Ophthal. Physiol. Opt.

2008 28: 115126

Gender differences in early accommodation

and vergence development
Anna M. Horwood and Patricia M. Riddell
Infant Vision Laboratory, School of Psychology & Clinical Language Sciences, University of Reading,
Earley Gate, Reading, UK

Abstract
A remote haploscopic photorefractor was used to assess objective binocular vergence and
accommodation responses in 157 full-term healthy infants aged 16 months while fixating a brightly
coloured target moving between fixation distances at 2, 1, 0.5 and 0.33 m. Vergence and
accommodation response gain matured rapidly from flat neonatal responses at an intercept of
approximately 2 dioptres (D) for accommodation and 2.5 metre angles(MA) for vergence, reaching
adult-like values at 4 months. Vergence gain was marginally higher in females (p = 0.064), but
accommodation gain (p = 0.034) was higher and accommodative intercept closer to zero (p = 0.004)
in males in the first 3 months as they relaxed accommodation more appropriately for distant targets.
More females showed flat accommodation responses (p = 0.029). More males behaved hyperme-
tropically in the first two months of life, but when these hypermetropic infants were excluded from the
analysis, the gender difference remained. Gender differences disappeared after three months. Data
showed variable responses and infants could behave appropriately and simultaneously on both,
neither or only one measure at all ages. If accommodation was appropriate (gain between 0.7 and
1.3; r2 > 0.7) but vergence was not, males over- and under-converged equally, while the females
who accommodated appropriately were more likely to overconverge (p = 0.008). The apparent
earlier maturity of the male accommodative responses may be due to refractive error differences but
could also reflect gender-specific male preference for blur cues while females show earlier
preference for disparity, which may underpin the earlier emerging, disparity dependent, stereopsis
and full vergence found in females in other studies.

Keywords: accommodation, development, gender, infant, vergence

development (Held et al., 1980; Birch et al., 1982) are

Introduction
Gender differences are rarely the focus of developmental
vision research and in the majority of the developmental
literature, it is difcult to ascertain if gender was
ignored, or considered and found to be insignicant,
and so not reported. Differences have been reported,
however, in many aspects of early vision. In terms of
binocularity, preference for binocularly fusible targets,
full convergence (Held et al., 1996) and stereopsis
Received: 26 September 2007
Revised form: 28 November, 4 January 2008
Accepted: 12 January 2008
Correspondence and reprint requests to: Anna M. Horwood.
Tel.: +44 0118 378523; Fax: +44 0118 3786715.
E-mail address: a.m.horwood@reading.ac.uk
all reported to develop earlier during infancy in females.
These differences appear to be most marked between
approximately 10 and 20 weeks. For acuity, vernier
acuity develops earlier in females (Held et al., 1984), and
VEP acuity has been reported to be poorer in 16-week-
old males (Makrides et al., 2001) but grating acuity does
not appear to show a developmental gender difference
during the rst year of life (Held et al., 1996).
The available evidence is clearer for earlier female
development in processes that require disparity detec-
tion, such as vergence, preference for fusible targets and
stereopsis, while being more equivocal for blur detection
tasks such as acuity measures. Broadly stable ocular
alignment is likely to be necessary for emergence of
stereopsis and accurate vergence at 1216 weeks, and
has been shown to be present from the rst days,
provided allowance is made for the large angle lambdas

