may need to be performed slowly 

at that age for them to keep up. A normal 

response is approximately 3 to 5 cm. We often 

record NPC for adults as ‘bridge of nose’, however, 

infants have not yet developed a nasal bridge. 

Figure 1. Performing a confrontation visual field test on a 

young infant. The infant’s attention had been attracted to 

the brightly-colored plastic toy held in front of her. The 

target was then brought in from her left peripheral field 

and she turned her head to look at it. 

Pupils 

Infants of less than 3 months may have small 

looking pupils that are relatively unresponsive 

(including to dilation). By five to six months 

however the pupils should be large and very 

responsive. Carefully check for an afferent 

pupillary defect, especially with toddlers, as this 

can reveal neurological pathology that would 

otherwise not be found in the rest of the exam. 

The combination of an exotropia and positive 

afferent pupillary defect should be a red flag and 

result in an immediate referral for further testing. 

Visual field/Confrontation 

The easiest way to test the peripheral visual 

field in an infant or toddler is to have one person sit 

with a central fixation toy. When the patient is 

fixating the target, a second person brings an 

illuminated toy in from the periphery (while 

standing behind the patient’s chair). A finger over 

the end of a penlight is typically sufficient in a dimly 

lit room (Figure 1). The task is to estimate the 

point at which the patient orients to the peripheral 

target. The response will depend heavily on the 

patient’s interest in the central target (how 

distractible they are) in addition to the size of their 

peripheral visual field. Infants will therefore have a 

wide range of apparent visual field sizes while 

having no clinical field defect. This test is most 

informative for detecting asymmetries (e.g., 

hemianopia) in the visual field, when there is a 

question of cortical visual impairment, for example. 

It is helpful to practice this test on a number of 

normal infants first, however, to get a sense of the 

responses to expect. 

Acuity 

The most basic acuity test is to look for an 

occlusion preference on cover test. With practice, 

the strength of a preference can be graded into 

three or four levels. It is worth noting that some 

children dislike having either eye covered, and so it 

is really an asymmetry in avoidance response that 

............................................................ Indiana Journal of Optometry ... Spring 2006 ... Vol 9, No. 1... page 5

should raise concern. The next level of 

sophistication is to note whether the patient will 

fixate a target and track it smoothly (the ‘fix and 

follow’ response). It is much more informative if 

the patient responds to a small detailed target than 

a large internally-illuminated toy that can be 

tracked with poor acuity. 

The most popular acuity tests designed for 

infants are currently the Teller cards, Cardiff cards, 

Lea Symbols, and HOTV letters (Figure 2). In our 

experience, the Teller cards work very well with 

young infants, but infants become bored with them 

at around 9 months of age. At this point, they 

usually do well with the Cardiff cards (which have 

the added interest of shapes to find). When the 

child becomes capable of matching symbols, 

usually at around 2 years, it is an advantage to 

move up to the Lea symbols as they are available 

in a crowded format. Crowded targets are a more 

sensitive test for amblyopia than either resolution 

(Teller or Cardiff cards) or single optotype 

formats. 3, 4 The child will usually proudly progress 

from matching the target to naming the shapes or 

letters at around 2.5 to 3 years of age. A shy older 

child will do much better showing the matching 

shape on the card than naming it however. We 

usually start playing the matching game sitting with 

the acuity test and reference card literally next to 

each other in the patient’s lap, while they gain 

practice and confidence. We then move back 

across the room telling the child that they are so 

good at the game that we will have to go all the 

way over to the other end of the room now to see if 

they can do it there too. It is helpful to start with 

binocular acuities first to get the child acquainted 

with the game before attempting monocular 

acuities. 

One of the big goals of the exam is to record 

monocular acuity values for each child. We use 

three approaches to this: a conventional adhesive 

B 

A 

Figure 2. Acuity tests designed for use with infants and toddlers. 

Panel A – Crowded Lea symbols, with matching card. Panel B – 

Cardiff acuity card, also for use in a preferential-looking protocol. 

Panel C – Teller acuity card for use in a preferential-looking 

protocol. 

occlusion patch, pairs of kids sunglasses that have 

had one lens removed and the other painted black, 

or the palm of a hand. If the patient has glasses, 

we stick an occlusion patch over one lens. If they 

have no glasses, we try the sunglasses first. Many 

young patients are happy to wear them, although 

they tell us that they are broken. If that doesn’t 

work we don’t persevere, as we are likely to upset 

them – we play ‘peekaboo’ with the palm of our 

hand. If that doesn’t work, we try the palm of a 

parent’s hand. If we can still not get a reliable 

monocular acuity measurement because the child 

is fatigued and we are concerned about possible 

amblyopia, we continue with the rest of the exam 

but have the parent bring the child back on a 

different day and test monocular acuities first. 

All of the acuity tests have different visual 

demands, and require different levels of maturity 

from the child. The results are therefore very 

variable across children. Each test comes with 

expected values for the normal population, which 

cover a relatively wide range. Even though a wide 

range of binocular values can be considered 

normal, a reliable difference between the eyes 

should raise concern. If this difference is greater 

than a couple of lines and stable, it is unlikely to be 

due to lack of practice with the test. 

Refraction 

Infants are typically hyperopic at birth. 5 The 

mean refraction is approximately +2.00D and the 

standard deviation is also around 2D. Therefore 

70% of babies will have routine refractions 

between plano and +4.00D at birth. Approximately 

60% of them will also have astigmatism of greater 

than 1.00D with an axis either with- or against-therule. 

Oblique astigmatism is actually relatively rare 

in infants. 6 Although they are typically hyperopic, 

infants less than two months of age tend to overaccommodate 

for distant targets. They focus 

between 30 and 50cm and appear myopic on a dry 

retinoscopy even though they are hyperopic. 

As infants age, they typically lose their 

hyperopia and astigmatism. The mean refraction 

by a year of age is +1.00D with a standard 

deviation of 1.00D. Thus infants tend to undergo 

‘emmetropization’. Although anisometropia is also 

prevalent during infancy, longitudinal studies 7 

suggest that it appears and disappears in an 

individual over time, so small amounts (less than 

approximately 1.50D) 8 can be monitored for a few 

months without prescribing correction. The total 

optical power of the small newborn eye is 

approximately 90D at birth, with a loss of around 

30D to reach 60D in adulthood. There is, 

therefore, a dramatic reconfiguration of the optical 

components of the eye during growth. 

While we are used to seeing hyperopia and 

astigmatism in infancy and typically do not 

prescribe a correction for them (to encourage 

emmetropization), there are obviously some 

Page 6 ... Vol 9, No. 2 ... Spring 2006 ... Indiana Journal of Optometry .............................................................. 

C

patients who are at risk for refractive esotropia 

and amblyopia. What constitutes a high 

hyperopia in infancy? This question is actually 

Age/Error OD MD 

6 Months 4.5 D 5.5D 

2 Years 3.5 D 5.0D 

4 Years 3.0 D 4.5D 

Table 1. The mean level of asymptomatic hyperopia at which the 

ODs and MDs surveyed by Lyons et al. 9 prescribe optical correction 

as a function of age. 

poorly understood at present but being explored 

in studies at IU and in other research 

environments. Lyons et al. 9 surveyed 

optometrists and ophthalmologists to determine 

the amount of asymptomatic hyperopia that they 

typically prescribe for as a function of age. An 

analysis of their results is shown in Table 1. The 

core point is that we have little systematic data 

on the topic, but clinical wisdom suggests we 

prescribe only for amounts greater than 

approximately 5 D at 6 months and 

approximately 4 D at 4 years. 

