ILL-SUSTAINED ACCOMMODATION

Noor Munirah binti Awang Abu BakarOptometrist

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

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).

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

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

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. 

Etiology1. Stage of convalescence from

debilitating(weakening) illness2. Stage of generalized tiredness

general muscle fatigue3. Uncorrected refractive error especially

hyperopia or astigmatism4. Small difference of anisometropia

between 2 eyes

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.

2. Added lenses Ill-sustained accommodation respond best to added

plus lenses Suitable for pt with hard to stimulate accommodation.

3. Vision therapy (VT) To restore normal accommodative function.

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)

Management & Care Process Vision therapy (VT)

3 phases Table 1 : Objectives Table 2 : Samples of VT program

Vision Therapy: Phase 1 (Table 1)

Vision Therapy: Phase 1 (Table 2)

Vision Therapy: Phase 2 (Table 1)

Vision Therapy: Phase 2 (Table 2)

Vision Therapy: Phase 3 (Table 1)

Vision Therapy: Phase 3 (Table 2)

Vision therapy

Brock string

Lens sorting

Vision therapy

Variable tranaglyphs

Vision therapy

Hart Chart rock

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.

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

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. Ocular history:

Never had ocular problems & did not wear glass before

Health Condition: Healthy and not taking any medication

Family History: Unremarkable

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 LEVA (D/N) D: 6/6 ; N:6/6 D: 6/6 ; N:6/6NPC 5cmCover test -D

Orthophoria

-N

4 Exophoria

Subj RX Plano Plano

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

Case study: 13/C/M (cont.) Accommodative assessment

Test RE LEAA (Exp= 14D)

10D 10D

Repeated AA 8D 8DMAF 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 -2.00DNRA +2.50DMEM +0.75D +0.75D

Case study: 13/C/M (cont.) Diagnosis : Ill-sustained accommodation Management : (Patient & parents preferred the treatment without the need of glasses)

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

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

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.

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

References1. 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.