2008 The Authors. Journal compilation 2008 The College of Optometrists doi: 10.1111/j.1475-1313.2008.00547.x
116 Ophthal. Physiol. Opt. 2008 28: No. 2
of infancy (Horwood, 1993, 2003b; Hainline and Rid-
dell, 1995, 1996). In a period when acuity is poor
(Gwiazda et al., 1980), and refractive errors are com-
mon and change rapidly (Gwiazda et al., 1980, 1993;
Gwiazda and Thorn, 1998), however, blur may be a less
reliable visual cue.
The development of accommodation responses in
infants has been shown to progress from relatively xed
near focus in neonates to adult-like response slopes by
34 months (Haynes et al., 1965; Braddick et al., 1979;
Banks, 1980; Brookman, 1983; Howland et al., 1987;
Currie and Manny, 1997). Motor accommodation
responses have recently been shown to mature earlier
than sensory aspects of the visual system (Tondel and
Candy, 2007) and can be adult-like by 8 weeks of age,
well before the majority of emmetropisation has taken
place (Mohindra and Held, 1981; Gwiazda et al., 1984,
1993; Ehrlich et al., 1997), but gender differences have
not been reported so far.
Our laboratory is studying the precursors to the
development of mature vergence and accommodation in
terms of responses to different near cues. In view of the
reported gender differences in the emergence of the
disparity-dependent aspects of binocular vision, we
looked for gender differences in the weeks preceding
the emergence of these processes as part of our
preliminary data analysis of a longitudinal study of
infant accommodation and vergence development.
Although gender differences were not the main motiva-
tion for the study, we predicted that the earlier sensory
development of retinal disparity detection found by
others in females could be underpinned by a similar
earlier maturation in adult-like vergence control.
Early gender differences are less likely to be due to
environmental inuences that are thought to inuence
later refractive development (Adams and McBrien,
1992; Troilo, 1992; Zylbermann et al., 1993; Simensen
and Thorud, 1994; Goldschmidt, 2003), but could form
the foundation for later visual development. They might
also inuence the prevalence of later-developing ocular
conditions such as clinically signicant refractive error,
strabismus, accommodative, or convergence anomalies,
in which abnormalities of the typically developing
vergence, accommodation, or binocular vision mecha-
nisms are implicated. Conversely, innate or genetically
determined gender differences may be compensated by
later adaptive mechanisms, such as emmetropisation
and vergence adaptation, and so disappear during
development.
While many studies have looked for gender differ-
ences in older children, the evidence is sparse and
equivocal. What evidence there is could equally support
environmental differences or genetic factors (Parssinen
et al., 1989; Adams and McBrien, 1992; Zylbermann
et al., 1993; Simensen and Thorud, 1994; Hung and
Ciuffreda, 1999; Goldschmidt, 2003). For instance,
myopia has been reported to be more common in
school age females by some authors (Dandona et al.,
2002; Morgan et al., 2006), but not others (Gwiazda
et al., 2002; Zadnik et al., 2003; Lam et al., 2004).
Wesson et al. (1990) failed to nd refractive gender
differences in a group of younger children between
3 months and 9 years. Hypermetropia and astigmatism
were found to be less common in 67 year old males
than females by Chen et al. (1996). Krause et al. (1982)
found hypermetropia and myopia to be less common in
14-year-old males but more severe when it did occur.
Zadnik et al. (2003), however, found that school-aged
females have steeper corneas. Similarly, anisometropia
(Pointer and Gilmartin, 2004; Garcia et al., 2005) and
intermittent exotropia have been reported to be more
common in school age females (Nusz et al., 2005).
Accommodation and convergence anomalies have not
been reported to show a gender difference (Rouse et al.,
1999), but are commonly found in conditions such as
dyslexia, which is more frequently reported in boys
(Evans et al., 1994). Amblyopia does not appear to
show a gender difference (Attebo et al., 1998).
In this study, we found a previously unreported
gender difference in the very early development of
ocular accommodation, and to a lesser extent ocular
convergence, which we relate to current literature on the
development of vergence and accommodation and
which highlights gender as an issue that should be
considered in early developmental research.
Methods
Sixty-seven female and 90 male full-term, healthy infants
attended the Infant Vision Lab as part of a large
longitudinal study of the development of vergence and
accommodation between the rst and sixth months of
life [see Table 1, which details the number of infants
providing reliable data (in terms of attention and
photograph quality) at each age group]. Infants
attended for a mean of 3.12 visits with no difference
between the number of visits for male and female infants
[t (157) = 0.51, p = 0.62]. Here we report the infants at
monthly intervals up to 6 months. Ethical approval was
obtained from the University of Reading Research
Table 1. Numbers of infants in each age group who provided
reliable data in terms of attention and photograph quality
Age (months)
1 2 3 4 5 6
Males (n) 18 52 66 57 40 33
Females (n) 13 32 42 35 23 30
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 Gender differences in vergence and accommodation: A. M. Horwood and P. M. Riddell 117

Ethics Committee and informed consent was obtained (Choi et al., 2000; Gwiazda and Weber, 2002; Allen
according to the Declaration of Helsinki. et al., 2003) so two independent scorers made a
Accommodation and convergence were assessed using judgement of the position of crescent border. Corre-
a remote haploscopic off-axis photorefractor (RHP) lation between scorers was r2 = 0.9946 and Bland
reported in detail elsewhere (Horwood et al., 2001; Altman analysis (Bland and Altman, 1986, 1999)
Turner et al., 2002) and similar to that described by provided limits of agreement (around the mean
Abramov et al. (1990). This photographed the infants inter-scorer difference of 0.0063 D) of 0.19 D. All
eyes while they xated a monitor displaying a brightly measurements for photorefraction and calibration
coloured picture of a clown with gross and ne details were taken in the vertical meridian. While we accept
(subtending 2.8 4.2 at 2 m). Photographs were taken that there is an increased prevalence of astigmatism in
with the infant xating the target on a monitor which infants and we were unable to calibrate the measure-
moved along a motorised beam to positions at 2, 1, 0.5 ments for each infant as suggested by Blade and Candy
and 0.33 m from the infants eyes, presented in a pseudo (2006), our data primarily report change in response
random order starting at 0.33 m. As we needed good between target distances within individuals rather
photographs at each of four xation distances and some than absolute refractive error. Even if a measure of
of the infants were extremely young, only one photo- absolute refraction between infants is subject to
graph was taken at each xation distance. We were some variability, the response at each xation distance
therefore unable to obtain repeatability data. We did, within an individual infant should be changed by the
however, make great efforts to ensure that the infants same constant and so response slopes should not be
were in a calm alert state during testing and photo- inuenced by this increased variance (provided it is
graphs were only taken when the infant was observed by additive). From our original calibrations, we have no
the examiner (on a separate infra-red monitor) to be evidence that the constant was multiplicative rather
attending to the target. A recent study has suggested than additive.
that infants from 8 weeks of age have a response latency Graphs were plotted of the simultaneous vergence and
of <1 s (Tondel et al., 2005). This period was always accommodation responses for each infant against target
exceeded in our laboratory by the time it took for the demand (Figure 1). Vergence data were converted to
examiner to decide attention was adequate and for the metre angles (MA), taking into account inter-pupillary
photograph to be taken. distance (IPD) at each visit, and in dioptres (D) for
Photorefraction photographs of the eyes were taken accommodation, so that slopes could be plotted on the
via a beam splitter so that the photorefracting camera
and the target appeared directly in front of the infant,
while being on separate visual pathways. Ocular ver-
gence angle was calculated in metre angles from
changes in position of the rst Purkinje image in
relation to the pupil centre on each photograph, with
an age-appropriate correction made for angle lambda
(Riddell et al., 1994)1. An adult control group xated a
series of ve targets at 5 horizontal intervals so that we
could assess gaze accuracy, which was 1.1 (Horwood
et al., 2001).
The accommodation (in dioptres) was calculated
from measurements of the size of retinal reex crescent
in the pupil. Accommodation responses were calibrated
using an adult control group where RHP responses
were compared with dynamic retinoscopy while the
participants xated the same target. The data were then
processed using neural network techniques to produce
a smooth two-dimensional surface that could be used
for all photorefraction data. Accuracy was 0.3 D
for accommodation data. Our study started before
the availability of more recent automated methods