Which is the easiest way to measure the 

refractive error of an infant? It is helpful to do an 

uncyclopleged retinoscopy even if a cycloplegic 

refraction is going to be done. Seeing how well 

an infant accommodates to a near target reveals 

anisometropia (sweeping both eyes 

simultaneously is very helpful) and how well they 

are coping with their refractive error of potentially 

four or five diopters of hyperopia. A Mohindra 

retinoscopy can also be performed. For this 

technique the room lights are turned off 

completely and the child is encouraged to look in 

the direction of the retinoscope beam (the only 

thing visible in the room), while their other eye is 

covered. The idea is that the retinoscope beam 

forms a poor accommodative target and infants 

will relax their accommodation. They do not 

relax completely and so, although the 

retinoscopy is done at 50cm, a working distance 

compensation of only 0.75D is removed. 10 This 

technique works well, but does require significant 

practice. 

Alternatively one can perform a conventional 

cycloplegic retinoscopy, especially if the eyes are 

going to be dilated anyway for an ocular health 

check. Some pediatric specialists recommend 

using an anesthetic before the cycloplegic drops, 

for the logical reasons of decreasing discomfort 

when the cycloplegic drop is instilled and 

increasing its effect. However, we find for 

patients aged birth to three that it is easiest to 

just use one drop of the cycloplegic in each eye, 

as the child is typically more frustrated by being 

held to put the drop in than by the drop itself. 

They are easily distracted into playing with a toy 

after the drops have been put into the eyes 

quickly and efficiently. We use one drop of 0.5% 

cyclopentolate in each eye at less than 6 months 

of age, and one drop of 1.0% cyclopentolate at 

more than 6 months. Some people use two 

drops in each eye separated by 5 minutes, while 

others use tropicamide – preferences vary. 11 

After playing with toys in the waiting room 

while the drops take effect a small number of 

patients will be upset with the prospect of coming 

back into the exam room. If this happens, it is 

much easier to take them into any other dark 

room to perform retinoscopy and the health 

check than to deal with their anxiety in the real 

exam room. Infants and toddlers will usually 

tolerate 3 to 4 lenses being held in front of their 

eye (particularly if they are described as ‘magic 

windows’, and the lenses are allowing them to 

see in their cyclopleged hyperopic state). The 

most efficient strategy is therefore to estimate the 

refraction from the uncorrected retinoscopy reflex 

and then take large jumps in lens power (2 or 3D 

steps) to bracket the neutral point. If the patient 

cooperates the neutralization is performed 

precisely, while if they become uncooperative the 

bracketing provides a good estimate. 

Health check 

Once the refraction has been determined, the 

health of the eyes can be assessed. This can be 

achieved using a hand-held slit lamp or 

combination of transilluminator and 20D lens for 

the anterior segment, and a monocular or 

binocular indirect ophthalmoscope for the 

posterior segment (use of a direct 

ophthalmoscope requires practice). The 

youngest infants often don’t dilate fully, but 

should still be manageable. It is not possible to 

routinely examine the peripheral fundus in 

infants, and any infant requiring a rigorous 

peripheral exam should be referred for 

examination under anesthesia. It is important to 

see the posterior pole, however, and the nerve 

and macula area should be examined in every 

case. Significant pathology is relatively rare in 

infancy fortunately, but is still often only detected 

at the stage of a leucocoria in a flash photograph 

unfortunately. Detecting pathology prior to that 

time is a critical goal. 

Excessive tearing is one of the most common 

parental concerns with infants. The most 

common cause of tearing is NLDO. A good 

number of cases of NLDO will spontaneously 

resolve within in the first year and referral 

strategies vary according to the preference of the 

pediatric ophthalmologist. Some prefer to see 

infants while they are around 6 months of age, 

for an in-office procedure, while others prefer to 

wait in the hope that it will resolve but then need 

to anesthetize the older infant to do the 

...........................................Indiana Journal of Optometry ... Spring 2006 ... Vol 9, No. 1... page 7

procedure. It is important to remember that 

excessive tearing can also be a sign of infantile 

glaucoma, particularly in the presence of 

photophobia, megalocornea, myopia and corneal 

clouding. Infants with a number of these signs will 

need to have their IOP checked. 

Retinopathy of prematurity (ROP) is more 

common again now, as babies of lower and lower 

birthweight are surviving. This is a disruption of 

the growth of the retinal vasculature as it reaches 

the peripheral retina near the end of gestation. 

Infants at risk for ROP should have had their 

peripheral fundus examined before leaving 

hospital. If they are found to have the condition, 

they should have been or should be managed 

within the ophthalmological setting. The condition 

is usually only active for a few months after birth. 

The risk of retinoblastoma sometimes 

discourages optometrists from examining infants. 

This condition is currently being detected most 

often as leucocoria, 2 however. We can do better 

than this. Retinoblastoma has an average age at 

presentation of between one and three years for 

sporadic monocular cases and around 12 months 

for binocular and familial cases. It is relatively rare 

(1 in 15,000) and so it is only by examining large 

numbers of infants that we will be able to find and 

help these patients. 

Summary 

In summary 90 to 95% of infants and toddlers 

have no clinical abnormalities and may follow the 

schedule of routine checks. Other infants with 

externally obvious conditions (e.g., NLDO, 

strabismus, leucocoria) will hopefully be taken for 

an examination by their caregivers. The hardest 

questions currently involve conditions such as 

anisometropia and amblyopia, which are not 

externally obvious. There is much discussion 

about the ways in which to find these children, and 

potentially how to prevent these conditions. Even 

if a child is not going to be taken for an eye 

examination, we try to impress upon the public the 

idea that a game of covering one eye after the 

other and comparing vision in the two eyes is a 

very valuable exercise. 

We have attempted to provide enough 

information here to perform a ‘hassle-free’ infant 

eye examination, and hope that some ODs might 

feel comfortable doing this. If a clinical abnormality 

is found, we usually have an initial follow-up 

schedule centered on visits every 6 weeks or so 

until the situation becomes stable. Particularly if 

an optical correction has been prescribed. Six 

weeks of full-time glasses wear is a good initial 

adaptation period after which strabismus can be 

reassessed, or, if the patient is not willing to wear 

the glasses this is a good time to check in with the 

family and provide help, moral support and 

encouragement. The last thing we want to happen 

is for a family to decide that glasses or patching 

are not going to work and find months later that 

they have stopped trying. 

References 

1. Brodie SE. Photographic calibration of the 

Hirschberg test. Invest Ophthalmol Vis Sci 

1987;28:736-42. 

2. American Academy of Ophthalmology Basic and 

Clinical Science Course. Volume 6: LEO; 2004. 

3. Morad Y, Werker E, Nemet P. Visual acuity tests 

using chart, line, and single optotype in healthy and 

amblyopic children. J Am Assoc Ped Ophthalmol 

Strab 1999;3:94-7. 

4. Rydberg A, Ericson B, Lennerstrand G, Jacobson L, 

Lindstedt E. Assessment of visual acuity in children 

aged 1 1/2-6 years, with normal and subnormal 

vision. Strabismus 1999;7:1-24. 

5. Mayer DL, Hansen RM, Moore BD, Kim S, Fulton 

AB. Cycloplegic refractions in healthy children aged 

1 through 48 months. Arch Ophthalmol 

2001;119:1625-8. 

6. Saunders KJ. Early refractive development in 

humans. Surv Ophthalmol 1995;40:207-16. 

7. Almeder LM, Peck LB, Howland HC. Prevalence of 

anisometropia in volunteer laboratory and school 

screening populations. Invest Ophthalmol Vis Sci 

1990;31:2448-55. 

8. American Academy of Ophthalmology. Preferred 

Practice Pattern - Pediatric Eye Evaluations; 2002. 

9. Lyons SA, Jones LA, Walline JJ, Bartolone AG, 

Carlson NB, Kattouf V, Harris M, Moore B, Mutti DO, 

Twelker JD. A survey of clinical prescribing 

philosophies for hyperopia. Optom Vis Sci 

2004;81:233-7. 

10. Saunders KJ, Westall CA. Comparison between 

near retinoscopy and cycloplegic retinoscopy in the 

refraction of infants and children. Optom Vis Sci 

1992;69:615-22. 

11. Twelker JD, Mutti DO. Retinoscopy in infants using a 

near noncycloplegic technique, cycloplegia with 

tropicamide 1%, and cycloplegia with cyclopentolate 

1%. Optom Vis Sci 2001;78:215-22. 

