5a. Case Analysis Overview and Diagnosis Management of Accommodative disorders

What is the general approach to integrative case analysis?

• Compare findings to expected values.

• Identify abnormal findings.

• Look for relationships among abnormal findings.

• Determine the diagnosis that best explains the pattern.

What are the three major steps of OEP analytical case analysis?

• Checking = compare findings to expected values

• Chaining = group related abnormal findings

• Case typing = determine diagnosis category (e.g., accommodative vs vergence disorder)

What is the major advantage and major limitation of graphical analysis?

• Advantage: helps visualize relationships and identify findings that don't fit

• Limitation: misses important disorders such as accommodative excess, accommodative infacility, accommodative fatigue, and oculomotor dysfunction

What is the main principle behind diagnosis of accommodative and binocular vision disorders?

Diagnosis is based on recognizing patterns of findings and understanding how different clinical tests relate to one another rather than relying on a single abnormal result

Which tests provide information about accommodative ability?

• Accommodative amplitude

• Monocular accommodative facility

• Binocular accommodative facility

• NRA/PRA

• Accommodative response (lag/lead)

Which findings provide information about positive fusional vergence (PFV)?

• BO fusion ranges

• NPC

• Vergence facility with BO

• BAF through plus lenses

• NRA

• Binocular accommodative response

Which findings provide information about negative fusional vergence (NFV)?

• BI fusion ranges

• Vergence facility with BI

• BAF through minus lenses

• PRA

• Binocular accommodative response

What is accommodative insufficiency?

An inability to generate adequate accommodation for near tasks, characterized by reduced accommodative ability and high accommodative lag

What symptoms are most characteristic of accommodative insufficiency?

• Near blur

• Headaches

• Eyestrain

• Reading difficulty

• Fatigue with near work

• Poor concentration

• Avoidance of reading

• Difficulty changing focus between distances

What are the hallmark clinical findings of accommodative insufficiency?

• Reduced accommodative amplitude (>2 D below age expected)

• Reduced monocular facility with minus lenses

• Reduced binocular facility with minus lenses

• High accommodative lag

• Low PRA

What binocular vision disorders are commonly associated with accommodative insufficiency?

• Near esophoria

• Convergence insufficiency

• Pseudoconvergence insufficiency (near exophoria secondary to AI)

How is accommodative insufficiency managed?

• Correct refractive error

• Vision therapy

• Plus lenses for near work

What treatment has the strongest evidence for accommodative insufficiency?

Vision therapy.

Studies cited in class reported:

• 87.5-96% success

• Improved accommodative amplitude

• Improved accommodative facility

• Measurable physiologic changes in accommodative function

How do plus lenses compare with vision therapy for accommodative insufficiency?

Both can improve symptoms, but vision therapy generally produces greater improvement in overall accommodative function. A +1.00 D add was favored over +2.00 D in studies discussed in class

What is accommodative excess?

Excessive or sustained accommodation caused by difficulty relaxing accommodation. Also called accommodative spasm or pseudomyopia

What symptoms suggest accommodative excess?

• Intermittent distance blur

• Worse after prolonged near work

• Headaches

• Asthenopia

• Difficulty relaxing focus

• Frequent prescription changes

• Diplopia

• Ocular discomfort

What are the hallmark signs of accommodative excess?

• Difficulty clearing plus lenses

• Reduced MAF and BAF with plus

• Low NRA

• Plano or lead accommodative response

• Variable retinoscopy/refraction findings

What binocular vision finding is commonly associated with accommodative excess?

Near esophoria because excessive accommodation can drive excessive accommodative convergence.

How is accommodative excess managed?

• Correct refractive error

• Cycloplegic refraction when indicated

• Vision therapy

• Frequent visual breaks

• Severe cases may require short-term cycloplegia with near plus lenses

What is accommodative infacility?

Difficulty changing accommodative focus rapidly and efficiently between different viewing demands

What symptoms suggest accommodative infacility?

• Intermittent blur

• Difficulty refocusing from distance to near and vice versa

• Headaches

• Eyestrain

• Diplopia

• Reading problems

• Poor concentration during sustained reading

What are the hallmark findings of accommodative infacility?

• Reduced monocular accommodative facility

• Reduced binocular accommodative facility

• Difficulty with both plus and minus lenses

• Low NRA and PRA

• Normal accommodative amplitude

• Typically normal accommodative response

How is accommodative infacility managed?

• Correct refractive error

• Vision therapy (76-96% success reported)

• Follow-up after approximately 12-16 sessions

What is accommodative fatigue?

Also called ill-sustained accommodation. Accommodative performance is initially normal but deteriorates with prolonged near work or repeated testing

What findings support a diagnosis of accommodative fatigue?

• Initially normal amplitude that decreases with repeated testing

• Reduced accommodative facility with minus lenses

• Low PRA

• Increasing accommodative lag over time

• Symptoms worsen with sustained near work

How is accommodative fatigue managed?

• Vision therapy

• Plus lenses for near work when appropriate

Compare accommodative insufficiency, accommodative excess, and accommodative infacility.

Disorder	Amplitude	Facility Problem	Accommodative Response
AI	↓	Minus difficult	High lag
AE	Usually normal	Plus difficult	Lead / plano
AIF	Usually normal	Both plus & minus difficult	Usually normal

A patient has low amplitude, high lag, low PRA, and difficulty with minus lenses. What is the diagnosis?

Accommodative insufficiency

A patient has normal amplitude, lead of accommodation, low NRA, and difficulty with plus lenses. What is the diagnosis?

Accommodative excess

A patient has normal amplitude but difficulty with both plus and minus lenses on facility testing. What is the diagnosis?

Accommodative infacility