1
Angle lambda is dened as the angle between the line of sight and the Figure 1. Actual data from an infant aged 17 weeks. Total vergence
pupillary axis. equals the sum of the two separate adduction measurements.

2008 The Authors. Journal compilation 2008 The College of Optometrists

118 Ophthal. Physiol. Opt. 2008 28: No. 2
same graph. Any obvious outlying points from a
monotonic response were excluded from the four data
points tested [such as the intermittent large neonatal
misalignments that occur in many infants (Horwood,
2003a; Horwood and Riddell, 2002; Horwood and
Williams, 2001), which were dened as more than
two standard deviations of the total sample response
in excess of target demand, or more than two stan-
dard deviations more divergent than orthoposition].
Because a pseudo-random order of testing was
used, where a near target was always preceded by a
more distant one or vice versa, any appropriate and
linear response slope was likely to indicate reliable
xation.
Vergence angle and accommodation from at least
three of the four possible xation distances (and four
if available) were used to calculate slope, r2 and
y-intercept of the line that best tted the data. Slope
represents the gain of the response to target distance
and y-intercept reects an estimate of focus at innity.
A slope of 1.0 represents perfect response to target
demand, while any slope of <1 can be produced by
under-response for near and/or failure to relax at
distance. A positive intercept represents overconver-
gence and overaccommodation at innity, while a
negative intercept represents negative accommodation,
i.e. a hypermetropic crescent. As cycloplegic eyedrops
were not used, this y-intercept gives an estimate of
manifest refractive error, but can mask latent hyper-
metropia. A negative y-intercept according to our
analytical procedure represents a degree of hypermetro-
pia, but the absence of negative y-intercept may mean an
infant is either truly not hypermetropic, or is over-
coming their hypermetropia appropriately by accom-
modation. A positive y-intercept could reect true
myopic refractive error or xation proximal to innity.
Range of responses was taken as the difference between
the maximum and minimum responses found over the
four target distances.
Statistical analysis was performed using SPSS 14. Due
to increased variance in the younger groups, post hoc
testing was carried out using the more conservative
GamesHowell procedure. It would have been prefera-
ble to do within groups analysis, but only a small
number of subjects provided reliable data over the whole
testing period. Although trends were very similar (and
indeed prompted us to re-visit our cross-sectional data),
the small numbers who provided a full set of longitu-
dinal data prevented us being able to detect the effect
statistically that we report here.
Results
There were no signicant gender differences in the
number of infants who provided three rather than four
photographs because of poor cooperation or exclusion
of outliers. If a photograph was excluded or missing, the
possible optimum range could vary between 1.5 D or
MA (if the 3 D target was missing), 2.0 D or MA (if the
0.5 D target was missing), and 2.5 D or MA (if the 1 D
or 2 D photograph was missing). There were no
signicant gender differences in the number of photo-
graphs at each distance that were missing [v2 (2) = 1.84,
p = 0.4], or in the mean optimum range possible [t
(561) = 1.3, p = 0.63], i.e. missing data were equally
distributed between the genders. Infants around
16 weeks were more intensely interested in the target
than those both younger and older, and missing data
points were evenly distributed between the older and
younger infants, i.e. more stable and appropriate
responses in the older infants were not due to the
absence of data.
Responses are illustrated in Figure 2. Vergence slope
(Figure 2a) increased rapidly in the rst 4 months. A
two-way between-groups overall ANOVA [F(11,431) =
4.429, p < 0.0001] with age and gender as factors
showed a highly signicant main effect of age
[F(5,431) = 7.841, p < 0.0001]. There was also a mar-
ginal main effect of gender [F(1,431) = 1.206,
p = 0.064] with females having slightly higher slopes
than males. There was no signicant interaction and
post hoc t-tests did not show any individually signicant
gender differences in any single month.
Similarly, vergence y-intercept, and r2-values (Fig-
ure 2c,e) all showed signicant improvements with age,
although range (Figure 2g; difference between maximum
and minimum response) did not change signicantly
across the ages tested. (y-intercept: overall
F(5,431) = 3.998, p < 0.0001, main effect of age
F(5,431) = 8.193, p < 0.0001, no main effect of gen-
der; r2: overall F(11,431) = 6.641, p < 0.0001), main
effect of age F(5,431) = 12.782, p < 0.0001, no main
effect of gender; range: overall F(11,431) = 1.647,
p = 0.083). Post hoc testing generally showed that the
greatest change occurred between months 2 and 4 (for
age effects see Appendix 1), with some reduction in
vergence and accommodation slope between months 4
and 6. In general, infants at four months were intensely
engaged by the target, but by 6 months were more easily
distractible and more difcult to test, as has been found
by others (Braddick and Atkinson, 1979; Hainline et al.,
1992; Atkinson, 2000).
The gender differences were signicant in the accom-
modative domain. As with vergence, there were signi-
cant main effects of age on all four measures
(Figure 2b,d,f,h; slope: F(11,431) = 6.797, p < 0.0001;
y-intercept: F(5,431) = 22.974, p < 0.0001; range:
F(5,431) = 8.037, p < 0001; r2: F(5,431) = 11.597,
p < 0.0001, see Appendix 1). Gender differences were
signicant for both accommodative slope and y-inter-
2008 The Authors. Journal compilation 2008 The College of Optometrists
 Gender differences in vergence and accommodation: A. M. Horwood and P. M. Riddell 119

