Ophthalmic & Physiological Optics ISSN 0275-5408

A comparison of the reliability of dynamic retinoscopy and

subjective measurements of amplitude of accommodation
Alejandro Alvarez Leon1, Sandra Milena Medrano2 and Mark Rosenfield3
Fundacion Universitaria del Area Andina Pereira, Pereira, Colombia, 2Universidad de la Salle, Bogota, Colombia, and 3SUNY College of
Optometry, New York, USA

Citation information: Leon AA, Medrano SM & Rosenfield M. A comparison of the reliability of dynamic retinoscopy and subjective measurements of amplitude of accommodation. Ophthalmic Physiol Opt 2012, 32, 133141. doi: 10.1111/j.1475-1313.2012.00891.x

Keywords: amplitude of accommodation,

dynamic retinoscopy, minus lens, modified
push-down, near work, repeatability
Correspondence: Alejandro A Leon
E-mail address: aleon@funandi.edu.co
Received: 11 May 2011; Accepted: 3
January 2011

Abstract
Purpose: Dynamic retinoscopy (DR) is an objective technique for assessing maximum accommodative responsivity. The present study examined the test-retest
reliability of this procedure when measuring the amplitude of accommodation
(AA).
Methods: In the first trial, the within-session repeatability of the AA was
measured in 79 subjects between 18 and 30 years of age using DR and two
subjective procedures, namely the modified push-down (MPD) and minus
lens (ML) techniques. Data were collected by two different examiners. In a
second trial, the inter-session repeatability of the AA was assessed in 76 subjects by a single evaluator with a time interval of 7 days between the first
and second sessions. The repeatability, reproducibility and agreement between
the methods were determined using the mean difference, 95% limits of agreement, intraclass correlation coefficient and concordance correlation coefficient.
Results: DR showed the lowest mean value of AA in each trial (average for the
two trials = 7.44 D) while the equivalent mean values for the MPD and ML
techniques were 9.84 and 9.43 D, respectively. Further, DR showed the best
repeatability in both the repeatability trials and poorer inter-examiner
agreement was observed for the MPD and ML procedures. The concordance
correlation coefficient for DR)MPD, DR)ML and MPD)ML procedures were
0.32, 0.33 and 0.62, respectively for the within-session trial and 0.31, 0.36 and
0.76, respectively for the inter-session trial.
Conclusion: The DR technique provides a more veridical measurement of the
AA because it avoids the overestimation resulting from the depth-of-field.
Moreover, the DR technique exhibited higher reproducibility, when compared
with subjective methods. These differences may be important when evaluating
accommodative dysfunctions or monitoring accommodative therapy. The fact
that the DR procedure can be performed using standard clinical equipment
makes this a valuable technique both for vision screening programs and routine
eye care.

Introduction
The normal values for the amplitude of accommodation
(AA), i.e., maximum accommodative ability as a function
of age were determined by Donders towards the end of

the 19th century and by Duane in the early 20th century.1

In both cases the subjective push-up method was used to
measure this parameter. However, several studies have
shown that the amplitude findings cited in these classic
papers probably overestimated the true result as the

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Leon AA et al.

