OPT312

THE ACCOMMODATIVE PROCESS

Accommodation refers to the process whereby changes in the dioptric power of the
crystalline lens occur so that an in-focus retinal image of an object of regard is
obtained and maintained at the high-resolution fovea.
Accurate accommodation is essential in accomplishing clear, undistorted vision when
viewing objects at different distances. To view something at a close distance, a person
must accommodate. In order to return to viewing a distant object, accommodation
must be relaxed. Because the lens is flexible and elastic, it can change its curved
shape to focus on objects and people that are either nearby or at a distance. The ciliary
muscles, which are part of the ciliary body, are attached to the lens and contract or
release to change the lens shape and curvature.

COMPONENTS OF ACCOMMODATION
i)Reflex Accommodation
Reflex accommodation is the automatic adjustment of refractive state to obtain and
maintain a sharply defined and focused retinal image in response to a blur input.
Reflex accommodation is probably the largest and most important component of
accommodation under both monocular and binocular viewing conditions.
ii)Vergence Accommodation
Vergence accommodation is the accommodation induced by the innate neurological
linking and action of disparity (fusional) vergence. Vergence accommodation is
probably the second major component of accommodation.
iii)Proximal Accommodation
Proximal accommodation is the accommodation due to the influence or knowledge of
apparent (or perceived) nearness of an object. It is stimulated by targets located within
3m of the individual, hence its name. It represents a tertiary component of
accommodation.
iv)Tonic Accommodation
Tonic accommodation is revealed in the absence of blur, disparity, and proximal
inputs. There is no stimulus per se for tonic accommodation, as there is for the other
three components. Rather, it presumably reflects baseline neural innervation from the
midbrain. Tonic accommodation reduces with age because biomechanical limits of the
crystalline lens.
MEASUREMENT OF ACCOMMODATION
Amplitude of accommodation
Accommodation can be stimulated either by moving a test object closer to the eyes or
by placing minus lenses in front of the eyes. Either of these procedures can be used to
determine the amplitude of accommodation.
a) Push up technique
This procedure seeks to locate the near point of accommodation that is the closest
distance at which the target still appears in focus. The patient observes a finely
detailed test object (eg a reduced snellen chart with 20/20 row of letters) at 40 cm
which is advanced toward the eye until the detail just begins to blur and remains
blurred that is the first slight and sustained blur. The patient should always be
encouraged to try and clear the target when they first report blur, since the aim is to
achieve the maximum accommodative response. The reciprocal of the distance from
the target at this position of first slight sustained blur to the spectacle plane (in metres)
represents the amplitude of accommodation (in dioptres). Most patients under the age
40 will have no difficulty reading the 20/20 letters at 40cm. If the patient is a
beginning presbyope and reports the letters are blurred at 40cm, the letters will
sometimes clear up if the card is moved farther away. The examiner then brings the
card towards the patient's eyes until a first sustained blur is recorded. If moving the
card to a distance farther than 40 cm does not clear the letters, the card should be
moved back to 40cm and plus lenses should be added binocularly until the 20/20
letters are clear. The card is then moved towards the patient’s eyes until the first
sustained blur is recorded. The power of the plus lenses (above the best visual acuity
subjective finding) must then be subtracted from the amplitude indicated on the
reading rod to determine the patient actual amplitude of accommodation. For example
, if the patient reports first sustained blur at a distance of 33cm (equivalent to 3.00D)
while wearing a plus +2.00D in addition to his or her best visual acuity subjective
correction, the amplitude of accommodation is 3.00D- 2.00D, or 1.00D.The push up
amplitude is typically measured both monocularly and binocularly. The latter reflects
the maximum accommodation possible when converging accurately on a near target.

b)Minus lens technique

In this procedure, the target remains at a fixed position (typically 40cm,
corresponding to a stimulus of 2.50D) and minus lenses are introduced to move the
location of the optical image of this target. Lenses are typically introduced in 0.25D
steps until the patient reports the first noticeable sustained blur that cannot be cleared
by further conscious effort. The total amplitude is equal to the amount of minus lens
power introduced plus the 2.50D required to focus initially on the target. For example,
if addition of -4.00D to the subjective correction blurs the letters, the amplitude of
accommodation is 4.00D +2.50D or, 6.50D. If it is necessary to add plus lenses to the
subjective lenses to clear up the letters at 40cm, the amount of plus lens power
necessary to clear up the letters is subtracted from 2.50D to determine the amplitude
of accommodation.
This should be carried out for each eye individually. However it is not performed
binocularly as this would be testing positive relative accommodation (PRA).