(a) Vergence Slope (b) Accommodation Slope

1.2 1.2
1.0 1.0
0.8 0.8
0.6 0.6

Gain

Gain
0.4 Males 0.4
Males
0.2 Females 0.2
Females
0.0 0.0
0.2 0.2
0 2 4 6 8 0 2 4 6 8
Months Months

(c) Vergence intercept (d) Accommodation intercept

4.0 4.0
3.5 Males 3.5 Males
3.0
(*)
3.0
Intercept (MA)

Intercept (MA)
2.5 Females 2.5 Females
2.0 2.0
1.5 1.5 *
1.0 1.0
0.5 0.5
0.0 0.0
0.5 0.5
1.0 1.0
0 2 4 6 8 0 2 4 6 8
Months Months
(e) Vergence Rsq (f) Accommodation Rsq
1.0 1.0
0.9
0.8 0.8
0.7
0.6 0.6
2 0.5
r2 r
0.4 0.4
0.3 Males
Males 0.2
0.2
Females 0.1 Females
0.0 0.0
0 2 4 6 8 0 2 4 6 8
Months Months

(g) Vergence range (h) Accommodation range

4.0 4.0
3.5 3.5
3.0 3.0
Range (MA)

Range (D)

2.5 2.5
2.0 2.0
1.5 1.5
1.0 Males 1.0 Males
0.5 Females 0.5 Females
0.0 0.0
0 2 4 6 8 0 2 4 6 8
Months Months
Figure 2. Vergence (a, c, e, g) and accommodative (b, d, f, h) responses (SE) at each age group. Slope increases to near 1.0, y-intercept
reduces to near zero, Rsq increases and accommodative range increases with age. Gender differences are evident for accommodation slope
and intercept, with males showing more adult-like responses. There is a significant main effect of gender on accommodative slope and
y-intercept, and a marginal gender main effect on vergence slope. Post hoc significant gender differences (p < 0.05) marked *, marginal
difference marked (*) (p > 0.05 < 0.07).

cept (slope F(1,431) = 4.522, p = 0.034; y-intercept (32) = )1.93, p = 0.06]. The gender difference was,
F(1,431) = 8.337, p = 0.004) but not for range or r2. however, signicant in month 2 [t (82) = )2.047,
Girls showed atter accommodative slopes and higher p = 0.044]. The difference was not signicant at any
y-intercepts than the boys. Agegender interactions were other age tested.
not signicant. Accommodation response slope becomes steeper with
Post hoc t-testing of accommodative y-intercept age, as infants both increase accommodation for near
showed that, although the mean difference between targets, and, more particularly, relax accommodation at
males and females for the 1 month infants was greater distance. The steeper slopes in males may be due to
than at other ages, reduced power as a result of the males making more appropriate responses to near or
smaller number of infants tested resulted in an distant targets, males inappropriately overaccommodat-
only marginally signicant difference at month 1 [t ing at near or females overaccommodating at distance.