Reliability of dynamic retinoscopy

authors failed to consider the depth-of-field of the eye,

i.e., the dioptric range of object distances over which
visual acuity does not deteriorate.24 In addition, subjective measurement techniques imply that some amplitude
(approximately 1 D) persists beyond 60 years of age,
whereas objective findings (which are not biased by the
depth-of-field) verify that the AA reaches zero around
55 years of age.5
A modified push-down (MPD) method has been proposed as an alternative technique to assess the AA with
the purpose of minimizing factors that might alter the
accommodative response during the more common pushup procedure.6 For example, an elevated response can
occur when testing with the push-up technique because
the image subtends a larger angle at the eye as it is
advanced toward the observer which may result in a delay
in subjects first reporting blur, as well as changes in proximal accommodation. To minimize the change in image
size, the AA can be measured through a )4.00 D lens,
thereby reducing the angular subtense to approximately
half its original value. The negative lens also moves the
near point away from the observer, thus reducing the
effects of proximal accommodation. Additionally, Rosenfield and Cohen7 noted that as the target approaches the
end-point of the push-up procedure, there may be a delay
before the patient first reports the presence of blur,
resulting in a higher AA. Chen and OLeary8 compared
measurements of AA obtained using the push-up and
MPD techniques in 29 young subjects. Higher values were
recorded for the push-up procedure, with mean differences of 0.40 and 1.30 D being recorded under monocular and binocular conditions, respectively.
The maximum accommodative response can be
assessed using an optometer such as an autorefractor or
retinoscope. Using these devices, the expected AA is lower
than the values cited in both Donders and Duanes tables,
and these differences may be as high as 1.502.00 D.5,9
Dynamic retinoscopy (DR) provides a straightforward
method of determining the accommodative response
objectively using a relatively inexpensive and widely available instrument. Hokoda and Ciuffreda10 compared the
AA measured with an objective retinoscopy technique
(termed heterodynamic retinoscopy) with subjectivelydetermined minus lens (ML) and push-up values in seven
amblyopes and five control subjects. For the heterodynamic retinoscopy procedure, subjects held a reduced
Snellen chart and advanced it toward them until the letters first became blurry. With the target at the subjective
near point of accommodation, the examiner performed
retinoscopy, adjusting the working distance until a neutral
reflex was observed. The authors found that in the
normal control subjects, the mean objective AA was lower
than the values obtained with either the push-up (mean
134

difference = 2.4 D) or ML (mean difference = 0.77 D)

procedures. In the amblyopic eyes, the results were more
variable, with the difference between the mean objective
finding and the subjective push-up and ML procedures
being 5.00 D (PU being higher) and 0.46 D (DR findings
being higher), respectively.
Rutstein et al.11 also used DR to measure accommodation in 54 subjects between 6 and 35 years of age, and
compared the results with the push-up technique. For
subjects under 12 years of age (N = 29), the mean finding
using DR was 1.73 D higher than the push-up value,
while for subjects over 12 years of age (N = 28), the
mean DR result was 3.74 D higher than the push-up
value. This observation of a higher value for AA measured with retinoscopy, when compared with the subjective finding is unexpected. In this investigation, the near
point of accommodation was taken as the point when the
retinoscopy reflex became narrow, its colour dimmed and
its speed became slow, rather than determining a neutral
reflex. The use of this endpoint criterion, rather than the
more commonly adopted neutral reflex, may be responsible for the observed higher findings.
Additionally, Woodhouse et al.12 used DR to measure
the AA in children with Down syndrome. In order to
validate the method they measured two groups of adults
(each containing seven individuals either between 20 and
21 or 2542 years of age). Stimulus values of 6.00 D,
8.00 D and 11.00 D were used. The position of neutralization was noted for each distance and the AA estimated
as the actual accommodation exerted plus the uncorrected distance refractive error. They found no significant
difference between the push-up and DR findings (mean
difference = 0.28 D) although a significant correlation
was observed between the two measurements.
The repeatability of subjective AA values may vary with
the measurement procedure used. For example, Antona
et al.13 reported a lower coefficient of repeatability (COR)
for the ML technique (2.52) compared with the pushup (4.76) and push down (4.00) procedures. In contrast, Rosenfield and Cohen7 found similar CORs for all
three of these techniques. However, there are few investigations of the repeatability of objective measurements of
the AA. Win-Hall et al.14 used both the Grand Seiko WR
5100K open-field, infra-red autorefractor and Hartinger
coincidence optometer to measure the AA objectively
(with accommodation being stimulated with minus
lenses) and compared the results with a subjective pushup procedure. They observed that both the mean and
range of values obtained using the push-up procedure
were greater than those found with either of the objective
techniques. However, we are not aware of an investigation
which assessed the repeatability (several measures
obtained by one observer on the same subject under

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Leon AA et al.

