title: Accommodative and vergence difficulties interfering with image clarity through a binocular indirect ophthalmoscope.
abstract: OBJECTIVE
  This study sought to identify accommodative and vergence deficiencies that could explain why some students have difficulty seeing clearly when using a binocular indirect ophthalmoscope (BIO) containing its standard +2.00 D lenses.
  
  
  METHODS
  A survey was distributed to Illinois College of Optometry 3rd- and 4th-year students. Based on the information supplied by the survey, students were divided into two groups: those who are unable ("BIO plano") and those who are able ("BIO plus") to obtain a clear image with the +2.00 D lenses in their BIO's. Forty-seven subjects participated: 22 in the BIO plano group and 25 in BIO plus group. Two of the authors, masked to subject group, measured all subjects' accommodative amplitudes and facilities, monocular estimation method (MEM) retinoscopy, negative relative accommodation and positive relative accommodation (NRA/PRA), distance and near vergence ranges, distance and near phorias, Worth 4-dot test, and near point of convergence (five times).
  
  
  RESULTS
  The Mann-Whitney U analysis of numerical data for the two groups showed a statistically significant difference for accommodative facility in the right eye (p = 0.004). The difference between the two groups approached significance for accommodative facility with both eyes (p = 0.02), facility in the left eye (p = 0.03), distance base-out blur (p = 0.02), near base-out break (p = 0.02), and near base-out recovery (p = 0.04). For all findings in which the difference between the two groups was significant or approached significance, the BIO plus group had higher median values. When subjects were classified by difficulty with the plus side of the flippers during accommodative facility testing, there was a statistically significant difference with both eyes (Fisher exact test, p = 0.003) and with the right eye (p = 0.008) between the BIO plus and BIO plano groups. When subjects were classified by the presence or absence of an accommodative or binocular vision syndrome, categorical data analysis showed the difference between the two groups approached significance, with more BIO plano subjects having syndromes (p = 0.03).
  
  
  CONCLUSIONS
  No one test absolutely defined who would have difficulty with the +2.00 D lenses in the BIO. There are several skills required; less developed plus acceptance and convergence may cause difficulties.
authors.affiliation: Illinois College of Optometry, Chicago, Illinois 60616, USA. jwinters@eyecare.ico.edu
authors.forename: Janis Ecklund
authors.initials: JE
authors.lastname: Winters
authors.forename: Kelly A
authors.initials: KA
authors.lastname: Frantz
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Kern
mesh_terms: D000065:Accommodation, Ocular; D000328:Adult; D003290:Convergence, Ocular; D003625:Data Collection; D006801:Humans; D019721:Ophthalmoscopes; D016037:Single-Blind Method; D014786:Vision Disorders / Q000503:physiopathology*; D015348:Vision, Binocular; D014792:Visual Acuity