2008 The Authors. Journal compilation 2008 The College of Optometrists

120 Ophthal. Physiol. Opt. 2008 28: No. 2

The mean data from the female infants made the

Figure 3. Accommodation responses (SE) at each fixation dis-
tance at 2 months of age. (a) responses of whole group. (b)
responses of infants who had never shown a hypermetropic
response at any age, showing greater gender difference. Post hoc
significant gender differences are marked * (p < 0.05), and marginal
differences are marked (*) (p > 0.05 < 0.07).
Figure 3a shows that at 2 months of age males are
making marginally more appropriate distance responses
than the females [t (65.98) = )1.705, p = 0.078] while
near responses are similar.
accommodative slope in Figure 3(a) appear nonlinear,
perhaps implying that females are less sensitive to subtle
target differences between 0.5 and 1 D. We considered
whether tting a nonlinear function to individuals plots
would better reect the data, or whether more female
infants showed an all or nothing (S shaped curve;
Hainline et al., 1992) response, but on examination of
individual responses it was clear that trying to t any
more complex curves would be spurious in view of the
limited amount of data points tested and the variability
of responses. There were no gender differences in the
number of all or nothing responses.
The y-intercept (estimate of focus at innity) repre-
sents an estimate of manifest refractive error. While this
cannot be compared with cycloplegic refraction and may
mask hypermetropia controlled by appropriate accom-
modation, any hypermetropic crescent found during
testing indicates a degree of hypermetropia at some
time, which may be useful in identifying hypermetropic
infants. Although, over all age groups, there were no
signicant differences in the number of infants who
showed hypermetropic y-intercepts, Table 2 shows that,
in the rst 3 months, many more males showed hyper-
metropic y-intercepts than females (v2 = 5.7, d.f. = 1,
p = 0.017). In the rst two months of life, indeed, the
gender difference is marked (v2 = 8.9, d.f. = 1,
p = 0.003) while after three months of age these
differences disappear (v2 = 0.076, d.f. = 1, p = 0.78).
As hypermetropic infants might produce steeper slopes
if over-relaxing accommodation for distant (and smal-
ler, perhaps less engaging) targets but accommodating
appropriately for near, a larger number of hypermetro-
pic males may have caused an apparent difference in the
mean accommodation responses, so we excluded all the
data from any infant who had demonstrated a hyper-
metropic crescent at any time in the rst 4 months of life
and re-examined the data from the 31 females and 33
males remaining, concentrating on actual responses to
the different target demands rather than the y-inter-
cepts. While the gender difference in accommodative
response at 0.5 m at 2 months was only marginally
signicant when the infants who showed hypermetropic
crescents were included, despite smaller numbers,
the difference was greater if these hypermetropic
infants were excluded [t (28.53) = )2.33, p = 0.027;

Table 2. Numbers of infants (and percentages of numbers tested in each category) at each age group who showed hypermetropic y-intercepts
(top row) and hypermetropic y-intercepts >1.00 D (bottom row)
Age (months) 1 2 3 4 5 6

m f m f m f m f m f m f

Any hypermetropic intercept 3 (16) 0 (0) 22 (42) 5 (16) 43 (65) 26 (47) 41 (71) 24 (68) 25 (63) 15 (65) 18 (55) 20 (66)
Hypermetropic intercept >1.0 1 (6) 0 (0) 10 (19) 1 (3) 15 (23) 8 (19) 14 (25) 11 (31) 10 (25) 5 (22) 8 (24) 4 (13)

2008 The Authors. Journal compilation 2008 The College of Optometrists

 Gender differences in vergence and accommodation: A. M. Horwood and P. M. Riddell 121

Figure 3b]. Males continued to show more accurate

accommodation to the distant target while females
over-accommodated to it.
The data from individual participants were variable,
as might be expected at this age, but also reects the
variability that we found at all ages in this naturalistic
setting. Positive correlation between vergence and
accommodation responses was statistically signicant
at each month, but was generally not strong (r-values
of between 0.33 and 0.49, with no developmental
trends) The r2-values of the slopes, however, (rather
than accommodation vs vergence responses) of approx-
imately 0.5 even in the youngest infants indicate largely
linear responses to demand even when slopes were
low and accommodation was not necessarily doing
the same as vergence. It was noticeable that for many
testing sessions, vergence responses were reliably better
than accommodation or vice versa, despite responses
for both measures being taken from the same photo-
graphs and the data recording session itself being
reliable in terms of attention. Thus, infants could show
accurate vergence, accommodation, both, or neither, at
each testing. Signicantly more females showed at
accommodation slopes (slope of <0.3 and y-intercept
>1.5 D) in the rst 3 months of life than males
(v2 = 4.76, p = 0.029).
We classied the good responses as those showing a
slope of between 0.7 and 1.3 with an r2 of at least 0.7.
Not having a good response does not mean that the Figure 4. Percentages of infants in each age group showing good
infant was behaving unreliably, but only with gain responses (slope between 0.7 and 1.3 and r2 > 0.7) to vergence,
outside these limits. Overall, from the fourth month accommodation or both.
onwards, approximately 50% of infants showed good
responses on only one of the two measures, and this nostic determinants of VEP acuity. To check whether
proportion did not change with increasing age (Fig- birth weight was an important factor in our study, we
ure 4). reanalysed the data using an ANCOVA, with birth weight
We looked at the relationship between vergence and as a covariate, but this did not change the results.
accommodation in males and females. If a male showed
good accommodation, but not good vergence, the
Discussion
vergence was equally likely to be an underconvergence
or overconvergence. In comparison, 61.9% of females Gender differences are rarely the focus of ocular
with good accommodation responses showed higher developmental literature and, as in our report, may
vergence slopes (v2 = 7.062, p = 0.008), i.e. girls not have been the main motivation of studies where such
tended to overconverge when they accommodated differences have been found. There is, however, a small
appropriately. When vergence was good but accom- body of literature on gender differences in early devel-
modation inaccurate there were no signicant gender opment (Held et al., 1980, 1984, 1996; Birch et al., 1982;
differences. Makrides et al., 2001), to which this study adds, which
As male birth weight is generally higher than that of suggests that gender is a variable that should be
females (Scott et al., 1982), this apparent gender differ- considered more systematically.
ence might be accounted for by differences in birth The overall developmental ndings presented here are
weight (and therefore possibly associated axial length or similar to other published studies (Brookman, 1983;
neural development) rather than gender. Indeed, Mak- Hainline et al., 1992; Hainline and Riddell, 1996; Currie
rides et al. (2001) showed that, at 16 weeks of age, and Manny, 1997). While Hainline and Riddell (1996)
higher birth weight was associated with better VEP reported on a larger group, the group size reported here
acuity, while male gender was associated with poorer compares well with other studies (Brookman, 1983;
acuity in a dietary intervention trial looking at prog- Howland et al., 1987; Currie and Manny, 1997). Our

