Lecture V:

Anomalies of Accommodation

Mr. Natnael L.(lecturer)

April/2017

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 Objectives
 At the end of this session, you will be
able to:
 Explain the anomalies of
accommodation
 Differentiate the different anomalies of
accommodation
 Describe the diagnose and treatment of
different anomalies of accommodation

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 outline
• Spasm of Accommodation
• Lag of Accommodation
• Infacility of Accommodation
• Fatigue of Accommodation
• Insufficiency of Accommodation
• Paralysis of Accommodation

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 Anomalies of Accommodation
• General symptoms:
– Problems are longstanding
– Intermittently blurred vision
– Eyestrain and/or headache with visual tasks
– Fatigue/sleepiness with visual tasks
– Inattentiveness over time

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Anomalies of Accommodation

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 1. Spasm of Accommodation
• This is a disorder in which the crystalline
lens of the eye accommodates normally but
doesn't relax appropriately resulting in
sharp vision for near but not for distance
• It is involuntary contraction of the ciliary
muscle producing excess accommodation

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 1. Spasm of Accommodation
• Spasm of accommodation is a constant or
intermittent involuntary and inappropriate
ciliary contraction
– Emmetrope- myope
– Hyperope- emmetrope or myope
– Myope-more myope

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 Spasm of Accommodation
• It may be constant, intermittent, unilateral or
bilateral
– Associated with hysteria and headache
• It responds to Atropine, eye exercises, or
time

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Possible etiologies of spasm of accommodation

• Uncorrected high hypermetropia

• Excessive accommodation
• Drugs
• Inflammation of cilliary muscle

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 Clinical features
 Symptoms include:
– Distance blur
– Visual distortion
– Drawing or pulling sensation,
– Intermittent or persistent diplopia
– Asthenopia
– Headaches
– Photophobia
– Reading problems

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 Clinical features
• Signs
– Dynamic Retinoscopy shows lead of
Accommodation
– The entire near reflex is also in spasm with:
 Pupils constricted
 Eyes over converged(esotropia)
 Pseudomyopia
– Difficulty clearing +2.00 D. lenses on monocular
and binocular accommodative facility testing
– NRA lower than +1.50 D
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 Management
• First aimed at the removal of the primary
cause
• Low powered plus lenses for near work
• However, in advanced condition: minus
lenses may also be needed for distance vision
•  Investigate with cycloplegic refraction and
Correction of the hypermetropia
• Complete ciliary paralysis with atropine
 
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 2. Lag of Accommodation
• The amount by which the accommodative
response of the eye is less than the dioptric
stimulus to accommodation
• It is also the condition occuring in dynamic
retinoscopy in which the neutral point is
situated further from the eyes than is the
Retinoscopic target

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 2. Lag of Accommodation
• +0.75 is significant
• Usually associated with other anomalies,
such as accommodative infacility
• it tests accommodative accuracy objectively
under normal reading conditions

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3. Accommodation Infacility
• Facility of accommodation = speed with which a
patient increases or decreases the amount of
accommodation in play
– Infacility of accommodation= unable to change the
accommodative effort while changing distance
• Measured by either:
Having the patient change their accommodation
from one distance to another
The alternate use of plus and minus “flipper”
lenses

 
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 Clinical features
• Specific symptoms:
– Blurred vision when CHANGING focus far →
near and near → far
• Clinical signs :
– Difficulty clearing both +2.00 and -2.00 D. lenses
on monocular and binocular accommodative
facility testing
– PRA lower than -1.50
– NRA lower than +1.50

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 Management:
• Vision Therapy: to stimulate/relax accommodation
monocularly
– Alternately focusing on small print targets at near and
far (with the near target slowly moved closer to the eye)
– Reading near print
through alternating
PLUS and MINUS lenses
(gradually increasing the power)

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 4. Fatigue of Accommodation
• AKA= Ill-sustained Accommodation
• Initial stage of true insufficiency
• Range is normal
• Normal amplitude of accommodation
• During prolonged near work, accommodative
power weakens, the near point gradually
recedes and vision becomes blurred
 

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 4. Fatigue of Accommodation
• The patient may have an abnormal lag of
accommodation associated with a low AC/A
ratio, with the result of having a large
exophoria at near.
• A type of insufficiency that occurs when the
patient is fatigued
• Accommodation couldn't sustained for longer
periods of near vision

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 Management:

• A combination of accommodative facility

training and convergence training
 

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5. Insufficiency of Accommodation

• Is a condition in which the amplitude of

accommodation is chronically below the lower
limits of the expected amplitude of
accommodation for the patient’s age
• OR accommodative sustaining ability is
constantly poor

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 Accommodative insufficiency----
• Commonly found in young adults and has been
incorrectly called premature presbyopia
• Insufficiency of accommodation occurs when the
accommodative amplitude is reduced by more than 2
D below Duane’s expected values for age

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Possible etiologies of accommodative insufficiency

• Idiopathic

• Anoxia

• Uveitis

• Diabetes mellitus

• Anemia

• Alcoholism

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 Clinical features
• Associatedsymptoms
– Asthenopia
– Near blur
– Headaches
– Diplopia
– Photophobia
– Reading problems are the most frequently
reported symptoms

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 Cont..
• Clinical Signs
• Reduced amplitude accommodative
• Accommodative facility problems
• Reduced relative accommodation
• Reduced cilliary muscle function
• Associated with high lag of accommodation

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 Diagnosis
• Diagnostic criteria
• The accommodative amplitude is reduced by
more than 2 D below Duane’s expected values
for age
• Failure to clear with -2.00Ds flipper lenses
during facility testing
• PRA <-1.50D
• Mostly If the patient is young adult with any
associated symptoms, not presbyope

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 Management
 In cases of accommodative insufficiency, treatment
consists of:
– Providing proper distance refractive correction
– A plus add for near, or both
– Base out prism may be added to patient associated
with convergence insufficiency
– Orthoptic exercises such as “push-up” training or
flip lens training
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 6. Paralysis of Accommodation
• Total or partial loss of accommodation due
to paralysis of the ciliary muscle
• Significantly reduced amplitude of
accommodation
• Very Rare

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 6. Paralysis of Accommodation
• Causes:
– Drug induced cycloplegia –atropine ,homatropine
– Internal opthalmoplegia [paralysis of cilliary muscle &
sphincter pupillae]
– Neuritis associated with chronic alcoholism, diabetes
– CNS infections
– Head Injury
• Specific Symptoms:
– Blurring of near vision
– Photophobia [glare]

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 Management:

• Refer for investigation of cause

• Head injury
• Degenerative conditions affecting the brain stem
• Third nerve anomalies 
• Self recovery occurs in drug induced paralysis
• Dark glasses are effective in reducing the glare
• Convex lenses for near vision may be prescribed

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 General management for all of the above
• First look carefully for any pathology
• Look carefully for any latent hypermetropia –
cycloplegic refraction
• Treatment:
 Correct refractive error
 Orthoptic exercises
 Plus addition
 Plus addition with base-in prisms (if combined
with convergence insufficiency
 Combinations of the above
 

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 Orthoptic Exercises
• 1. Push-up
• 2. Near-Distance Facility
• 3. Flipper facility
 Can do monoc and/or binoc
 Start with powers of lenses/viewing distances
that Px can cope with
 10-15 min, 2 x daily
 Brief, aggressive treatment works best with
motivated Px

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Any question??

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