1040-5488/04/8112-0929/0 VOL. 81, NO. 12, PP.

929933 OPTOMETRY AND VISION SCIENCE Copyright 2004 American Academy of Optometry

ORIGINAL ARTICLE

Accommodative Lag Using Dynamic Retinoscopy: Age Norms for School-Age Children
JULIE F. MCCLELLAND, PhD, MCOptom and KATHRYN J. SAUNDERS, PhD, MCOptom
Vision Science Research Group, School of Biomedical Sciences, University of Ulster, Londonderry, Northern Ireland

ABSTRACT: Background. Nott dynamic retinoscopy (DR) is a technique that provides an objective, rapid assessment of accommodative function. Presently there are no data available regarding age norms of accommodative function for school-age children using Nott DR. Methods. Accommodative responses were assessed in a group of 125 school-age children (4 to 15 years of age) using Nott DR. A range of accommodative demands was included [4 D (25 cm), 6 D (16.7 cm), and 10 D (10 cm)]. All the subjects had fully corrected refractive errors and a binocular visual acuity of at least 6/6. Results. Accommodative responses were assessed successfully at each distance with all the subjects (N 125). A mean overall lag of accommodation was noted with each age group at each distance tested. Regression analysis demonstrated no significant difference in accommodative responses between age groups (p 0.531 at 4 D, p 0.062 at 6 D, and p 0.883 at 10 D). Therefore, results for all the age categories were grouped together to produce a table of normal ranges of accommodation for children aged 4 to 15 years for the three stimuli demands. The mean lag of accommodation was found to be 0.30 0.39 D at 4 D, 0.74 0.58 D at 6 D, and 2.50 1.27 D at 10 D. The normal ranges of accommodation (95% confidence limits) were 2.94 to 4.46 D at 4 D, 4.12 to 6.40 D at 6 D, and 5.02 to 10.00 D at 10 D. Conclusions. A comprehensive table has been produced detailing the mean lags and normal ranges of accommodative responses expected for school-age children when using Nott DR. These data allow practitioners and researchers to determine whether accommodative responses measured using Nott DR are within normal limits. (Optom Vis Sci 2004;81:929933) Key Words: accommodative lag, accommodative response, Nott dynamic retinoscopy, age norms, school-age children

n assessment of accommodative function should form an important part of the optometric examination of all children. This may be achieved using a number of different techniques. Ocular accommodation is most commonly assessed clinically using the subjective push-up test, which measures the amplitude of accommodation using the RAF rule. It is also important to examine other aspects of a subjects accommodative status, including his or her accommodative accuracy or response. Nott dynamic retinoscopy (DR) is a technique that provides the clinician with a rapid objective measurement of the refractive status of the eyes while the subject views a near target. A modified Nott DR technique has previously been shown to provide valid and repeatable measurements of accommodative response in adults and children.1 It is a technique that may be used to assess accommodative function in situations in which subjective methods are unsuitable and has been used to study accommodative function in

people with cerebral palsy and Down syndrome.2, 3 Although many researchers have used Nott DR, there is a paucity of data describing what constitutes a normal accommodative response with this technique.4 6 Rouse et al.7 performed an extensive study examining accommodative responses of 721 school-age children (4 to 12 years of age). They used the monocular estimate method (MEM) of DR to determine the lag of accommodation at the childs usual working distance. This type of DR involves using spherical lenses to assess accommodative responses. The study provides clinicians with useful data regarding normal lags of accommodation. When examining young adults, Del Pilar Cacho et al.8 report that MEM DR is not the optimal technique to assess accommodative responses. Del Pilar Cacho et al.8 reported that the Nott method9 (which uses changes in working distances rather than introducing lenses) was a more appropriate technique to assess lags of accommodation in

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930 Accommodation Lag in School ChildrenMcClelland & Saunders

young adults because it is the method that least contaminates the results. Leat and Gargon10 examined the accommodative response of a diverse group of 55 visually and developmentally normal subjects aged 3 to 35 years using a modification of Nott DR. They provided graphs detailing the mean accommodative response and 95% confidence limits for four different age groups. These data allow practitioners using Nott DR to determine whether the accommodative response measured is within normal limits. However, the graphical presentation of the normal ranges makes application of these results to clinical data cumbersome. The present study aims to provide clinicians with comprehensive normative accommodative response data for developmentally and visually normal school-age children (4 to 15 years of age) using Nott DR. The present study aims to enhance Leat and Gargons study10 by producing easily accessible data from a larger subject base for clinicians in practice.

FIGURE 1.
Dynamic retinoscopy.

