Week 6 - Accommodation Anomalies Flashcards
what part of the eye is responsible for accommodation?
• The lens makes up 15D refractive power of the eye
•The lens is held in place by zonules/suspensory ligaments.
• Zonules are attached to the ciliary muscle.
• Supplied by the Illrd N- parasympathetic system
Dioptres of accommodation = 1 / fixation distance in metres, i.e at 25cm so 1/0.25=4D
Accommodation vs No Accommodation
• No accommodation - fixing near object (A) image out of focus
• Accommodation - lens becomes more convex Image now clear
Components of Accommodation
• Blur driven: Chromatic aberration gives cue as to direction of adjustment needed. Pupil size can also increase depth of focus and reduce blur
• Proximal: Occurs for targets up to 3m away
• Cognitive: Mental effort increases the level of accommodation
• Tonic: Resting point of accommodation (dark accommodation)
• Convergence accommodation: Produced as eyes converge. For every 10^ forced convergence about 1D accommodation occurs - counteract with relative negative accommodation
Accommodation and Age:
•Normal aging process
•Onset usually between 40-50 years old
•Onset can be premature
•Nutritional
•Environmental
•Disease related
What four aspects of Accommodation can be measured?
• Near Point of Accommodation
• Amplitude of Accommodation
• Accommodation Facility
• Accommodation Response
Near Point of Accommodation Measuring:
• Performed using RAF rule.
• Refraction worn.
• N series type used as target.
• Pushed towards patient and patient says when text becomes blurred.
• Binocularly and then monocularly.
• Repeated x3
Why is it important to measure accommodation?
•Assess if the amplitude is the same in both eyes
• Assess if its normal for the patient’s age.
•Assess if the amplitude is sufficient for the patient’s needs
• As we know, amplitude of accommodation reduces with age- 0 by approx 60 years.
Amplitude of Accommodation:
• The maximum amount of accommodation that can be exerted either eye.
• Quantified in dioptres (D).
• Equivalent to the difference of the far and near points of accommodation.
Push Up- Pull Down Method: Explain
• RAF rule as used
• Patient wears maximum distance rx.
• In presbyopes (patients >40 years) with low amplitude, add +2.00DS to distance rx. Sets far point to RAF rule (50cm).
• In children (<16 years) with high amplitudes- add -3.00DS to distance rx.
• Occlude on eye.
• Assesses smallest text patient can read at 40cm.
Push up- Pull down method: Method
• Move your target to a point closer than this measurement, move the target backwards away from the patient and asked the patient to tell you when it becomes clear.
• Note this measurement in diopters.
• This is the pull-down result.
• Average pull up and pull-down result: amplitude of accommodation.
Repeat for other eye.
AC/A Ratio:
• Accommodative Convergence /Accommodation Ratio
• Normal if 4:1 or less
• Gradient method
(Measurement on accommodation - Measurement without accommodation) / (Accommodation exerted (lens used))
Example:
PCT N c+3.0012^BO
N 30^ BO
30 - 12/ 3 = 6:1
Accommodation Facility:
• A measure of the eyes ability to change accommodation status.
•Reduced accommodation facility may create near vision problems-even if the amplitude is normal!
• Training the accommodation facility can result in an improvement.
• Flipper lenses are used,+ 2.00DS are used.
• Introducing these lenses in front of the eyes will relax the accommodation (+2.00DS) and stimulate accommodation (-2.00DS).
Method of measuring accommodation facility:
• Measure binocularly in first instance.
• If this is abnormal, measure monocularly.
If binocular accommodation is abnormal but monocular is abnormal= other binocular vision anomaly.
Procedure:
• Full distance prescription corrected.
• Given patient a reading chart to hold at 40cm.
• Determine smallest text they can read clearly.
• Ask patient to fix on a word this size.
• Give clear instructions
“There will be a lens put in front of your eye that may blur the word, try and focus to make it clear and say “clear” as soon as it happens. I will continue to repeat this process for 1 minute”
• Start timer for 1 minute the second you place first lens (+2.00DS) in front of the eyes.
• As soon as the patient says “clear” flip the lens to the -2.00DS lens.
•One clear of +2.00DS and one clear of -2.00DS= one complete cycle.
Repeat.
normal results measuring speed of accommodation:
• Count the number of cycles completed in one minute.
• Young adult: 10-12 cycles per minute is considered normal (using +/-2.00DS flippers).