2008 The Authors. Journal compilation 2008 The College of Optometrists

122 Ophthal. Physiol. Opt. 2008 28: No. 2
infants progressed from at response slopes and rela-
tively xed y-intercepts of approximately 2 D for
accommodation and 2.5 MA for vergence, to more
adult-like responses by 4 months. It is possible that the
33 cm starting point may cause early at-lining result-
ing from the distance at which the rst target appeared.
While this is possible, our ndings are very similar to
reports from other laboratories using different methods
and presentation order (Haynes et al., 1965; Brookman,
1983; Aslin et al., 1990; Currie and Manny, 1997). Some
infants needed to be distracted or comforted in between
photographs in the testing sequence, so that the starting
point for the resumed testing was not the 3 D target.
There was no difference in the intercept of the at
responses from these infants.
The large variance in response (see error bars in
Figure 2), particularly for slope and y-intercept of both
vergence and accommodation, reect the wide response
variability found in all age groups, but particularly in
the youngest infants.
The apparent steady improvement in mean gain for
both accommodation and convergence is somewhat
misleading as this combines the results from many
infants who showed at response slopes in their rst at accommodative responses but appropriate vergence
weeks then rapidly changed to adult-like responses by
the next testing session, with those who truly made a
gradual developmental change. Vergence, in particular,
is extremely variable in early infancy. Although we
excluded very large neonatal misalignments (Horwood
and Riddell, 2002; Horwood, 2003a), which represent
the extremes of the distribution, early vergence is still
much more active than accommodation. Some infants
showed appropriate vergence even on their rst visit,
while others showed at responses, and most infants had
at accommodation at rst. This early variability also
accounts for the lack of increase in vergence range with
age (as might be expected as responses become more
target-appropriate). Greater range in the youngest
infants was due to neonatal inter-individual variability,
but in the older infants was due to appropriate near to
distance response.
The only gender difference in the vergence domain
was the marginally signicant lower slopes for the males,
suggesting they might have atter vergence responses.
The increased variance in the early vergence responses
reduced the power of the analysis, and thus the ability to
demonstrate a signicant effect, but we cannot exclude
the hypothesis that males could be slightly less
responsive to disparity than the females. This would
support the hypothesis that the early disparity difference
in females is underpinned by an earlier motor
advantage.
The gender difference in the accommodation data,
however, is more robust, but in this case it is the males
who appear to behave in the more adult-like manner.
Male infants have steeper slopes, larger ranges and
lower (less myopic/more hypermetropic) y-intercepts
than female infants who at rst show atter responses
(low range, slope and more myopic distance focus). This
appears to conict with the other visual developmental
literature (Held et al., 1980, 1984, 1996; Birch et al.,
1982; Makrides et al., 2001), which suggests that females
are generally developmentally ahead of males, and
importantly in this case, earlier to demonstrate both
sensory and motor aspects of binocular vision (Held
et al., 1980, 1996; Birch et al., 1982). The gender
differences we found occur in the rst 2 months of life,
before the age that differences in vernier and stereoa-
cuity are reported to be maximal (Held et al., 1996),
thus the earlier differences we report here may underpin
these processes.
Adult studies have demonstrated links between ver-
gence and accommodation (Fincham and Walton, 1957;
Flom, 1960) and these have been extensively researched
over the years (e.g.Ciuffreda et al., 1997; Schor, 1986b).
If vergence and accommodation are linked early in
development, we would expect the vergence and accom-
modation responses to be similar. Many infants showed
(or vice versa) at the same visit, despite estimates of both
measures being taken from the same photographs. The
fact that our data suggest that for many infants
accommodation and vergence can act independently at
the same point in time, and that greater gender
differences were found in accommodation than vergence
argues against any early strong linkage between the two
systems. Since we report binocular data in this study,
however, we are unable to make any further inferences
about their relationship.
In terms of style of response, if infants accommo-
dated appropriately, females were more likely to show
overconvergence rather than underconvergence, while
males who accommodated appropriately were equally
likely to show under- or over-convergence. Females
were more likely to have at accommodation slopes.
The larger number of females who had vergence slopes
close to and above 1.0 has the effect of raising their
overall mean vergence slope in the rst months and may
account for the marginal vergence slope effect.
There are three possible explanations for our ndings.
Firstly, it may be true that males generally have an
