Purpose: Uncorrected hyperopic children must overcome an apparent conflict between accommodation and vergence demands to focus and align their retinal images. This study tested hypotheses about simultaneous accommodation and vergence performance of young hyperopes to gain insight into ocular motor strategies used to maintain eye alignment. Methods: Simultaneous eccentric photorefraction and Purkinje image tracking were used to assess accommodative and vergence responses of 26 adult emmetropes (AE) and 94 children (0–13 years) viewing cartoons. Children were habitually uncorrected (CU) (spherical equivalent refractive error [SE] −0.5 to +4 D), corrected and aligned (CCA), or corrected with a history of refractive esotropia (CCS). Accommodative and vergence accuracy, dissociated heterophoria, and vergence/accommodation ratios in the absence of retinal disparity cues were measured for 33- and 80-cm viewing distances. Results: In binocular viewing, median accommodative lags for 33 cm were 1.0 D (AE), 1.33 D (CU), 1.25 D (CCA), and 1.0 D (CCS). Median exophorias at 80 and 33 cm were 1.2 and 4.5 pd (AE), 0.8 and 2.5 pd (CU), and 0 and 1.2 pd (CCA), respectively. Without disparity cues, most response vergence/accommodation ratios were between 1 and 2 meter angle/D (∼5–10 pd/D) (69% of AE, 44% of CU, 60% of CCA, and 50% of CCS). Conclusions: Despite apparent conflict in motor coupling, uncorrected hyperopes were typically exophoric and achieved adultlike accuracy of both vergence and accommodation simultaneously, indicating ability to compensate for conflicting demands rather than bias to accurate vergence while tolerating inaccurate accommodation. Large lags and esophoria are therefore atypical. This analysis provides normative guidelines for clinicians and a deeper mechanistic understanding of how hyperopes avoid strabismus.

BACKGROUND The effectiveness of amblyopia therapy can be limited by poor adherence. Dichoptic therapies are a new approach, but recent trials have demonstrated difficulty maintaining high adherence over extended periods of at-home treatment. We evaluated the efficacy and adherence of Luminopia One-a dichoptic treatment that applies therapeutic modifications to streaming content chosen by the patient. METHODS This single-arm, multicenter prospective pilot study enrolled children aged 4-12 with anisometropic, strabismic, or mixed amblyopia at 10 pediatric ophthalmic and optometric practices across the United States. The therapeutic was prescribed for 1 hour/day, 6 days/ week for 12 weeks of at-home use. The primary endpoint was best-corrected visual acuity (BCVA) at the 12-week follow-up visit. RESULTS In total, 90 participants (mean age, 6.7 +/- 2.0 years) were enrolled, and 73/90 participants (81%) had prior treatment beyond refractive correction. For those who completed the 12-week visit, mean amblyopic eye BCVA improved from 0.50 logMAR to 0.35 logMAR (1.5 logMAR lines; 95% CI, 1.2-1.8 lines; P < 0.0001). Mean stereoacuity improved by 0.28 log arcsec (95% CI, 0.14-0.42 log arcsec; P < 0.0001). Median adherence was 86% (interquartile range, 70%-97%). CONCLUSIONS In our study cohort, adherence over the 12-week study period was high, and participants demonstrated clinically and statistically significant improvements in visual acuity and stereoacuity.

A growing body of evidence demonstrates visual, perceptual, and oculomotor abilities contribute to batting performance in baseball and there is interest in whether training such abilities can transfer positively to batting performance. The current study tested this question through a pre-registered randomized, and placebo-controlled intervention, conducted with 24 collegiate baseball players at two Division 1 universities. Athletes were randomized to receive either dynamic vision training consisting of stroboscopic, anticipatory timing, and eye quickness drills, or placebo drills stylized after control procedures in previous vision therapy studies. Generalized near-transfer was tested via a digital visual-motor task battery (n = 20), while sports-specific intermediate and far transfer of training were evaluated through instrumented batting practice metrics (n = 14) and box score performance in NCAA-sanctioned games (n = 12). The effects of training group were tested on these outcome measures while controlling for covariates such as pre-training expectations and site. Participants averaged 8.50 hours of training with no significant training group differences in adherence, expectations, or baseline assessments. ANCOVA revealed no group differences in measures of visual-motor skills or NCAA game statistics. However, batting practice demonstrated significant improvements in launch angle (p = 0.002, Cohen’s d = 0.74) and hit distance (p < 0.001, Cohen’s d = 0.70) for the active cohort relative to the placebo control. This controlled and pre-registered pilot study therefore provides preliminary evidence that vision training may improve batting practice performance, creating new opportunities for the transfer of skill training and warranting further study. Pre-Registration At Open Science Framework on August 9, 2018. DOI 10.17605/OSF.IO/496RX. Accessible at https://osf.io/jxh8u

