Measurement of Amplitude of Accommodation in

Different Methods at a Tertiary Eye Hospital

Tanzia Habib Tisha

B. Optom, Roll no: 2014/10
Registration No: 255
Institute of Community Ophthalmology
University of Chittagong

Supervisor: Prof. Dr. Khurshid Alam

Co-supervisor: Ms. RahnomaTarannom
 Introduction

• The accommodative system of the human eye is one of the several highly
complicated functions necessary to execute and carry out very fine and
detailed near work. Accommodation can be defined as an increase in the
dioptric or refractive power of the eye to focus clearly on objects at
various distances.1
• The accommodative system of the human eye is one of the several highly
complicated functions necessary to execute and carry out very fine and
detailed near work. Accommodation can be defined as an increase in the
dioptric or refractive power of the eye to focus clearly on objects at
various distances.1,2,3,4,5,6,7
• In view of the paucity of studies, the purpose of this study was to compare
subjective and objective methods of stimulating and measuring AOA in
young pre-presbyopic (18–28 years old) children of young age to
understand the benefit and drawbacks of each method.
 Aims and Objectives
• The broad objective of this study was to determine the Amplitude of
Accommodation in different methods among the young age (18-28)
groups of patients in Chittagong Eye Infirmary and Training Complex,
Chittagong.

•  Specific objectives:
1) To measure the amplitude of accommodation in emmetropic
individuals.
2) To compare the amplitude of accommodation in different
methods.
 Rationale

• The detection and management of common refractive conditions,

including Presbiyopia and latent hypermetropia are frequently assisted by
determining amplitude of accommodation. Some pathological conditions
and prescribed medications can influence accommodation.

• A wide range of physiological and other factors like refractive error,

ethnicity of race, adaptation to sunlight, periocular temperature, dyslaxia
and other reading difficulties, intraocular pressure, diabetes, Down
Syndrome, Thyroid dysfunction, alcohol consumption, premature birth,
systemic medications and visual axis declination influence amplitude of
accommodation. The significance of these factors is difficult to determine
because of limitations in the accuracy of the measurement of amplitude of
accommodation.
 Continue….
• The increased use of small display screen devices such as smart phones is
associated with higher levels of accommodation than conventional near
vision tasks. Analysis of visual efficiency for such work would require
precise measurement of amplitude of accommodation because the visual
task may require maximal levels of accommodation.
 Methodology

• Study approach: The whole study was approached in qualitative method.

• Study design: This is a hospital based cross-sectional study of
measurement of amplitude of accommodation.
• Study place: All data was collected from the refraction clinic of Chittagong
Eye Infirmary and Training Complex, Chittagong.
• Study population: The study was assessed in young persons aged
between 18 to 28 years.
• Sampling Size: Sampling size of the study was 40.
• Study Period: Study period of this study was January 2021 to September
2021.
• Inclusion Criteria:
1) Persons with visual acuity of 6/6.
2) Persons who are aged between 18 to 28 years.
• Exclusion Criteria:
1) Persons with any systemic diseases.
2) Non verbal and mentally retard patients.
3) Persons with delayed maturity or developmental delay.
4) Persons who have Myopia or Hypermetropia of 0.50D or
greater and Astigmatism of 0.50D or greater
 Data collection Technique  

Demographic & socioeconomic information

History taking

Visual status

Refractive Status
 Methods for measuring Amplitude of
Accommodation
•Push up methods: In this method the patient, optically corrected for distance vision,
views a detailed test object approaching the eye and reports when there is ‘the first
slight, sustained blur’. The test object is then said to be at the eye’s near point and
its distance to the eye is measured. The measurement (in meters) is converted to its
reciprocal to provide the amplitude of accommodation in diopter. This method,
often using an instrument known as the RAF ruler is well established in clinical
practice and research.

•Minus lens method: In this method negative spherical lenses are added to the
distance refractive correction until the subject cannot maintain the initial acuity at a
preset viewing distance. The amplitude of accommodation is given by the maximum
negative lens power added while the patient can maintain focus. This method
should only be used under monocular conditions because it results in an excess of
accommodative convergence which would be likely to disrupt binocularity.
 
 Continue…
• Dynamic Retinoscopy Method: In this technique the practitioner
determines the end-point by observation of the retinoscopic reflex. This
technique can be used for patients with whom communication can be
challenging with patients who have a visual impairment. Only monocular
measurement can be made, although measurement conditions can be
monocular or binocular.
 Data Analysis

Statistical Analysis: SPSS, version 16.0

Graphical Presentation: Microsoft Excel.

Data description: Graphs, Frequency and

Distribution tables.
 Result
Male Female

48%
33% 53%
18-22 years
23-28 years

68%

Figure 1: Percentage distribution of Figure 2: Percentage distribution of

age among the study respondents. gender among study respondents.
 Distribution of Gender according to Age
and Amplitude of Accommodation
Gender
Age Range Gender Total(n) Amplitude Total
of
Male Female
accommod Male Female
ation
18-22 12 15 27

8.33 3 2 5
23-28 7 6 13
9.09 8 3 11

10.0 4 7 11

Total 19 21 40
11.11 3 8 11

12.5 1 1 2

Total 19 21 40
Table 1: Cross distribution of gender
according to age. Table 2: The male and female distribution
of amplitude of accommodation.
 Distribution of Occupation and Descriptive
statistics of Amplitude of Accommodation
Occupation Frequency Percent Statistics Dynamic Push Up Minus Hofstetter'
Retinosco Method Lens s Equation
pic Method Average
Student 23 57.5%
Method