accommodative response that is more adult-like than
female infants, or it might be that the proportion of
males that show early maturation of accommodation
responses is greater than in females. Figure 3 shows that
at two months males are making more appropriate
responses to distant targets. This could be explained by
better visual acuity development and therefore ability to
resolve the distant target, but evidence in the literature is
sparse, and what exists suggests that some (Held et al.,
2008 The Authors. Journal compilation 2008 The College of Optometrists
 Gender differences in vergence and accommodation: A. M. Horwood and P. M. Riddell
1984; Makrides et al., 2001), if not all (Held et al.,
1996), aspects of acuity are worse in males. Alternatively
it may reect gender differences in motor development
of the accommodation mechanism. Males have been
found to precede females in other motor control
domains (Pomerleau et al., 1992; Piek et al., 2002).
A second explanation may be to do with differences in
refractive error, which we only assessed by non-cyclo-
plegic methods and in one meridian, so cannot fully
explore. (We were unable to use cycloplegia as these
infants were part of a large longitudinal study where we
needed to retain maximum co-operation for repeated
testing). A hypermetropic infant would have to accom-
modate more to clear a near target, but may relax
accommodation to hypermetropic focus for a distant,
smaller and therefore possibly less stimulating target. In
this case a hypermetropic infant would have a steeper
response slope (accurate for near and hypermetropic for
distance). A steeper response slope might also have the
effect of producing a lower extrapolated y-intercept.
Males, therefore, might be genuinely more hypermetro-
pic than girls, or the refractive errors could be equally
distributed across gender, but the female infants pro-
duce greater accommodative effort to overcome their
refractive error at all distances. Further examination of
the data showed that there was indeed a larger number
of males who produced a y-intercept of <0 (i.e.
hypermetropic), but this was true only in the rst
2 months. This suggests that males could either be truly
more hypermetropic than the girls at this age, or that the
males of this age were not controlling their hyperme-
tropia in the distance. From the third month of age
onwards, approximately 65% of infants of both genders
had a hypermetropic y-intercept, as would be expected
from the cycloplegic studies documenting hypermetro-
pia in early childhood (for review see Thorn et al. 1996).
Thus, the early gender difference disappears, perhaps as
male infants begin to accommodate to overcome their
hypermetropia in the distance as well as for near.
If the gender difference was due to a higher number of
males being hypermetropic, then the gender difference in
accommodation slope should reduce when hyperopes are
excluded. In fact, the gender difference was even more
marked (Figure 3) and showed that the difference in
slopes results from the males focusing more accurately at
distance than the females, rather than resulting from
differences in hypermetropic manifest refractive error.
This argues against a true refractive error difference.
No gender differences have been reported in published
infant cycloplegic refraction data and our manifest
refraction data (estimated by y-intercept) are similar to
published studies (Mohindra and Held, 1981). The
photorefraction camera ash was mounted above the
camera and so we were only able to refract in one
meridian. It is possible that our results were inuenced
2008 The Authors. Journal compilation 2008 The College of Optometrists
123
by gender differences in the type or amount of
astigmatism that is known to occur in infants, although
such differences have not been reported in the literature
(Gwiazda et al., 1984; Ehrlich et al., 1997).
A third hypothesis is that females use disparity cues
[or at this age, bifoveal xation (Hainline and Riddell,
1996)] in preference to blur, thus producing atter
accommodation slopes, while males use blur more than
disparity. Previous studies have shown gender differ-
ences in stereopsis and full convergence (Held et al.,
1980, 1996; Birch et al., 1982), processes which depend
on disparity (rather than blur) detection. If disparity
cues and the responses to them are carrying more weight
than blur cues in females, it may explain the earlier
emergence of the disparity-dependent full vergence
(Held et al., 1996) and stereopsis (Held et al., 1980;
Birch et al., 1982).
We were unable to explore accommodative conver-
gence/accommodation(AC/A) and vergence accommo-
dation/vergence (CA/C) relationships in this closed loop
study, but it might be predicted that if females prefer to
use disparity and males prefer blur, the CA/C ratio
might be higher in females and the AC/A ratio higher in
males. Further studies are addressing this question.
Accommodation has been reported to be present in
some infants from 8 weeks (Tondel and Candy, 2007).
We report data from infants younger than those tested
by Tondel and Candy, who do not report gender
differences in their slightly older group. Experience from
our lab (Turner et al., 2002) and others (Hainline et al.,
1992) suggests that infants start to use accommodation