Purpose: Infants are typically hyperopic with a narrower inter-pupillary distance than adults. To achieve focused and aligned retinal images to promote typical visual development a young child must accommodate more than a typical adult while generating less vergence. This puts their two motor systems in apparent conflict relative to a typical adult. We made simultaneous recordings of accommodation and vergence performance of young children to determine the extent to which their accommodation and vergence systems could overcome their motor demands. Methods: Simultaneous Purkinje image tracking and eccentric photorefraction (PlusOptix PowerRef 3) were used to record eye alignment and refractive state of age-matched non-strabismic hyperopic and emmetropic children with no optical correction (N=32, Mean Age: 4.66 years). Subjects viewed naturalistic images at 80 & 33cm distances in monocular and binocular viewing. Some of the hyperopes then received optical correction from their clinician. Results: The emmetropes exhibited typical relationships between accommodation and vergence at these distances in binocular conditions (Change: A=1.97±0.84D, V=1.68±0.67 MA). The hyperopes exhibited a range of behaviors. On average they were similar to the emmetropes even in the absence of optical correction (Change: A=1.97±0.76D, V=1.81±0.3 MA). The hyperopes who were prescribed optical correction exhibited relatively minimal changes in phoria despite their change in accommodative effort. Conclusion: Simultaneous measures of accommodation and vergence provide critical information about the conflict between coupled vergence and accommodation responses in hyperopes. The data suggest these individuals can display an unexpected range of behaviors from fully typical to decompensated convergent deviation.

Purpose: Accommodative esotropia is associated with significant hyperopia in childhood. Only about 20% of these hyperopes develop esotropia however. What are the factors differentiating the two groups? In this study, we compared accommodation and vergence behavior of strabismic hyperopic, non strabismic hyperopic and emmetropic children. Methods: Simultaneous Purkinje image tracking and eccentric photorefraction (PlusOptix PowerRefractor) were used to record eye alignment and refractive state of age-matched strabismic hyperopes (N=7, Mean Age: 4.36 years, mean cycloplegic refraction: +6.25 D), non-strabismic hyperopes with no optical correction (N=7, Mean Age: 4.61 years, mean cycloplegic refraction: +3.18 D) and emmetropic children (N=10, Mean Age: 5.53 years, mean cycloplegic refraction: +1.13 D). Subjects viewed naturalistic images at 80 & 33cm distances in monocular and binocular viewing conditions. The mean accommodation and alignment postures at the two distances were determined for each participant and compared across groups. Results: The emmetropic group (E) exhibited typical relationships between accommodation(A) and vergence(V) at these distances in binocular conditions (Change: A = 2.01D±0.57, V = 8.47pd±3.35). The hyperopic groups exhibited a range of behaviors. On average non-strabismics (NS) were similar to the emmetropes even in the absence of optical correction (Change: A = 1.64±0.70D, V = 9.53±1.5pd), while the strabismic group (S) were misaligned for the same demands (Change: A = 1.13±1.94D, V = 4.92±9.66pd),). In monocular conditions, the emmetropes exhibited typical response coupling (mean 4.17pd/D of accommodation), which agreed well with the NS group (mean 5.80pd/D of accommodation). Counter to common expectation, the strabismic group did not all exhibit high coupling ratios (mean 3.82 pd/D of accommodation). Conclusion: Simultaneous measures of accommodation and vergence provide critical information about the conflict between coupled vergence and accommodation responses in hyperopes. The data suggest these individuals display an unexpected range of behaviors from fully typical to decompensated convergent deviation. Meeting abstract presented at VSS 2018

Introduction: Approximately 20% of children with hyperopia greater than +3.5D develop accommodative esotropia. How do strabismic children differ from the 80% with aligned eyes? Infants and young children experience changing accommodation and vergence demands due to emmetropization and head growth. Typically developing young children and pre-presbyopic adults demonstrate vergence adaptation to extra demands in maintaining eye alignment (in both convergent and divergent directions). This study asked whether vergence adaptation differed between hyperopes with and without a history of strabismus. Methods: The hyperopic participants were children and pre-presbyopic adults with spherical dquivalent refractive error ≥+3D in at least one eye and cylinder power ≤2D. They were compared to age-matched emmetropes. Vergence adaptation was assessed using changes in heterophoria after subjects viewed through a 6pd prism binocularly for four 1-min intervals. Eccentric photorefraction and Purkinje image eye tracking were used to monitor accommodation and eye alignment at 50Hz. All participants were tested with base in prisms requiring divergent adaptation. Results: Of 17 hyperopic participants (3.6-21.9 years of age, Mean 8.0, SD 4.9), 7 currently aligned with a history of strabismus showed -12% to 70% adaptation (Median 37%, IQR 2%-65%) and 5 generated < 50% adaptation; 10 hyperopes with no strabismus history adapted by -17% to 86% (Median 64%, IQR 29%-72%), with 3 showing < 50% adaptation. The age-matched emmetropes showed 2% to 118% adaptation (Median 72%, IQR 35%-81%), with 3 of 11 showing < 50% adaptation. Accommodation responses were monitored in each trial. Conclusion: These data suggest that strabismic hyperopes are more likely to have poor vergence adaptation. After a larger clinical trial, this factor could identify those at higher risk for refractive esotropia. Meeting abstract presented at VSS 2018