similar conditions) and reproducibility (comparing measurements obtained by multiple examiners)15 of objectively obtained measurements of AA determined using
DR. Accordingly, the aim of the present investigation was
to examine the test-retest reliability (both within and
across sessions) of the DR technique for measuring the
AA and compare the values with those obtained using
subjective procedures.
Materials and methods
In order to assess the within-session repeatability, measurements of the AA were obtained from 79 subjects, all
of whom were optometry students at the Fundacion Universitaria del Area Andina in Pereira. All had visual acuity
of 0.2 logMAR or better (at both distance and near) when
measured using an ETDRS 2000 series chart (http://
www.richmondproducts.com/shop/index.php?route=product/
product&product_id=47). Subjects wore a full refractive
correction and had no ocular pathology. Any subject with
a refractive error greater than 2.00 D (sphere or cylinder), accommodative dysfunction (i.e., a lag of accommodation outside a range of 0.250.75 D and/or binocular
accommodative facility using 2.00 D flippers of <8
cycles min)1) strabismus, aphakia or amblyopia was
excluded. The protocol followed the tenets of the Declaration of Helsinki and Decree 8430 (1993) of the Ministry
of Social Protection in Colombia. Following a full explanation of the experimental protocol, the objectives of the
investigation and having been given an opportunity to
ask questions of the experimenters, all subjects signed a
written consent form prior to participation.
Data were obtained by two optometrists, each with a
minimum of 10 years experience in carrying out the test
procedures. They were assisted by a third year optometry student. Results were recorded by the student assistant who did not provide this information to the
evaluators in order to minimize the possibility of bias.
Initially, a pilot study was conducted on 10 subjects to
evaluate the variability of the data and to allow a population size calculation to be conducted. From this pilot
trial, taking a minimum correlation coefficient of 0.90
with a standard deviation of 0.03 and a two-tail error
type of 0.01, a required sample size of 74 subjects was
calculated.16
Before recording AA measurements, the refractive error
of each subject was determined using static retinoscopy
and subjective refraction (Jackson crossed cylinder). The
measured refractive correction was worn for all trials. AA
was assessed using two subjective and one objective
method as described below. To assess the within-session
reliability, the three procedures were repeated by a second
evaluator 30 min later using the same protocol. The order

Reliability of dynamic retinoscopy

of carrying out the three techniques in each trial was

randomized.
Modified push down
The distance refractive correction was placed in a trial
frame, together with an additional )4.00 DS6 and the
non-dominant eye occluded. The target comprised two
rows of high contrast letters with each letter being
0.9 mm high, printed on a dynamic retinoscopy card.
The target was placed on a Krimsky accommodation
rule (http://www.empresario.com.co/ofroltda/). Using the
method described by Chen and OLeary,8 the target was
initially positioned close to the trial frame and subjects
were asked to push the card away from them slowly (at
approximately 4 cm s)1), and to stop as soon as they
could observe the letters clearly and sharply.
The MPD amplitude was calculated as the reciprocal of
the distance from the target to the plane of the trial lens
(measured in metres) when the letters first appeared
absolutely clear, +4.00 D (to compensate for the additional )4.00 lens). The procedure was repeated three
times on each subject, with a 1 min interval allowed
between each measurement. Each measurement took
approximately 30 s to complete.
Minus lens
The distance refractive correction was introduced into a
phoropter. A near vision card with high contrast letters
(0.7 mm high) was positioned in front of the phoropter
at a viewing distance of 33 cm. Again, the non-dominant
eye was occluded. Subjects were asked to keep the letters
clear and sharp and to indicate as soon as they noticed
the first, slight, sustained blur as minus lenses were introduced over the distance correction. The AA was the
amount of additional minus lens power added when the
subject first reported sustained blur +3 D. The procedure
was repeated three times on each subject, with a 1-min
interval allowed between each measurement. Each
measurement took about 1 min to complete.
Dynamic retinoscopy
A variation of the heterodynamic retinoscope method
described by Pascal10 was used. Using a similar procedure
to the MPD technique described above, subjects were
asked to keep the letters clear and sharp. The fixation
target was placed close to the trial frame and then the
subject pushed the card away until the letters became
absolutely clear. With the target at this location, the
examiner positioned the retinoscope at a working distance
approximately twice the distance between the fixation

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Leon AA et al.

