Amplitude of accommodation measurement in school aged

children using methods of spheres and royal air force ruler

Aryani Vindhya Putri1, Anny Sulistiyowati1, Nanda Wahyu Anandita1, Lely Retno
Wulandari1
1Ophthalmology Department, Faculty of Medicine Universitas Brawijaya, Dr. Saiful Anwar General
Hospital, Malang-Indonesia

Correspondence: Nanda Wahyu Anandita, Department of Ophthalmology, Faculty of Medicine,

Universitas Brawijaya, Dr. Saiful Anwar General Hospital, Malang 65145, Indonesia.
E-mail: nan_anandita@yahoo.com

ABSTRACT

Purpose: To compare the differences between amplitude accommodation in school aged

children’s refractive state using methods of spheres and Royal Air Force (RAF) Ruler in an urban
rural school area.

Design: This was a cross sectional observative analytical study conducted at Lesanpuro 2
Elementary School and State Junior High School 27 Malang (SMP 27 Malang).

Methods: 245 students age between 6-16 years old are participated in this study. Amplitudes of
accommodation were measured using methods of spheres and RAF ruler, with refractive state
classified as emmetropia, myopia, astigmatism, and hypermetropia. Amplitude of
accommodations was measured monocularly and binocularly.

Results: Based on age group, the highest amplitude of accommodations was shown in a <10
year-age group, using RAF Ruler and methods of spheres. The number of female (128
respondents) is higher than than male (117 respondents), and the biggest age group is 14 years
old. Refractive state is dominated by emmetropia (188 RE and 192 LE). Myopia is the second
(RE: 30, LE: 28), and the last is astigmatisma (RE: 27, LE: 25). Hypermetropia is not found in this
study. Myopia has the highest amplitude of accommodation among emmetropia and astigmatism,
both in RAF Ruler and in methods of spheres. RAF Ruler has higher results compared to methods
of spheres monocularly or binocularly. Binocular measurements showed higher results in two
kinds of measurements compared with monocular measurements.

Conclusion: Myopia has the highest amplitude of accommodation. Measurement using RAF
ruler gives a higher result than measurement using methods of spheres.

Keywords: Amplitude of accommodation, refractive state, RAF ruler, methods of spheres,

school-aged children

Introduction

Refractive state is a state of eye conjugated with optical infinity in a minimal state of
accommodation. In this situation, there are two kinds of conditions, namely emmetropia and
ametropia. When a light beam is parallel from a distant object in the retina with the eye resting or
not accommodating, this refractive state of the eye is known as emmetropia. Individuals with
emmetropic eyes can clearly see long distances without accommodation. Refractive
abnormalities occur when the beam of light that comes in does not exactly fall into the retina. This
type of refractive disorder consists of myopia, hypermetropia, and astigmatisma. 1,2,3,4

The accommodation process plays an important role in vision. The eye can change its focus from
objects over long distances to close distances because of the ability of the lens to change its
shape. When the eyes look at a close object, the lens of the eye must be more convex, and when
the eyes look at far distance object the lens must be more flat. This event of change is called
accommodation. This accommodation process involves several parts of the eye, namely the eye
lens, zonula, and ciliary muscles. Increasing the strength of the lens diopters causes the lens to
become more convex. This accommodation ability diminishes as we age, where close focal points
will be further. At a young age, accommodation capabilities vary greatly where accommodation
can occur when viewing objects from infinite distance to very close distance. 5,6 7, 8

Identifying deficiency of accommodation in young individuals as soon as possible after starting

school is important because the eye's focus system has a contribution in the learning process.
Accommodation dysfunction makes it difficult for children to do close work such as reading and
will hinder the development of children in school. Measuring the amplitude of accommodation can
be done through several methods, including: Donders push-up method, Methods of Spheres, and
Subjective Focometer.9, 10

Research on refractive state and its effect on amplitude of accommodation at school age children
which compares two types of accommodation amplitude measurements are still very rare.
Therefore, this study aims to see the effect of refractive abnormalities on students with amplitude
of accommodation and compare the results of accommodation amplitude calculations using the
method of spheres which uses spherical lens on trial lens and Donders push-up methods that use
RAF (Royal Air Force) Ruler.

