CONVERGENCE
NAZMA SULTANA HUSSAIN
Binocular Anomalies
• LOW AC/A RATIO
Orthophoria at distance—convergence
insufficiency
Exophoria at distance—convergence insufficiency
Esophoria at distance—divergence insufficiency
• High AC/A ratio
Orthophoria at distance—convergence excess
Esophoria at distance—convergence excess
Exophoria at distance—divergence excess
Orthophoria at Distance: Convergence
Insufficiency
• This is a patient who has orthophoria at distance (normal tonic vergence), a low
AC/A ratio, and moderate to high exophoria at near.
• Symptoms
• All of the following are associated with reading or other near tasks:
• Asthenopia and headaches
• Intermittent blur
• Intermittent diplopia
• Symptoms worse at end of day
• Burning and tearing
• Inability to sustain and concentrate
• Words move on the page
• Sleepiness when reading
• Decreased reading comprehension over time
• Slow reading
Continue..
• Signs
• Moderate to high exophoria or intermittent exotropia at near
• Reduced PFV at near
• Reduced vergence facility at near with base-out prism
• Intermittent suppression at near
• Receded near point of convergence
• Low AC/A ratio
• Fails binocular accommodative facility testing with +2.00
• Low MEM and fused cross-cylinder findings
• Low NRA
• Exofixation disparity
Exophoria at Distance: Convergence
Insufficiency
This is a patient who has exophoria at distance (low tonic vergence) and low AC/A ratio, and
thus the near phoria will be significantly greater than the distance phoria. This patient’s
exophoria differs from the previous type in which the phoria at distance is ortho.
• Symptoms
• All of the following are associated with reading or other near tasks:
• Asthenopia and headaches
• Intermittent blur
• Intermittent diplopia
• Symptoms worse at end of day
• Burning and tearing
• Inability to sustain and concentrate
• Words move on the page
• Sleepiness when reading
• Decreased reading comprehension over time
• Slow reading
• If the exophoria is large at distance, many of the above symptoms may be present at
distance as well.
Continue
• Signs
• Greater exophoria at near than at distance
• Reduced PFV at distance and near
• Reduced vergence facility at near and possibly at distance with base out
prism
• Intermittent suppression at near
• If the suppression is significant, stereopsis may be reduced
• Receded near point of convergence
• Low AC/A ratio
• Fails binocular accommodative facility testing with +2.00 D
• Low MEM and fused cross-cylinder findings
• Low NRA
• Exofixation disparity at distance and near
Esophoria at Distance: Divergence
Insufficiency
• This is a patient who has esophoria at distance (high tonic vergence) and low AC/A
ratio, and thus the distance phoria will be significantly greater than the near phoria.
• Symptoms
• Asthenopia associated with distance tasks
• Intermittent blur at distance
• Intermittent diplopia at distance
• Symptoms worse at end of day
• These symptoms will generally be long-standing, in contrast to a history of acute
symptoms.
• Signs
• Esophoria greater at distance than at near
• Reduced NFV at distance
• Reduced vergence facility at distance with base-in prism
• Esofixation disparity at distance
Orthophoria at Distance: Convergence Excess
• This is a patient with orthophoria at distance (normal tonic vergence) and a high AC/A ratio. There is,
therefore, a significant amount of esophoria at near.
• Symptoms
• All of the following are associated with reading or other near tasks:
• Asthenopia and headaches
• Intermittent blur
• Intermittent diplopia
• Symptoms worse at end of day
• Burning and tearing
• Inability to sustain and concentrate
• Words move on the page
• Sleepiness when reading
• Decreased reading comprehension over time
• Slow reading.
Signs
• Significant esophoria at near
• Reduced NFV at near
• Reduced vergence facility at near with base-in prism
• Low PRA
• Fails binocular accommodative facility with minus lenses
• High MEM and cross-cylinder findings
Esophoria at Distance: Convergence Excess
• This is a patient who has a low to moderate degree of esophoria at distance (high
tonic vergence) and a high AC/A ratio as well. Thus, the degree of esophoria at near
will be significantly greater than that at distance.
• Symptoms
• All of the following are associated with reading or other near tasks:
• Asthenopia and headaches
• Intermittent blur
• Intermittent diplopia
• Symptoms worse at end of day
• Burning and tearing
• Inability to sustain and concentrate
• Words move on the page
• Sleepiness when reading
• Decreased reading comprehension over time
• Slow reading
• If the esophoria is large enough at distance, there may be symptoms of intermittent
diplopia, blur, and asthenopia at distance as well.
Continue
• Signs
• Esophoria greater at distance and near
• Reduced NFV at distance and near
• Reduced vergence facility at distance and near with
base-in prism
• Low PRA
• Fails binocular accommodative facility with minus
• High MEM and cross-cylinder findings
• Esofixation disparity at distance and at near
Exophoria at Distance: Divergence Excess
• This is a patient who has a low to moderate degree of exophoria at distance (low
tonic vergence) and a high AC/A ratio. Thus, the degree of exophoria at near will be
significantly less than that at distance.
• Symptoms
• Parents complain of eye turning out
• Occasional near point asthenopia
• Child closes one eye in bright light.
• Signs
• Greater exophoria or intermittent exotropia at distance than at near
• High calculated AC/A ratio
• Suppression at distance
• Normal near point of convergence
• Limited NFV, adequate PFV
• Difficulty with first- and second-degree fusion
• Generally normal stereopsis at near.