Reliability of dynamic retinoscopy

card to the subject. The retinoscopy reflex was observed

and if an against movement was seen (the expected
response), the observer moved closer to the eye until a
neutral reflex was found. Once this was achieved, the distance between the spectacle plane and the retinoscope was
measured with a metre rule. The objective AA was taken
as the reciprocal of this distance in metres, +4.00 D (corresponding to the additional )4.00 lens added to the distance correction). The procedure was repeated three times
on each subject, with a 1-min interval allowed between
each measurement. Each measurement took approximately 40 s to complete.
To assess the inter-session repeatability, a second study
was conducted in a further 76 subjects drawn from the
student body at the Fundacion Universitaria del Area
Andina from Pereira. Their mean age was 20.4 years
(range 1827 years). All met the inclusion and exclusion
criterion described above. Here, AA was measured using
the three procedures described above by a single examiner
(ALA) on two occasions, with the two sessions being
scheduled 1 week apart.
Data analysis
A descriptive univariate analysis of the data was performed. The Student t-test and analysis of variance were
used to compare the mean findings from the DR, MPD
and ML procedures in each trial. To evaluate the test-retest reliability (i.e., repeatability within subjects and reproducibility between examiners for each measurement
technique), the intraclass correlation coefficient (ICC)
[calculated as the ratio of the between-sample variance
and the total variance (both between- and within-samples) to measure the precision under the model of equal
marginal distributions],17 and the coefficient of repeatability and reproducibility (COR) (calculated as 1.96 multiplied by the standard deviation of the differences) were
used. Additionally, the difference between the findings for
the three procedures, i.e., (DR)MPD), (DR)ML) and
(MPD)ML) was compared using the concordance correlation coefficient (CCC).18 This coefficient evaluates the
agreement between two tests that measure the same para-

meter to determine if they are interchangeable.19 At the

same time it assesses how repeatable the procedures are
between observers (i.e., repeatability between observers or
reproducibility) or when taking measurements by the
same evaluator in different sessions (repeatability within
subjects).20,21 The CCC is composed of two elements; the
coefficient of correlation (r) that evaluates the precision
(which is equivalent to the Pearson coefficient), and the
bias correction factor that quantifies accuracy, i.e., deviation away from the 45 line through the origin that marks
perfect agreement.20 Although a descriptive scale for the
values of this coefficient has not been provided, a tentative scale21 is that CCC >0.99 represents almost perfect
agreement, while CCCs between 0.95 and 0.99, equal to
0.90 and <0.90 represent substantial, moderate and poor
agreement, respectively. All calculations were performed
using the statistical software SPSS 17 (http://www01.ibm.com/software/analytics/spss/) and Stata 10 (http://
www.stata.com/).
Results
Mean values of age, visual acuity, objective and subjective
refraction are shown in Table 1. In comparing the findings for the within-session and inter-session trials, no significant difference was observed between any of these
parameters.
The mean and range of values for the three techniques
for each examiner are shown in Table 2. The KolmogorovSmirnov test confirmed that the AAs were distributed normally (p > 0.05) for both the within-session and
inter-session trials. When considering the within-session
data (Table 2a), two-factor (examiner, method of measurement) analysis of variance indicated no significant
difference between the findings for the two examiners
(F1,1416 = 0.04, p = 0.85) but a significant difference in
findings between the three methods of measurement
(F2,1416 = 95.4, p < 0.0001). In addition the Bonferroni
correction confirmed that the difference between the
mean DR value and those obtained using each of the subjective procedures were significant. For the inter-session
trials (Table 2b), the findings are similar to those

Table 1. Mean and range of values for age, visual acuity, objective (static retinoscopy) and subjective refraction for both the within-session
repeatability (WSR) (N = 79) and inter-session repeatability (ISR) (N = 76) trials. The p values indicate the level of significance between the findings
for the WSR and ISR trials. Figures in parentheses show 1 S.D.
Mean

Age (years)
Visual acuity (logMAR)
Static retinoscopy (D)
Subjective refraction (D)

136

Range

WSR

ISR

WSR

ISR

20.4 (2.8)
)0.06 (0.09)
+0.18 (0.41)
)0.08 (0.24)

20.4 (2.4)
)0.03 (0.11)
+0.17 (0.75)
)0.01 (0.61)

1829
)0.3 to 0.12
)1.25 to +1.00
)1.25 to +0.25

1827
)0.2 to 0.2
)2.00 to +2.00
)2.00 to +1.75

1.00
0.07
0.92
0.35

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Leon AA et al.

