The document discusses accommodative anomalies, including definitions, classifications, diagnostic evaluations, and management. It defines accommodation and describes several types of anomalies: decreased accommodation (insufficiency, ill-sustained, inertia, paralysis), and increased accommodation (excess, spasm). Accommodative insufficiency, fatigue, infacility, spasm, and paralysis are explained in detail with regards to etiology, symptoms, signs, and treatment approaches. The diagnostic evaluation of accommodative anomalies and general management strategies are also summarized.

1. UNIVERSITY OF GONDAR COLLEGE OF
MEDICINE AND HEALTH SCIENCE
DEPARTMENT OF OPTOMETRY
CLINICAL 4 SEMINAR
title-accommodative anomalies
by-gebru getaye
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2. OBJECTIVE
 At the end of this session, you will be able to:
 Define accommodation
 Explain anomalies of accommodation
 Differentiate anomalies of accommodation
 Define different diagnostic method
 Differentiate the possible management option
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3. OUTLINE
 Αaccommodation
 Accommodation anomaly
 Accommodation anomaly classification
 Diagnostic evaluation for accommodation anomalies
 General management for all accommodative anomalies
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4. ACCOMMODATION
 Accommodation is the reflex action of the eye by which
the eye changes refractive power by altering the shape
of its crystalline lens and automatically focus objects at
various distances on the retina.
 the ability of the eye to change its focus from distant to
near objects and vice versa.
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5. CONT...
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6. ACCOMMODATION ANOMALIES
 It is one of the binocularity dysfunction the eye become
dysfunction the automatic adjustment in the shape of the
lens of the eye to permit retinal focus of images of
objects at varying distances .
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7. CLASSIFICATION
 The classification was developed by DUANES
but later modified by others.
 Decreased Accommodation
Insufficiency
Ill-Sustained Accommodation (fatigue)
Inertia (infaciity)
Paralysis/paresis
Increased Accommodation
Excess
Spasm
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8. ACCOMMODATIVE INSUFFICIENCY
 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 .
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9. CONT..
 Commonly found in young adults and has been
incorrectly called premature presbyopia
 It occurs when the accommodative amplitude is reduced
by more than 2 D below Duane’s expected values for age
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10. ETIOLOGY
 systemic cause
Anoxia(hypoxia with severity
specially in pregnant women)
Diabetes mellitus
alcoholism
 local cause
Uveitis
Primary open angle glaucoma
Idiopathic (mostly) and also
associated with convergence
insufficiency
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11. ASSOCIATED SYMPTOMS
Asthenopia
Near vision blurred
Headaches
Intermittent Diplopia at near
Patient says ‘’My near vision becomes blurred
from the beginning while starting reading and I
prefer to hold the target away’’
Patients with accommodative insufficiency
complain of blurred vision, difficulty reading,
irritability, poor concentration.
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12. CLINICAL SIGNS
Reduced accommodative amplitude( <2.00D)
Accommodative facility problems(fail with -2.00
flipper
Reduced relative accommodation(PRA <-1.50D)
Reduced ciliary muscle function
Associated with high lag of accommodation.
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13. MANAGEMENT
Treat the underlying cause/refer for
investigation
 providing proper distance refractive
correction, a plus add for near, or both
 orthoptic exercises aimed at strengthening
the accommodative, such as “push-up”
training or flip lens training 13

14. ACCOMMODATIVE SPASM
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 meaning the exertion of
abnormally excessive accommodation.
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15. CONT..
 Spasm of accommodation is a constant or
intermittent involuntary and inappropriate ciliary
contraction resulting from constant
parasympathetic stimulation when the refractive
error is at or near emmetropia . It changes,
 Emmetropia- myopia
 Low Hyperopic- emmetropic or myopic-
common
 Myopic-more myopic rare ,except drug effect
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16. CAUSES
 The use of strong miotic drug
 Uncorrected high hypermetropia
 Inflammation of ciliary muscle
 Excessive near work done in bad illumination, bad
reading position, mental stress/anxiety
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17. SYMPTOMS
 Distance Blur
 A Drawing Or Pulling Sensation,
 Asthenopia,
 Headaches,
 Photophobia
 Macropsia
 Reading problem
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18. SIGNS
A dynamic retinoscopy shows a lead of
accommodation
The entire near reflex is also in spasm (near triad)
It responds to Atropine, eye exercises
difference in Cycloplegic and non Cycloplegic
Cycloplegic refraction show an increase of more
than 2D difference of relative plus power than
manifest refraction.
Difficult in clearing +2.00D lens
NRА lower than +1.50D 18

