CONVERGENCE AND THE

NEAR POINT OF CONVERGENCE

AUTHOR
Pirindhavellie Govender: University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER
Bina Patel: New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Convergence

 Near Point of Convergence (NPC).

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Chapter 6-1
Convergence and the Near Point of Convergence

CONVERGENCE

Convergence is a fusional movement that is essentially reflex in nature; however, an individual

can exert conscious control over the movement. Most people can be trained to exercise
voluntary control. Convergence can thus be stimulated voluntarily, disparate stimulation
(disparity or fusional vergence) and accommodation (accommodative-convergence
synkinesis). The voluntary centre is situated in the frontal oculogyric centre while the reflex
action originates in the occipital lobe.

CONVERGENCE

Figure 6.1: Schematic showing movement of eyes when converging

If an object is brought closer to the eye from a distant position, the light rays from that object
are divergent and hence won’t form a clear, single image on the retina as the eye would be in
a distance viewing position. The eye therefore has to make adjustments to clear the image and
make it single. The change in the refractive power of the crystalline lens enables the patient to
restore the clarity of the object, this is known as accommodation. Simultaneously, compound
movements of the extraocular muscles, predominantly the medial rectii muscles position the
eyes in such a way that the visual axes now intersect at the object of regard and it is seen
singly, this is known as convergence (Figure 6.1). The medial rectii like all other extraocular
muscles (EOMs) is striate in nature and is therefore under control of the voluntary nervous
system. Therefore, convergence is faster acting than accommodation.

TONIC CONVERGENCE
All muscles exist at a certain base line level of contraction, this inherent convergence due to
muscle tonus is referred to as tonic convergence and the accompanying eye position is
referred as the “physiological position of rest”. When there is no tonus or innervation to any of
the EOMs then the position of the eye is referred to as the “anatomical position of rest”.

PROXIMAL CONVERGENCE
Proximal convergence is also referred to as voluntary convergence and is induced by the
awareness of the nearness of an object.
TYPES OF
CONVERGENCE
ACCOMMODATIVE CONVERGENCE
Accommodative convergence occurs due to the link between accommodation and
convergence and is described as a function of the accommodative effort.

FUSIONAL CONVERGENCE
This type of convergence is also referred to as reflex convergence and is characterised by the
eye’s ability to move into a position to fuse two single images into a single concept. It
compensates for any excess or deficiency in tonic convergence using retinal disparity as its
stimulus.

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Chapter 6-2
Convergence and the Near Point of Convergence

CONVERGENCE (cont.)

METRE ANGLE
While accommodation is measured in dioptres it was difficult to apply to convergence and
therefore the concept of the METRE ANGLE was introduced by Nagel in 1880.
Metre angle is defined as that rotation (amount of convergence) of the eye to view an object on
the midline at 1 metre (m) distance (Figure 6.2).

Figure 6.2 The metre angle

The metre angle is also defined as “the reciprocal of the target distance in metres”, and is
QUANTIFYING equal to the product of the vergence demand in prism dioptres and the interpupillary distance
CONVERGENCE in centimetres.
Therefore for both eyes to converge at a point 1 m in distance, two MA effort is required since
each eye will rotate by one MA. It was found that patients with wider interpupillary distances
would need to make a greater rotational effort versus those that have a narrow interpupillary
distance (PD). This presented a problem and thus the concept of the prism dioptre was
introduced.

PRISM DIOPTRE
A prism dioptre takes into account the distance by which an image appears to have been
displaced. It expresses this displacement as a function of the distance of a prism from the
object (Figure 6.3).

Figure 6.3 Prism dioptre

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Chapter 6-3
Convergence and the Near Point of Convergence

CONVERGENCE (cont.)

If a patient has with a PD of 6 cm converges to the midline to fixate a point at a distance of

1 m, each eye will turn inward by 3 prism dioptres and there will be a total convergence for
both eyes of 6 prism dioptres.

( = prism dioptre)

For distance other than 1 m, we used the following formula:

1
Convergence (in ∆) = 
Distance (m) 
P.D. (cm)

QUANTIFYING
CONVERGENCE (N.B.: The above formula applies to convergence of one eye only)
(cont.)
Example:
A patient having a PD = 60 mm fixates on an object along the midline 2 m away.
Calculate the total convergence in prism dioptre.

Convergence = 1/2  6/2

= 1.5 for each eye

Therefore total convergence = 3

In order for the above patient to rotate one eye to view an object on the midline 2 m away, he
will have to create the equivalent of 1.5 of deviational effort in order to make the same effort if
a single binocular concept of a total of 3 is to be obtained.

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Chapter 6-4
Convergence and the Near Point of Convergence

NEAR POINT OF CONVERGENCE (NPC)

The near point of convergence is the point of intersection of the lines of sight of the eyes when maximum
convergence is utilised, while still preserving single binocular vision. The measurement obtained is more correctly
called the “NPC distance”. However, in clinical practice it is referred to as the NPC. Patients who have reduced NPC
distances may have visual and ocular discomfort when performing near point vision tasks.