METHODS
Ethical approval for this study was obtained from the Northern Education and Library Board and the University of Ulster ethical committees. This research followed the tenets of the Declaration of Helsinki. Two local schools were contacted, one primary level and one secondary level. The study was discussed with the school principals, and information letters and consent forms were sent to parents. Written consent forms were received from 128 parents. The subjects ages ranged from 4 to 15 years (mean age, 9.27 3.53 years; 64 male, 64 female). Children with a binocular acuity of 6/6 and/or with a significant uncorrected refractive error1113 (myopia 0.50 DS, hypermetropia 2.00 DS, or astigmatism 1.00 DC as ascertained by the author J.M. using distance static retinoscopy) were excluded from the study (N 3), and a letter was sent to their parents or guardians advising the children to attend an optometrist for a full eye examination. All the other children with significant refractive errors were tested with appropriate spectacle correction in place. Accommodative responses were assessed using a Nott DR technique at three different accommodative demands (4 D, 6 D, and 10 D). A distance of 25 cm (4 D) was selected because it corresponded with the average working distance of a child (25.4 cm).7 A distance of 10 cm (10 D) was chosen because the authors hoped to examine the accommodative response while the visual system was under stress. The three distances used in the present study also allow for comparisons to be made with previous studies.10, 14 The targets were presented first at 25 cm, then moved to 16.7 cm, and finally to 10 cm. The order of target presentation has been shown to have no significant impact on the results.10 The target used to stimulate accommodation was an internally illuminated, translucent, white Perspex cube measuring 4 4 4 cm. High contrast pictures containing a range of spatial frequencies were drawn on each face of the cube (Fig. 1). The DR technique used in the present study was the same as the modified Nott technique and has been shown to provide valid and repeatable measurements of accommodative response.1, 3, 10 The meter rule was held in place to ensure the zero mark was aligned with the corneal apex (Fig. 1). The subject was encouraged to view the fine detail at the center of the target by being asked questions about the pictures. This helped to maintain interest and accommodative effort. The retinoscope was placed alongside and as close as possible to the target, and the retinoscope reflex was observed while the subject was fixating the target. All the measurements were taken under binocular viewing conditions from the least hypermetropic meridian of the subjects eyes. A with movement indicated a lag of accommodation, and the practitioner moved farther away from the subject to reach a neutral point. An against movement indicated a lead of accommodation, and the practitioner moved closer to the patient to achieve neutrality. The target remained in its original position. The examiner placed a finger on the ruler to correspond with the distance of the retinoscope. The dioptric distance from the corneal apex to the edge of the retinoscope was noted when neutrality was achieved (when the with or against movement disappeared) and was recorded as the lag (or lead) of accommodation. Although the retinoscope was held as close to the rule as possible, it could not be exactly along the line of sight. Brookman4 reported that if the retinoscope were within 10, this would induce an error of no more than 0.25 D. Because the subjects were encouraged to view the center of the target, this off axis error would have been 11.3 at 10 cm, 6.8 at 16.7 cm, and 4.6 at 25 cm. The same observer (J.M.) made all the measurements.

RESULTS
Accommodative responses were successfully assessed at all the distances from all the subjects. Data from 125 subjects were included in the analysis. Between 7 and 17 subjects were included in each age group (Table 1). Descriptive statistical analysis of the results demonstrated an overall lag of accommodation at each distance in all the age groups. In all the age groups, the normal range (mean accommodative response 1.96 SD) widened with an increase in the accommodative demand. As the subjects age increased, there was less variability in the normative range. The broadest normal range and most variability were found at the 10-D stimulus distance in the 4-year-old age group (3.82 to 11.26 D). Leads of accommodation were not commonly demonstrated. At

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TABLE 1. Mean accommodative response and 95% confidence limits (mean 1.96 SD) of accommodative response for each age group at each accommodative demand
Accommodative Response (D) Age (yrs) n Mean (D) 11 10 17 10 10 9 7 9 12 11 9 10 3.70 3.86 3.73 3.77 3.73 3.73 3.42 3.71 3.79 3.75 3.49 3.60 4 D Demand Normal Range (D) 2.524.88 3.374.35 2.754.71 3.214.31 3.244.22 3.084.38 2.873.97 3.024.39 3.074.51 3.044.46 2.784.20 2.664.54 Mean (D) 5.57 5.32 5.22 5.65 5.36 5.06 4.82 5.30 5.29 5.28 4.82 5.19 6 D Demand Normal Range (D) 4.286.86 4.486.14 3.986.44 4.776.53 3.976.75 4.295.81 4.015.62 4.106.50 4.316.25 4.106.46 3.805.84 3.996.39 Mean (D) 7.54 7.67 7.85 8.12 7.36 7.09 6.92 7.71 7.17 6.98 7.25 8.10 10 D Demand Normal Range (D) 3.8211.26 5.369.98 5.0110.69 6.0610.18 4.4210.30 4.399.79 5.638.21 6.099.33 4.949.40 5.598.37 4.829.68 5.6510.55