19. MANAGEMENT
 First aimed at the removal of the primary cause
 Low powered plus lenses for near work to relax
accommodation.
 However, in advanced condition: minus lenses may also be
needed for distance vision
 Investigate with Cycloplegic refraction and Correction of the
hypermetropia
 Orthoptic exercise
 Complete paralysis with atropine
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20. ACCOMMODATIVE FATIGUE
 Fatigue of accommodation is described as the inability of
the ciliary muscle to maintain contraction while viewing
a near target with a resulting shift in accommodation
toward the far point
 Accommodation couldn't sustained for longer periods of
near vision
 Ocular fatigue occurs at the end of the day
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21. CONT..
 Ill-sustained accommodation is a condition in which the
AA is normal, but fatigue occurs with repeated
accommodative stimulation.
 Type of insufficiency that occur when the patient is
fatigue
Cause
 the commonest cause is debilitating illness,
 Prolonged near work
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22. SYMPTOMS
Asthenopia
Near Blur
Headaches
Photophobia
 Patient says ‘’My near vision becomes blurred after some
minutes(30 or 60) while starting reading and I prefer to take rest’’
 The most common sign or symptom of ill-sustained
accommodation is blurred vision after prolonged near work.
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23. SIGNS
 Normal amplitude of accommodation but drops
during repeated measurement
 Reduced ciliary muscle function
 Reduced relative accommodation
 Reduced accommodative facility
 low АC /А ratio
 which is similar to accommodative
insufficiency, except that the AA is normal, the
patient generally fails the +/-2.00 D flipper test
and has a decreased PRA.
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24. MANAGEMENT
A combination of accommodative facility
training and vision therapy
Plus lenses for near
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25. ACCOMMODATION INFACILITY
Infacility of accommodation is the condition
in which the ability to rapidly change
accommodation effort from far to near
distance is failing
It differs from accommodative insufficiency
in that clear vision is eventually achieve.
There is a considerable time lag b/n the
stimulus change and the accommodative
response
The normal latency period is approximately
0.7 seconds
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26. CONT..
 Accommodative infacility or accommodative inertia occurs when
the accommodative system is slow in making a change, or
 when there is a considerable lag between the stimulus to
accommodation and the accommodative response.
 The patient often reports blurred distance vision immediately
following sustained near work
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27. ETHIOLOGY/ASSOCIATES
 Prolonged near work
 Ocular motor imbalance
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28. SYMPTOMS
Asthenopia
Headache
Blurred vision when CHANGING focus far
→ near and near → far
Patient says ‘’My vision becomes blurred for few
minutes when I change my fixation from distance
to near or vice versa and I wait some minutes to
clear my vision’’
Patient reports that after prolonged near focusing,
my distance vision is blurred and/or that, after
prolonged distance viewing, my near vision is
blurred. 28

29. SIGNS
Reduced accommodative facility
 Normal amplitude of accommodation
PRA lower than ̵ 1.50
NRA lower than +1.50
These patients invariably fail the +/- 2.00 D
accommodative facility test monocularly and
binocularly.
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30. MANAGEMENT
Vision therapy/Orthoptic exercises
 “accommodative facility training” or
“accommodative rock”
 Sometimes low plus lenses
 Reading near print through alternating
PLUS and MINUS lenses
(gradually increasing the power
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31. PARALYSIS/PARESIS OF ACCOMMODATION
 Total or partial loss of accommodation due to paralysis
of the ciliary muscle.
 a rare condition in which the accommodative system
fails to respond to any stimulus
 It may be unilateral or bilateral ,sudden or insidious
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32. ETIOLOGY
 The use of cycloplegic drug
 Paralysis of ciliary muscle
 CNS infection
 Neuritis associated with alcoholism diabeties
 Head injuries
 Adies syndrome
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33. Symptoms
 Extreme near point blur
 Asthenopic symptoms
 Photophobia (glare)
Signs
 Diluted pupil
 Significantly reduced amplitude of
accommodation
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34. MANAGEMENT
Refer for investigation of cause
 Head injury, degenerative conditions affecting the
brain stem, third nerve anomalies,
Prescribe near addition for close work
Resolution usually occur within six months
Self recovery occur in drug induced pαrαlysis
Dark glasses are effective in reducing the glare
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35. PRESBYPIA
Presbypia is age related functional loss of
lens accommodation that results in an
inability to focus at near distances.
It is the most common physiological change
occurring in the adult eye and is thought to
cause universal near vision impairment with
advancing age
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36. DIAGNOSTIC EVALUATION FOR ACCOMMODATIVE ANOMALIES
A. Patient history
B. Ocular examination
C. Visual acuity
D. Refraction
E. Аaccommodation facility test
F. Dynamic retinoscopy
G. Relative accommodation measurements
H. Meαsure Accommodative amplitude
I. Determine АС ̸ А ratio
J. Ocular health assessment and systemic
health screening
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37. REFERENCE
 Optometric clinical practice guideline
 Eye essentials: Routine eye examination, Harvey and
Franklin, Butterworth Heinenmann
 Clinical management of Binocular vision
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38. THANK YOU SO
QUESTION
DOUT
U CAN
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