MATERIAL AND METHOD

This study was an observational analytical study with a cross-sectional approach conducted at
Lesanpuro 2 Elementary School and State Junior High School 27 Malang (SMP 27 Malang) in
December 2018. It has obtained ethical approval from the Medical Research Ethics Team of the
Faculty of Medicine, Brawijaya University number 280/EC/KEPK /08/2017. The inclusion criteria
of this study were all students of Lesanpuro 2 Elementary School 2 and SMP Negeri 27 Malang
who were able to show approval letters signed by parents to be the subject of research, students
who attended school at the time of research, and students who were able to follow all research
procedures from beginning to end. Respondents will be excluded if there are corrections of more
than 6 diopters (both myopia and hypermetropia), if they have a history of systemic diseases, a
history of long-term use of cycloplegic drugs, eye abnormalities that can affect their refractive
status, and if there are red eyes. The total population of this school is 606 students, and using the
Slovin formula, it was found that the minimum number of samples was 245 respondents
determined by stratified random sampling based on age.

Visual acuity examination

Respondents who met the inclusion criteria were then examined for UCVA (Uncorrected Visual
Acuity) in a classroom with sufficient lighting. The Snellen card is placed 6 meters from the
respondent. If the respondent can read the Snellen card 6/6 line at a distance of 6 meters without
correction, then it is categorized as emmetropia. However, if the respondent cannot read up to
line 6/6, then a correction is made. Correction with a minus lens is categorized as myopia,
correction with a plus lens is categorized as hypermetropia, and correction with a cylindrical lens
is categorized as astigmatism. Visual examination was carried out by two refractionists.
Amplitude of Accommodation Examination

Method of Spheres: using a SVR trial lens and checked by two people. After making the best
corrections on both eyes and left eye is closed using occluder, the subject is asked to hold the
Jaeger Card with a distance of 40 cm and read the card in number 40. The examiner adds a plus
lens until the subject says the vision is blurred, then he adds a minus lens until the subject says
the vision is blurred. The amplitude of accommodation is generated from the calculation of the
number of pluses and minuses obtained, and the examination is then carried out for the left eye
and for both eyes.

RAF ruler: Haag Streit brand, inspection is carried out by one person. The RAF Ruler method is
carried out by placing RAF Ruler on the patient's cheek, and the patient is asked to close his left
eye after the best correction is performed in both eyes. The examiner then shifts the box at RAF
Ruler to the patient's eye at a constant speed, and then the patient is asked to give a signal if the
writing on the box is blurred. If the patient says it is blurred, the results are recorded according to
the number printed on the RAF ruler, and then an examination on the left eye is conducted and
followed by examination on both eyes. All measurements of amplitude of accommodation are
repeated three times, and the mean is calculated.

Statistical analysis

The Kruskal-Wallis and t-independent test are used for data analysis in this study. The data are
in the form of mean ± standard deviation (SD). p value of less than 0.05 is said to be statistically
significant.

RESULTS

Characteristics of Respondents

In this study, the number of respondents was 245 respondents, the number of male respondents
was 117 (48%) and 128 of them were female (52%). The age of respondents in this study was
varied. The youngest was 6 years, and the oldest was 16 years. The highest number of
respondents was 14 years old, which was as many as 52 respondents (21.2%). The status of
refraction in the most respondent's right eye was emmetropia with 188 respondents (76%),
myopia with 30 respondents (12%), and astigmatism with 27 respondents (11%).

The status of refraction in the left eye of most respondents was emmetropia with 192 respondents
(78%), myopia with 28 respondents (11%), and astigmatism with 25 respondents (10%).

Refractive state RE Refractive state LE

300
188 192
200

100 30 28 27 25
0
Emmetropia Myopia Astigmatisma

Fig. 1. Distribution of Refraction Status. The distribution of the refractive state of the right eye
and left eye is not much different, with more emmetropia.

Amplitude of Accommodation Distribution

On the amplitude of accommodation examination for the right eye using the Method of
Spheres, the average result was 9,151 D ± 1,683 while for the left eye it was 9,078 D ± 1,583,
and the two eyes were 10,869 D ± 1,732. Meanwhile, for the amplitude of accommodation
examination using RAF Ruler, the mean of amplitude of accommodation in the right eye was
12,029 D ± 1,631, in left eye was 11,763 D ± 1,672, and in both eyes were 14,016 D ± 1,184.

