Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available
Accomodative anomalies
1. UNIVERSITY OF GONDAR COLLEGE OF
MEDICINE AND HEALTH SCIENCE
DEPARTMENT OF OPTOMETRY
CLINICAL 4 SEMINAR
title-accommodative anomalies
by-gebru getaye
1
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
2
3. OUTLINE
Αaccommodation
Accommodation anomaly
Accommodation anomaly classification
Diagnostic evaluation for accommodation anomalies
General management for all accommodative anomalies
3
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.
4
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 .
6
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
7
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 .
8
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
9
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
10
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.
11
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.
12
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.
14
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
15
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
16
17. SYMPTOMS
Distance Blur
A Drawing Or Pulling Sensation,
Asthenopia,
Headaches,
Photophobia
Macropsia
Reading problem
17
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
19
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
20
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
21
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.
22
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.
23
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
25
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
26
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.
29
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
30
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
31
32. ETIOLOGY
The use of cycloplegic drug
Paralysis of ciliary muscle
CNS infection
Neuritis associated with alcoholism diabeties
Head injuries
Adies syndrome
32
33. Symptoms
Extreme near point blur
Asthenopic symptoms
Photophobia (glare)
Signs
Diluted pupil
Significantly reduced amplitude of
accommodation
33
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
34
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
35
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
36
37. REFERENCE
Optometric clinical practice guideline
Eye essentials: Routine eye examination, Harvey and
Franklin, Butterworth Heinenmann
Clinical management of Binocular vision
37