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1.
The AC/A
Ratio
Catherine L. Heyman,O.D
Assistant Professor
2.
AC/A Ratio
Definition
Determination
Clinical significance
3.
AC/A Ratio
Definition: The measurement of the
convergence induced by accommodation per
diopter of accommodation
Purpose: To determine the change in
accommodative convergence that occurs
when the patient accommodates or relaxes
accommodates a given amount
5.
AC/A Ratio
Importance
Significant in
Diagnosis
Treatment
6.
AC/A Ratio
Distance phoria dependant on
Tonic vergence
Near phoria dependant on
AC/A ratio
7.
AC/A Ratio
Two ways to determine AC/A
Calculation
Gradient
8.
AC/A Ratio
Calculated AC/A
AC/A = IPD (cm) + N (m) (D’-D)
IPD = interpupillary distance in centimeters
N = near fixation distance in meters
D’ = near phoria (eso is plus and exo is minus)
D = far phoria (eso is plus and exo is minus)
9.
AC/A Ratio
Calculation method continued
Example: IPD = 60 mm, the patient is 2Δ
exophoric at distance and 10Δ exophoric at near
(40 cm)
AC/A = 6 + 0.4(-10 - (-2))
= 6 + 0.4(-10 + 2)
= 6 + 0.4(-8) = 6 + (-3.2)
= 2.8
10.
AC/A Ratio
Example: IPD = 56 mm, the patient is 3Δ
exophoric at distance and 7Δ esophoric at
near (40 cm)
AC/A = 5.6 + 0.4(7 -(-3))
= 5.6 + 0.4(10)
= 5.6 + 4
= 9.6
11.
AC/A Ratio
Note
Be sure to use the correct signs for Eso and Exo
Be sure to use correct units
12.
AC/A Ratio
Gradient AC/A
Phoria is measured a second time using a -1.00/
+1.00 lens
The change in phoria with the additional minus
or plus is the AC/A ratio
13.
AC/A Ratio
Gradient continued
Example: If the near phoria is 2Δ eso through the
subjective finding and with -1.00 it is 7Δ eso
AC/A ratio is 5/1
14.
AC/A Ratio
Gradient continued
Example: If the near phoria is 4Δ exo through
the subjective finding and with +1.00 it is 10Δ
exo
AC/A ratio is 6/1
15.
AC/A Ratio
Clinically both methods are used
Calculation
Only requires a cover test and simple math
Gradient
Quick and easy
Gives Dr immediate feedback
16.
AC/A Ratio
Differences between the two methods
Proximal vergence
Lag of accommodation
17.
AC/A Ratio
Difference between the two methods:
Calculated AC/A includes the effect of proximal
vergence
Gradient AC/A measures the near phoria twice at
a fixed distance, proximal vergence is held
constant and thus does not alter the final result
18.
AC/A Ratio
Response vs Stimulus
Alpern et.al (1959) found that the accommodative
response will be about 10% less than the stimulus.
Thus when we measure accommodative response
directly we find for a +2.50 D (40 cm) stimulus there
will be a lag of accommodation of about +0.25 to
+0.75D
Clinically we measure the stimulus AC/A
19.
AC/A Ratio
Lag of accommodation
Generally +0.25 to +0.50 D
This under accommodation can significantly effect
your findings
20.
AC/A Ratio
Controlling Accommodation
Can be a source of measurement error
Clinician should emphasize that clarity of the target is
essential
A target with detail will help control accommodation
21.
AC/A Ratio
Expected AC/A Ratio values
4/1with a standard deviation of +/- 2
Between 2-6 normal
Morgan (1944)
High > 6/1
Low < 2/1
22.
AC/A Ratio
Ocular Deviation AC/A
Dist = Near IPD (cm)
More eso at near >IPD (cm)
More exo at near <IPD (cm)
25.
AC/A Ratio
AC/A is a measure of the amount of
accommodative induced convergence per
unit of accommodation
The amount convergence is affected by
changes in accommodation
26.
AC/A Ratio
Two ways to measure the AC/A Ratio
Calculation
Gradient
27.
AC/A Ratio
Calculation method
Example: IPD = 60 mm, the patient is 3Δ
exophoric at distance and 3Δ exophoric at near
(40 cm)
AC/A = 6 + 0.4(-3 - (-3))
= 6 + 0.4(-3+ 3)
= 6 + 0.4(0)
= 6/1
28.
AC/A Ratio
Expected AC/A Ratio values
4/1with a standard deviation of +/- 2
Between 2-6 normal
Morgan (1944)
High > 7/1
Low < 3/1
29.
AC/A Ratio
Ocular Deviation AC/A
Dist = Near IPD (cm)
More eso at near >IPD (cm)
More exo at near <IPD (cm)
30.
AC/A Ratio
Effect of uncorrected refractive errors on
phorias
Myopia
Hyperopia
Astigmatism
Anisometropia
32.
Case #1
AC a 7 year old girl presents with complains of
headaches and eye strain with near work
Unaided VA’s
OD 20/20
OS 20/20
At distance and near
Cover Test: Ortho/5EP’
IPD=53mm
36.
Case #1
Gradient
Trial frame + 1.00 DS
Re measure CT at near find?
37.
Case #1
Through +1.00 DS AC’s near phoria
measures 2XP’
Treatment
Rx +1.00 DS OU for near only
RTC 1 month
38.
Case #1
F/U one month after SRx
AC asymptomatic and loves her new glasses
The OD (YOU) are the hero!!
39.
Case #2
TA a 8 year old boy presents with complaints of
headaches and eye strain with near work
Unaided VA’s at distance
OD 20/50
OS 20/50
At near 20/20 OD,OS,OU
Cover Test: 2XP/10XP’
IPD=54mm
45.
Case #2
Management
Rx -1.50 DS OU
RCT 1 month
What do we expect?
46.
Case #2
F/U visit one month after Rx wear
Aided VA’s at distance
OD 20/20
OS 20/20
At near 20/20 OD,OS,OU
Cover Test: 2XP/8XP’
BO: 10/12/5
Pt. still symptomatic c/o HA’s and asthenopia
47.
Case #2
Treatment
Vision Therapy
Treat the compensating vergence