A profile of Dr. Candy and her work at Indiana 

University can be found in this issue. Dr. Hohenbary 

is a 2003 graduate of Indiana University School of 

Optometry. She completed a residency in pediatrics 

and binocular vision at Indiana University in 2003- 

2004. She currently is at Effingham Ophthalmology 

Associates of Effingham, Illinois. 

Page 8 ... Vol 9, No. 1 ... Spring 2006 ... Indiana Journal of Optometry ...........................................................

Clinical Theory: Use of Dynamic Retinoscopy to 

Determine Changes in Accommodative Response 

with Varying Amounts of Plus Add 

by David A. Goss, O.D. Ph.D., and Danielle F. Warren, O.D. 

Dynamic retinoscopy is a useful clinical 

procedure for assessing accommodative 

response. And it is commonly used for prescribing 

plus adds for nearpoint vision disorders. Probably 

the most commonly used form of dynamic 

retinoscopy is the monocular estimation method 

(MEM). 1 Another common dynamic retinoscopy 

procedure is the low neutral method (LN). 2 

With MEM retinoscopy, the amount of lag or 

lead of accommodation is estimated while patients 

view a nearpoint target through lenses which are 

usually equal in power to their subjective refraction. 

On LN retinoscopy, plus lenses are added 

binocularly until the first neutral reflex is observed. 

Therefore, MEM retinoscopy, as it is typically 

performed, yields the lag (or lead) of 

accommodation at one accommodative stimulus 

level. And LN retinoscopy determines the 

accommodative stimulus level at which 

accommodative response and accommodative 

stimulus are equal – again only one 

accommodative stimulus level. 

It would be helpful to the practitioner to know 

how patients respond to plus adds. Therefore, it 

would be advantageous to know how 

accommodative response changes with the 

changes in accommodative stimulus produced by 

plus adds. This could easily be done in the clinical 

setting by performing MEM retinoscopy not only 

through the subjective refraction lenses, but also 

through varying amounts of plus add. Haynes 3 

referred to that as a combined MEM-LN procedure. 

Tassinari 4 has described what he calls a MEMtwice 

procedure to evaluate response to plus adds. 

This paper will review the work by Haynes and 

Tassinari and will present some preliminary data 

on the use of dynamic retinoscopy to find 

accommodative response with varying amounts of 

plus add. 

Haynes’ MEM-LN procedure 

Haynes 3 suggested that MEM could be 

performed first with the subjective refraction lenses 

and then with increasing amounts of plus until 

neutral and then “against” motion was observed. 

MEM performed with the subjective refraction 

lenses would be the typical manner in which MEM 

is performed. The amount of plus at which neutral 

is first observed would be the low neutral finding – 

thus the acronym MEM-LN for the procedure. 

Haynes presented seven patterns of results 

which were obtained with MEM-LN with subjects 

looking at letters 40 cm from them. Because the 

target was at 40 cm, the accommodative stimulus 

was 2.50 D when subjects were viewing through 

their subjective refraction lenses, 2.25 D when 

viewing through a +0.25 D add, 2.00 D when 

viewing through a +0.50 D add, and so on. MEM 

retinoscopy was performed with the different lens 

powers in place. A 0.25 D “with” motion indicated 

Retinoscopy findings with varying plus add powers in diopters 

(Accommodative stimulus in diopters in parentheses) 

Patient 0 +0.25 +0.50 +0.75 +1.00 +1.25 +1.50 +1.75 +2.00 +2.25 

pattern (2.50) (2.25) (2.00) (1.75) (1.50) (1.25) (1.00) (0.75) (0.50) (0.25) 

A 0.25W 0.25W 0.25W 0.12W N 0.25A 0.50A 

B 0.25W 0.12W N N 0.12A 0.25A 0.50A 

C 1.00W 0.75W 0.50W 0.25W N 0.25A 0.50A 

D 1.00W 0.75W 0.50W 0.25W N 

E 0.75W 0.50W 0.50W 0.50W 0.50W 0.25W 0.25W 0.25W N 0.25A 

F 1.50W 1.50W 1.50W 1.25W 1.00W 0.75W 0.50W 0.25W N 0.25A 

G 2.00W 1.75W 1.50W 0.37W 0.37W 0.25W 0.25W N 0.25A 

Table 1. Patterns of change in accommodative response with plus adds as determined by Haynes 3 with the MEM-LN procedure. W indicates with 

motion on dynamic retinoscopy and A indicates against motion, so, for example, 0.25W indicates 0.25 D of with motion. N indicates a neutral 

retinoscopy motion. 

....................................................................Indiana Journal of Optometry ... Spring 2006 ... Vol 9, No. 1 ... page 9

that the accommodative response was 0.25 D less 

than the accommodative stimulus. A neutral reflex 

indicated that accommodative response and 

accommodative stimulus were equal, and a 0.25 D 

“against” motion indicated that the accommodative 

response was 0.25 D greater than the 

accommodative stimulus. 

Table 1 is a table with the findings that Haynes 

presented as seven patterns of MEM-LN results. 

Haynes gave these patterns as examples, with 

only a few occasional passing comments 

concerning how common the patterns were. 

Further he did not state whether he thought these 

patterns were representative of the entire 

population, or whether some patients have other 

patterns. He considered patterns A and B to 

represent “normal to superior accommodative 

behavior,” patterns C, D, F, and G to represent 

findings in accommodative dysfunctions, and 

pattern E to be a marginal case. Such conclusions 

Figure 1. The plot of 

accommodative response (AR) 

as a function of accommodative 

stimulus (AS) for Haynes’ case 

A. The units for 

accommodative stimulus and 

accommodative response are 

diopters. The diagonal line 

from lower left to upper right is 

a 1:1 line indicating points 

where AR and AS would be 

equal. Points on the 1:1 line 

would be points where neutral 

was observed on retinoscopy, 

points below it would indicate 

where with motion was 

observed, and points above it would be points where there was against motion. 

The dioptric distance of a given point from the 1:1 line would indicate the 

amount of retinoscopy motion. 

Figure 2. The AR/AS plot 

for Haynes’ case C. The units 

for accommodative stimulus 

and accommodative response 

are diopters. The diagonal 

line from lower left to upper 

right is a 1:1 line indicating 

points where AR and AS 

would be equal. 

Figure 3. The AR/AS plot 

for Haynes’ case D. The units 

for accommodative stimulus 

and accommodative response 

are diopters. The diagonal line 

from lower left to upper right is 

a 1:1 line indicating points 

where AR and AS would be 

equal. 

could be reached by simply looking at the MEM 

with 0 add: the lag of accommodation is normal in 

A and B; high in C, D, F, and G; and marginal in E. 

However, Haynes suggested that the lag by itself 

would not predict the response to plus lenses (nor 

would the low neutral by itself), because different 

individuals change accommodation differently in 

response to plus lenses. In other words, slopes of 

the accommodative response/accommodative 

stimulus (AR/AS) curve are variable from one 

person to another. 

Figures 1-3 show the findings of some of these 

cases in the form of graphs of accommodative 

response as a function of accommodative stimulus. 

Figure 1 shows the graph for case A. The lag of 

accommodation through the subjective refraction is 

0.25 D. Accommodative response decreases by 

0.25 D for the 0.25 D step reduction in stimulus 

from the subjective to a +0.25 D add and then to a 

+0.50 D add. The low neutral finding is +1.00 D, 

so the accommodative response and 

accommodative stimulus are equal at 1.50 D. 

Figures 2 and 3 show the graphs for cases C 

and D, respectively. Both have lags of 

accommodation of 1.00 D through the subjective 

refraction. However, in case C, the amount of with 

motion decreases by 0.25 D for each 0.25 D 

increase in plus add. In other words, the slope for 

case is zero, as can be seen in Figure 2. Because 

the slope is zero, the low neutral is equal to the lag 

through the subjective refraction (+1.00 D). In 

case D (Figure 3), accommodative response 

decreases with the addition of plus up to +1.00 D, 

and the low neutral finding is +1.50 D. 

