Horwood,A Riddell, P Brit J Ophthalmol 2012; 96(4): 508-513 ;bjophthalmol-2011-300138 Published Online First: 25 August 2011 doi:10.1136/bjophthalmol-2011-300138

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For many children the loss of disparity-driven accommodation results in significant blur, as well as loss of binocularity, when they decompensate

Objective

Disparity cues can be a major drive to accommodation via the convergence accommodation to convergence (CA/C) linkage, but, on decompensation of exotropia, disparity cues are extinguished by suppression so this drive is lost. This study investigated accommodation and vergence responses to disparity, blur and proximal cues in a group of distance exotropes aged between 4 and 11 years both during decompensation and when exotropic.

Methods

19 participants with distance exotropia were tested using a PlusoptiXSO4 photo refractor set in a remote haploscopic device that assessed simultaneous vergence and accommodation to a range of targets incorporating different combinations of blur, disparity and proximal cues at four fixation distances between 2 m and 33 cm. Responses on decompensation were compared with those from the same children when their deviation was controlled.

Results

Manifest exotropia was more common in the more impoverished cue conditions. When decompensated for near, mean accommodation gain for the all-cue (naturalistic) target was significantly reduced (p<0.0001), with resultant mean under-accommodation of 2.33 D at 33 cm. The profile of near cues usage changed after decompensation, with blur and proximity driving residual responses, but these remaining cues did not compensate for loss of accommodation caused by the removal of disparity.

Conclusions

Accommodation often reduces on decompensation of distance exotropia as the drive from convergence is extinguished, providing a further reason to try to prevent decompensation for near.