relatively suddenly. If males respond preferentially to
blur in their rst weeks, they may switch on to
appropriate accommodation earlier than the females.
While VEP (Makrides et al., 2001) and vernier acuity
(Held et al., 1984) have been reported to be poorer in
males, grating acuity has not (Held et al., 1996), so
resolution differences should not limit responses.
While collecting data from our laboratory (Turner
et al., 2002), it was clear that removing disparity cues
disrupts accommodation much more in some individu-
als than others, and the clinical literature (Kushner,
1988; Ansons et al., 2001; Grifn and Grisham, 2002)
stresses that responses to therapies such as prisms and
lenses can be idiosyncratic. The characteristics of
individual idiosyncrasies of near cue use are rarely
reported, but may be important in both development,
and clinical diagnosis and decision-making, as stressed
throughout clinical texts (Kushner et al., 1993; Kushner,
1999; Ansons et al., 2001; Grifn and Grisham, 2002;
Taylor and Hoyt, 2005). We are carrying out new
studies to investigate whether style of near cue use can
characterise diagnosis-specic clinical patterns. The
gender differences we report here highlight the impor-
tance of considering gender as an additional variable.
124 Ophthal. Physiol. Opt. 2008 28: No. 2
The evidence for gender differences being signicant
in the prevalence of ocular problems in older children is
weaker, but this is not necessarily surprising because
there is an extensive theoretical and experimental
literature describing processes that allow for sensory
and motor adaptation and exibility of the developing
visual system in relation to, and to compensate for,
environmental, anatomical and developmental variabil-
ity (e.g.Ciuffreda et al., 2005; Schaeffel and Howland,
1991; Schaeffel et al., 1993; Schor, 1986a; Schor et al.,
1992; Schor and Horner, 1989; Ojaimi et al., 2005).
Perhaps a genetically determined gender bias may be
another factor that the developing system needs to
overcome. The later gender differences in refractive
error or strabismus can be confounded by environmen-
tal inuences such as close-work load, particularly in the
eld of refractive error (Parssinen et al., 1989; Adams
and McBrien, 1992; Zylbermann et al., 1993; Simensen
and Thorud, 1994; Ehrlich et al., 1997; Flitcroft, 1998;
Blackie and Howland, 1999; Hung and Ciuffreda, 1999;
Goldschmidt, 2003), so very early differences may not
be responsible for much (or any) of the variance later
on. Possible gendernearwork interactions are less easy
to explain in terms of anisometropia (Pointer and
Gilmartin, 2004; Garcia et al., 2005) and intermittent
exotropia (Kushner, 1999), so it is still possible that very
early differences in styles of near cue use could subtly
inuence the development of later refractive error and
binocularity. Our ndings and those of others (Held
et al., 1980, 1984; Birch et al., 1982) suggesting that
differences rapidly disappear, may even provide support
for the stronger role of environmental and developmen-
tal inuences over innate ones.
Our non-cycloplegic method of assessing refractive
state makes it impossible to differentiate between true
refractive error and accommodative inaccuracy, so
many questions remain. The evidence we present here,
and our interpretation of this evidence, however, offers
a possible explanation for some of the later gender
differences in binocular vision development.
Acknowledgement
This study was supported by MRC grant G9608874N.
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Appendix 1
Post hoc testing of effect of age
Vergence slopes in month 1 were signicantly smaller
than those in month 4 (p = 0.009), while responses at
2 months were signicantly smaller than 3, 4, and
5 months (p < 0.02 in all cases). The only other
signicant difference was between responses at 4 and
6 months (p = 0.02) with the slope at 4 months being
greater than that at 6 months.
Vergence y-intercept was signicantly higher in
months 1, 2, 3 and 4 and than in month 6 (p = 0.01
for months 1, 2 and 3 and p = 0.032 for month 4). For
vergence r2 there were no post hoc differences between
months 1 and 2, or between months 3, 4, 5 and 6, but
signicant increase occurred between months 1 and 2
and the later months (p < 0.003 in all cases).
Accommodation slope was lower in month 1 than all
other months (p = 0.002 between months 1 and 2, and
p < 0.0001 all other cases), in month 2 compared with
month 4 (p < 0.0001) and 5 (p = 0.04), but higher in
month 4 compared with month 6 (p = 0.041).
Accommodation y-intercept was higher in month 1
compared with all other months (p = 0.027 between
months 1 and 2, p < 0.0001 in all other cases), month 2
compared with all other months (p < 0.003 in all cases),
but there were no signicant difference between months
3, 4, 5 and 6.
Accommodation r2 showed no signicant differences
between months 1 and 2, or between months 4, 5 or 6.
Between months 1 and 3 p = 0.014, between months 2
and 3 p = 0.037, between months 3 and 4 p = 0.042,
and for all other comparisons, p < 0.001. Accommo-
dation range was signicantly lower in month 1 than all
other months (p < 0.001) and also between months 2
and 4 (p = 0.027), but all other comparisons were
non-signicant.
2008 The Authors. Journal compilation 2008 The College of Optometrists