Korean J Ophthalmol 2012;26(1):39-44

http://dx.doi.org/10.3341/kjo.2012.26.1.39
pISSN: 1011-8942 eISSN: 2092-9382

Original Article

The Analysis of AC/A Ratio in Nonrefractive Accommodative

Esotropia Treated with Bifocal Glasses
Wook Kyum Kim1,2, Sung Yong Kang1, Soolienah Rhiu2, Seung Ah Chung3, Jong Bok Lee2
1
B&VIIT Eye Center, Seoul, Korea
2
The Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea
3
Department of Ophthalmology, Aju University College of Medicine, Suwon, Korea

Purpose: To report the long term results of bifocal treatment in nonrefractive accommodative esotropia and to
analyze the changes of accommodative convergence to accommodation (AC/A) ratio.
Methods: Sixteen patients treated with bifocal glasses for at least 5 years were evaluated retrospectively. Angle
of deviation at near and distance, refractive error, and AC/A ratio by the lens gradient method were analyzed.
The changes of AC/A ratios were also compared after dividing the patients according to continuation or ces-
sation of bifocal therapy.
Results: Six patients (38%; bifocal stop group, BSG) were able to stop using bifocal glasses at an average age
of 10.8 years (range, 6.5 to 15.4 years) during their follow-up. However, the other ten patients (62%; bifocal
continue group, BCG) had to continue using bifocal glasses until the final visit, which was 13.8 years on aver-
age (range, 11.3 to 18.5 years). The AC/A ratio decreased from time of bifocal prescription to the last visit in
both groups, from 4.4 to 2.7 in the BSG and from 5.9 to 4.5 in the BCG. AC/A ratios were significantly higher
(p = 0.03) in the BCG than that of the BSG from the beginning of bifocal treatment and this difference was per-
sistent until the final visit (p = 0.03).
Conclusions: The AC/A ratio decreased with age in both groups but was significantly higher throughout the
entire follow-up period in the BCG. AC/A ratio at bifocal prescription could be an important factor in predicting
response to bifocal treatment.

Key Words: Accommodation, Convergence, Esotropia

Nonrefractive accommodative esotropia is a condition eyes, the ratio is thought to remain stable without change
that is diagnosed when an emmetropically corrected pa- until presbyopia, after which the AC/A ratio increases [1-3].
tient with a high accommodative convergence to accom- However, the change of the AC/A ratio with age in nonre-
modation (AC/A) ratio shows orthotropia at distance fixa- fractive accommodative esotropia has not yet been studied.
tion but displays more than 10 prism diopters of esotropia Nonrefractive accommodative esotropia can be treated
at near fixation which can be corrected with a +3.00 diop- with bifocal lenses or miotics [4-9]. Miotics pharmacologi-
ter add lens. cally decrease accommodative convergence and correct
The AC/A ratio is the amount of induced convergence esotropia at near fixation. Long term effects of miotics
that occurs when accommodation is exerted. In normal have been studied in detail and reports of iris cysts, cata-
racts, retinal detachment, iridocyclitis and punctal occlu-
sion are abundant in the literature and thus are used only
Received: October 20, 2010 Accepted: March 4, 2011
for diagnostic purposes or for short term correction. Bifo-
Corresponding Author: Jong Bok Lee, MD. Department of Ophthalmol- cal lenses horizontally divide the visual field with a +2.50
ogy, Yonsei University College of Medicine, #250 Seongsan-ro, Seodae- - +3.00 diopters add lens in the lower portion and uses the
mun-gu, Seoul 120-752, Korea. Tel: 82-2-2228-3574, Fax: 82-2-312-0541, upper and lower portions for distance and near fixation,
E-mail: [email protected]
respectively. Bifocal glasses induce orthotropia for both far
This paper was presented at the 101st annual meeting of the Korean Oph- and near vision and decrease chances of amblyopia with
thalmological Society in April 2009. appropriate development of stereopsis.

© 2012 The Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses
/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Korean J Ophthalmol Vol.26, No.1, 2012

