Volume 5, Issue 5, May – 2020 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Correlation between Near Point of Convergence

and Stereoacuity
Janak Poudel , B. Optom , Jewel Nammasundra , M. Optom,
Vittala International Institute of Ophthalmology , Bangalore, Former lecturer of Vittala International
560085, India Institute of Ophthalmology

Abstract:- I. INTRODUCTION

 Aim: A. Convergence :
To determine the correlation between stereo acuity Convergence is a conjugate movement in which both
NPC and among the students of Vittala International eyes rotate inward so that the lines of sight intersect in front
Institute of Ophthalmology (VIIO). of the eyes. Allows bifoveal single vision to be maintained
at any fixation distance. Convergence is a very complex
 Methodology ; process. Convergence is of two types. Namel ; Reflex and
Out of 47 subjects, 35 students with average age of voluntary convergence. Reflex convergence is defined as the
21.5 ± 2.44 years were selected according to inclusion convergence of visual axis which is not under complete
and exclusion criteria for this study. NPC and NPA were voluntary control. Reflex convergence has four components;
measured with push up method, after that NFV and PFV a) Tonic convergence
were measured with the help of prism bar, followed by b) Fusional convergence
assessment of stereo acuity with the help of TNO. Then, c) Accommodative convergence
forced vergence test was measured by the help of 4 prism d) Proximal convergence
diopter where first divergence was induced by the help of
base-in prism and NPC with the help of push up method, Tonic vergence innervation converges the eyes from
then stereo acuity was examined. After that, convergence their divergent anatomical position of rest approximately17
was induced with the help of base-out prism and NPC prism diopter horizontally in those with normal vision to the
and stereo acuity was measured. tonic vergence resting state, which is approximately 3 to5 Pd
convergent from straight ahead in those with normal vision.
 Results: Fusional convergence is produce to ensure those similar
The correlation between the parameters Normal retinal images are projected on to corresponding retinal
NPC& Normal Stereo acuity shows a Poor positive areas.
correlation, which is not statistically
significant(p=0.94).The correlation between BI NPC & Accommodative convergence is the convergence that
BI Stereo acuity shows a Poor positive correlation, which occurs when the eyes accommodate. Stimulus for the
is not statistically significant(p=0.302). The correlation accommodative convergence is blurred retinal images rather
between the parameters BO NPC & BO Stereo acuity than the retinal disparity that stimulates fusional
shows a Moderate positive correlation, and is not convergence. Convergence accommodation helps to clear
statistically significant (p= 0.216). the fixation target as disparity vergence aligns the eyes to
that target. Convergence accommodation serves as a
 Conclusion; proportional bias for reflex accommodation, which means
Since there was a moderate positive correlation that, as the accommodation and convergence demands
between induced convergence and stereo acuity and poor increase, so does the assistance to reflex accommodation
correlation between normal, induced divergence and from disparity vergence .This action helps to minimize blur
stereo acuity, there are chances to expect changes in at all distances so that reflex accommodation can perform
stereo acuity clinically in convergence related anomalies efficiently. Proximal convergence is induced by proximity
more compared to divergence related anomalies. of object of regard or the awareness of the proximity of a
near object. Proximal vergence and proximal
accommodation are triggered by any clue that elicts its depth
and distance perception. In other words, the stimulus to
proximal innervation is perceived nearness. The proximal
mechanism serves as a source of proportional bias
innervation for both reflex accommodation and disparity
vergence, helping to minimize blur and fixation disparity as
targets move closer.