Haynes noted that different criteria for 

prescribing nearpoint plus adds can be applied to 

dynamic retinoscopy results. He used four 

example criteria: (1) plus add equal to the MEM 

lag, (2) plus add which yields a 0.50 D with motion 

on MEM, (3) plus add to low neutral minus 0.87 D, 

and (4) the low neutral finding minus 0.37 D, to 

show that the plus adds derived from these four 

methods differed from each other for a given 

patient in an unpredictable manner (except for 

criteria 3 and 4). 3 The reason that the results of 

the criteria do not show a repeatable relationship to 

each other is because the slope of the 

accommodative response to accommodative 

stimulus curve varies from one patient to another. 

Haynes did not go as far as suggesting the 

criterion that would be most likely to improve 

patient accommodative function. 

As an interesting aside, Haynes’s case G 

appears to correspond to what is often called the 

pseudo convergence insufficiency case type, in 

Page 10 ... Vol 9, No. 1 ... Spring 2006 ... Indiana Journal of Optometry ..............................................................................

which there is an abnormally high exophoria at 

near due to a very low accommodative response. 

The increase in accommodative response with a 

plus add in case G would explain the observation 

of clinicians that the near point of convergence 

improves with a plus add in pseudo convergence 

insufficiency. 5 

Tassinari’s MEM-twice procedure 

Tassinari 4 reported results on 211 nonpresbyopic 

patients with what he called an MEMtwice 

procedure. MEM was performed first with 

the distance subjective refraction lenses in place 

and then with lenses derived on the basis of the 

binocular cross cylinder (BCC) test. When the 

BCC finding was +0.50 D or more over the 

subjective refraction, the add for the second MEM 

test was equal to the BCC finding. When the BCC 

was +0.25 D or less, the add for the second MEM 

retinoscopy was +0.50 D. The most commonly 

used add was +0.75 D (121 patients). Fifty-seven 

patients were tested with a +1.00 D add. The 

highest add used was +1.50 D (5 patients). 

Tassinari observed that a plus add could affect 

accommodative response in one of four ways: 

• Type 1 response: Accommodative response 

decreases an amount equal to the power of the 

plus add. In this type of response, the slope of the 

AR/AS curve would be 1 between the two points in 

question. 


decreases by an amount less than the power of the 

plus add. Here the slope of the AR/AS function 

would be less than 1 but greater than 0. 


does not change with the plus add. In this type of 

response, the AR/AS slope would be 0 between 

the two AS points. Haynes’ case C would fit into 

this response type. 


increases with the plus add. Here, the AR/AS 

curve slope would be negative. Haynes’ case G 

would fit into Tassinari’s Type 4 response. 

The 211 patients in Tassinari’s paper were 6 to 

37 years of age, with 169 of them 6 to 20 years 

old. Tassinari found a mean lag of accommodation 

of 0.35 D (SD=0.34 D) through the distance 

subjective refraction. One hundred sixty patients 

had lags of accommodation ranging from 0.25 to 

1.75 D, 39 patients had no lag or lead, and 12 had 

a lead of accommodation. Thirty-six patients had a 

lag of 0.75 D or greater. The median and mode 

MEM with the distance subjective refraction were 

both a lag of 0.25 D. 

The mean plus add used for the second MEM 

was +0.82 D. The mean decrease in 

accommodative response to the plus add was 0.51 

D. Tassinari noted that the mean decrease in 

accommodative response expressed as a 

percentage of the mean plus add power was 62%. 

The most common response type was the 

Type 2 response, observed in 146 (69%) of the 

patients. A Type 1 response was found in 50 

(24%) of the patients. A type 3 response was 

observed in 15 patients (7%). Tassinari did not 

find any Type 4 responses in the 211 patients. 

Based on the mean + 1 SD of the MEM with 

the distance refraction, Tassinari established 0 to 

0.70 D as a normal range for the lag of 

accommodation. Thirty-six patients had a high lag. 

When those patients were tested with the plus add 

based on the BCC, 25 (69%) then had a normal 

lag, 9 (25%) still had a high lag, and 2 (6%) had a 

lead. Thus, if a normal lag is the desired endpoint, 

MEM might have to be repeated with additional 

plus lens powers. 

Tassinari suggested that “The MEM-twice 

procedure could be used as one test among 

several in the ultimate determination of prescribing 

a plus lens addition and its amount. A useful line 

of research would be to investigate which test or 

tests are the best predictor of a successful plus 

lens addition.” 

Introduction to a Preliminary Study 

There is no one firmly established guideline for 

prescribing plus lens adds from dynamic 

retinoscopy. One common approach is to subtract 

some set amount from the MEM lag, as for 

example, prescribing a plus add with a power 

which is 0.25 D less than the amount of the lag 

through the distance refraction. Similarly, some 

amount, such as 0.50 D, could be subtracted from 

the low neutral finding. However, neither the MEM 

as it is usually performed (through only one lens 

power) nor the LN by itself tells us how the patient 

responds to other lens powers. In other words, 

each test represents only one point on the AR/AS 

function. 

Research approaches that might lead to more 

authoritative prescribing guidelines could include 

collecting more data with the Haynes MEM-LN 

procedure to better understand the variability in 

patient responses to plus adds and investigating 

lens powers which yield patient preference or best 

patient performance. The following describes a 

preliminary study on a small sample of subjects. 

The study consisted of two parts. In one part 

testing was done with the Haynes MEM-LN 

procedure. Another part involved having subjects 


indicate preferences of lenses derived from 

arbitrary MEM and LN criteria. 

Methods 

Twenty subjects were recruited from a 

population of optometry students. Ages ranged 

from 23 to 28 years. All subjects were required to 

have vision correctable to 20/20 at distance and 

near, without strabismus (confirmed by cover test), 

prior to participation. All subjects had an eye and 

vision examination in the previous year and 

reported not having any ocular disease discovered. 

The protocols of this study were approved by the 

Indiana University Human Subjects Committee, 

and all subjects were provided informed consent in 

order to participate. 

The Haynes MEM-LN retinoscopy procedure 

was performed with a Welch Allyn streak 

retinoscope. That is, MEM was performed through 

the subject’s distance prescription and then 

through varying amounts of plus add. Subjects 

wore the habitual prescription that was prescribed 

at their last eye and vision examination. Subjects 

who did not have glasses or contact lenses with 

them when they presented for the testing were 

refracted and their subjective refraction lenses 

were placed in a trial frame during the experiment. 

The retinoscope was placed 40 cm from the 

subject’s spectacle plane. The examiner estimated 

the dioptric value of the observed motion as the 

subjects viewed words on a magnetized nearpoint 

card (20/40, adult level words) attached to the 

retinoscope. The subjects viewed the words 

binocularly and read the words aloud. The 

examiner confirmed the estimate of the retinoscopy 

motion by inserting a neutralizing lens for less than 

one second. That confirming lens was in place for 

less than a second to decrease the likelihood of 

the lens affecting the accommodative response by 

becoming part of the stimulus. 

Then MEM was done through each of several 

plus adds. Plus sphere lenses were added 

binocularly, in 0.25 D steps until the first neutral 

was observed and then until the second against 

motion reflex was observed or until testing with a 

+2.00 D add was completed. The stimulus was a 

20/40 paragraph set at 40 cm that the subject was 

asked to read aloud as the MEM-LN procedure 

was performed. The interocular differences in 

accommodative responses were judged to be less 

than 0.25 D throughout the experiment for all 

subjects. 

In the lens comparison part of the study, a 

separate MEM retinoscopy was performed on the 

same subjects. MEM was performed with subjects 

viewing through the distance prescription. The 

same test target and target distance was used as 

in the first phase of the study. After the 

Table 2. Patterns of 

change in accommodative 

response with plus adds as 

determined in the present 

preliminary study with the 

MEM-LN procedure. W 

indicates with motion on 

dynamic retinoscopy and A 

indicates against motion, 

so, for example, 0.25W 

indicates 0.25 D of with 

motion. N indicates a 

neutral retinoscopy motion. 