1. RAF-rule (RAF= Royal Air Force)

2. Penlight (usually a preferred target)
INSTRUMENTATION
3. Wolff ball, finger puppet (these are motility targets, but can be used for patients who
have problems fixating on the penlight target).
There are several methods that may be utilised to measure the NPC. These include:

RAF-RULE TECHNIQUE
Procedure
1. Patient is seated comfortably and is wearing the habitual Rx under full room
illumination conditions.
2. The RAF-rule is held below the line of sight at an angle of 45 and the patient is
concentrating on the target consisting of a vertical line with a dot at the midpoint
(Figure 6.4). This position is selected as it is the habitual reading position.
3. Previously the NPC target merely consisted of a single line, but to facilitate better
fixation, the newer target has a single small dot on the vertical line target. Ask the
patient to fixate upon the dot with both eyes open. Move the target slowly and steadily
toward the bridge of the nose, the patient must try and keep the target single for as
long as he / she can and report when the line doubles. The speed of the target
movement should be such that it takes 10 seconds to move the target from 50 cm to
the bridge of the nose.
4. When the patient reports diplopia, note the distance from the bridge of the nose to the
point of diplopia. This is the subjective near point of convergence. In some cases the
patient may not report diplopia even though the point of maximum convergence has
been reached since the suppression mechanism takes effect to avoid diplopia. In this
case, one should employ the objective near point of convergence that is detected when
the examiner observes the deviation of the non-dominant eye. One needs to take note
of the break and recovery points when measuring the NPC.
MEASUREMENT OF
5. The break point is the point at which the patient reports double (subjective) or the
THE NPC
examiner sees one eye move out (objective).
6. The recovery point is the point at which the patient reports single vision once again as
the examiner slowly moves the target away from the patient (subjective) or the
practitioner notices that both eyes are directed at the target once again (objective).
7. The technique must be repeated several times since it has been known to recede with
fatigue. It has been noted that the NPC can recede in both normal and abnormal
patients, however, in patients with binocular and accommodative dysfunction, it has
been found to recede by a greater amount.

Figure 6.4: RAF rule technique

(Photo courtesy of Pirindha Govender, University of KwaZulu Natal [UKZN])

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Convergence and the Near Point of Convergence

NEAR POINT OF CONVERGENCE (NPC) (cont.)

Recording
The NPC measurement is recorded in centimetres from the bridge of the nose. It is
recorded as break / recovery, e.g. 10 cm / 15 cm. The measurements should be taken to
the nearest ½ centimetre.

Common errors with this procedure include:

1. The patient confuses blurring with diplopia
2. Inappropriate targets (like a pen)
3. Testing in an upward or primary gaze instead of in a slightly inferior position which is
the habitual reading / near point task posture for the eyes
4. Moving the target too rapidly and unsteadily
5. The practitioner not encouraging the patient enough to maintain single binocular vision.

RED LENS TECHNIQUE

Procedure:
 Patient is seated comfortably with habitual Rx in place.
 Place a red lens or filter before one of the patient’s eyes (Figure 6.5).
 A penlight torch is held at 40 cm away at the level of the bridge of the nose.
 The patient should see a single light that is a mixture of red and white.
 The penlight torch is then moved slowly towards the patient. The patient is instructed
and encouraged to fixate the light and report when a red and white light is seen.
Watch for one eye to turn out. This is the break point. Measure this distance with a
PD-rule.
 Move torch away from patient until patient sees a single light again. This is the
recovery point. Measure this distance with a PD-rule.

MEASUREMENT OF
THE NPC (cont.)

Figure 6.5: Patient using red lens before left eye

(Photo courtesy of Pirindha Govender, University of KwaZulu Natal [UKZN])

For both techniques, the examiner’s observed positions of the point at which the
convergence effort is abandoned by the patient is the indication of the objective NPC.

Outcomes of the NPC test:

1. One eye will swing out abruptly and the other eye which retains fixation is the dominant
eye.
2. Both eyes may turn out.
3. Both eyes may turn out and up.
4. The patient may be able to sustain binocular fixation by far a short distance but will try
to defeat your efforts to bring the target closer by backing away from it.
5. Some patients will fail to report diplopia because one eye “switches off” or suppresses
and the brain therefore cannot perceive diplopia. There is then no subjective NPC and
the objective NPC must suffice. If you notice suppression it needs to be investigated
further.

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Convergence and the Near Point of Convergence

NEAR POINT OF CONVERGENCE (NPC) (cont.)

Normal values:
According to Scheiman and Wick (2008), the normal values of the NPC differ depending on
the test target used.

Accommodative target:
Break: 5 cm ± 2.5
Recovery: 7 cm ± 4.0

MEASUREMENT OF
THE NPC (cont.) Penlight or red lens test:
Break: 7 cm ± 4.0
Recovery: 10 cm ± 5.0

Interpretation of findings:
If a patient has a remote NPC (usually greater than 10 cm), then he would most probably
present with symptoms such as diplopia, frontal headaches, decreased reading
comprehension, asthenopia and occasional fatigue when undertaking near tasks.
These problems are managed with vision training actively or prism prescription passively.

The NPC when determined using a non-accommodative target like in the case of the red
lens test tends to produce readings that are more receded than that determined by a
POINTS TO NOTE method that uses an accommodative target like that of the RAF-rule method. In addition,
FOR THE NPC more recent research conducted by Scheiman have revealed that the NPC when
determined by the RAF-rule method, should ideally be determined using a vertical row of
letters as the fixation target for the patient.

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Chapter 6-7
Convergence and the Near Point of Convergence

BIBLIOGRAPHY
Scheiman M and Wick B. Clinical Management of Binocular Vision: Heterophoric, Accommodative, and Eye Movement Disorders.
3rd Edition. Lippincott, Williams and Wilkins. Philadelphia. 2008.

Benjamin WJ. Borish’s Clinical Refraction. WB Saunders Company. Philadelphia. 1998.

Elliot DB. Clinical Procedures in Primary Eye Care. Butterworth-Heinemann. Oxford. 2001.

Eskridge JB, Amos JF and Bartlett JD. Clinical Procedures in Optometry. JB Lippincott Company. Philadelphia. 1991.

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Chapter 6-8