This document discusses anomalies of accommodation, including diminished or deficient accommodation (presbyopia, cycloplegia, insufficiency), and increased accommodation (excessive accommodation, spasm). Presbyopia is an age-related decrease in accommodation due to hardening of the lens or weakening of the ciliary muscles. Treatment includes optical corrections like glasses or surgery. Insufficiency of accommodation can be due to premature lens sclerosis or ciliary muscle weakness from various systemic or local causes. Treatment addresses the underlying cause and includes near vision corrections. Excessive accommodation can occur in young hyperopes or myopes doing excessive near work, while spasm of accommodation is an abnormal excessive accommodation outside voluntary control.

2. PRESENTATION LAY OUT
 Accommodation…….. Overview
 Anomalies of accommodation …..classification
 Clinical presentation
 Management

3. ANOMALY
 Anomaly means a deviation from the normal state .
 This deviation may be above or below the normal
state.
 In case of accommodation, anomalies simply
comprises of increase or decrease in accommodation.

4. ANOMALIES OF ACCOMMODATION
 CLASSIFICATION
 A: DIMINISHED OR DEFICIENT ACCOMMODATION
 1. physiological (presbyopia)
 2. pharmacological (cycloplegia)
 3. pathological
 insufficiency of acc;
 ill-sustained acc;
 inertia of acc;
 paralysis of acc;
 B: INCREASED ACCOMMODATION
 1. excessive accommodation
 2. spasm of accommodation

5. DIMINSHED ACCOMMODATION
 PRESBYOPIA
 It is not a state of refractive error but a condition
of physiological insufficiency of accommodation.
 The condition of failing near vision due to age
related decrease in the amplitude of
accommodation or
 Increase in punctum proximum is called
presbyopia.

7. Pathophysiology of presbyopia
 With increasing age there is a decrease in the
accommodative power of the crystalline lens due to
 sclerosis ( hardening) of the crystalline lens with
increasing age and/ or
 age related decrease in the power of ciliary's muscles

9. Symptoms of presbyopia
 Difficulty in near vision
 Asthenopic symptoms
 Intermittent diplopia at near ……..due to the
interrelationship b/w accommodation and
convergence.

11. Treatment of presbyopia
 Optical
 spectacles
 contact lenses
 Surgical
 IOL,s with near add
 LTK laser thermal keratoplasty

13. INSUFFICENCY OF ACCOMMODATION
 DEF;
 When the accommodative power is significantly less
than the normal physiological limits for the patient's
age.
 Should not be confused with presbyopia in which the
physiological insufficiency of acc is normal for the pt,
age.

14. Causes of accommodative insufficiency
 1.Premature sclerosis of lens
 2. weakness of CM either due to
 systemic causes e.g malnutrition ,DM ,
pregnancy ,anemia ,toxaemia and stress.
 local causes e.g POAG,

15. Clinical features
 Asthenopic symptoms such as headache ,fatigue,
irritabilty of the eyes while doing near work
 The pt remains comfortable if near work is not
attempted.
 Near work is blurred and difficult.
 Intermittent diplopia for near.

16. Clinical features All these symptoms are stable in accommodative
insufficiency of lenticular origin.however
 When the condition is due to CM weakness,then with
improvement in GH,or relaxation from overwork or
worry, the symptoms may considerably improve.

17. Treatment
 Treatment of the cause (systemic causes)
 Near vision spectacles
 Weakest convex lenses should be given after
distance correction if any .
 BI prisms if there is associated convergence
insufficiency.
 When convergence excess is associated then give
full spherical correction.

18. Accommodation exercises
 Accommodation exercises are helpful when the
general debility has passed and the lenticular
sclerosis is not the cause of diminished
accommodation.
 Accommodation exercises are carried out
binocularly when there is associated convergence
weakness otherwise
 One eye should be covered while exercising.

19. Accommodation test card exercises
 It is the most simple exercise
 The card consist of a black vertical line drawn on a
white card.
 The pt should be instructed to hold the card at a
considerable distance and then bring it closer until
the line appears blurred .
 He should be encouraged to attempt to bring his near
point as close as possible

20. Accommodation test card

21. ILL-SUSTAINED ACCOMMODATION
 It is also known as a condition of accommodation
fatigue may be defined as the situation in which
although the range of a accommodation is normal but
it cannot be sustained for sufficient time period.
 It causes a tendency for the near point of
accommodation of the patient to recede during close
work.

22. AETIOLOGY
 It is the initial stage of true insufficiency.
Accommodation fatigue is characteristically known to
occur in the following conditions.
 Stage of convalescence from debilitating illness
 Stage of general tiredness
 When patient is relaxed in the bed

23. CLINICAL FEATURES
 Since it is initial stage of true insufficiency, the
symptoms are largely the same. Typically the patients
complain that while doing near work, they start feeling
tired very soon. Their near point gradually recedes and
the near visions become blurred.

24. TREATMENT
 Avoiding the near work during situation described in
etiology
 General tonic measures.
 Improve visual hygiene with particular reference to
conditions of illumination and posture during study.

