Accommodative insufficiency

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Accommodative insufficiency
Differential diagnosis Convergence insufficiency.

Accommodative insufficiency (AI) involves the inability of the eye to focus properly on an object. Accommodation is the adjustment of the curvature of the lens to focus on objects near and far.

Contents

In this condition, amplitude of accommodation of a person is lesser compared to physiological limits for his age. [1] AI is generally considered separate from presbyopia, but mechanically both conditions represent a difficulty engaging the near vision system (accommodation) to see near objects clearly. Presbyopia is physiological insufficiency of accommodation due to age related changes in lens (decreased elasticity and increased hardness) and ciliary muscle power. [1]

AI is commonly present in people with convergence insufficiency. [2]

Categories

Accommodative insufficiency is further categorised into different categories.

Ill-sustained accommodation

Ill-sustained accommodation is a type of accommodative insufficiency in which, range of accommodation will be normal, but after excessive near work accommodative power will decrease. [3]

Paralysis of accommodation

In paralysis of accommodation, amplitude of accommodation is either markedly reduced or completely absent (cycloplegia). [4] It may occur due to ciliary muscle paralysis or oculomotor nerve paralysis. [1] Parasypatholytic drugs like atropine will also cause paralysis of accommodation. [3]

Unequal accommodation

If there is amplitude of accommodation between the eyes differ 0.5 dioptre or more, it is considered as unequal. [4] Organic diseases, head trauma or functional amblyopia may be responsible for unequal accommodation. [4]

Causes

Premature sclerosis of lens or ciliary muscle weaknesses due to systemic or local cases may cause accommodative insufficiency. [1] Systemic causes of ciliary muscle weakness include diabetes, pregnancy, stress, malnutrition etc. [1] Open angle glaucoma, Iridocyclitis etc. are known local causes. [1]

Signs and symptoms

Near vision will be blurred, and asthenopic symptoms like head ache and eye strain may occur while reading. [1] Reduction of amplitude of accommodation by 2 dioptre or more is one of the important sign. [4]

Treatment

Underlying systemic or local causes should be treated. Weak convex lenses may be prescribed for near vision until accommodation improves to normal level. [1] Accommodation exercises may be advised to improve accommodative power.

Related Research Articles

A dioptre or diopter is a unit of measurement with dimension of reciprocal length, equivalent to one reciprocal metre, 1 dioptre = 1 m−1. It is normally used to express the optical power of a lens or curved mirror, which is a physical quantity equal to the reciprocal of the focal length, expressed in metres. For example, a 3-dioptre lens brings parallel rays of light to focus at 13 metre. A flat window has an optical power of zero dioptres, as it does not cause light to converge or diverge. Dioptres are also sometimes used for other reciprocals of distance, particularly radii of curvature and the vergence of optical beams.

Far-sightedness Eye condition in which light is focused behind instead of on the retina

Far-sightedness, also known as long-sightedness, hypermetropia, or hyperopia, is a condition of the eye where distant objects are seen clearly but near objects appear blurred. This blurred effect is due to incoming light being focused behind, instead of on, the retina wall due to insufficient accommodation by the lens. Minor hypermetropia in young patients is usually corrected by their accommodation, without any defects in vision. But, due to this accommodative effort for distant vision, people may complain of asthenopic symptoms during prolonged reading. Some hypermetropes can see clear at distance, but near vision may be blurred due to insufficient accommodation. For this reason, this defect is referred as far-sightedness. If the hypermetropia is high, there will be defective vision for both distance and near. People may also experience accommodative dysfunction, binocular dysfunction, amblyopia, and strabismus. Newborns are almost invariably hypermetropic, but it gradually decreases as the newborn gets older.

Cycloplegia is paralysis of the ciliary muscle of the eye, resulting in a loss of accommodation. Because of the paralysis of the ciliary muscle, the curvature of the lens can no longer be adjusted to focus on nearby objects. This results in similar problems as those caused by presbyopia, in which the lens has lost elasticity and can also no longer focus on close-by objects. Cycloplegia with accompanying mydriasis is usually due to topical application of muscarinic antagonists such as atropine and cyclopentolate.

Presbyopia Medical condition associated with aging of the eye

Presbyopia is physiological insufficiency of accommodation associated with the aging of the eye that results in progressively worsening ability to focus clearly on close objects. Also known as age-related farsightedness, it affects many adults over the age of 40. A common sign of presbyopia is difficulty reading small print which results in having to hold reading material farther away. Other symptoms associated can be headaches and eyestrain. Different people will have different degrees of problems. Other types of refractive errors may exist at the same time as presbyopia. This condition is similar to hypermetropia or far-sightedness which starts in childhood and exhibits similar symptoms of blur in the vision for close objects.

Refractive error Problem with focusing light accurately on the retina due to the shape of the eye

Refractive error, also known as refraction error, is a problem with focusing light accurately on the retina due to the shape of the eye and or cornea. The most common types of refractive error are near-sightedness, far-sightedness, astigmatism, and presbyopia. Near-sightedness results in far away objects being blurry, far-sightedness and presbyopia result in close objects being blurry, and astigmatism causes objects to appear stretched out or blurry. Other symptoms may include double vision, headaches, and eye strain.

Human eye Mammalian eye

The human eye is a sensory organ, part of the sensory nervous system, that reacts to visible light and allows us to use visual information for various purposes including seeing things, keeping our balance, and maintaining circadian rhythm.