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Volume 5, Issue 5, May – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
B. Stereopsis: the convergence of the eyes measured objectively using
Stereopsis is the highest degree of binocular vision. It binocular search coils and subjectively using nonious lines.
is the ability of brain to neurologically integrate and fuse
two horizontally disparate retinal images, producing a The spatial characteristic of lateral shifts in retinal
sensation of depth.1,2 It is well established that horizontal correspondence induced by forced convergence is largely
disparities between the images presented to the two eyes unknown. There are two distinct possibilities. A uniform
induce a compelling sensation of depth. The lateral shift of the cortical correspondence maps may occur in
separation of the two frontally located eyes allows slightly which the cortical projections from the two eyes are
disparate views of an object and provides the geometrical displaced laterally relative to the normal locations. Such
basis for the phenomenon of stereoscopic depth perception. uniform lateral shifts in correspondence would have little
Generally it is not well developed in young infants before 3 effect on the shape of the line horopter. 2, 4
months and is believed to be developed by 6 months of life.3
II. AIM AND OBJECTIVE
C. Stereoacuity:  Aim:
Stereo acuity is basically based on the retinal disparity To determine the correlation between stereo acuity and
(two line of sight does not intersect at point of fixation) NPC among the students of Vittala International Institute of
created in the eye. It is the smallest binocular disparity that Ophthalmology (VIIO).
can be readily detected, i.e. it is the minimum disparity
beyond which no stereoscopic effect is produced. Generally  Objective:
a threshold of 15-30 arc can be regarded as excellent To find out the comparison and correlation between
stereoscopic acuity. stereo acuity and NPC in normal, Base in and Base out
conditions (Forced vergence)
D. TNO :
It is graded to provide retinal disparities ranging from III. METHODOLOGY
15 to 480 sec of arc. It is tested at a distance of 40 cm. It
consists of a booklet containing seven plates. Each test plate A total of 35 students of Vittala International Institute
consists of a stereogram in which various shapes have been of Ophthalmology, Bangalore were taken as subjects. The
created by random dots in complementary color. The plates age ranged between 18 to 25 years. It was a prospective
contain two types of figures, the one which can be perceived correlational study.
when viewed binocularly with red green spectacles by
normal subject having stereopsis. The second set of figures  Study design: Prospective and Pearson’s correlational
can be seen with and without spectacles even in the absence study
of stereopsis.  Study place: Vittala International Institute of
Ophthalmology, Bangalore
First 3 plates are demo plates just to see whether a  Data collection technique: Based on inclusion and
person has stereopsis or not, which have stereoscopic targets exclusion criteria subjects were enrolled in this study.
like Butterfly, plus sign, circle ,diamond , square, triangle.
 Inclusion criteria:
Fourth plate is for checking suppression and remaining  Normal subjects with no significant ocular pathologies
three plates (5-7) gives quantitative measurement of and abnormalities.
stereopsis from 480-15 arc sec. A person has to identify a  Stereo acuity ≥ 100 arc seconds as measured through the
circle with a cut edge and tell which side the circle is open TNO stereo acuity.
or cut.2
 Exclusion criteria:
E. Forced vergence (By using prism):  Subjects with significant ocular pathologies, or limitation
Prism power is presented in fixed amounts, alternating of extra ocular motility.
between base-in (to force divergence) and base out (to force  Subjects with refractive error more than 3D and
convergence). astigmatism ±0.75D
ARC is commonly associated only with strabismus.  Subjects with manifest strabismus (Tropias).
However, recently it has been shown that changes in retinal  Subjects with latent strabismus more than 7 prism
correspondence may occur in normal who are subjected to diopter.
binocular stress. Binocular stress can be produced by forced
convergence, which is the introduction of a change in the  Materials :
convergence stimulus without a coordinated change in the  Distance and Near log MAR visual acuity charts
accommodative stimulus. In previous study it has been  Trial set
reported that individuals subjected to forced convergence  Retinoscope (Heine Beta 200 STREAK RET.2.5V)
exhibited statistically significant shifts in retinal  Prism Bar
correspondence of up to about 1degree. The presence of
 Loose prisms
these vergence induced shifts in retinal correspondence were
 Slit lamp
disclosed by examination of the small differences between
 Direct ophthalmoscope