Reliability of dynamic retinoscopy

Table 2. Mean (1 SD) and range of AA values using the three methods of measurement (DR, Dynamic Retinoscopy; MPD, Modified push down;
ML, Minus lens). (a) shows the findings for each examiner in the Within-session repeatability trial. (b) shows the findings for each session in the
Inter-session repeatability trial
DR

MPD

Examiner 1
(a) Within-session repeatability
Mean
7.73 1.06
Range
5.3511.01
Session 1
(b) Inter-session repeatability
Mean
7.12 1.18
Range
3.889.18

ML

Examiner 2

Examiner 1

Examiner 2

Examiner 1

Examiner 2

7.75 1.00
5.5910.25

9.77 1.49
5.9714.37

9.94 1.42
6.714.37

9.47 1.66
6.3315.91

9.53 1.79
6.0015.33

Session 2

Session 1

Session 2

Session 1

Session 2

7.14 1.21
3.609.18

9.75 1.65
6.1713.14

9.89 1.75
6.2414.37

9.41 2.22
4.5814.91

9.32 1.92
4.4214.10

Table 3. Mean difference (1 S.D.) between the values of AA

obtained using the DR (dynamic retinoscopy), MPD (modified push
down), and ML (minus lens) techniques in the within-session repeatability (a) and inter-session repeatability (b) trials. The concordance
correlation coefficient (CCC) indicates the agreement between the
procedures, whereas the Pearson correlation coefficient (r) and biascorrection factor (Cb) measures describe the precision and the accuracy respectively
DR-MPD
(a) Within-session repeatability
Mean difference
)2.11 (0.79)
p*
<0.001
CCC
0.32
r
0.84
Cb
0.38
(b) Inter-session repeatability
Mean difference
)2.70 (0.80)
p*
<0.001
CCC
0.31
r
0.90
Cb
0.34

DR-ML

MPD-ML

)1.76 (1.21)
<0.001
0.33
0.68
0.49

0.35 (1.31)
0.39
0.62
0.65
0.96

)2.24 (1.26)
<0.001
0.36
0.80
0.45

0.46 (1.31)
0.04
0.76
0.79
0.95

Figure 1. Difference between the modified push down (MPD) and

minus lens (ML) values of amplitude of accommodation (N = 79)
plotted as a function of the mean of these measurements as assessed
in the within-session trial. The value for each technique is the average
from examiners 1 and 2. The solid horizontal lines represent the 95%
limits of agreement while the horizontal dashed line indicates the
mean difference.

*Bonferroni correction (p < 0.017).

observed in the within-session experiment. Two-factor

(session, method of measurement) analysis of variance
indicated no significant difference between the findings
for the two sessions (F1,1362 = 0.01, p = 0.91) but a significant difference in findings between the three methods of
measurement (F2,1362 = 94.7, p < 0.0001). Again, the
Bonferroni correction established that the difference
between the mean DR result and those achieved with each
of the subjective procedures were significant (Table 2b).
The mean difference between the findings, as well as the
concordance correlation coefficient (CCC), Pearson correlation coefficient (r) and the bias-correction factor are
shown in Table 3a and 3b for the within-session and
inter-session trials, respectively. The CCC values (Table 3)
showed poor agreement between the three techniques.
However, the 95% limits of agreement were similar for the

3 procedures. In all cases, the agreement between the three

methods as assessed by CCC was poor (CCC < 0.90).
BlandAltman plots illustrating the difference between
the MPD and ML, MPD and DR and ML and DR findings for the within-session trials are shown in Figures 13,
respectively. In considering the difference between the
MPD and ML results (Figure 1), this value did not vary
significantly with the mean findings (p = 0.095). However, the differences between both the MPD and DR and
between the ML and DR findings (see Figures 2 and 3)
varied significantly with the mean values (p < 0.0001),
(i.e., the difference between the findings of either of the
subjective procedures and DR increased with the AA) so
the limits of agreement were estimated using a regression
approach as suggested by Bland and Altman22. With
respect to the inter-session findings, again the difference
between the MPD and ML did not vary significantly with

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Leon AA et al.