Retinoscopy findings with varying plus add powers in diopters 

(Accommodative stimulus in diopters in parentheses) 

0 +0.25 +0.50 +0.75 +1.00 +1.25 +1.50 +1.75 +2.00 

Sub. (2.50) (2.25) (2.00) (1.75) (1.50) (1.25) (1.00) (0.75) (0.50) 

1 0.25W 0.25W N 0.25A 0.25A 0.50A 

2 0.50W 0.50W 0.25W 0.25W 0.25W N N 0.25A 0.50A 

3 0.75W 0.5W 0.25W N N N N 0.25A 0.25A 

4 0.25W 0.25W 0.25W N N 0.25A 

5 0.25W 0.25W 0.25W N N N 0.25A 0.25A 0.50A 

6 0.75W 0.50W 0.50W 0.25W N N N 0.25A 

7 0.25W N 0.25A 

8 0.25W 0.25W 0.25W 0.25W N N 0.25A 

9 0.75W 0.50W 0.25W 0.25W N N 0.25A 

10 0.50W 0.25W 0.25W N N N 0 0.25A 

11 1.00W 0.75W 0.50W 0.25W 0.25W N N N 0.25A 

12 0.75W 0.50W 0.25W N N 0.25A 

13 0.50W 0.25W 0.25W N 0.25A 

14 0.50W 0.25W 0.25W N N N N 0.25A 

15 1.00W 0.75W 0.75W 0.50W 0.50W 0.25W 0.25W N N 

16 1.00W 0.75W 0.50W 0.25W 0.25W N N N 0.25A 

17 0.50W 0.25W 0.25W N N N 0.25A 

18 0.50W 0.25W 0.25W N N N 0.25A 

19 0.50W 0.25W 0.25W N N N 0.25A 

20 0.50W 0.25W 0.25W N N N 0.25A 


etinoscopy procedure was completed, nearpoint 

test lenses were determined from the subject’s 

response to the retinoscopy procedures. The 

nearpoint lenses were determined by subtracting 

0.25 D from the MEM through the distance 

prescription lenses and 0.37 D from the LN 

endpoint from the first phase of the study. A 

control nearpoint add of 0.12 D was also used for 

comparison. Subjects were asked to read 

newspaper print with each of the three nearpoint 

adds over their habitual distance prescriptions. 

The lenses were presented in random order as 

subjects were given a one question questionnaire 

that asked “which of the lenses, did you feel, made 

the print the clearest and/or made you feel the 

most comfortable?” The lenses were labeled A, B 

and C and presented to the subjects in a random 

order. The subjects put the lenses in order from 1 

to 3, with 1 being the clearest/most comfortable 

and 3 being the least clear/comfortable. 

Results 

Individual subject results for the Haynes MEM- 

LN part of the study are summarized in Table 2. 

The individual AR/AS plots were mostly quite 

similar to Haynes’ patterns A, B, and E. The mean 

MEM through the distance prescription was 0.56 D 

(SD=0.25). The mean low neutral was 0.88 D 

(SD=0.32). An AR/AS plot of the mean responses 

at the different stimulus levels is shown in Figure 4. 

The AR/AS slopes determined by linear regression 

for individual subjects varied from 0 (subject 7) to 

0.68 (subject 8). The mean AR/AS slope was 0.49 

Figure 4. Mean 

accommodative 

responses for the 20 

subjects in the 

present study. 

(SD=0.17). The Pearson correlation coefficient of 

AR with AS was over 0.92 for 17 of the 20 

subjects. The AR/AS slopes in the other three 

subjects were 0 (subject 7), 0.23 (subject 12), and 

0.30 (subject 13). The slopes in the 17 subjects 

with correlation coefficients over 0.9 averaged 0.54 

(SD=0.09), and ranged from 0.37 (subject 1) to 

0.68 (subject 8). 

The individual results from the lens comparison 

part of the study are summarized in Table 3. The 

mean MEM with the distance prescription in this 

part of the study was 0.65 D (SD=0.31). Fourteen 

subjects had lags between 0.25 and 0.75 D. MEM 

lags within this range are typically considered to be 

normal or close to normal. 1,6-8 Of the fourteen 

subjects with normal lags, five preferred the MEM- 

0.25 D add over the other two adds, two preferred 

LN-0.37 D, and seven preferred the 0.12 D control 

add. However, for subjects within this normal lag 

range, the lenses being compared were frequently 

0.25 D or less different from each other. Six 

subjects had lags of 1.00 and 1.25 D. Of these six 

subjects, four preferred the MEM-0.25 D add over 

Subject MEM LN MEM-0.25 LN-0.37 ADD Preferred 

1 0.50 0.50 0.25 0.12 MEM-0.25 

2 0.50 1.25 0.25 0.87 MEM-0.25 

3 1.25 0.75 1.00 0.37 MEM-0.25 

4 0.25 0.75 0 0.37 LN-0.37 

5 0.25 0.75 0 0.37 0.12D CONTROL 

6 0.75 1.00 0.50 0.62 LN-0.37 

7 0.25 0.25 0 -0.12 0.12D CONTROL 

8 0.25 1.00 0 0.62 MEM-0.25 

9 0.75 1.00 0.50 0.62 0.12D CONTROL 

10 1.50 0.75 0.25 0.37 0.12D CONTROL 

11 1.00 1.25 0.75 0.87 MEM-0.25 

12 1.00 0.75 0.75 0.37 LN-0.37 

13 0.50 0.75 0.25 0.37 MEM-0.25 

14 1.00 0.75 0.75 0.37 0.12D CONTROL 

15 1.00 1.75 0.75 1.37 MEM-0.25 

16 1.00 1.25 0.75 0.87 MEM-0.25 

17 0.50 0.75 0.25 0.37 012D CONTROL 

18 0.75 0.75 0.50 0.37 0.12D CONTROL 

19 0.25 0.75 0.25 0.37 0.12D CONTROL 

20 0.50 0.75 0.25 0.37 MEM-0.25 

Table 3. Data for the subject plus add 

preference comparison. The three adds 

compared were MEM-0.25 D, LN- 

0.37 D, and a 0.12 D control add. 


the others, one preferred the LN-0.37 D add, and 

one preferred the 0.12 D add. While the sample 

size is obviously too small to draw any 

conclusions, it appears that there might be a trend 

toward preference of the MEM-0.25 D add in these 

higher lag cases where the use of nearpoint plus 

add would be more likely. 

Discussion 

The mean AR/AS slope of about 0.5 from the 

present study can be compared to the finding of 

Tassinari of the mean change in accommodation 

being 62% of the mean plus add power. While the 

range of lens powers over which testing was done 

was greater in the present study than in Tassinari’s 

study, it is apparent that during dynamic 

retinoscopy accommodative response changes on 

average only about half or little more of the amount 

of added lens power. There was quite a bit of 

variability in the slopes in the present study, with 

the range being 0 to 0.68. 

The repetition of MEM retinoscopy with plus 

adds after it is done in the traditional manner with 

the distance refraction can provide the examiner 

with information on how the patient responds to 

plus adds. The patterns published by Haynes, the 

data from Tassinari, and the data from the present 

preliminary study show that individuals differ in 

how much they change accommodation in 

response to a given power plus lens add. This has 

implications for the prescription of nearpoint plus 

adds from dynamic retinoscopy. 

A common guideline for prescription of plus 

adds from MEM retinoscopy is to subtract 0.25 D 

from the lag. Repetition of MEM with plus adds 

could provide further information to the practitioner. 

One approach could be to prescribe an add which 

would make the motion on MEM be within the 

normal range of lags of accommodation. 

Birnbaum 9 recommended prescribing the plus add 

that would result in the 0.12 to 0.50D with motion 

that he considered to be normal on MEM. The 

plus add to be prescribed can also be refined by 

observing effects on performance measures such 

as reading performance, eye movements, or 

stereopsis. 10-12 The familiar refrain that further 

study is needed appears to apply to this topic. 

lens power determination. Am J Optom Physiol 

Opt 1985;62:375-385. 