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Volume 5, Issue 5, May – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 RAF ruler V, VI &VII was shown and subjects were asked to
 TNO stereopsis book show the cut end of the circle. They were instructed that
they will see a cake of which a piece is cut and they need to
 Study Parameter: show from which portion the piece was cut or is missing. As
The study was conducted in the premises of Vittala for each level from 480 to 15 sec of arc, there are two targets
International Institute Of Ophthalmology, Bangalore in and those two targets only were shown at a time by covering
subjects of classes from BSC first year to Intern students. the remaining target by a piece of paper. Then the result up
After explaining about the procedure clearly consent was to which patient is able to recognize is recorded.
taken from the subjects. After which demographic data was
collected. Subjects were assessed for any pathology using After performing all the above mention procedures, we
slit lamp as well as fundus was also examined through selected sample size of 35 students, based on our inclusion
Direct Ophthalmoscope. After fundus examination certain criteria.
gap was given for patient of minimum 2 hour .Then Cover The forced vergence test was measured by the help of
test was done to check whether there was phoria or not. Both 4 prism diopter. First divergence was induced by the help of
the distance and near visual acuity was performed using Log base-in prism and Near point of convergence was measured
MAR visual acuity chart. Objective as well as subjective by the push up method and then stereo acuity was examined.
retinoscopy was performed. Those who came under the After that, convergence was induced by the help of base-out
inclusion criteria were taken for the study. prism and Near point of convergence and stereo acuity was
measured.
Ocular motility test was carried out to determine the
normality of extraocular muscles and their impact on eye IV. RESULTS
movement.
Descriptives:
A C/A ratio was determined and then the Near point of Out of 47 subjects, 35 subjects were taken for the
accommodation was measured by push up method. It is done study based on inclusion and exclusion criteria. Out of them
monocularly as well as binocularly. Here patient was 35 subjects 20(57.14%) were female and 15(42.85%) were
instructed that the image gets blur and we asked patient to male with average age of 21.5±2.44 (18-25) years.
inform those blur, and recovery points.

After NPA, Near point of convergence (NPC) was also

measured by using push-up method where patient was
instructed to inform break point.

Both Negative Fusional Vergence (NFV) and Positive

Fusional Vergence (PFV) was measured for distance and
near by using prism bar. Base out prism was used for
positive fusional vergence (PFV) and Base in prism was
used for Negative fusional vergence (NFV). Here we have
instructed the patient to look straight on the target, and on Fig;1. Male and female percentage
increasing the strength of prism first target gets blur then it
becomes double and gets recovered. So we asked patient to 1. Comparison of Mean and p value of NPC Normal, Base
inform those blur, break and recovery points. –IN, and Base OUT
For measurement of stereopsis in order to keep the
book parallel to subject’s face it was hold by the examiner,
and the stereopsis testing was done at the sufficient room
illumination. TNO book was kept at 40cm and at first patient
was instructed about the chart and subjects were asked to
wear red green glasses over their corrections. For general
screening test, the first four plates were useful as the
disparity is large and provide a qualitative assessment of
stereopsis.
Plate 1; two butterflies; one is easily seen, monocularly, the
other is only seen in stereopsis. Table.1;- Mean difference of NPC Normal, base-in and
Plate2; four disc; two are seen without stereopsis. Ask the base-out with P value.
patient; how many circles? Which is the biggest?
Plate3; four; “HIDDEN” shapes (circle/ square/triangle/ On comparison of the mean values of normal NPC and
diamond) are arrange around a centrally easily visible cross. BI NPC the mean values of normal NPC was higher with a
Plate 4; three disc; one seen with right eye, one seen by left difference of -1.05714 was statistically significant with a p
and one seen binocularly. Then for the quantitative value of 0.019.
assessment plate

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Volume 5, Issue 5, May – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
On comparison of the mean values of normal NPC and of 4.14286 was statistically not significant with a p value of
BO NPC the mean values of was higher with a difference 0.317.
of -0.08571 is statistically not significant with a p value of
0.891.

On comparison of the mean values of NPC BI and

NPC BO the mean values of NPC BO was higher with a
difference of -1.14286 is statistically significant with a p
value of 0.016.

Fig 3:- Bar diagram showing Mean value of stereo acuity

normal, Base- in and Base-out

3. Correlation between NPC and stereo acuity:

Fig 2:- Bar diagram showing Mean value of NPC for

Normal, Base-in and Base-out

2. Comparison of Mean and p value of stereo acuity with

normal, Base in and Base out: Table-3; P value and r value of NPC and stereoacuity.

The correlation between the parameters NORMAL

NPC & NORMAL STEREOACUITY shows a Poor
POSITIVE correlation, and is NOT SIGNIFICANT with a p
value of 0.94.The correlation between the parameters BI
NPC &BI STEREOACUITY shows a Poor POSITIVE
correlation, and is NOT SIGNIFICANT with a p value of
0.302.The correlation between the parameters BO NPC&
BO STEREOACUITY shows a Moderate POSITIVE
correlation, and is NOT SIGNIFICANT with a p value of
0.216.

