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.
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