4 5 6 7 8 9 10 11 12 13 14 15

the greatest accommodative demand (10 D), two subjects demonstrated a lead of accommodation, 11 subjects demonstrated leads of accommodation at the 6-D stimulus, and 16 subjects at the 4-D stimulus. Fig. 2 illustrates the accommodative response at different distances by different age groups and suggests little, if any, effect of age within the tested range. Regression analysis revealed that the slope of the regression line fitted did not differ significantly from zero (p 0.531 at 4 D, p 0.062 at 6 D, and p 0.883 at 10 D). A one-way analysis of variance was performed on the results to determine the effect of age on accommodative response. Analysis demonstrated that there was no statistically significant difference in mean accommodative responses across the age groups for the 10-D stimulus distance (p 0.549), the 6-D stimulus distance (p 0.057), and the 4-D stimulus distance (p 0.385). Therefore, results for all the age categories were grouped together to produce

normal ranges for the three different stimulus distances. The normal ranges of accommodative responses for each target distance are shown in Table 2. This table will allow clinicians to categorize patients as having either normal or reduced accommodative responses for these stimulus distances.

DISCUSSION
The present study describes normal data for accommodative lags of school-age children using a modified version of Nott DR with targets at different distances. A table has been produced that provides the clinician using Nott DR with a rapid means for deciding whether a childs accommodative response falls outside the normal range. In the present study, the mean lag of accommodation was found to be 0.30 0.39 D at 4 D, 0.74 0.58 D at 6 D, and 2.50 1.27 D at 10 D. This is in good agreement with other studies examining lag of accommodation. Nott9 described how at 33 cm (3 D) the subject would under-accommodate by about 0.50 D. Rouse et al.7 demonstrated an overall lag of accommodation of 0.33 0.35 D and 0.35 0.34 D for the right and left eyes, respectively. Subjects in Rouse et al.s study7 were allowed to use their preferred working distance while measurements were taken. The mean working distance was 25.4 cm. This compares well with the mean accommodative lag of 0.30 0.39 D in the present study at the 25-cm target distance. In the present study, the widest range of accommodative responses was present in the group of 4-year-old children. This could be attributed to a concentration or attention difficulty in this youngest group. Woodhouse et al.3 assessed accommodative responses of 26 children aged 7 to 11 years using a similar DR technique. Woodhouse et al.3 demonstrated a mean lag of accommodation of 0.20 D to an 11-D stimulus demand. This is a much lower lag than the present study, in which at 10 D a mean lag of 2.49 D was shown. The relatively few subjects, narrower age range,

FIGURE 2.
Accommodative responses at 4 D (), 6 D (), and 10 D () for all the subjects. The solid line indicates the regression line.

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932 Accommodation Lag in School ChildrenMcClelland & Saunders

TABLE 2. Mean accommodative response and 95% confidence limits for all age groups
Age, 415 yrs Normal range (mean response 2SD) (D) Response (mean SD) (D) Lag (mean SD) (D) 4 D Demand 2.944.46 3.70 0.39 0.30 0.39 6 D Demand 4.126.40 5.26 0.58 0.74 0.58 10 D Demand 5.0210.00 7.51 1.27 2.49 1.27

and higher mean age in Woodhouse et al.s study3 may account for this difference. The greatest variability in the results was found at the greatest accommodative demand. This is similar to findings of Leat and Gargon.10 They reported that lags of accommodation increased with an increase in age and an increase in accommodative demand. In the present study, the mean lag at 4 D in the 4-yearold age group was 0.30 D, which increased to 2.46 D at the 10-D demand. The lag also increased with age (mean lag at 4 D increased from 0.30 D in the 4-year-old group to 0.40 D in the 15-year-old age group) but not to a statistically significant degree. Leat and Gargon10 showed that at the 4-D demand the accommodative lag increased significantly from 0.48 0.42 D in the 6- to 10-year-old age group to 0.60 0.44 D in the 11to 26-year-old group. This is similar to findings reported by Rouse et al.,7 who demonstrated a statistically significant increase in accommodative lag from 0.28 0.44 D in 4-year-old children to 0.45 0.30 D in 12-years-old children. The differences between the results of the present study and those of Rouse et al.7 might be attributed to the different type of DR (monocular estimate method) used by Rouse et al. and might also be compounded by the variable test distances used in Rouse et al.s study. It might be that the older children used reduced working distances compared with younger children; therefore, lags appeared greater in older children. The smaller number of subjects in Leat and Gargons study10 and the higher age of the oldest subject may explain the discrepancy between their results and those of the present study. Chen and OLeary15 examined accommodative responses of 118 children (aged 3 to 14 years) using a Canon Autoref R-1 (Tokyo, Japan). Their fixation target, which was used at six different stimulus distances (0, 1, 2, 3, 4, and 5 D), was the 6/24 line of The Osterberg Pictorial Sight Test Chart for Little Children. Their results agreed with the present study because they found no significant difference between accommodative responses across all the age groups. Unfortunately, they did not report the mean accommodative responses or normal ranges that might be expected when assessing accommodative responses using the Canon R-1 Autorefractor. The aim of the present study was to provide practitioners with a guide to determine whether accommodative responses assessed with a modified version of Nott DR are within normal limits. We have produced a simple table that practitioners may consult detailing the mean accommodative response and 95% confidence limits for three different target distances. To identify cases of accommodative dysfunction, it is desirable to have a clear idea of what a normal response should be. These normative data allow clinicians