4. Tassinari JT. Change in accommodative 

response and posture induced by nearpoint plus 

lenses per monocular estimate method 

retinoscopy. J Behav Optom 2005;16:87-93. 

5. Richman JE, Cron MT. Guide to Vision Therapy. 

South Bend, IN: Bernell corporation, 1987:17-18. 

6. Cooper J. Accommodative dysfunction. In: 

Amos JF, ed. Diagnosis and Management in 

Vision Care. Boston: Butterworths, 1987:431- 

459. 

7. Daum KM. Accommodative response. In: 

Eskridge JB, Amos JF, Bartlett JD, eds. Clinical 

Procedures in Optometry. Philadelphia: 

Lippincott, 1991:677-686. 

8. Tassinari JT. Monocular estimate method 

retinoscopy: central tendency measures and 

relationship to refractive status and 

heterophoria. Optom Vis Sci 2002;79:708-714. 

9. Birnbaum MH. Optometric Management of 

Nearpoint Vision Disorders. Boston: Butterworth- 

Heinemann, 1993:173. 

10. Sohrab-Jam G. Eye movement patterns and 

reading performance in poor readers: 

immediate effects of convex lenses indicated 

by book retinoscopy. Am J Optom Physiol Opt 

1976;53:720-726. 

11. Apell RJ. Performance test battery: A very 

useful tool for prescribing lenses. J Behav 

Optom 1996;7:7-10. 

12. Saladin JJ. Stereopsis from a performance 

perspective. Optom Vis Sci 2005;82:186-205. 

References 

1. Saladin JJ. Phorometry and stereopsis. In: 

Benjamin WJ, ed. Borish’s Clinical Refraction. 

Philadelphia: Saunders, 1998:724-773. 

2. Grosvenor T. Primary Care Optometry, 4th ed. 

Boston: Butterworth-Heinemann, 2002:242. 

3. Haynes HM. Clinical approaches to nearpoint 

Page 14... Vol 9, No. 1 ... Spring 2006 ... Indiana Journal of Optometry ..............................................................................

Book Review: Phantoms in the Brain: Probing the 

Mysteries of the Human Mind. 

Reviewed by Craig Andrews, O.D. 

Phantoms in the Brain: Probing the Mysteries of the Human Mind. V.S. Ramachandran 

and Sandra Blakeslee. New York, NY: Harper Collins, 1998. Pages: 328. Paperback. Price: 

$16.00. ISBN 0-688-17217-2. 

The primary author, V.S. Ramachandran, M.D., 

Ph.D., is a neuroscientist who is Professor and 

Director of the Center for Brain and Cognition at 

the University of California, San Diego. 

Ramachandran is a story teller who weaves his 

tales with humor and insights. Newsweek lists him 

as one of the one 

hundred most important 

people to watch in the 

next century. 

Ramachandran has 

spoken to at least one 

optometric audience, at a 

meeting of NORA 

(Neurological Optometric 

Rehabilitation 

Association). The 

second author, Sandra 

Blakeslee, is a science 

writer for The New York 

Times. 

The book thoroughly discusses modern 

concepts of vision and neurology and their 

anatomical basis. Twelve chapters deal with topics 

such as “phantom limbs” and his experiments on 

visual treatments of their pain, blindsight where 

one has usable vision without a cortex, motion 

blindness and V4, Charles Bonnet syndrome seen 

in many older patients who visually hallucinate, 

hemi-neglect, Capgras’ syndrome where a patient 

believes his parents are imposters, and other 

syndromes. The author presents case histories 

and his hypotheses for each of these interesting 

areas. Finally, the author develops his theory of 

consciousness. 

The publishers give the following apt 

description of the book: “A brilliant ‘Sherlock 

Holmes’ of neuroscience reveals the strangest 

cases he has solved – and the insights they yield 

about human nature and the mind…. Dr. 

Ramachandran uncovers answers to deep and 

quirky questions of human nature that few 

scientists have dared to address, including why we 

laugh or become depressed; how we make 

decisions, deceive ourselves, and dream; why we 

may believe in God; and more….” Nobel laureate 

Francis Crick wrote that: “This is a splendid 

book…If you are interested in how your brain 

works, this is a book you must read.” 

Ramachandran has been compared to 

neurologist Oliver Sacks, who is noted for 

authorship of such books as Awakenings, The Man 

Who Mistook His Wife for a Hat, and A Leg to 

Stand On. Sacks contributed a foreword to this 

book. The book contains a bibliography and 

suggested reading list. 

Dr. Andrews graduated from optometry school 

at IU in 1979. He started the Salem Eye Clinic 

in Salem, IL, which is now a five doctor office. 

He is also the President of Bernell Corporation 

(Mishawaka, IN; 800-348-2225). He and his 

optometry school classmate, Charlie Shearer, 

of Mishawaka, resurrected the company in 1997 

when a bank was going to close its doors. 

Andrews notes that “Bernell sells this book, 

but you can also get it elsewhere.” 


Review: Recent Studies on Convergence 

Insufficiency Treatments and Associations 

by David A. Goss, O.D., Ph.D. 

Convergence insufficiency (CI) is a common 

clinical condition which can cause eyestrain 

symptoms, occasional diplopia, and blurred vision 

during near work activities. It is characterized by a 

high exophoria at near, receded near point of 

convergence, and reduced base-out vergence 

ranges at near. There have been several studies 

on convergence insufficiency published in the last 

three or four years. This short review will briefly 

summarize some of the best and most provocative 

of those studies. 

Association with Attention Deficit Hyperactivity 

Disorder (ADHD) 

A study headed by David Granet, an 

ophthalmologist at the University of California, San 

Diego (UCSD), suggested an association of 

convergence insufficiency with ADHD. 1 Granet 

and his coauthors did a chart review of 266 

patients that had been diagnosed with 

convergence insufficiency by the first author in his 

academic pediatric ophthalmology practice. 

Twenty-six of those patients (9.8%) had a history 

of ADHD. Twenty-one of the 26 were male. 

Twenty of the 26 were using some medication for 

ADHD at the time that CI was diagnosed. The 

authors noted that the 9.8% prevalence of ADHD 

in patients with convergence insufficiency was 

much higher than the 1.8 to 3.3% prevalence of 

ADHD in the general population of the United 

States. 

The authors also searched the UCSD 

electronic patient database for patients with a 

diagnosis of ADHD. There were records of eye 

examinations for 176 of those patients. Of those 

176 patients, 28 (15.9%) had a diagnosis of 

convergence insufficiency. The authors observed 

that this 15.9% prevalence of CI in patients with 

ADHD was much higher than the convergence 

insufficiency prevalences of 2.25 to 4.2% in the 

literature that they cited. 

The authors of the paper recognized that a 

limitation of their study was that they examined a 

selected sample. They further noted that it was not 

possible to determine whether the medication for 

ADHD or the lack of attention that ADHD patients 

might have during clinical testing could have 

contributed to a convergence insufficiency 

diagnosis. However, they state that, “It seems 

obvious that CI could aggravate the academic 

performance of a patient with ADHD.” They 

recommended that patients with ADHD or 

suspected of having ADHD should be evaluated for 

convergence insufficiency. In addition, they 

suggested that treatment of convergence 

insufficiency without relief of symptoms might be 

explained by the presence of ADHD. 

Survey on Most Common Treatment Methods 

Scheiman et al. 2 mailed surveys concerning 

treatment methods for convergence insufficiency to 

863 ophthalmologists and 863 optometrists. 

Addresses for optometrists were obtained from the 

American Optometric Association. Addresses for 

general and pediatric ophthalmologists were 

obtained from the Official American Board of 

Medical Specialties Directory of Board Certified 

Medical Specialists. Lists were arranged by zip 

code and then names were selected at regular 

intervals, every 20th name in the case of the 

optometrists. 