Differences between minus lens and push up findings

During testing with minus lens technique, the target remains fixed and accordingly the
psychological proximal stimulus to accommodation remains relatively constant.
However the target minification resulting from the minus lenses will make the target
smaller. This change in image size will make the patient more sensitive to identify the
first noticeable blur and therefore they are likely to report the test end point earlier.
Both the size effect and reduced proximal stimulus will account for the lower
amplitude of accommodation generally observed with the minus lens procedure when
compared with the push up technique.

Average amplitude of accommodation, in diopters, for a patient of a given age was

estimated by Hofstetter in 1950 to be 18.5 - (0.30 ×patient age in years) with the
minimum amplitude of accommodation as 15 - (0.25 × age in years), and the
maximum as 25 - (0.40 ×age in years).

Assessment of the accommodative response

The assessment of the accommodative response to a range of stimuli is an important
part of the clinical optometric examination. Measurement of the amplitude only
provides information with regard to the maximum potential accommodative response
rather than the actual response to a submaximal stimulus. Patient's symptoms
frequently relate to near- visual activities and inappropriate responses whether under
or over accommodative relative to the plane of the object of regard are a frequent
cause of asthenopia.

Accommodative response is a measure of the actual accommodation that is present

If your accommodative system likes to “hang out”:
Right on the target (accommodative response= stimulus)
In front of target (accommodative response > stimulus)
Accommodative LEAD
Behind the target (accommodative response < stimulus)
Accommodative LAG

Accommodative stimulus is defined by the near target stimulus

Because of depth of field, the accommodative response is generally less than the
stimulus. In other words pupillary constriction increase the depth of field by reducing
the aperture of the eye, and thus reduce the amount of accommodation needed to
bring the image in focus on the retina.
A number of techniques are available to the clinician for assessment of the near
accommodative response and these will be discussed below

a)Dynamic cross- cylinder

In this test, subjects view a pattern of intersecting horizontal and vertical lines through
a cross- cylinder (typically +/- 0.50D) to create mixed astigmatism, with the
horizontal and vertical lines theoretically equidistant in front of and behind the retina.
The cross cylinder usually introduced before the eye with the negative cylinder axis
vertical. This will produce a myopic horizontal focal line and a hyperopic vertical
focal line. The patient is directed to view the rectilinear target through the cross
cylinder and asked to indicate whether the vertical or horizontal lines appear clearer.
If the patient is accommodating exactly in the plane of the target, then after
introduction of the cross cylinder, the circle of least confusion will lie on the retina
and the patient will report that both sets of lines (horizontal and vertical are equally
clear). However, if the patient was initially under accommodating for the target that is
a lag of accommodation was present, then following introduction of the cross cylinder
the patient should report that the horizontal lines are clearer. Alternatively, if the
patient was initially over accommodating for the target (a lead of accommodation)
then following the introduction of the cross- cylinder the patient should report that the
vertical lines are clearer. In the case of a lag of accommodation (horizontal lines
clearer), positive spherical lenses are introduced until both sets of lines appear equally
clear, for a lead of accommodation (vertical lines clearer), minus spheres are
introduced. The lens power required to make the two sets appear equally clear provide
a measure of the accommodative error. For example, if the patient is viewing a target
at 40 (accommodative stimulus=2.50D) and requires a +0.50 D lens to equalize the
two set of lines, then a 0.50D lag of accommodation is present and the initial
accommodative response was 2.00D.This test is usually performed under dim
illumination in order to minimize the depth of focus of the eye by achieving the
largest pupillary diameter. However sufficient illumination must be provided to allow
the patient to see the target clearly. The procedure may be carried out under both
monocular and binocular fused conditions. The former will primarily assess the blur
driven accommodative response, although there may be significant contribution from
proximally induced accommodation. Under binocular fused conditions (the most
naturalistic viewing environment), blur-driven, proximal and convergent
accommodation will stimulated.