Eye examination A series of tests assessing vision and pertaining to the eyes

An eye examination is a series of tests performed to assess vision and ability to focus on and discern objects. It also includes other tests and examinations pertaining to the eyes. Eye examinations are primarily performed by an optometrist, ophthalmologist, or an orthoptist. Health care professionals often recommend that all people should have periodic and thorough eye examinations as part of routine primary care, especially since many eye diseases are asymptomatic.

Accommodation reflex

The accommodation reflex is a reflex action of the eye, in response to focusing on a near object, then looking at a distant object, comprising coordinated changes in vergence, lens shape (accommodation) and pupil size. It is dependent on cranial nerve II, superior centers (interneuron) and cranial nerve III. The change in the shape of the lens is controlled by ciliary muscles inside the eye. Changes in contraction of the ciliary muscles alters the focal distance of the eye, causing nearer or farther images to come into focus on the retina; this process is known as accommodation. The reflex, controlled by the parasympathetic nervous system, involves three responses: pupil constriction, lens accommodation, and convergence.

Accommodation (eye) Focusing ability of eye

Accommodation is the process by which the vertebrate eye changes optical power to maintain a clear image or focus on an object as its distance varies. In this, distances vary for individuals from the far point—the maximum distance from the eye for which a clear image of an object can be seen, to the near point—the minimum distance for a clear image. Accommodation usually acts like a reflex, including part of the accommodation-vergence reflex, but it can also be consciously controlled. Mammals, birds and reptiles vary their eyes' optical power by changing the form of the elastic lens using the ciliary body. Fish and amphibians vary the power by changing the distance between a rigid lens and the retina with muscles.

Ciliary muscle Eye muscle which is used for focussing

The ciliary muscle is an intrinsic muscle of the eye formed as a ring of smooth muscle in the eye's middle layer, uvea. It controls accommodation for viewing objects at varying distances and regulates the flow of aqueous humor into Schlemm's canal. It also changes the shape of the lens within the eye but not the size of the pupil which is carried out by the sphincter pupillae muscle and dilator pupillae.

Vergence Simultaneous movement of eyes in binocular vision

A vergence is the simultaneous movement of both eyes in opposite directions to obtain or maintain single binocular vision.

The amplitude of accommodation is the maximum potential increase in optical power that an eye can achieve in adjusting its focus. It refers to a certain range of object distances for which the retinal image is as sharply focussed as possible.

Accommodative convergence is that portion of the range of inward rotation of both eyes that occurs in response to an increase in optical power for focusing by the crystalline lens. When the human eye engages the accommodation system to focus on a near object, signal is automatically sent to the extraocular muscles that are responsible for turning their eyes inward. This is helpful for maintaining single, clear, and comfortable vision during reading or similar near tasks. However, errors in this relationship can cause problems, such as hyperopic individuals having a tendency for crossed eyes because of the over exertion of their accommodation system.

Exophoria is a form of heterophoria in which there is a tendency of the eyes to deviate outward. During examination, when the eyes are dissociated, the visual axes will appear to diverge away from one another.

Pseudomyopia occurs when a spasm of the ciliary muscle prevents the eye from focusing in the distance, sometimes intermittently; this is different from myopia which is caused by the eye's shape or other basic anatomy. Pseudomyopia may be either organic, through stimulation of the parasympathetic nervous system, or functional in origin, through eye strain or fatigue of ocular systems. It is common in young adults who have active accommodation, and classically occurs after a change in visual requirements, such as students preparing for an exam, or a change in occupation.

A spasm of accommodation is a condition in which the ciliary muscle of the eye remains in a constant state of contraction. Normal accommodation allows the eye to "accommodate" for near-vision. However, in a state of perpetual contraction, the ciliary muscle cannot relax when viewing distant objects. This causes vision to blur when attempting to view objects from a distance. This may cause pseudomyopia or latent hyperopia.

Blurred vision Medical condition

Blurred vision is an ocular symptom where vision becomes less precise and there is added difficulty to resolve fine details.

Pupillary reflex refers to one of the reflexes associated with pupillary function.

Multifocal and accommodating intraocular lenses are artificial intraocular lenses (IOLs) that are designed to provide focus of both distance and near objects, in contrast to monofocal intraocular lenses which only have one focal point and correct distance vision. The issue of restoring accommodation following cataract surgery or through refractive lens exchange is becoming an increasingly important topic in ophthalmology.

Accommodative excess Medical condition

In ophthalmology, accommodative excess occurs when an individual uses more than normal accommodation for performing certain near work. Accommodative excess has traditionally been defined as accommodation that is persistently higher than expected for the patient's age. Modern definitions simply regard it as an inability to relax accommodation readily. Excessive accommodation is seen in association with excessive convergence also.

References

  1. 1 2 3 4 5 6 7 8 Khurana, AK (September 2008). "Asthenopia, anomalies of accommodation and convergence". Theory and practice of optics and refraction (2nd ed.). Elsevier. pp. 100–107. ISBN   978-81-312-1132-8.
  2. Synopsis of Clinical Ophthalmology (3 ed.). Elsevier. 2013. pp. 321–333.
  3. 1 2 Duke, Elder's (1969). "Anomalies of accommodation". The practice of refraction (8th ed.). London: Churchill. ISBN   0-7000-1410-1.
  4. 1 2 3 4 William J., Benjamin (2006). "Accommodation, the Pupil, and Presbyopia". Borish's clinical refraction (2nd ed.). St. Louis Mo.: Butterworth Heinemann/Elsevier. p. 112. ISBN   978-0-7506-7524-6.