20
14.016
15 12.029 11.763 10.869
9.151 9.078
10
D
5
0
RE LE RLE
Methods of spheris RAF Ruler

Fig. 2. Mean of Amplitude of Accommodation. Overall, the results of RAF Ruler are higher
than those of the Method of Spheres.

Mean of Amplitude of Accommodation Distribution in a Various Refractive States

From the results of the study, the mean of amplitude of accommodation’s measurement using
method of spheres on the emmetropic of the right eye was 9,213 D, myopia had a higher value
than emmetropia, which was 10,5333 D, and astigmatism was 8.5185 D. Meanwhile, for the
results of the examination using RAF Ruler in the right eye, it was found that the mean of the
amplitude of accommodation in emmetropia was 11.8351 D, in myopia the results were higher,
namely 13.3668 D, while for astigmatism it was 11.8889 D. The Kruskal Wallis test was used to
see the difference between amplitude of accommodation and refractive state.

15 13.3668
11.8351 10.5333 11.8889
9.0213 8.5185
10
D
5
0
Emmetropia Myopia Astigmatism
Method of spheris RAF Ruler

Fig. 3. Amplitude of Accomodation in Each Refractive State on the Right Eye. Overall, from
the two methods the results of myopia were higher when compared with emmetropia and
astigmatism.

From the measurement of left eye’s amplitude of accommodation using method of spheres, it was
found that the mean amplitude of the accommodation on the emmetropic eye was 8.8698 D,
myopia had a higher mean value than emmetropia, which was 10.6429 D, while astigmatism had
an average of 8.9200 D. On the measurement with RAF Ruler of the left eye, it was found that
eyes with emmetropia had a mean of 11.5469 D, in myopia the mean was 13.1071 D, while in
astigmatism the mean was 11.9200 D.
 Method os spheres RAF Ruler
15 13.1071
11.5469 11.9200
10.6429
10 8.8698 8.9200

D
5

0
Emmetropia Myopia Astigmatism

Fig. 4. Amplitude of Accommodation Measurement Results in Each Refractive State on the

Left Eye. Overall, almost the same as the right eye, on the left eye from the two methods higher
myopia was found when compared with emmetropia and astigmatism.

Kruskal Wallis was performed to test the differences between each group of refractive status with
amplitude of accomodation using method of spheres and RAF Ruler method. From the statistical
test, the significance value of amplitude of accommodation measurement using method of
spheres and RAF Ruler methods on refraction status was obtained, where emmetropia, myopia,
and astigmatism were smaller than α (0.05). Thus, it can be concluded that there were differences
in the mean of amplitude of accommodation in each group of refraction status. To see the location
of the differences, a further test was performed by using the Mann Whitney test.

The results of the statistical tests of each method in the right and left eyes showed that the
emmetropia group had a significant difference with myopia, but the emmetropia group had no
significant difference with astigmatism (p> 0.05) while the myopia group had a significant
difference with astigmatism (p <0.05). Meanwhile, for each amplitude of accommodation
measurement, from the results of the statistical test using t-independent it was found that the
mean of measurement results using RAF Ruler was significantly higher when compared to that
of the method of spheres.

Tab. 1. Results of difference test between the method of spheres and RAF Ruler show that the
amplitude of accommodation examination using the method of spheres and RAF Ruler methods
has a significant difference, both in monocular and binocular.

Amplitude of Accomodation Method N Mean ± Sd p Information

24
RAF Ruler 5 12.029 ± 1.631
0.000 Significant
Right eye 24
Method of Spheres 5 9.151 ± 1.683
24
RAF Ruler 5 11.763 ± 1.672
Left eye 0.000 Significant
24
Method of Spheres 5 9.078 ± 1.583
24
RAF Ruler 5 14.016 ± 1.184
0.000 Significant
Binocular 24
Method of Spheres 5 10.869 ± 1.732

Test of Amplitude of Accommodation Difference in the Age group

Based on age, the results of amplitude of accommodation calculation with RAF Ruler were higher
when compared to those with method of spheres. At the age of <10 years, the mean amplitude
of accommodation using RAF Ruler in monocular eyes was 13,500 D, at the ages of 10-15 years
the mean was 11,594 D and at > 15 years was 10,600 D. In the method of spheres, the mean of
measurement results at age <10 years was 10.102 D, in age 10-15 years the mean was 8.8925
D, and in the age group > 15 years the mean was 9,000 D, which was higher when compared to
the 10-15 year age group. In binocular measurements, the mean of RAF Ruler was higher than
that of method of spheres, both for monocular and binocular.

