Ill-sustained accommodation

1. ILL-SUSTAINED ACCOMMODATION Noor Munirah binti Awang Abu Bakar Optometrist

2. Outlines  Description  Characteristics (Signs & Symptoms)  Etiology  Management & Care Process  Case study  Conclusion

3. Description  WHAT?:  A condition in which the AA is normal under typical test conditions, but deteriorates over time with repeated accommodative stimulation.  If ill-sustained acc. is suspected, important to repeat AA test several times.  AKA accommodative fatigue.  Sub-classification of accommodative insufficiency.  An early stage of accommodative insufficiency (Duane and Duke-Elder & Abrams).

4. Characteristics-Symptoms  Symptoms (~ Accommodative Insufficiency)  Blurred at near vision after prolong work  Discomfort and eyestrain associated with near task  Fatigue & sleepiness associated with near point tasks  Difficulty with attention and concentration when reading  WHY?:  The accommodative system fails to sustain long- term accommodative effort

5. Characteristics  Signs (Hard on clinical tests that require stimulation of accommodation):  AA:  Decreased if repeated 5-10 times;  Normal if administered once only.  PRA: Low /reduced  Acc. Facility test:  Fail –ve lens (monocularly or binocularly)  Performance decreases over time  Esophoria at near  MEM: High (>+0.75DS)  Fused cross cylinder: High

6. Distance Near •Ill-sustained accommodation is similar to accommodative insufficiency except print may initially appear clear and easy to read without effort. • With time, the task at near begins to require more effort to focus. •Blurred vision, eyestrain and headaches can occur with sustained effort.

7. Etiology 1. Stage of convalescence from debilitating(weakening) illness 2. Stage of generalized tiredness general muscle fatigue 3. Uncorrected refractive error especially hyperopia or astigmatism 4. Small difference of anisometropia between 2 eyes

8. Management & Care Process  3 options for management: 1. Correction of ametropia  Uncorrected rx can cause acc. Fatigue.  Small degrees of ametropia may significant to prescribe.  Can be first management for acc. fatigue. 1. Added lenses  Ill-sustained accommodation respond best to added plus lenses  Suitable for pt with hard to stimulate accommodation. 1. Vision therapy (VT)  To restore normal accommodative function.

9. Management & Care Process  Plus lenses and vision therapy are effective in treating ill-sustained accommodation. Vision therapy is used to improve the speed of the accommodative response, and it is generally the treatment of choice. (AOA, 2011)

10. Management & Care Process  Vision therapy (VT)  3 phases  Table 1 : Objectives  Table 2 : Samples of VT program

11. Vision Therapy: Phase 1 (Table 1)

17. Vision therapy Brock string Lens sorting

18. Vision therapy Variable tranaglyphs

19. Vision therapy Hart Chart rock

20. Vision therapy  Re-evaluate about 3 to 4 weeks  If no improvement, there may be an underlying organic basis to low AA.  Terminate VT, start with added plus lenses  If got improvement, re-evaluate till the end of therapy.  Once VT completed, recommend home VT maintenance programme.

21. Management & Care Process  Patient education  Accommodative anomalies are neuromuscular problems and not refractive problems.  The effective treatment not only spectacles, but active vision therapy to eliminate neuromuscular dysfunction.  Prognosis & Follow up  Cooperation from patient for excellent prognosis  Follow-up: for this case, requires 12-24 in-office visits

22. Case study: 13/C/M  Chief complaint:  Discomfort, blurred vision & tearing after 30-40 minutes of reading.  Began about 6-9 months ago.  Had already been to see 2 doctors, but no eye problem detected.  Ocularhistory:  Never had ocular problems & did not wear glass before  Health Condition:  Healthy and not taking any medication  Family History:  Unremarkable

23. Case study: 13/C/M (cont.)  Examination results:  Pupils were normal, colour vision normal, comitant deviation, all external & internal health tests were negative Test RE LE VA (D/N) D: 6/6 ; N:6/6 D: 6/6 ; N:6/6 NPC 5cm Covertest -D Orthophoria -N 4 Exophoria Subj RX Plano Plano

24. Case study: 13/C/M (cont.)  Vergence assessment Test Phoria -D Orthophoria Vergence -D BI: X/6/4 BO: X/16/9 Phoria -N 4 exophoria Vergence -N BI: 9/15/10 BO: 10/17/10 -1.00 gradiet Ortho Gradient AC/A 4:1 Vergence facility 16cpm

25. Case study: 13/C/M (cont.)  Accommodative assessment Test RE LE AA (Exp= 14D) 10D 10D Repeated AA 8D 8D MAF 5cpm (hard on minus & performance deteriorates after 30 secs) 5cpm (hard on minus & performance deteriorates after 30 secs) BAF 3cpm (hard on minus & performance deteriorates after 30 secs) PRA -2.00D NRA +2.50D MEM +0.75D +0.75D

26. Case study: 13/C/M (cont.)  Diagnosis: Ill-sustained accommodation  Management : (Patie nt & pare nts pre fe rre d the tre atm e nt witho ut the ne e d o f g lasse s)  Remember 3 options: Correction, added plus & vision therapy.  Vision therapy was given as in Table 1 & Table 2.  18 visits of therapy done.  End of treatment results as following:  AA : 14D RE & LE  MAF : 18cpm RE & LE  BAF : 15cpm  MEM : +0.50D RE & LE  Patient now comfortable when reading , no discomfort.  Thus, dismiss from active VT, start maintenance program

27. Case analysis  Distance & near phoria are both normal  Thus, the best initial approach to analyze accommodative data:  Difficulty with MAF & BAF test:  Hard on minus lens  Overal cpm are borderline  Gradual deterioration with minus lens after 30secs  Amplitude of Accommodation (AA)  AA was repeated 10 times: Gradually decreased over time: Final AA: 8D  Other findings within normal range  PRA: slightly reduced  MEM: high side of normal

28. Case analysis  This case is characteristic of Ill-sustained accommodation.  Match the symptoms and complete measurement of accommodative component findings would help to elicit the diagnosis:  Accommodative facility test, repeated AA measurement, MEM & PRA  One time measurement wont be able to elicit the meaningful results.

29. Conclusion  Ill-sustained accommodation is a condition in which the AA is normal, but fatigue occurs with repeated accommodative stimulation.  It is medically necessary for the optometrist  to evaluate all accommodative components, repeated measurement.  to diagnose the condition accurately  to discuss the diagnosis, risks & potential treatment

30. References 1. Scheiman, M. & Wick, B., 2014. Clinical Management of Binocular Vision: Heterophoric, Accommodative, and Eye Movement Disorders (4th ed.). Lippincott Williams & Wilkins. 2. Cooper, J.S., Burns C.R., Cotter, S.A., Daum, K.M., Griffin, J.R., & Scheiman, M.M., 2011. Care of the patient with Accommodative and Vergence dysfunction. American Optometric Association.