This document discusses accommodative insufficiency, including its definition, signs and symptoms, assessment methods, and management approaches. Accommodative insufficiency is characterized by an inability to focus or sustain focus at near due to an insufficient amplitude of accommodation based on age-expected norms. Evaluation involves assessing near point of accommodation and determining amplitude of accommodation. Management includes prescribing reading glasses to reduce accommodative demand, vision therapy using techniques like flippers and Hart charts to strengthen accommodation, and occasionally multifocal lenses. The goal of treatment is to improve the ability to make rapid accommodative responses without fatigue.

1. GauriSh Shrestha,
M.Optom, FIACLE
Program Co-ordinator
Institute of Medicine
Sadhana Sharma, B.Optom II year

2.  Accommodation
 Unit of measurement
 Accommodative insufficiency
 Signs & symptoms
 Care process
 Management
 Conclusion
 References

3.  It is the dioptric adjustment of the crystalline
lens of the eye to obtain clear vision for a
given target of regard.
 It is the process by which the refractive
power of eye is altered to ensure a clear
retinal image.

4.  Ciliary muscle contracts (ciliary ring
shortens & zonules are relaxed)
 Tension in capsule is relieved (equator
of lens move forward & lens becomes
spherical)
 Dioptric power of lens increases (near
object focuses clearly on retina)

5.  The lens fibers & lens capsule lose their elasticity
 Size & shape of the lens increases
 Decrease accommodative amplitude
 The difference between the dioptric power need to
focus for near(P) and distance (R) is called
amplitude of accommodationamplitude of accommodation
 A= P-RA= P-R

6. Time from birth Amp Acco
Birth 18.5D
8 years 14D
40 years 4D
70 years 0.0D
We lose 1D every 4 years

7. 10
15
20
25
30
35
40
45
50
55
14 12 10 8.5 7 5.5 4.5 3.5 2.5 1.75
0
10
20
30
40
50
60
1 2 3 4 5 6 7 8 9 10
Age(yrs) Amp(D)

8.  Max= 25-0.4 (Age)
 Average= 18.5- 0.3 (age)
 Min= 15.5-0.25 (Age)

9.  Accommodative insufficiency is an anomaly
that is characterized by an inability to focus
or sustain focus at near
 An insufficient amplitude of accommodation
based on age-expected norms

10.  Headache: “Do you get a headache when you read
or study?”
 Asthenopia: “Do you feel tiredness or tearing in
the eyes when you read or study?”
 Floating text: “Do you see the words appear to
float on the page, swim, jump or wiggle when you
read or study?”
 Facility problems: “Do you have difficulties in
quickly changing focus from the board, to your
textbook, and back to the board again?”

11.  Some children with
accommodative insufficiency do
not present complaint? Why

12.  Relationship between AC/A ratio
 Relationship between CA/C

13. 1. Ophthalmic :
 Disease of accommodating components
 Hypermetropia
 Uncorrected myopia (noticed by the patient after
correction of refractive error)
2. Medical :
 Poor general health, malnutrition, general
weakness

14. 3. Trauma :
 Trauma to eye resulting in loss of
acommodation
4. Drugs :
 Certain drugs adversely affect
accommodation such as antidepressants,
cycloplegics, antihistamines, Marijuana
etc

15.  Blurred vision
for near
 Headaches
 Eyestrains
 Reading
problems
 Fatigue &
sleepiness
 Loss of
comprehensio
n over time

16.  Pulling sensation
around eye
 Movement of print

17. Visual acuity
Variability between
near & distance VA
may indicate
accommodative
anomaly.

18. Refraction
- uncorrected hyperopia (Latent
hyperopia)

19.  Esotropia
Reduced convergence demand
causing accommodative dysfunction
 Exotropia
Vergence dysfunction causing
accommodative dysfunction

20.  CI notices
clear vision
 AI notices blur
vision

21.  RAF rule Method (Push up method)
moving a test object closer to eyes
 Positive relative accommodation
(PRA) Method
placing a minus lens in front of eyes
 Lag of Accommodation
Dynamic retinoscopy

23.  Near point card is placed at a distance
of 40 cm.
 Patient is instructed to watch 20/20 line
of letter each eye separately
 Asked to report when letter begins to
blur as minus power is gradually added
to patient’s subjective correction.

24.  To arrive at amplitude of accommodation, Add
2.50 D (for 40 cm WD) to minus lens power used
to blur the letters.
 For e.g. if add of -4.00D to subjective refraction
blurs the letters, the amplitude of accommodation
is
+4.00 + 2.50 D = 6.50D
 If positive lenses is necessary to add to clear up
the letter at 40 cm, the amount of plus power
necessary to clear up the letter is subtracted from
2.50D to determine amplitude of accommodation.

25. Basis for treatment
- General Principles are :
 To assist the patient to function efficiently
in near vision tasks
 To relieve ocular, physical & psychological
symptoms associated with disorders.

26. Cause should be eradicated ( medical
problems, drugs, ophthalmic etc…) if present

27. Optical correction
Appropriate refractive correction
first
Estimate amount of amplitude of
accommodation for given age if it is
disabling for near visual task,
Prescribe glass to relieve symptoms

28.  Prescribing reading glasses
decrease the demand on
accommodative system. However,
accommodation becomes passive
(it is problem we are
discussing)

29.  Solution:
Amp of Accommodation =6.0D
Functional amplitude of
accommodation=3.0D
Max near working distance = 33.3cm
Normal Amp of accommodation for
the age= 13D

30. Deficit is 7 D for the age= not
practicable to prescribe
Maintain least distance of distinct
vision= 25cm= 4.0D
Glasses should be prescribed at least
1.0D
Range of accommodation for near
work= 25cm to 50cm

31.  The purpose of accommodative therapy
is to increase the amplitude, speed,
accuracy & ease of accommodative
response.
 At the end of therapy patient should be
able to make the rapid accommodative
responses without evidence of fatigue.
 A vision therapy for accommodative
insufficiency usually requires 12 to 24
office visits

32. In office
1.Flippers
2.Brock-string
exercise
3.Hart-chart rock
exercise
4.minus lens
procedure
In home
1. Push up paddle
2. Hart chart rock
exercise
3. Flippers
4. Brock-string
exercises

33.  It is a holder with two minus & two
plus lenses of equal magnitude
 Subject focuses through one pair of
lenses at an object at near distance
(40 cm)
 When object is clearly focused, a
flick is quickly performed to the
other lens pair & subject focuses
through this.
 Process is then again repeated.

34.  Through changing the fixation distance it is
done with large & small hart charts,
consisting of ten rows, each with ten letters
 Letters of large chart have a visual subtense
of 20/20 at a distance of 20 feet.
 Small chart is a small version of large hart
chart
 Children using these charts practice keeping
their places when switching from far to near.

35.  Consists of a white string
of approximately 10 feet
in length with 3-5 small
wooden beads of
different colors.
 During therapy one end
of string is held at tip of
nose whereas the other
end is tied to a fixed
point.

36. Explain the procedure

37.  Monocular versus binocular
 Person reads a letter in a push
up paddle while moving the
target closer until sustained blur
is noticed
 Can be combined with distance
Hart chart rock

38.  Principle similar to flipper lens.
 Minus lens of increased strength is
gradually introduced in front of each eye
while the subject reads 20/20 equivalent
letters at near until s/he notices blur. S/he
must be encouraged to make letters read
clear

39.  Treatment is best addressed by use of
therapeutic spectacle lenses. The usually
prescribed ones are multifocal form to
allow improved near vision while not
disturbing distance vision.