Fifty-eight percent of the optometrists returned 

the survey, and 23% of the ophthalmologists 

responded. Respondents indicated how often they 

used the following treatments: base-in prism 

reading glasses, reading glasses with no prism, 

pencil push-ups, home-based vision therapy, 

office-based vision therapy, or no treatment. They 

marked whether they used each of those 

treatments never, occasionally, fairly often, often, 

or always. 

For the optometrists, the most common 

treatment method was pencil push-ups (36% of 

respondents), with home-based vision therapy 

(22%) next, followed by office-based vision therapy 

(16%). Among the ophthalmologists, the most 

common treatment was pencil push-ups (50%), 

with home-based vision therapy next (21%), and 

base-in prism glasses third (10%). The authors 

pointed out that while pencil push-ups, the most 

common treatment, require a minimum of cost and 

time, there is more support in the literature for 

office-based vision therapy. 

Effectiveness of Base-In Prism Reading 

Glasses in Children 

Having studied how commonly different 

treatment methods were used, Mitch Scheiman, a 

faculty member at Pennsylvania College of 

Optometry, and his co-investigators turned their 


Pencil Push Ups 

Office-based 

Vision Therapy 

# Subjects 11 15 12 

Symptom survey 

Score at Baseline 

Symptom survey Score 

after treatment 

Stat. sig. of change in 

symptom score 

NPC break at 

baseline (cm) 

NPC Break after 

treatment (cm) 

Stat. sig.of change 

in NPC 

Near BO break at 

baseline (Δ) 

Near BO break after 

treatment (Δ) 

Stat. sig. of change on 

BO break 

29.3 

(5.4) 

25.9 

(7.3) 

32.1 

(7.9) 

9.5 

(8.2) 

Placebo 

Vision Therapy 

30.7 

(10.6) 

24.2 

(11.9) 

p=0.24 p

Subjects were recruited and followed at five 

locations, all of them optometry schools. Eligibility 

and exclusion criteria were very similar to those for 

the base-in prism study. Subjects were 

randomized into one of three groups: pencil pushups, 

office-based vision therapy, and placebo 

vision therapy. 

Treatment was conducted over a twelve week 

period. The training procedures for the officebased 

vision therapy included accommodative 

facility, Brock string, barrel card, vectograms, 

computer orthoptics, aperture rule, eccentric circles 

free space fusion cards, life saver free-space 

fusion cards, and loose prism facility. The placebo 

group did procedures which simulated office-based 

vision therapy without changing stimuli to 

accommodation or vergence or saccades. 

The primary outcome variable to test the 

effectiveness of treatment was the 15 question 

symptom survey questionnaire that was also used 

in the base-in prism study. Other data presented 

in the paper were the NPC and the near base-out 

(BO) vergence range break. 

The study results are summarized in Table 1. 

The changes in symptom scores, NPC, and BO 

break were statistically significant in the officebased 

vision therapy group, but not in the pencil 

push-up group. The symptom score, NPC, and BO 

break at the end of the study were all significantly 

better in the office-based VT group than in either 

the pencil push-up group or the placebo group. 

(p

group achieved an NPC of less than 6 cm by the 

end of the study: 67% of the vision therapy group, 

23% of the placebo group, and 47% of the pencil 

push-up group. The mean NPC for the officebased 

vision therapy group at the end of the study 

was significantly better than that of the placebo 

group (p=0.02), but not compared to that for the 

pencil push-up group (p=0.18). 

All three groups had statistically significant 

improvements in near BO break findings, but the 

largest increase occurred in the vision therapy 

group. At the end of the study, the BO break in the 

vision therapy group was significantly greater than 

those of both the placebo group (p=0.002) and the 

pencil push-ups group (p=0.04). 

The authors observed that of the three 

treatments, “only vision therapy/orthoptics was 

effective in achieving normal clinical values for 

both the near point of convergence and positive 

fusional vergence.” They noted that the 

improvements from vision therapy could not be 

explained on the basis of a placebo effect. They 

further concluded that the improvement with pencil 

push-ups, though statistically significant, may not 

be considered to be clinically significant. 

Comments 

The findings of the recent studies reviewed 

here suggest that although pencil push-ups may be 

the most commonly used method of treating 

convergence insufficiency, it is not as effective as 

office-based vision therapy. The fact that 

programs of office-based placebo training 

procedures were not as effective as vision therapy 

shows that the greater results with vision therapy 

over pencil push-ups were not due simply to 

contact with the therapist. The administration of 

proper procedures in the office might increase the 

likelihood of success over the less controlled home 

environment. 

The better results with vision therapy over 

pencil push-ups could also be due to the fact that 

several of the office-based procedures train 

fusional vergence independent of accommodation. 

With pencil push-ups, both the convergence 

stimulus and the accommodative stimulus are 

increasing as the pencil is brought closer. 

Therefore, accommodative convergence is 

assisting positive fusional vergence during the 

training. The office-based vision therapy included 

training with vectograms, aperture rules, eccentric 

circles and life saver free space fusion cards, and 

loose prism facility. On all of those procedures, the 

vergence stimulus changes as the accommodative 

stimulus remains constant. Having patients keep 

the targets for these procedures clear requires 

them to use positive fusional vergence without an 

assist from accommodative convergence, thus 

providing a greater training effect on fusional 

vergence. 

References 

1. Granet DB, Gomi CF, Ventura R, Miller-Scholte 

A. The relationship between convergence 

insufficiency and ADHD. Strabismus 

2005;13:163-168. 

2. Scheiman M, Cooper J, Mitchell GL, et al. A 

survey of treatment modalities for convergence 

insufficiency. Optom Vis Sci 2002;79:151-157. 

3. Scheiman M, Cotter S, Mitchell GL, et al. 

Randomised clinical trial of the effectiveness of 

base-in prism reading glasses versus placebo 

reading glasses for symptomatic convergence 

insufficiency in children. Br J Ophthalmol 

2005;89:1318-1323. 

4. Stavis M, Murray M, Jenkins P, et al. Objective 

improvement from base-in prisms for reading 

discomfort associated with mini-convergence 

insufficiency type exophoria in school children. 

Bin Vis Strab Quart 2002;17:135-142. 

5. Scheiman M, Mitchell GL, Cotter S, et al. A 

randomized clinical trial of treatments for 

convergence insufficiency in children. Arch 

Ophthalmol 2005;123:14-24. 

6. Scheiman M, Mitchell GL, Cotter S, et al. A 

randomized clinical trial of vision 

therapy/orthoptics versus pencil push-ups for 

the treatment of convergence insufficiency in 

young adults. Optom Vis Sci 2005;82:583-593. 


Letter to the Editor and Author’s Replies 

Ithoroughly enjoy the Indiana Journal of 

Optometry and usually read the entire journal. I 

received the Fall, 2005 issue and read the entire 

issue. The following lists a few comments on the 

articles. 

Terson’s syndrome is one condition all 

optometrists should be familiar with. In addition to 

Terson’s syndrome, subarachnoid hemorrhage 

(SAH) can result from many causes including 

closed head injury (CHI), traumatic brain injury 

(TBI), arteriovenous (A/V) malformations, and 

aneurysms. The classic case is of severe 

headache - the worst the person has ever had. 

Because of the patient base I see, I average about 

twelve of these each year. The first one that I saw 

was from TBI and the patient was about three 

months old at the time. The blood had moved 

anterior and was only a partial hemorrhage. The 

appearance of the vitreous was such that there 

were areas of clear retina and other areas that 

appeared like a retinal detachment. 

One patient of interest relates to binocular 

vision and a complete unilateral Terson’s 

syndrome. The patient was seen in the 

rehabilitation hospital within two to three weeks of 

the SAH. The patient’s eye was completely filled 

with hemorrhage and there was no fundus view. In 

such cases, I always ask for a retinal consult for 

ultrasound scan and confirmation of my diagnosis. 