Table-2: Mean difference of stereo acuity normal, Base in

and Base- out with p value

On comparison of the mean values of

STEREOACUITY NORMAL and STEREOACUITY BI the
mean values of STEREOACUITY BI was higher with a
difference of 3.42857 was statistically not significant with a
p-value of 0.309.

Whereas on comparison of the mean values of

STEREOACUITY NORMAL and STEREOACUITY BO
the mean values of STEREOACUITY BO was higher with a
difference of 7.57143 was statistically not significant with a
p value of 0.223.

As well as on comparison of the mean values of

STEREOACUITY BI and STEREOACUITY BO the mean Fig 4:- Graphical representation of normal NPC and
value of STEREOACUITY BO was higher with a difference stereo acuity

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Volume 5, Issue 5, May – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Similarly, Philip W. laird, Sarah R. Hatt, 2007, by
experimentally inducing exodeviations in normal subjects
found that stereo acuity was reduced at the point of first
fusion in most subjects, and that this was not associated with
reduced binocular visual acuity. Studies of increasing
convergence stress have reported reduced levels of stereo
acuity and proposed that small shifts in retinal
correspondence can occur without disrupting Panum’s
fusional process.5

We want to explore the possible associations of forced

vergence with stereo acuity, by comparing NPC in normal,
induced convergence and induced divergence and finding
out the stereo acuity in above three conditions in a sample of
35 students. The idea is to understand, weather near point of
convergence changes will affect stereo acuity. For the study
we tried to increase the NPC by base out prism and reduce
Fig. 5:- Graphical representation of Base IN NPC and the NPC by base in prism, and there by finding the stereo
stereo acuity acuity in induced conditions. The major finding of this study
is that the mean value of normal NPC is higher than the
mean value of BI NPC which is statistically significant,
whereas the mean value of NPC base-out is higher than the
mean value of base-in NPC which is statistically significant,
but the mean value of BO NPC is higher than the normal
NPC which is statistically not significant.

Also, the mean value of stereo acuity Base-in is higher

than the mean value of normal stereo acuity which is not
statistically significant. But the mean value of stereo acuity
Base-out was higher on comparison with mean value of
normal streoacuity and was not statistically significant.
Whereas, mean value of stereo acuity base-out is higher than
the mean value of stereo acuity base-in and also not
statistically significant. Additionally, the Base-out NPC and
Base-out stereo acuity shows a moderate positive correlation
and is also not statistically significant, whereas normal NPC
`Fig; 6:- Graphical representation of Base –IN NPC and and normal stereo acuity, Base-in NPC and Base-in stereo
stereo acuity acuity shows poor positive correlation and is not statistically
significant.
V. DISCUSSION
VI. LIMITATIONS;
Sam Otabor Wajuihian, Rekha Hansraj (2018) reported
that the mean stereo acuity of those with vergence anomalies The standard Von Graefe technique is used to assess
was significantly better than that of those with either heterophoria and FV in some studies which would have
refractive errors or accommodative anomalies (p = 0.02)3. allowed for consistency in approach. But we have used
The mean stereo acuity of cases of accommodative prism bar as a preferred tool in a screening, where setting as
anomalies was significantly reduced compared to those it is quicker and allows for easy viewing of eye movements
without such anomalies. Similarly, the mean stereo acuity of and it is easier for school-aged children to perform and
cases with vergence anomalies was significantly reduced understand in terms of their instructions. Also we have
compared to those without vergence anomalies (p = 0.02). excluded moderate to severe phoria conditions, as the study
Also, Nick fogt and Ronald Jones (1997) studied the spatial is basically interested in understanding the normal
characteristics of the changes in retinal correspondence deviations with stereo acuity.
produced by forced convergence. The results indicated that
binocular stress from forced convergence induces a small There are some studies which correlated forced
but significant change in retinal correspondence. When a vergence with refractive error, accommodation, ARC and
small central point of regard was used as the fusion target phorias, where there were significant changes in stereo
the changes in retinal correspondence occurred only within acuity has been reported.
about 3* of the fixation point.4
Also in this study we have preferred to use only TNO
stereo book to assess stereo acuity and push up method to
assess NPC.