DISCUSSION

Characteristics of Respondents

School age is the age where children often do close reading activities, especially when lessons
take place. Good near vision requires a good accommodation system. In this study, the
respondents were between 6 and 16 years old, with 13-15 years being the biggest age group due
to the fact that in the study area, the number of junior high school students was higher than that
of elementary school students. Most students of this school have never taken eye examinations
and refraction corrections due to limited fund even though there are complaints of decreased
vision.

The most prevalent refractive state of this study was emmetropia, followed by myopia, and then
astigmatism. In this study, hypermetropia was not found because in this study cycloplegic action
which could detect latent hypermetropia was not carried out. This is in accordance with the
research of Anera, Soler et al., 2009, which examined the refractive state of school-age children
in Morocco showed that the most prevalent was emmetropia, followed by myopia, astigmatism,
and the least was hypermetropia. Another study conducted by Ju and Park in an area in South
Korea in 2015 revealed a slightly different problem. The study found that the most prevalent
refractive state in children age between 8-13 years was myopia, followed by emmetropia,
astigmatism, and hypermetropia.

The factors underlying the occurrence of refractive disorders according to previous studies are
gender, genes, ethnicity, lifestyle, and environmental factors. In this study, it was found that the
number of myopia was less than emmetropia, possibly due to the profile of this school which is
located in rural urban areas with middle to lower socio-economic status. Children often play
outdoors or help their parents rather than play indoors or play with gadgets. Even so, further
research needs to be carried out which serves to compare the status of refraction in school-age
children in urban rural, rural, and urban areas.11, 12, 13

Amplitude of Accommodation with Refractive State

Based on the measurement results of the amplitude of accommodation against the refractive
state, myopia has higher amplitude of accommodation compared to emmetropia and
hypermetropia according to Fledelius, 1981. Maddock et al, 1981 stated that mild myopia has
higher amplitude of accommodation than severe myopia or emmetropia because myopia has a
weak sympathetic system or strong parasympathetic innervation, which allows to reduce the
range that can be attained from sympathetic response that will affect long distance vision. When
myopia eyes are corrected with the appropriate minus lens, the tonic position of accommodation
will be lower in term of diopters than emmetropia. Myopia, if not corrected, does not require
accommodation to see short distances, so it has fewer accommodation ranges with lower
accommodation amplitude values. 13, 14

In this study, the measurement of accommodation amplitude was conducted using the best
correction, according to the refractive abnormalities experienced by respondents. The results of
accommodation amplitude measurement using both methods in the emmetropic refraction status
were significantly lower for myopia, but the results were not too different for astigmatism. The
insignificance of the results between emmetropia and astigmatism is probably due to the size of
the astigmatism that is not too large, so the results are almost the same as emmetropia. Research
by Fong, 1997, showed different results, because in this study, the measurements of
accommodation amplitude were carried out without the best correction.15

The Results of Accommodation Amplitude Measurement with Age

The biggest age group in this study was in the age group of 13 to 15 years, because in
this school the number of classes at the junior high school level was more than the number of
classes at elementary schools. Based on age, the measurement results of the amplitude of
accommodation with RAF Ruler are higher when compared to the measurement results using
Method of Spheres. At the age of <10 years, the mean of the amplitude of accommodation
measurement using RAF Ruler in monocular eyes is 13,500 D, for ages 10-15 years the value is
11,594 D, and at the age of > 15 years it is 10,600 D. An almost similar result was shown by
Hosftetter, who predicts the amplitude of accommodation based on age. At <10 years old the
amplitude of accommodation is 13,125 D, followed by 11,875 D at 10-15 years and 11,000 D at
> 15 years. In the method of spheres, the mean of measurement result at <10 years monocularly
is 10.102 D. At 10-15 years, the measurement of accommodation amplitude decreases, which is
8.8925 D. In the age group > 15 years, the measurement of accommodation amplitude using
method of spheres was 9,000 D, higher than the age group 10-15 years, but the results of different
tests do not show a significant difference. This is slightly different from the research of Castagno
et al, 2016 which stated that the median of amplitude of accommodation for 10-year-olds was
15.5 D, higher when compared to the median of amplitude of accommodation for this study. The
difference results in this study and in other studies is likely due to differences in the methods of
measurement carried out, number of samples, and characteristics of respondents from each
study.