Author Affiliations: Assistant Professor (Dr Hensel), School of Nursing, and Clinical Professor and Chief of Pediatrics/Binocular Vision Services (Dr Lyon), School of Optometry, Indiana University, Bloomington. The authors declare no conflicts of interest. Correspondence: Dr Hensel, Indiana University, 1033 E 3rd St, SY402, Bloomington, IN 47405 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: December 14, 2014 Published ahead of print: February 25, 2015

Purpose: Focused binocular fixation on a target relies on a combination of accommodation and vergence oculomotor responses. These require recalibration during early development, as a result of changes in refractive error and increases in inter-pupillary distance (IPD). This study tracked the roles of blur and disparity cues in these motor responses during this period. Methods: 103 infants were followed from 3 months until 3 years of age. Their accommodation and vergence responses to a movie with naturalistic spatial amplitude spectra were recorded simultaneously using eccentric photorefraction and Purkinje image tracking (PowerRefractor, MCS). The target was moved repeatedly between 90 and 33cm and recordings were made in i) full cue binocular conditions (Bn), ii) the absence of disparity cues while occluding one eye with an IR filter (Oc), and iii) a reduced blur cue condition (Bl) (the image was covered with a lowpass spatial filter and masked with a Difference of Gaussian). Results: Changes in vergence and accommodation between the two viewing distances were computed for each condition. The ratio of vergence to accommodation was compared across the three conditions. Relative to the full cue Bn baseline, the ratio in the absence of disparity (Oc) was reduced at all ages (F = 0.22, p=0.80), suggesting that accommodative convergence is consistently low in early childhood. In contrast, the ratio in the Bl condition was lower in infancy and childhood than in adults (F=4.78, p=0.02), suggesting convergence accommodation is higher during early development. Conclusions: The results suggest that vergence driven by cues other than disparity remains low in early childhood, while accommodation driven by cues other than blur is increased. This relationship is theoretically beneficial during the developmental period when accommodative demand is typically high due to hyperopia and vergence demand is low due to the narrow IPD. Meeting abstract presented at VSS 2015

Purpose We conducted a pilot randomized clinical trial of office-based active vision therapy for the treatment of childhood amblyopia to determine the feasibility of conducting a full-scale randomized clinical trial. Methods A training and certification program and manual of procedures were developed to certify therapists to administer a standardized vision therapy program in ophthalmology and optometry offices consisting of weekly visits for 16 weeks. Nineteen children, aged 7 to less than 13 years, with amblyopia (20/40–20/100) were randomly assigned to receive either 2 hours of daily patching with active vision therapy or 2 hours of daily patching with placebo vision therapy. Results Therapists in diverse practice settings were successfully trained and certified to perform standardized vision therapy in strict adherence with protocol. Subjects completed 85% of required weekly in-office vision therapy visits. Eligibility criteria based on age, visual acuity, and stereoacuity, designed to identify children able to complete a standardized vision therapy program and judged likely to benefit from this treatment, led to a high proportion of screened subjects being judged ineligible, resulting in insufficient recruitment. There were difficulties in retrieving adherence data for the computerized home therapy procedures. Conclusions This study demonstrated that a 16-week treatment trial of vision therapy was feasible with respect to maintaining protocol adherence; however, recruitment under the proposed eligibility criteria, necessitated by the standardized approach to vision therapy, was not successful. A randomized clinical trial of in-office vision therapy for the treatment of amblyopia would require broadening of the eligibility criteria and improved methods to gather objective data regarding the home therapy. A more flexible approach that customizes vision therapy based on subject age, visual acuity, and stereopsis might be required to allow enrollment of a broader group of subjects.