Reliability of dynamic retinoscopy

Table 4. Mean and standard deviation of the differences, coefficient

of reproducibility (COR) and intraclass correlation coefficient (ICC) for
the three methods (DR, Dynamic Retinoscopy; MPD, Modified push
down; ML, Minus lens) of determining the AA in the WSR (a) and ISR
(b) trials to determine the reproducibility either between examiners
(WSR) or between sessions (ISR). The 95% confidence intervals are
shown in parentheses below each ICC
DR

Figure 2. Difference between the modified push down (MPD) and

dynamic retinoscopy (DR) values of AA (N = 79) plotted as a function
of the mean of these measurements when assessed in thewithin-session trial. The value for each method is the average from examiner 1
and 2. The solid diagonal lines represent the 95% limits of agreement
while the diagonal dashed line indicates the mean difference. Since the
difference between the findings varied significantly with the mean
values (p = 0.00), the limits of agreement were estimated using a
regression approach where the upper limit = 0.295 + 0.36A, and lower
limit = )2.37 + 0.36A. (with A = mean AA for both procedures).

MPD

ML

(a) Within-session repeatability (WSR)

Mean )0.02 0.31
0.17 0.62
COR
0.61
1.21
ICC
0.96 (0.930.97)
0.91 (0.860.94)

0.07 1.03
2.01
0.82 (0.740.88)

(b) Inter-session repeatability (ISR)

Mean )0.02 0.41
)0.14 0.73
COR
0.80
1.43
ICC
0.94 (0.910.96)
0.91 (0.860.94)

0.10 1.18
2.30
0.84 (0.760.90)

limits of agreement were again estimated using a regression approach.22 (Equivalent figures showing the 95%
limits of agreement for the inter-session findings have not
been included as they were broadly similar to those
shown in Figures 13).
The mean and standard deviation of the differences,
together with the reproducibility between examiners and
sessions as assessed by the coefficient of reproducibility
(COR) and intraclass correlation coefficient (ICC) for the
three measurement techniques are shown in Table 4. For
the within-session trials (Table 4a), the DR showed the
lowest mean difference and COR, indicating that its reproducibility is higher than the other two techniques. The
high ICC values in both trials confirm that all three techniques had excellent reliability with DR again having the
best reproducibility. The DR COR was lower in the intersession trial compared with the within-session findings,
whereas increases in COR were observed for the MPD and
particularly the ML procedures in the inter-session trials.
Discussion

Figure 3. Difference between the minus lens (ML) and dynamic retinoscopy (DR) values of AA (N = 79) plotted as a function of the mean
of these measurements as assessed in the within-session trial. The
value for each method is the average from examiner 1 and 2. The
solid diagonal lines represent the 95% limits of agreement while the
diagonal dashed line indicates the mean difference. Since the difference between the findings varied significantly with the mean values
(p = 0.00), the limits of agreement were estimated using a regression
approach where the upper limit = )1.04 + 0.55A, and the lower
limit = )4.96 + 0.55A. (with A = mean AA for both procedures).

the mean findings (p = 0.07). However, the difference

between both the DR)MPD and DR)ML findings varied
significantly with the mean values (p < 0.0001), so the
138

As predicted, DR showed the lowest mean AA of the

three techniques. The differences between the objective
(DR) and subjective methods (MPD and ML) can be
explained by the lag of accommodation. Subjective assessment measures the closest distance at which the patient
can see clearly. This will exceed the near point of accommodation (point conjugate with the retina when accommodation is maximally exerted) by approximately half the
total depth-of-field of the eye.23 Objective procedures
evaluate the actual increase in refractive power of the eye.
The lag of accommodation increases with the accommodative stimulus,24 probably due to pupillary miosis which
increases the depth-of-focus. Therefore, the difference