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Volume 5, Issue 5, May – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
VII. CONCLUSION; [10]. Marjean Taylor Kulp, OD, MS, FAAO, Gui-shuang
Ying, PhD; “Associations between Hyperopia and
1. There was a poor positive correlation between normal other Vision and Refractive Error Characteristics”.
NPC and normal stereo acuity, Base in NPC and Base in Optom Vis Sci. 2014 Apr; 91(4): 383–389.
stereo acuity, which is not significant, where the value of https://www.ncbi.nlm.nih.gov/pmc/articles/PMC40518
one parameter increases then the value of another 21/
parameter also increases. There was a moderate positive [11]. Sarah R. Richardson; Charlotte M. Wright; Susan
correlation between Base out NPC and Base out stereo Hrisos; Deborah Buck; Michael P. Clarke; “stereo
acuity but it is not statistically significant. acuity in Unilateral Visual Impairment Detected at
Preschool Screening: Outcomes from a Randomized
2. Since there was a poor positive correlation between Controlled Trial”. Investigative Ophthalmology &
normal, induced divergence and stereo acuity and Visual Science January 2005, Vol.46, 150-154.
moderate positive correlation between induced doi:10.1167/iovs.04-0672.
convergence and stereo acuity, there are chances of [12]. Barry SR1, Bridgeman B.; “An Assessment of
changes in stereo acuity clinically in convergence related Stereovision Acquired in Adulthood.” Optom
anomalies more compared to divergence related VisSci. 2017Oct; 94(10):993-999.PMID: 28858047
anomalies. https://www.ncbi.nlm.nih.gov/pubmed/28858047
[13]. Y. Pang; H. Gabriel; F.Saeed; K. Frantz; “A
REFERENCES prospective study of different test targets for the
Nearpoint of Convergence.” Investigate
[1]. William J Benjamin, 2nd edition; Borish’s Clinical Ophthalmology and visual science 2010 May;
Refraction P.no.167-173 30(3):298-303 vol.48,5881. PMID: 20444137
[2]. Fiona Rowe, 3rd edition ;Clinical Orthoptics p.no- [14]. F Koç; N Sefi-Yurdakul; “Predictors of stereo acuity
22,81-2 outcome in visually mature subjects with exotropia”
[3]. Sam Otabor Wajuihian; Rekha Hansraj; “stereo acuity .Eye (Lond).2016 Feb; 30(2): 264-9. PMID: 26584792
and refractive, accommodative and vergence https://www.ncbi.nlm.nih.gov/pmc/articles/PMC47631
anomalies of South African school children, aged13-18 28/
years. Afr Vision Eye Health. 2018; 77 (1), 400
https://avehjournal.org/index.php/aveh/article/view/40
0/782
[4]. Nick Fogt, Ronald Jones, “The Effect of Forced
Vergence on Retinal Correspondence”. Vision research
38, September (1998), pages 2711-2719.
PMID:9775320
https://www.ncbi.nlm.nih.gov/m/pubmed/9775320/
[5]. Philip W. Liard, Sarah R. Hatt, and Jonathan M.
Holmes, “stereo acuity and Binocular Visual Acuity in
Prism Induced Exodeviation”. J AAPOS. 2007Aug;
11(4): 362-366, PMID: 17419082
https://www.ncbi.nlm.nih.gov/m/pubmed/17419082/
[6]. Samuel Otabor Wajuihian; “Normalative values for
clinical measures used to classify accommodative and
vergence anomalies in a sample of high school
children in south Africa (2019)” Journal of Optometry
volume 12, issue 3 pages 143-160. PMID: 29887298
https://www.ncbi.nlm.nih.gov/m/pubmed/29887298/
[7]. Schroth V, Joos R, Jaschinski W; “Effects of Prism
Eyeglasses on Objective and Subjective Fixation
Disparity (2015)” PLoS ONE 10(10):e013887.
doi:10.1371/journal.pone.0138871 PMCID:
PMC4592239
https://www.ncbi.nlm.nih.gov/m/pubmed/26431525/
[8]. Wajuihian SO. Prevalence of heterophoria and its
association with near fusional vergence ranges and
refractive error. Afr vision Eye Health.
2018;77(1),a420.
https://doi.org/10.4102/aveh.v77i1.420
[9]. Hamed M, David AG, Marzieh E; “The relationship
between binocular vision symptoms and near point of
convergence.” Indian J ophthalmol 2013; 61:325-8.
https://www.ncbi.nlm.nih.gov/m/pubmed/23552348/

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