Industrial Worker 5 12.5%

Mean .6188 9.9712 -7.7625 12.1400

House Wife 9 22.55%

Median .6250 10.0000 -8.2500 12.5000

Service Holder 3 7.5%

Mode .75 9.09 -8.25 13.10

Total 40 100.0% Std. .13853 1.12174 2.69196 1.10217

Deviation

Table 3: Frequency and percentage Table 4: Descriptive statistics of the

distribution of occupation. measurement of amplitude of accommodation
using modified dynamic retinoscopy, push up,
minus lens and Hofstatter's equation.
 Chief complain of the respondents
Redness, Itching 2.50%

Itching, Foreign Body sensation 2.50%

Redness, Itching, Photophobia 12.50%

Blurring of vision during near work 2.50%

Itching ,Eyeache 7.50%

Headache at bitemporal lobe 5.00%

Headache at bitemporal lobe with vomiting 2.50%

Headache at frontal lobe during near work 12.50%

Headache at frontal lobe 15.00%

Itching,Watering 7.50%
2.50%
Blurring of vision while doing near work

Headache at temporal lobe 5.00%

Watering, Photophobia 5.00%

Itching, Watering ,Photophobia 5.00%

Blurring of vision at distance 12.50%

 Distribution of Accommodative response in
Dynamic Retinoscopy and Push Up methods
NPA in DRM Frequency Percent NPA in PU method
method Frequency Percent
8.33D
0.25D 1 2.5% 5 12.5%

9.09D
11 27.5%
0.5D 19 47.5%
10D
11 27.5%

11.11D
0.75D 20 50.0% 11 27.5%

12.5D
2 5.0%
Total 40 100.0%
Total
40 100.0%

Table 6: Frequency and percentage Table 7: Frequency and percentage

distribution of accommodative response of the distribution of accommodative response of
study respondents in Dynamic Retinoscopy the study respondents in Push Up method.
method.
 Distribution of Accommodative response in
Minus Lens method
Accommodative response in ML method
Frequency Percent
-9.75D 1 2.5%

-9D 1 2.5%

-8.75D 5 12.5%

-8.5D 8 20.0%

-8.25D 10 25.0%
-8D 5 12.5%
-7.75D 2 5.0%
-7.5D 4 10.0%

-7.25D 4 10.0%

Total 40 100.0%

Table 8: Frequency and percentage distribution of accommodative response of the study

respondents in Minus Lens method.
 Distribution according to Hofstetter’s
Equation
Hofstetter’s Equation Frequency Percent
10.1D 5 12.5%
10.4D 1 2.5%
10.7D 1 2.5%
11D 2 5.0%
11.3D 1 2.5%
11.6D 3 7.5%
11.9D 2 5.0%
12.2D 2 5.0%
12.5D 5 12.5%
12.8D 6 15.0%
13.1D 9 22.5%
13.4D 2 5.0%
13.7D 1 2.5%
Total 40 100.0%

Table 9: Frequency and percentage distribution of the study respondents according

to Hofstetter’s equation.
 Discussion
• A total of 40 respondents aged between 16 and 28 years with a mean age
22 and standard deviation of 4 years were included in the study.
• Among 40 respondents, 19(47.5%) were females and 21(52.5%) were
males. The number of female respondents were more than the male one.
• The average amplitude of accommodation ranged from 7.76D to 9.97D.
The push up procedure had the highest average while the modified
dynamic Retinoscopy had the smallest means. The expected mean AOA
computed using Hofstetter’s equation (AOA=18.5-0.3*age) for the
respondents of the current study was 12.14 ± 1.10D. Using Hofstetter’s
equation for maximum AOA(AOA=25.0-0.4*age),The mean maximum
expected AOA was 16.5 ± 1.46D, while the minimum expected AOA
(AOA=15.0-0.25*age) was 9.70 ± 0.91D.
 Continue….
• In Push Up method, most of the respondents had accommodative
response (9-11)D i.e; 27.5% and a very few had below (12.5% had 8.3D)or
above (5% had 12.5D) that
• Among all the 40 respondents, 2.5% had accommodative response -9.75D,
2.5% had -9D, 12.5% had -8.75D, 17.5% had -8.5D, 25.0% had -8.25D,
12.5% had -8D, 5.0% had -7.75D, 10.0% had 7.5D,10.0% had -7.25D, 2.5%
had 8.5D in minus lens method.

• Among all the 40 respondents, according to Hofstetter’s equation 12.5%

had amplitude of accommodation 10.1D, 2.5% had 10.4D, 2.5% had 10.7D,
5.0% had 11D, 2.5% had 11.3D, 7.5% had 11.6D, 5.0% had 11.9D, 5.0% had
12.2D, 12.5%had 12.5D, 15.0% had 12.8D, 22.5% had 13.1D, 5.0% had
13.4D, 2.5% had 13.7D.
 Conclusion
• The push up method overestimate the true amplitude of accommodation

• The amplitude of accommodation measured using objective methods

agreed with each other but differed from subjectively measured
amplitude of accommodation.

• Again the study respondents might have higher amplitude of

accommodation than what might be predicted using Hofstatter’s formula.

• Therefore further study are needed with a large sample to establish

normative values for the amplitude of accommodation of the study
respondents and to validate modified dynamic retinoscopy method as the
optimal routine clinical method to assess amplitude of accommodation.
 Study Summery
Total respondents 40 respondents

Gender Male 21(52.50%), Female 19(47.50%)

Mean Age 22 ±4 years

Mean in Dynamic Retinoscopy Method 0.62 ±0.15 D

Mean in Push Up Method 9.97 ±1.12 D

Mean in Minus Lens Method -7.76 ±2.69 D

Mean in Hofstatter’s Equation 12.14 ±1.10 D

Mean in Hofstatter’s Equation Maximum 16.52 ±1.47 D

Mean in Hofstatter’s Equation Minimum 9.70 ±0.91 D

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