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Leon AA et al.

between the subjective and objective techniques can vary

by as much as 1.502.00 D.10
It is important to note that the DR and MPD procedures were made with lenses mounted in a trial frame
whereas the ML technique was carried out using a phoropter. This was done because of the ease of changing
lenses rapidly in the phoropter. We feel that this difference is unlikely to have affected the results since it would
not alter the comparison of the same procedure between
examiners or across sessions.
The DR values found in the present study are slightly
higher than the measurements of accommodative response
obtained by Anderson et al.25 (6.86 D at 20 years, 6.49 D
at 25 years of age) using a WR 5100K Grand Seiko optometer (http://www.grandseiko.com/english/GR-2100.htm)
and adding minus lenses to stimulate accommodation.
Since their methodology required higher minus lens values
when compared with the present investigation, this would
have resulted in a smaller image size. This variation, combined with the difference in accommodative measurement
technique might account for the change in findings.
Nevertheless, these results support the proposal that DR is
an appropriate method of measuring AA clinically. The
mean difference between the DR and MPD procedures
(average for the within-session and inter-session trials =
2.41 D) was higher than that between DR and ML (average for the within-session and inter-session trials = 2.00
D), but examination of the standard deviations shows less
variation in the differences between DR and MPD (average for the within-session and inter-session trials = 0.80),
compared with DR and ML (average for the within-session and inter-session trials trials = 1.24 D). Similar differences between objective and subjective procedures were
reported by Hokoda and Ciuffreda.10
However, comparing means alone might yield erroneous
results,20 as both outlying data and sample size will affect
the outcome.26,27 Moreover, when comparing means, no
information is given regarding test accuracy.28 While the
coefficient of correlation measures the strength between
two variables, it would be surprising if data obtained by
two evaluators using the same test conditions and procedures were not related.29 We used the BlandAltman plot
and concordance correlation coefficient (CCC) because
they are complementary statistical tests; the BlandAltman
plot indicates the agreement between two methods,30 while
the CCC provides information as to how close the data are
to perfect agreement (or reproducibility).
While the intraclass correlation coefficient (ICC)
assesses the concordance (agreement) between different
methods that measure the same clinical characteristics,
the test assumes that the measurement error of both procedures is equivalent, which is a significant (and often
unjustified31) assumption. The CCC consists of two parts,

Reliability of dynamic retinoscopy

a bias-correction factor (accuracy) and Pearson correlation coefficient (precision). Since the Pearson correlation
coefficient does not consider inaccuracy, the CCC can
segregate inaccuracy from imprecision, which the ICC
does not.17 Accordingly, we used the CCC to assess the
agreement between the methods to measure the AA. This
parameter showed low agreement in both the within-session and inter-session trials between the subjective and
objective procedures (MPD-DR: CCC = 0.315; ML-DR:
CCC = 0.357) because of low accuracy (bias-correction
factor <0.50). This indicates a significant discrepancy
between these techniques. The agreement between the
two subjective techniques was also poor (CCC = 0.69)
with moderate precision (r = 0.72) but high accuracy
(bias-correction factor = 0.96). Both methods tend to
obtain results clustered around a similar mean value, but
with a broad spread of findings. In contrast, the objective
DR technique shows high test-retest reliability (reproducibility ICC = 0.94, COR = 0.80), presumably because it
combines two reliable techniques, i.e., push up7 and Nott
retinoscopy.32 Nott retinoscopy was used in the present
investigation rather than the Monocular Estimate Method
(MEM) firstly because the addition of supplementary plus
lenses may influence the accommodative response and
secondly because attempting to insert the lenses for a period shorter than the typical accommodative response
(approximately 350 ms) is practically impossible.23
Further, the 95% limits of agreement between the various techniques found in this study are similar to those
reported by Winn-Hall et al.,14 who used both a Hartinger coincidence optometer (HCR) and an open field WR
5100K Grand Seiko optometer with minus lens-stimulated
accommodation to evaluate the accommodative response
at the point of maximum accommodative effort. When
comparing the objective push-up findings with the ML
results, the mean difference and 95% limits of agreement
(LoA) were 0.03 and 1.26 D, respectively. In the present
investigation, we assessed the reproducibility of DR using
the ICC and obtained a very high value (0.96); therefore
measurements obtained are likely to be similar across
observers. These results demonstrate that findings
obtained using DR are significantly more reliable that
those obtained using subjective procedures. Accordingly,
it is advisable for future research studies into the AA to
adopt this objective method of measurement, since the
reduced variability will allow for a smaller sample size.
With regard to the repeatability of the subjective techniques, Antona et al.,13 reported a coefficient of repeatability for AA with the ML and push-up techniques of
2.52 and 4.00 D, respectively. However, no clear explanation for these differences was provided. These authors
also evaluated the agreement between the two tests,
obtaining a coefficient of agreement of 4.51, which is

