Dynamic Retinoscopy
The method by which you determine the patients neat point (location
in space that a patients eyes are focused when fixating a near target)
o Patients accommodative response to a target
It defines the patients accommodative posture
o Most patients under accommodate for the target but some will
over accommodate
It is primarily used to confirm suspected cases of vergence and/or
accommodative dysfunction
o Also used to determine:
Whether a patient is over or under corrected
Any eye exam in which a patient has a near complaint or if
you suspect accommodative problems such as latent
hyperopia or other accommodative spasm
Record near complaints (near blur, asthenopia,
diplopia, headache) as pertinent negatives when
applicable
ALL pediatric exams
BV exams (follow ups if warranted)
It also reveals the stability or the degree of fluctuation of the
accommodative system
o If results seem stable, accommodation is probably not fluctuating
much
o If results seem to fluctuate, you may be dealing with
accommodative spasm
Accommodation must be engaged/functioning in order to determine
near point
o Differs from static retinoscopy where the accommodation must
be relaxed in order to determine the far point
Same movement as with static
o With: eye conjugate to a point either behind the eye or behind
the retinoscope
o Against: eye conjugate to a point between the eye and the
retinoscope
o Neutrality: eye conjugate with the retinoscope
Accommodative
response
is a measure of the actual
accommodation that is present
o If your accommodative system likes to hang out:
Right on the target accommodative response= stimulus
In front of target accommodative response > stimulus
Accommodative LEAD
Behind the target accommodative response < stimulus
Accommodative LAG
Accommodative stimulus is defined by the near target stimulus
Because of depth of focus and depth of field, the accommodative
response is generally less than the stimulus
o Near point is usually located around 10-17cm beyond near target
at 40cm
Accommodative demand is provided by the target distance as well
as the refractive error
o Over-minused or under-plussed: has extra accommodative
demand required to see target clearly
o Under-minused: does not have to accommodate as much
Monocular Estimate Method (MEM): clinician neutralizes the reflex
of the eye while the patient accommodates to fixate a target at near
(usually at 40cm)
o With motion: Lag of accommodation --- Add PLUS
o Against motion: Lead of accommodation --- Add MINUS
o Procedure
Use patients correction for distance or near
TRUE measurement of lag/lead if measured with BVA
Place the target at their working distance
Adults: usually 40 cm
Children: use Harmons distance
Room illumination should be dim but with target
illuminated
Keep desired testing distance consistent
Remain as close to the patients line of sight as possible
when neutralizing (if off axis can induce cyl)
Examine the reflex in the horizontal meridian (can alter
beam orientation if cylinder axis requires it)
Briefly insert lens into line of sight
Measurements should be made within 1second per
lens used to minimize the dazzle of light and the
effect of lens on accommodation system
o The lens that creates neutrality is the value of the
accommodative lag/lead
o Record lag as net (+) and lead as net (-)
Nott Method: clinician moves toward and away from the patient until
neutrality is seen (can be performed in or out of phoropter)
Against motion: move closer to the patient
With motion: move further away from patient
Results
o Expected
Non-presbyopes: Lag of +0.50D to +0.75D when tested at
40cm
Presbyopes: accommodation ability declines, increasing
expected lag of accommodation (dynamic ret is an
accepted form of TNA determination)
Absolute presbyopes: expected lag is +2.50D at 40cm
If patient fully corrected, equal results between the two
eyes
Stable results when fixation is maintained
Results should be similar to that of FCC/BCC (net)
Lag of accommodation changes as a function of the
accommodative demand
Expected lag increases dramatically as the
accommodative demand increases
o Can happen when the target distance
decreases or patient is over-minused or underplussed
o High Lag (>+0.75D)
Esophoria at near with insufficient compensating vergence
Accommodative dysfunction: insufficiency, fatigue, paresis,
infacility
Presbyopia or pre-presbyopia
Uncorrected or under corrected hyperope
Over minused
Inaccurate results: patient not keeping the target clear
during the test and so not accommodating
o High Lag (+2.50D)
Uncorrected or under corrected hyperope
Way over minused
Presbyopia
Inaccurate results: patient not keeping the target clear
during the test and so not accommodating
o Low lag or lead of accommodation (<+0.25D)
Exophoria at near with insufficient compensating vergence
Spasm of accommodation: pseudomyopia
Uncorrected or under corrected myope
o Other abnormal
Unequal results between the two eyes usually results from
a near balance secondary to anisometropia (unequal
accommodative demand), improper balance of distance
Rx, or unilateral or asymmetric Adies tonic pupil (unilateral
paresis)
Fluctuation of reflex also often indicates a near imbalance
or accommodative spasm
Sources of error
o Same as those with static: scissors, small pupils, dim media
(cataracts, etc.), angle
o More sensitive to physical arrangement for the measurement
(distance, lens adaptation), instructions given and patients
cooperation
o Changes in patients fixation or accommodative level (often
related to failure to understand task or to cooperate)
o Patient looking at a target at a different distance than requested
A +0.50 to +0.75 lag is not normal if not testing at 40cm
Lag increases as fixation distance is reduced
o Adaptation to lenses with MEM: relaxes with plus lenses,
stimulates with minus lenses
FYI: accommodative system has a latency of 250-500ms