PURPOSE:To determine the accommodative accuracy of infants and young children before they had had any form of clinical intervention or treatment, in an attempt to determine the difference between 'normal' and 'abnormal' visual experience for these individuals.METHODS:Nott retinoscopy was performed on 111 subjects in binocular viewing conditions at a viewing distance of 50 cm. The target was a naturalistic cartoon image with a broadband spatial frequency amplitude spectrum.RESULTS:Accommodative accuracy was not related to age (4-90 months). In the group found to have no apparent clinical abnormality (n = 71), the mean lag in the more hyperopic meridian of the least ametropic eye was 0.34 diopters (D). When considering the group as a whole, those with less than approximately 4 D of hyperopia demonstrated similar lags, while those with higher hyperopia, amblyopia, or strabismus had more variable lags. An ROC analysis designed to detect hyperopia >5 D in any meridian, amblyopia and/or strabismus had an area under the curve of 0.90 (95% confidence interval [CI], 0.82 to 0.95), and for a lag criterion of 1.3 D had a sensitivity of 83.3% and a specificity of 96.5%.CONCLUSIONS:These data from a relatively small but broad sampling of age and clinical status suggest that clinically normal young infants and children with low amounts of hyperopia have similar lags of accommodation from the first few months after birth. Subjects with greater than 4 D of hyperopia, or amblyopia or strabismus, have more variable lags and therefore evidence of abnormal visual experience.

PURPOSE. To determine whether progressive-addition lenses (PALs) relative to single-vision lenses (SVLs) slow the progression of low myopia in children with high accommodative lag and near esophoria.METHODS. One hundred eighteen children 8 to < 12 years of age with spherical equivalent refraction (SER) from -0.75 to -2.50 D and near esophoria >= 2 PD were enrolled in this double-masked multicenter randomized trial. A key additional eligibility criterion was high accommodative lag, initially defined as at least 0.50 D (accommodative response less than 2.50 D for a 3.00-D demand) and later restricted further to at least 1.00 D. One hundred four subjects had accommodative lag of at least 1.00 D, and 14 had lag between 0.50 and 0.99 D. The children were randomized to receive either PALs with a + 2.00-D addition or standard SVLs. The clinicians performing the outcome testing, as well as the children and their families, were masked to treatment group. Follow-up visits occurred every 6 months for 3 years. At annual visits, refractive error was assessed in each eye by using cycloplegic autorefraction. The main outcome measure was change from baseline to 3 years in SER by cycloplegic autorefraction.RESULTS. The mean change in SER between baseline and the 3-year primary outcome visit was -0.87 D in the PAL group and -1.15 D in the SVL group, for a difference of 0.28 D (95% confidence interval [CI], 0.01-0.55D).CONCLUSIONS. The PALs used in this study were found to have a statistically but not clinically significant effect of slowing myopia progression in children with high accommodative lag and near esophoria. (ClinicalTrials.gov number, NCT00320593.) (Invest Ophthalmol Vis Sci. 2011;52:2749-2757) DOI: 10.1167/iovs.10-6631

Purpose: To determine whether performing near activities while patching for amblyopia enhances improvement in visual acuity.Design: Randomized clinical trial.Participants: A total of 425 children, aged 3 to < 7 years, with amblyopia (20/40-20/400) that was caused by anisometropia, strabismus, or both, and that persisted after treatment with spectacles.Methods: Children were randomized to 2 hours of patching per day with near activities or 2 hours of patching per day with distance activities. Instruction sheets describing common near and distance activities were given to the parents. Study visits were scheduled at 2, 5, 8, and 17 weeks. In weeks without a visit, weekly telephone calls were made to the parent to monitor and encourage compliance during the first 8 weeks.Main Outcome Measure: Masked assessment of visual acuity by isolated crowded HOTV optotypes at 8 weeks.Results: At 8 weeks, improvement in amblyopic eye visual acuity averaged 2.6 lines in the distance activities group and 2.5 lines in the near activities group (mean difference in acuity between groups, adjusted for baseline acuity, 0.0 lines 95% confidence interval, -0.3 to 0.3). The 2 groups also appeared statistically similar at the 2-, 5-, and 17-week visits. At the 17-week examination, children with severe amblyopia improved a mean of 3.6 lines with 2 hours of daily patching.Conclusions: Performing common near activities does not improve visual acuity outcome when treating anisometropic, strabismic, or combined amblyopia with 2 hours of daily patching. Children with severe amblyopia may respond to 2 hours of daily patching.

•“Early visual experience drives the architecture of the visual brain.”•Screening eye examinations are important in all infants, regardless of gestational age. All neonates should have an examination of the red reflex before discharge from the newborn nursery.•The absence of visual responsiveness by 2 months of age should prompt an urgent ophthalmologic evaluation.•Most full-term infants establish normal ocular alignment within the first 2 months.•Nystagmus can be a manifestation of a congenital motor entity, secondary to visual pathway defects or neurologic disease. Nystagmus caused by defective vision does not develop until approximately 3 months of age.•Successful treatment of congenital cataracts is highly dependent on early diagnosis and prompt referral.•The successful management of retinoblastoma depends on the ability to detect the disease while it is still intraocular; disease stage correlates with delay in diagnosis.•Neonatologists have both a clinical and a medicolegal responsibility to arrange timely diagnostic retinopathy of prematurity examinations for preterm babies in the neonatal intensive care unit and to communicate to parents the vital importance of keeping outpatient ophthalmology appointments.

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