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Leon AA et al.

Reliability of dynamic retinoscopy

higher than the finding of 3.14 obtained in the present

investigation. Antona et al. suggested that the negative
magnifying effect encountered during the ML technique
caused the perceived image to appear smaller and thereby
increased sensitivity to blur. In the present study, minus
lenses were used both in the ML and MPD procedures
(although the value of the minus lens changed during the
ML technique but remained constant for the MPD
procedure), which should also increase blur sensitivity.
We observed a significant difference between the MPD
and ML findings while the CCC values indicated that
while the repeated measurements have high accuracy,
their precision is poor. Accordingly, we concur with
Antona et al.,13 that the two subjective techniques are not
interchangeable.
The mean visual acuity determined here (see Table 1)
was poorer than has been reported previously in equivalent age groups. For example, Elliott et al.33 observed
mean visual acuity of )0.13 0.06 logMAR for subjects
between 18 and 24 years of age. The reason for this difference is unclear as a similar type of chart was used in both
studies. Data in the Elliott et al. report were drawn from
three different investigations which measured visual acuity
in British undergraduate students, while the present study
included students from Colombia. However, we are not
aware of any published data showing significant differences in best corrected logMAR visual acuity with ethnicity in healthy, young individuals. Interestingly, Leon and
Estrada34 reported mean visual acuity in healthy Colombian adults between 15 and 30 years of )0.07 logMAR
equivalent (S.D. = 0.06; 95% confidence intervals of )0.08
to )0.05) when measured with a Snellen chart. These findings are very similar to the results presented here. These
differences in best corrected visual acuity with geographic
location and ethnicity are worthy of further investigation.
While the findings of the present study provide information regarding the validity of these clinical tests, a limitation of the present research is that only normal subjects
were included in the investigation. Symptomatic subjects
having abnormalities as a result of accommodative disorders did not participate and it is possible that the findings
of an abnormal population would have been different.
Further, all of the subjects in the within-session repeatability trial were optometry students. However, they were first
or second year students who were not familiar with the
procedures being tested. Nevertheless, it is likely that they
were more accustomed to the instrumentation being used,
and therefore may not have yielded typical clinical
responses when compared with nave patients. In the
inter-session repeatability trial, while the subjects were university students, none of them were studying optometry.
The DR technique avoids the overestimation of the AA
resulting from the depth-of-focus that occurs during sub140

jective assessment. While high precision was observed

between the DR and MPD procedures, the mean findings
were significantly lower with the DR technique. This
difference is important when evaluating accommodative
dysfunctions such as accommodative insufficiency, or
assessing the accommodative function in aphakic patients
with accommodating intra-ocular lenses. The higher
reproducibility found with the DR technique, when compared with subjective methods may provide a useful tool
for monitoring accommodative therapy. The fact that the
DR procedure can be performed using standard clinical
equipment makes this a valuable technique both for
vision screening programs and routine eye care.
Acknowledgements
The Fundacion Universitaria del Area Andina seccional
from Pereira which sponsored this study, Professor Jorge
Mario Estrada Alvarez for his contributions to the experimental and statistical methodology and optometry students Ketty Marcela Cruz, Jennifer Lopez and Alexandra
Cardenas for their assistance in the investigation.
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