b)Dynamic Retinoscopy
The method by which you determine the patient's near point (location in space that a
patient's eyes are focused when fixating on a near target).It is the patient's
accommodative response to the target. It defines the patient accommodative posture.
Most patients under accommodate for the target but some will over accommodate. It
is primarily used to confirm suspected cases of accommodative dysfunction. Also
used to determine whether a patient is over or under corrected. It is used in any eye
exam in which the patient has a near compliant or if you suspect accommodative
problem such as latent hyperopia or accommodative spasm, all pediatric cases. It also
reveals the stability or the degree of fluctuation. If results seem to fluctuate you may
be dealing with accommodative spasm.
i) Nott technique
In this procedure the patient should wear his/her optimal distance refractive
correction. A reading chart is attached to a near rod at the patient's reading distance
(40cm) .The card should contain letters(pictures for young children) in a position that
permits you to perform retinoscopy close the patient's visual axis. A near chart with a
central aperture works well. The letter should be one line bigger than the binocular
near visual acuity (typically N6, 20/30). The room lights are turned off but
additionally lighting is used to illuminate the near chart. The patient is then told to
focus on the letters with both eyes. Retinoscopy is then performed on the right eye
from 50cm (typically 10cm behind the near point card) along the horizontal meridian
(the streak vertical). Retinoscopy should be performed as quickly has possible. If
neutrality is not observed at 50cm, change the working distance (further away if 'with'
is seen at 50cm, closer if against is seen) until the neutral point is seen. Take note of
the distance of the retinoscope on the reading rod when the neutral point is obtained.
The procedure should be reported on the left eye. The dioptric difference between the
near chart and the position of the retinoscope when neutrality was observed should be
recorded. If the neutrality point is behind the near chart position, then there is
accommodative lag. If the neutrality point is in front of the near chart position then
there is accommodative lead. For example, if the near chart is at 40 cm and neutrality
is observed at 57cm, then the accommodative lag is + 2.50 - 1.75 = 0.75.
ii) Monocular estimation method (MEM)
A card is attached to the front of the retinoscope. The card contains letters or pictures
around a central aperture, through which retinoscopy is performed. The room lights
are turned off and additional lighting are used to illuminate the chart. The patient
should focus on the letters with both eyes. To maintain appropriate fixation and
accommodation you may need to ask the children to read some of the letters out loud
or name details in the picture. Perform retinoscopy on the right eye from the patient's
working distance (typically 40cm) along the horizontal meridian (with the streak
vertical). Retinoscopy should be performed in the usual manner but the lenses should
only be placed in front of the patient's eyes for the least amount of time possible (0.5
seconds or less). This is to ensure that the accommodative system does not change in
response to the added lenses. Positive lenses indicate accommodative lag and negative
lenses indicate accommodative lead.

Positive and negative relative accommodation

Positive relative accommodation (PRA) is a measure of the maximum ability to
stimulate accommodation while maintaining clear, single binocular vision. Negative
relative accommodation (NRA) is a measure of the maximum ability to relax
accommodation while maintaining clear, single binocular. Measurements of relative
accommodation do not test the accommodation system in isolation but rather examine
the interaction between accommodation and convergence. These parameters are
measured clinically by introducing increasing minus(for PRA) or plus ( for NRA)
while the patient views a near target typically located at a viewing distance of 40cm
(2.50D). The end point is taken when the patient reports the first slight, sustained blur.
The amount of additional spherical power which has been added to distance
correction represents the magnitude of accommodation. As for NRA test, most
patients have sufficient range of positive fusional vergence to enable the relaxation of
most if not all of the accommodation in play, with the result of the expected finding is
about +2.00 to +2.50D. The limiting factor for the expected value of the PRA test is
the amplitude of accommodation. If a patient has an amplitude of accommodation of
only 1.50D, we would expect the minus lens to blur to be no greater than than -1.50D.