and researchers to readily identify patients and subjects whose accommodative responses fall outside the normal range for their age. These data allow decisions to be made on whether accommodative responses measured using a modified version of Nott DR are within normal limits for 4- to 15-year-old children. These data are necessary for future studies on accommodative responses in neurologically and visually normal children and in those with impairments. They will also aid clinicians treating these children to identify accommodative deficits and target treatment appropriately.

ACKNOWLEDGMENTS
We thank the schools that participated in the study, Mill Strand Primary School, Portrush and Dominican College, Portstewart, and the pupils for taking part. J.M. was supported by The College of Optometrists. Supported by a Nuffield equipment grant (SCI/180/96/41/G). Received March 10, 2004; accepted August 30, 2004.

REFERENCES
1. Leat SJ. Reduced accommodation in children with cerebral palsy. Ophthalmic Physiol Opt 1996;16:38590. 2. McClelland JF, Saunders KJ. The repeatability and validity of dynamic retinoscopy in assessing the accommodative response. Ophthalmic Physiol Opt 2003;23:24350. 3. Woodhouse JM, Meades JS, Leat SJ, Saunders KJ. Reduced accommodation in children with Down syndrome. Invest Ophthalmol Vis Sci 1993;34:23827. 4. Brookman KE. A retinoscopic method of assessing accommodative performance of young human infants. J Am Optom Assoc 1981;52: 8659. 5. Banks MS. Infant refraction and accommodation. Int Ophthalmol Clin 1980;20:20532. 6. Jackson TW, Goss DA. Variation and correlation of clinical tests of accommodative function in a sample of school-age children. J Am Optom Assoc 1991;62:85766. 7. Rouse MW, Hutter RF, Shiftlett R. A normative study of the accommodative lag in elementary school children. Am J Optom Physiol Opt 1984;61:6937. 8. del Pilar Cacho M, Garcia-Munoz A, Garcia-Bernabeu JR, Lopez A. Comparison between MEM and Nott dynamic retinoscopy. Optom Vis Sci 1999;76:6505. 9. Nott IS. Dynamic skiametry, accommodation and convergence. Am J Physiol Opt 1925;6:490503. 10. Leat SJ, Gargon JL. Accommodative response in children and young adults using dynamic retinoscopy. Ophthalmic Physiol Opt 1996;16: 37584.

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Accommodation Lag in School ChildrenMcClelland & Saunders 11. Leat SJ, Shute RH, Westall CA. Assessing Childrens Vision: A Handbook. Oxford: Butterworth-Heinemann, 1993. 12. Ingram RM, Walker C. Refraction as a means of predicting squint or amblyopia in preschool siblings of children known to have these defects. Br J Ophthalmol 1979;63:23842. 13. Abrahamsson M, Fabian G, Sjostrand J. Changes in astigmatism between the ages of 1 and 4 years: a longitudinal study. Br J Ophthalmol 1988;72:1459. 14. Woodhouse JM, Cregg M, Gunter HL, Sanders DP, Saunders KJ, Pakeman VH, Parker M, Fraser WI, Sastry P. The effect of age, size of target, and cognitive factors on accommodative responses of children with Down syndrome. Invest Ophthalmol Vis Sci 2000; 41:247985.

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15. Chen AH, OLeary DJ. Are there age differences in the accommodative response curve between 3 and 14 years of age? Ophthalmic Physiol Opt 2002;22:11925.

J. F. McClelland Vision Science Research Group School of Biomedical Sciences University of Ulster Coleraine Co., Londonderry Northern Ireland BT52 1SA e-mail: JF.McClelland@ulster.ac.uk

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