As patients grow older, some can discontinue the use of without +3.00 lenses at near fixation. The AC/A ratio was
bifocal lenses due to spontaneous normalization of the AC/ calculated from the difference between the upper and
A ratio [10], but others need to keep their bifocal lenses or lower segments of a bifocal lens which was divided by the
undergo strabismus surgery in an attempt to eliminate the added power of the lower segment.
need for bifocals [11-13]. Surgical options include augment- Bifocal lenses were prescribed if the angle of esodevia-
ed recession, slanted recession, and recession with poste- tion with near fixation was at least 10 prism diopters great-
rior fixation suture of the medial rectus muscles [12,14,15]. er than the angle with distance fixation with full optical
The AC/A ratio can be calculated in several ways, among correction and the angle of esodeviation with near fixation
which only the lens gradient method gives a true estimate could be eliminated or nearly eliminated with plus spheri-
of the ratio. In the lens gradient method, the change in cal lenses. Plus adds were initially prescribed from +2.50
stimulus to accommodation is produced by means of an to +3.00 diopters but were decreased to +2.50 diopters dur-
ophthalmic lens, not a change in viewing distance. France- ing the follow up period if a patient who was prescribed
schetti and Burian [16] reported that the normal range of +3.00 diopters at initial visit showed orthotropia at near
the AC/A ratio by the lens gradient method is lower than fixation.
that by the heterophoria method. The heterophoria method During the course of follow-up, cycloplegic refractions
does not account for proximal convergence, which is kept were performed semiannually, and the diopters of glasses
constant in the lens gradient method by performing both were adjusted if the refractive error had changed. Bifocals
measurements at the same distance [17]. Previous stud- were discontinued if the patient was able to keep fusion
ies did not evaluate the AC/A ratio by the lens gradient at near through distance correction lenses and showed no
method, but by heterophoria methods [9,18]. However, in or only minute differences in angle of deviation at both
this study we computed the AC/A ratio by the lens gradi- distance and near fixation. Binocular vision was also tested
ent method. when stopping bifocals.
Statistical analysis was performed using descriptive
analysis and the Mann-Whitney U-test. A p-value of <0.05
Materials and Methods
was considered statistically significant. SPSS ver. 12.0
Medical records of nonrefractive accommodative eso- (SPSS Inc., Chicago, IL, USA) was used.
tropia patients who were treated with bifocal glasses for
at least 5 years were retrospectively reviewed. Sixteen
Results
patients were included (Table 1). Institutional review board
approval was obtained for this study and the research ad- Patient demographics
hered to the tenets of the Declaration of Helsinki. Patients
who received strabismus surgery, which could affect the Tables 1 and 2 show the demographic data of 16 patients
AC/A ratio, were excluded. Visual acuity, angle of devia- who were included (Table 1). Average age at last visit was
tion at near and distance fixation, cycloplegic refraction, 13.5 years (range, 9.4 to 18.5 years) and the average age at
and the AC/A ratio at each follow-up visit were collected. bifocal prescription was 6.1 years (range, 2.4 to 11.2 years).
Ocular alignment was measured with the prism cover test, Average follow-up duration was 88 months (range, 60 to
and cycloplegic refraction was assessed approximately 30 142 months). Average added power was +2.78 diopters
minutes after final instillation of two topical eye drops of (Table 2).
Cyclogyl (cyclopentolate 1.0%) and Mydrin-P (tropicamide
0.5% and phenylephrine 0.5%), which were used three Comparisons of bifocal stop group and bifocal continue group
times at 10 minute intervals. Complete cycloplegia was
confirmed by no pupillary response to light. Of the 16 patients, six patients (38%), referred to as the
In this study, we computed the AC/A ratio by the lens bifocal stop group (BSG), were able to stop using bifocal
gradient method using the angle of deviation with and lenses at an average age of 10.8 years during their follow-

Table 2. Characteristics of 16 patients with nonrefractive ac-

commodative esotropia
Table 1. Sex distribution of included 16 patients with nonre-
fractive accommodative esotropia Characteristics Mean (range)
Characteristics Number (%) Age at last visit (yr) 13.5 (10.0-18.5)
Male 7 (44) Age at bifocal prescription (yr) 6.1 (2.4-11.2)
Female 9 (56) Add power (diopter) +2.78 (+2.50-[+3.00])
Total 16 (100) Duration of follow-up (mon) 88 (60-142)

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 WK Kim, et al. AC/A ratio in nonrefractive accommodative ET

up, and ten patients (62%), referred to as the bifocal con- Change in accommodative convergence to accommoda-
tinue group (BCG), continued using bifocal lenses until tion ratio over time for the two groups
their last visit (Table 3).
The mean angle of esodeviation at near fixation at pre- The AC/A ratio decreased with age from 4.4 to 2.7 in the
scription in the BCG was 24 prism diopters, which was BSG and from 5.9 to 4.5 in the BCG (Table 6). The AC/A
significantly larger than the 18 prism diopters in the BSG. ratio at bifocal prescription in the BSG was 4.4, which was
Differences of angle of deviation between distance and significantly lower than the 5.9 in the BCG ( p = 0.03). The
near fixation in the BCG were 19.8 prism diopters, which AC/A ratio at last visit in the BSG was 2.7, which was sig-
were larger than the 15.7 prism diopters in BSG (Table 4). nificantly lower than the 4.5 in the BCG. The AC/A ratio
The average refractive errors in BSG were 1.5 diopters decreased with age in both groups, but the initially higher
in the right eye and 2.5 diopters in the left eye, which were AC/A ratio of the BCG remained higher than that of the
not significantly different with those in the BCG (Table 5). BSG until the last visit. The AC/A ratio changes very slow-

Table 3. Clinical characteristics of 16 patients with nonrefractive accommodative esotropia grouped according to therapeutic re-
sults
Bifocal stop group Bifocal continue group
Characteristics p-value*
Mean (range)
Age at bifocal prescription (yr) 6.4 (3.9-11.2) 5.8 (2.4-8.6) 0.91
Add power (diopter) +2.83 (+2.50-[+3.00]) +2.75 (+2.50-[+3.00]) 0.53
Duration of wearing bifocal glasses (mon) 53 (26-70) 94 (64-142) 0.13
Age at bifocal discontinuation (yr) 10.8 (6.5-15.4)