Unlike the Hofstetter formula which says that the amplitude of accommodation does not
seem to decrease gradually from the age of 6 years, on the contrary, it remains the same from
the age of 6-10 years and decreases after that age. This is similar to other studies which also
stated that the magnitude of accommodation amplitude variability in the 9-12 year age group with
a peak at the age of 10 years. In the 4th grade of elementary school (age 9 years), children often
read with longer paragraphs, standard font sizes, and reading speed becomes important.
Anderson's research in 2014 about the amplitude of accommodation at a young age using
subjective push-up methods varied greatly. This happens because of the difficulty in carrying out
examination and interpretations accurately in children who have difficulty understanding the point
of blurring of the examination performed. 16, 17, 18

The Different Results of Accommodation Amplitude Measurement with RAF Ruler and
Method of Spheres

In accommodation amplitude measurements using the Method of Spheres, the mean of

monocular (9.1145 D) was lower when compared with the mean of monocular of RAF Ruler,
which was 11,896 D. This was in accordance with a research conducted in Australia by
Moghadam, et al in 2014 which compared push-up methods with minus lenses. The push-up
method showed a higher accommodation amplitude compared to the minus lens method. This is
because the closer distance, the angular size of the retinal picture increases and proximal
stimulation of accommodation also increases in contrast to the target distance. In the push-up
method, the mean of amplitude of accommodation was 11.21 D, while the lens minus method had
a mean of 9.31 D.13, 14

This different results occur because in the minus lens method there is a minification process due
to the optical properties of the concave lens. Unlike the push-up method, there is no relative
magnification distance on the minus lens method, so proximal stimulation tends to be constant.
The same opinion was also expressed by Rosenfield and Leon in 2012 who stated that measuring
the amplitude of accommodation using the push-up method will produce higher number because
the target distance is reduced, so it will increase the size of the angle of the retinal picture.
Grosvernor, 2007, in his research said that in measuring the amplitude of accommodation by
push-up method, there are factors of focus depth, target size, and lighting. 15, 16, 17, 18

Differences in Monocular and Binocular Accommodation Amplitude Measurements

The difference in the measurement results of binocular and monocular accommodation amplitude
of the two methods shows that binocular measurement results are greater than monocular. In the
method of spheres the mean of binocular is 10,869 D ± 1,732, higher than monocular
accommodation amplitude (OD: 9,151 D ± 1,683, OS: 9,078 D ± 1,583). In measurements using
RAF Ruler, the measurements of the amplitude of binocular accommodation were also higher
(14,016 D ± 1,184) than monocular (OD: 12,029 D ± 1,631, OS: 11,763 D ± 1,672). The same
was stated by Duane who conducted a study comparing the amplitude of monocular and binocular
accommodations. From Duane's research on 4200 eyes, it was found that the mean difference
between monocular and binocular was 1.5 D.

In this study, it was found that the difference between binocular and monocular method of
Spheress was 1.7 D, while RAF Ruler binocular and monocular had a difference of 2.12 D. This
difference is likely to occur because subjects in the Duane study range from 8-60 years, whereas
in this study the age range of the respondent is 6-16 years, so the results obtained are higher.
The amplitude of binocular accommodation is higher than that of monocular accommodation
because in binocular conditions, there will be a process of convergence in both eyes and pupillary
contractions which will lead to higher accommodation efforts. The same thing was stated by
Sterner, et al in 2004 who examined the amplitude of accommodation in children aged 6-10 years
using RAF Ruler. The difference in monocular and binocular amplitude accommodation from
Sterner's study is 2.75 D. 19, 20, 21, 22, 23

This study has several limitations related to the conduct of research. In this study
cycloplegic action was not carried out, so refractive abnormalities such as latent hypermetropia
could not be removed. The accommodation amplitude measurement method in this study has a
high subjectivity that relies on understanding whether or not the respondent determines that his
vision is blurred during the examination. Detection of blurred vision depends on the sharpness
and alertness that vary among several respondents. Focus affects the whole method of
measuring amplitude of accommodation which requires the awareness of respondents to
recognize blurred vision. In addition, because this research was conducted at schools with
adjacent locations, the respondents' profiles were not too different. Further research needs to be
done to see the difference in refraction status of school-age children in schools located in urban
areas and in regencies. In this study also subjective and objective accommodation amplitude was
not compared.

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