Accommodation response: Lag vs lead
• The accommodation response to a near target can-at times- not match exactly with the accommodation stimulus.
• If the accommodation response is less than the stimulus: Accommodation Lag.
• A target at 40cm should elicit at 2.50DS response but may only elicit a 2.00DS response.
• A lead of accommodation is when the response exceeds the stimulus.
Accommodation response: Accommodation lag of 1D
• An accommodation lag of 1D or more may be an indication of the following:
• Presbyopia.
• Uncorrected or under corrected hypermetropia.
•Reduced amplitude of accommodation.
Accommodation lead may represent:
• Accommodative Spasm
• Pseudo myopia
Dynamic Retinoscopy:
• An accommodation lag or lead can be identified and measured by dynamic retinoscopy.
• There are two methods:
- Monocular Estimation Method (MEM)
- Nott Method
MEM Dynamic Ret
• Patient wears full distance prescription.
• A near chart is attached to the front of the retinoscope.
• Measure patients habitual working distance.
• Dim room lights.
• Patient fixes on suitable sized letter on near chart.
• Perform ret at habitual working distance with vertical alignment.
MEM Dynamic Ret: Observations
• Observe light reflex: against, with or neutral.
•If with or against, place lens in front of the eve until neutral achieved.
•Observe this for a little while to assure no change!
• Repeat with the other eye.
•Record neutralising lens for each eye.
Positive lenses= Lag
Negative lenses= Lead
Nott Dynamic Retinoscopy
•Patients wears full distance prescription.
• Measure patients habitual working distance.
•Place near chart at patient’s habitual working distance.
• Patient fixes on word of suitable size.
•Dim room lights
• Perform ret from 10cm behind the near chart with streak vertical.
• If reflex isn’t neutral: Change position.
- Reflex is with: Further away.
- Reflex is against: Closer
• Measure distance from your retinoscope from the patient when the reflex is neutral.
- Neutral point behind target=Lag
- Neutral point in front of target= Lead
Nott Dynamic Retinoscopy calculation
• The dioptric distance between the near chart and the neutral point is a measure of the lag or lead.
• Near chart position: 40cm (2.50D)
• Neutral position: 50cm (2.00D)
• 2.50-2.00: Lag= 0.50DS
Accommodation Anomalies:
• Accommodation insufficiency
• Accommodation paralysis
• Accommodation infacility/inertia
• Accommodation spasm
• Accommodation anomaly with down syndrome
Accommodation insufficiency and symptoms
• Patient has a reduced amplitude of accommodation compared to their age-matched normal.
This can be sub categorised:
• Ill-sustained accommodation- accommodation response cannot be sustained (fatigue).
•Paralysis- ability to accommodate is totally absent.
•Paresis- markedly reduced.
• Unequal: amplitude is 0.50DS more different between the eyes.
•May be associated with convergence insufficiency.
Symptoms
- Usually bilateral
- Blurred vision for near
- Asthenopic symptoms
Accommodation Paralysis
• Patient has lost ability to exert accommodation completely.
• May come hand in hand with convergence paralysis.
Symptoms
Blurred near vision
Diplopia if associated with accommodation paralysis
May have dilated pupil- so photophobia.
Accommodative Paralysis: Aetiology
•Drugs
• Trauma to the eye
• Closed head injury / whiplash
• Illrd CNP
• Midbrain disorders (rostral area)
- Pineal tumour
• Conditions affecting CNS
- Alcoholism, encephalitis
Accommodation Infacility/Inertia
• The patient has difficulty focusing from distance to near.
• The dynamics of accommodation are slowed down.
Symptoms
• Blurred vision when changing fixation
• Accommodation is reduced for age- facility and amplitude.
Accommodative Spasm and Aetiology
• Contraction of the ciliary muscles: excessive accommodation.
• Distance vision is blurred: pseudo myopia.
• Usually associated with convergence spasm.
Aetiology:
> May happen in young, uncorrected hypermetropes.
> Functional response
> Lack of relaxation after close work
> Nystagmus blocking syndrome- manipulation of accommodation
> Closed head trauma
> Rostral midbrain lesion
> Increased ICP
> Drugs
> Para sympathomimetics
> Anticholinesterase agents
Accommodation Anomaly in Patient’s with Down Syndrome
• Accommodation deficit in patients with down syndrome 55-76%
• Accommodation response assessed.
• Bifocal use incorporated.