(Best for insurance to have the diagnosis 

confirmed) The patient also had a partial third 

nerve exotropia. I had instructed the therapist to 

occlude the eye with the hemorrhage and the 

exotropia. The retinal ophthalmologist confirmed 

the Terson’s syndrome, and he told the hospital to 

not occlude the eye. The next visit to the hospital 

the patient was waiting to be seen. She had gone 

in the van to the mall for shopping with the hospital 

staff. She had to close her eyes until the van 

reached the mall. The patient was nauseated with 

both eyes open. The patient had a Fresnel press 

on prism placed over her glasses to reduce the 

visual confusion. The argument can be made for 

the parvo/magno pathways as a cause of the 

confusion or the fact the one eye now turns out 

and the proprioception from the muscle is causing 

the confusion. Terson’s syndrome is often 

accompanied by an ocular motor disorder which 

could be obvious, such as complete nerve palsy or 

more frequently a subtle vertical deviation. 

The article by Elli J. Kollbaum on driving and 

hemianopsia was interesting. The article starts on 

the premise that the diagnosis of hemianopsia 

alone can or should be used as a means of 

determining how a person will drive. A visual 

acuity standard as a means to determine if the 

visual system is functioning sufficiently to allow a 

person to drive is a similar false standard. The 

patient who has a field loss will usually have other 

neurologic deficits. A question each of us should 

ask would be what area of the brain had the injury 

that caused the field loss. Also: What kind of injury 

did they have? Was the injury to the brain a 

stroke? Was it ischemic in nature or hemorrhagic? 

Did you get to read the radiological report or the 

hospital record to see is if any other areas of the 

brain were involved? Was the field loss from a CHI 

or TBI injury and what type of brain injury was 

listed on the report? Was the brain injury on the 

dominant or nondominant side of the brain? How 

is the patient’s speech, and does the patient have 

aphasia or perseveration? Did the patient have 

neglect initially? Was there an initial gaze 

“paralysis”? Did the patient have posture distortion 

right after the event? Was stereopsis preserved or 

was the field loss too close to the midline and 

stereopsis compromised? 

The nature of my practice allows ample 

opportunity to see many of these patients. I often 

see them early in the recovery process in the 

hospital setting. The patient will have multiple 

deficits besides the hemianopsia. The deficits may 

improve just by the recovery process of the brain 

healing or they may need multiple therapies to 

improve. I can think of very few patients that I 

have seen where only field loss existed. 

The patient should have smooth motor 

pursuits checked as early in the recovery as 

possible. If the patient has the lesion in the 

parietal area the pursuits will be affected. Such 

patients will have problems with pursuits into the 

blind field years later if they don’t have intensive 

therapies. Saccadic eye movements are also 

affected and the deficit can also be seen even after 

therapies. The local hospital therapy program 

uses a computer program called Captain’s log. 

The program has multiple visual programs to aid in 

both recovery and to follow the recovery progress. 

A test that optometrists can use which other 

professionals don’t often use is a tachistoscope. I 

prefer to use four numbers for 1/10 of a second 

and run ten trials. The patient may no longer show 

neglect on a pencil and paper test but will show it 

on the tachistoscope. The tachistoscope will also 

show sequence errors and number reversals. 

I would encourage all optometrists to look 

beyond the visual field loss, diplopia, or other initial 

presenting diagnosis and look for any other 

deficits. The example that comes to my mind is a 

young 20 year old referred for evaluation regarding 

possible employment or education placement. I 

personally prefer to watch patients walk to the 

exam room and watch how they seat themselves. 

This particular patient had difficulty in walking. The 

patient had significant medical history with the 

diagnosis of cerebral palsy (CP). The available 

history included two recent examinations by two 

different neurologists. The diagnosis of CP was 

consistent in both reports. The chart also included 

two neuro-psychology reports by the same 


examiner in which the patient had lost cognitive 

abilities over the five years between exams. The 

patient had recent eye exams which showed 

myopia but no other problems. 

The patient told me in the case history that he 

didn’t like to read. The patient says moving his 

eyes bothered him. The other history was only 

significant for myopia. The significant testing was 

in pursuits and saccades. The patient was asked 

to follow a moving object. The second time 

through the pattern he could not follow the object 

vertically. Saccade testing also confirmed the 

vertical loss within two cycles. The only other 

ocular finding of significance was greatly reduced 

accommodation. The visual fields, external, 

tonometry, and dilated internal exam were normal. 

The neurology reports both listed pursuits as 

being intact. I called the neurologist that I work 

with. I explained the test findings from the other 

neurologists. I also explained my observations of 

ataxia, pursuit and saccade abnormalities, and 

partial 3rd nerve lesion. The patient was seen and 

even though several reference texts would match 

this with progressive supernuclear palsy the patient 

is not in the right age category. Living in the 

computer age makes finding references much 

easier. Checking the search engine of your choice 

with ataxia, pursuit and saccade abnormalities, and 

accommodation deficit will bring up congenital 

cerebellum stem degenerations as the most likely 

diagnosis. 

The point is, don’t assume the diagnosis is 

correct just because the patient has more than one 

confirming diagnosis. The patient should be tested 

thoroughly and the case history matched to the 

symptoms. Then if the previous diagnosis does 

not match your findings, start looking for other 

possible explanations. 

An important principle for brain injury patients 

is to look for other problems like the hemianopsia 

and driving difficulties. The hemianopsia will not 

exist in isolation. Once one determines whether 

the patient has other findings, then one can talk 

about driving and how the brain insult has changed 

the visual process. 

Steven F. Sampson, O.D. 

Dr. Sampson completed undergraduate school 

at Indiana University with an A.B. degree in 

chemistry in 1974 and is a 1978 graduate of 

Indiana University School of Optometry. He is 

a member of several optometric organizations, 

including the Indiana Optometric Association, 

American Optometric Association, College of 

Optometrists in Vision Development, and 

Neurological Optometric Rehabilitation 

Association, and is a Fellow of the American 

Academy of Optometry. He practices in 

Evansville, Indiana. 

Authors’ Replies 

It was a pleasure to see the letter written by 

Steven F. Sampson. He has highlighted a very 

important scenario which many patients with 

Terson’s syndrome experience, i.e., nausea, 

confusion, and problems with binocular vision. 

Clinical practice in the United States is slightly 

different from the way we proceed in the United 

Kingdom. For all the patients with Terson’s 

syndrome undergoing rehabilitation in our unit, we 

make sure that it is a joint effort involving 

ophthalmologists, orthoptists, and optometrists 

under the supervision of geriatrics. This not only 

provides us with the best clinical results addressing 

the patient’s symptoms but is also a continuous 

reminder for medics of the greater morbidity they 

have as compared to patients with subarachnoid 

hemorrhage not having vitreous hemorrhage. Our 

orthoptics department recently came up with a 

protocol to make sure that every patient with 

subarachnoid hemorrhage gets a routine 

assessment including visual fields even in absence 

of any symptoms. This has helped us to identify 

some Terson’s syndrome patients who otherwise 

could have been missed. 

Ali A. Bodla, M.D. 

Dr. Bodla and his colleagues contributed two 

photo essays to the Fall, 2005 issue of the 

Indiana Journal of Optometry. Dr. Bodla is at 

the Ophthalmology Department, The Ayr 

Hospital, Dalmellington Road, Ayr, Scotland. 

I thank Dr. Sampson for his comments on my 

article, “Homonymous Hemianopsia and Driving: 

Is It Safe?”, that appeared in the Fall, 2005 issue of 

IJO. He expressed valid points that the patient 

with hemianopsia may have additional cognitive 

and visual deficits. These areas need to be 

addressed in the evaluation along with the patient’s 

other medical conditions. A helpful website that 

addresses the health care provider’s role in the 

driving evaluation is: 

http://www.nhtsa.dot.gov/PEOPLE/injury/olddrive/ 

OlderDriversBook 

Elli J. Kollbaum, O.D. 

Dr. Kollbaum, a member of the Indiana 

University School of Optometry faculty, was 

profiled in the Fall, 2005 issue of the Indiana 

Journal of Optometry. 


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IJO Spring 2006.qxp - Indiana University School of Optometry

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