6 Patients (38%) in the bifocal stop group and 10 patients (62%) in the bifocal continue group.
Calculated by Mann-Whitney U-test.
*

Table 4. Esodeviation of two groups according to therapeutic results

Bifocal stop group Bifocal continue group
Characteristics p-value*
Mean (range)
Esodeviation at onset of therapy (PD)
Distance 2.3 (0-8) 4.4 (0-10) 0.32
Near 18.0 (16-20) 24.0 (16-40) 0.05
Difference (near-distance) 15.7 (10-20) 19.8 (12-30) 0.15
Near after +3.00 sphere 5.3 (0-8.0) 5.0 (0-20) 0.61
Esodeviation at last visit (PD)
Distance 4.3 (0-8) 3.8 ([-8]-20) 0.82
Near 5.3 (0-12) 15.5 (0-30) 0.06
Difference (near-distance) 1.0 (0-4) 11.7 (0-20) 0.01
Near after +3.00 sphere 6.7 (0-20)
PD = prism diopters.
*
Calculated by Mann-Whitney U-test.

Table 5. Refractive errors in two groups according to therapeutic results

Bifocal stop group Bifocal continue group
Characteristics p-value*
Mean (range)
Refractive errors
Right (spherical equivalent, +diopter) 1.5 ([-1.6]-4.5) 1.7 ([-6.9]-6.0) 0.52
Left (spherical equivalent, +diopter) 2.5 ([-1.3]-6.2) 2.2 ([-2.4]-6.0) 0.79

Calculated by Mann-Whitney U-test.

*

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Korean J Ophthalmol Vol.26, No.1, 2012

Table 6. The change in AC/A ratio of 16 patients with nonrefractive accommodative esotropia
Bifocal stop group Bifocal continue group Total
Characteristics p-value*
Mean (range)
AC/A ratio† at bifocal prescription 4.4 (4.0-5.3) 5.9 (4.0-8.3) 5.3 (4.0-8.0) 0.03
†
AC/A ratio at last visit 2.7 (0-4.0) 4.5 (2.0-6.3) 3.9 (0-6.3) 0.03
†
Change of AC/A ratio 1.8 (0.8-4.0) 1.4 ([-2.3]-4.8) 1.5 ([-2.3]-4.8) 0.85

AC/A = accommodative convergence to accommodation.

Calculated by Mann-Whitney U-test; †Measured by lens gradient method.
*

Table 7. The AC/A ratio of two groups at the time of bifocal glasses prescription
AC/A ratio at bifocal prescription Bifocal stop group Bifocal continue group Total
4.0≤ AC/A ratio <4.5 4 2 6
4.5≤ AC/A ratio <5.0 0 1 1
5.0≤ AC/A ratio <5.5 2 1 3
5.5≤ AC/A ratio <6.0 0 0 0
6.0≤ AC/A ratio <6.5 0 2 2
6.5≤ AC/A ratio <7.0 0 3 3
7.0≤ AC/A ratio 0 1 1
Total 6 10 16
AC/A = accommodative convergence to accommodation.

Initial accommodative convergence to accommodation

ratio at bifocal prescription in both groups

All of the AC/A ratios of the BSG at bifocal prescription

were less than 5.5, but the AC/A ratios of the BCG were
distributed over a range from 4.0 to above 7.0 (Table 7). No
patient in the BSG had an AC/A ratio of more than 5.5 at
time of bifocal prescription.

Discussion
Treatment with bifocals to correct residual near esodevi-
ation is a well-established and popular method for patients
with nonrefractive accommodative esotropia [10,18]. In
this study, about one-third of patients with nonrefractive
accommodative esotropia were able to stop using bifocal
Fig. 1. Regression graph of the change in accommodative lenses during follow-up without surgery. The AC/A ratio
convergence to accommodation (AC/A) ratio according to age of these patients, measured by the lens gradient method,
in the bifocal stop group compared with the bifocal continue decreased with age and normalized. Binocular fusion was
group. Graphs depicting change in AC/A ratio over time for
two groups show a decrease in AC/A ratio with age, -0.01 × made by a spontaneous decrease of esodeviation at near
(age) + 4.84 in the bifocal stop group and -0.01 × (age) + 6.28 fixation [19]. A previous study reported that 37.0% (31 /
in the bifocal continue group. 84) of patients were either cured or improved with bifocals
[19]. Another study reported that 61.5% (40 / 65) of patients
ly with age. As the graphs depicting the change in AC/A were able to stop using bifocals at an average age of 9.7
ratio over time for the two groups show, the decrease in the years [10].
AC/A ratio with age was 0.01 per 1 month in both groups The average age at bifocal discontinuation in this study
(Fig. 1). was 10.8 years, which is older than that of the study just

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 WK Kim, et al. AC/A ratio in nonrefractive accommodative ET

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Conflict of Interest 17. Havertape SA, Cruz OA, Miyazaki EA. Comparison of
methods for determining the AC/A ratio in accommodative
No potential conflict of interest relevant to this article esotropia. J Pediatr Ophthalmol Strabismus 1999;36:178-83.
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