25. ACCOMMODATION INERTIA
 It is the condition in which there is difficulty in
adjusting the accommodation according to the
distance of regard so as to gain clear vision .It is
comparatively rare condition

26. CLINICAL FEATURES
 Patient typically complains that it takes some time and
involves some definite effort for him to focus a near
object after looking at a distance. Usually this
condition does not assume any serious symptoms, but
occasionally may give rise to some trouble and
annoyance

27. TREATMENT
 Correct any refractive error
 Practice of accommodation exercises

28. PARALYSIS OF ACCOMMODATION
 It refers to complete absence of accommodation also
known as cycloplegia

29. CAUSES
 Drug induced cycloplegia results due to the
effect of parasympatholytics drugs such as
atropine, homatropine and others.
 Internal ophthalmoplegia, it means paralysis of
sphincter pupillae muscles and ciliary muscle may
result from neuritis associated with diabetes,
chronic alcoholism ,cerebral or meningial diseases
including even a mild head injury

30. CAUSES
 Paralysis of accommodation as component of
complete 3rd nerve paralysis may occur due to
intracranial or orbital causes. the lesion may traumatic
inflammatory or neoplastic

31. CLINICAL FEATURES
 Blurring of near vision
 It is the main complaint in previously emmetropic
or hypermetropic patient. Blurring of vision may
not be marked in myopic patient
 Photophobia It is due to accompanying
mydriasis.Usually associated with blurring of near
vision.
 On examination there is abnormal receding of
NPA and markedly decrease range of
accommodation

32. TREATMENT
 Treat the systemic diseases such as diphtheria, syphilis
etc.
 Self recovery occur in drug induce paralysis.
 Dark glasses to reduce the glare
 In permanent paralysis plus lenses for near vision.

33. INCREASED ACCOMMODATION
 EXCESSIVE ACCOMMODATION
 SPASM OF ACCOMMODATION

34. EXCESSIVE ACCOMMODATION
 It is a situation in which an individual exerts more
than normal accommodation for performing certain
near work. it is with in the voluntary control of the
individual and is an intermittent process.

35. CAUSES
 Certain degree of excessive accommodation is
frequently noted under following circumstances
 Young hypermetropes frequently use excessive
accommodation as a physiological adaptation to
attain clear vision.
 Young myopes performing excessive near work
may also use excessive accommodation in
association with excessive convergence.

36. CAUSES Astigmatic errors in young persons may also be
occasionally with the use of excessive accommodation.
 Presbyopes in the beginning also use excessive
accommodation to accomplish near work.
 Use of improper or ill-fitting spectacles may also
cause use of excessive accommodation

37. Precipitating factors
 Large amount of near work.
 Habitual near work in deficient or excessive
illumination.
 General debility
 Physical or mental ill health

38. CLINICAL FEATURES
 Blurred vision of varying degree due to induced
pseudomyopia
 Symptoms of accommodative asthenopia
 Both far point ant near point are brought nearer to the
eye
 Near vision also suffers in the more marked degrees
and after reading for some time the printed page
becomes confused and clears up only after a temporary
rest.

39. TREATMENT
 The treatment is usually effective with good prognosis
 Optical treatment correct refractive error while
performing cycloplegic refraction
 General treatment near work should be forbidden
for a period
 General conditions of the patient’s health should
receive special attention

40. SPASM OF ACCOMMODATION
 Spasm of accommodation is a continuous prolonged
use of excessive accommodation or it refers to the
abnormally excessive accommodation which is out of
the voluntary control of the individual.

41. Causes
 Drug induced spasm of accommodation is known to
occur after use of strong miotics such as echothiophate
 Spontaneous spasm of accommodation
 Occasionally found in children usually in uncorrected
hypermetropes but also in astigmatic and even in myopes
children.
 It usually occur when the eyes are used for excessive near
work in unfavorable conditions such as bad illumination ,
bad reading position, lowered vitality , state of neurosis ,
mental stress and anxiety.
 Iridocyclitis may be associated with ciliary spasm.

42. Causes
 Spasm of near reflex is a clinical syndrome often
seen in disturbed and tense individuals. who
presents with
 Excessive accommodation
 Excessive convergence and
 Meiosis
 Lesion of brainstem e.g. encephalitis and
meningitis may be associated with ciliary spasm
 Toxic reaction exogenous poisons e.g.
sulphonamides, arsenic or even smoking can
sometime cause spasm of accommodation

43. Clinical features
 Varying blurred vision due to induced pseudomyopia
 Asthenopic symptoms are more marked than the
visual symptoms (blurr).
 Headache and brow ache are typical features.
 NPA is abnormally close.
 Macropsia may occur.

44. TREATMENT
 Relaxation of ciliary muscles
 The most effective method of treatment is the
production of complete ciliary paralysis with atropine .
 The cycloplegia should be kept for 4 weeks or more.
 Optical treatment
 correcting spectacle should be worn immediately
when eyes are used again after period of cycloplegia.

45. TREATMENT
 General treatment
 Near work should be forbidden for a period
 The general condition of the patient health should
receive special attention.
 Therefore, a holiday with a change of air usually has a
greater effect than anything else.

46. REFERENCES
 Duke-Elders practice of refraction 10th edition
 Theory and practice of optics and refraction A K
KHURANA