Accommodative Facility
The test examines the ability to make rapid step changes in accommodation. The test
is most frequently performed using flipper lenses under monocular or binocular
conditions. The patient views a line of fine prints at a distance of 40cm through their
distance refractive correction. Most commonly +/-2.00D lenses are introduced
alternatively before the viewing eye and the patient is required to indicate when the
target becomes absolutely clear. At this point the alternative lens is flipped in front of
the eye as rapidly as possible. The result is quantified in terms of the number of cycles
(that is clearing both the plus and minus lenses) completed in 60 seconds. Accordingly
this test examines the patient's ability to change PRA and NRA rapidly. Care must be
taken to note whether any asymmetry exist between the time taken to clear the plus
and minus lenses. Adequate performance with minus lenses, inadequate with plus-
lenses, such a response is indicative of overaccommodation, accommodative spasm or
accommodative excess. Adequate performance with plus lenses, inadequate
performance with minus lenses- the patient has difficulty stimulating accommodation
and will often have a reduced amplitude of accommodation. This is in response of an
individual presenting with an accommodative insufficiency or ill sustained
accommodation. Several investigators have suggested clinical pass criteria of
11cycles per minute (cpm) for monocular testing and 8 cpm for binocular assessment.
It was also noted that a difference of more than 2cpm between the two eyes (during
monocular testing) should be regarded as a possible indicator of accommodative
difficulties when accompanied by near visual symptoms.

ANOMALIES OF ACCOMMODATION
1) Accommodative insufficiency
Accommodative insufficiency is an anomaly that is characterized by an inability to
focus or sustain focus at near, diagnosed clinically by insufficient amplitude of
accommodation (AA) that is below the lower limit expected for the person’s age
based on age-expected norms. The direct clinical signs for diagnosing accommodative
insufficiency include low amplitude of accommodation, high monocular estimation
method retinoscopic findings and difficulty in clearing -2 D lenses with monocular
accommodative facility.

Its main symptom is general asthenopia related to nearwork.

Subcategories are as follows:
a.Ill-sustained accommodation
Accommodation, especially its amplitude, is initially sustained only with considerable
effort. Overtime, it cannot be maintained. This maybe the first stage of
accommodative insufficiency. It has also been referred to as accommodative fatigue.

b.Paralysis (or paresis) of accommodation

The accommodative amplitude is either markedly reduced (paresis) or totally absent
(paralysis), once compensation for the depth of focus is considered. It is frequently
the result of an organic condition or head trauma.

c.Unequal accommodation-
There is a persistent interocular difference in monocular accommodative amplitude of
at least 0.50D. This could result from organic disease, head trauma, or functional
amblyopia.

2) Accommodative excess
Accommodative excess describes an anomaly where an individual has difficulty in
relaxing accommodation. In accommodative excess, the individual has a greater
accommodative response than the stimulus (or demand) requires, with a tendency to
bring the primary focal point abnormally close to the eye. Accommodative excess has
been used interchangeably with ciliary spasm, hyper-accommodation, accommodative
spasm, pseudo-myopia and spasms of the near reflex. The direct diagnostic signs for
Accommodative excess include difficulty clearing +2D with monocular
accommodative facility and a lead on monocular estimation method retinoscopy,
3) Accommodative infacility
Accommodative infacility (AIF), also referred to as inertia or tonus, is an
accommodative anomaly where an individual has difficulty in shifting focus quickly
to various near and far distances. The direct diagnostic signs in AIF include difficulty
clearing the -2 D or +2 D lenses with monocular accommodative facility and reduced
relative accommodation findings.
OVERVIEW OF PRESBYOPIA
Presbyopia ("aged eye") refers to the slow, normal, naturally occurring, age-related,
irreversible reduction in maximal accommodative amplitude (i.e., recession of the
near point) sufficient to cause symptoms of blur and ocular discomfort or asthenopia
at the customary near working distance. Essentially, the near point approaches and
then becomes coincident with the farpoint. Presbyopia is generally first reported
clinically between 40 and 45 years of age, with its peak onset between ages 42 and 44
years, although its onset may occur anytime from 38 to 48 years of age, depending on
a variety of factors. Clinically, when the near-work distance dioptrically equals half of
an individual's residual accommodative amplitude, which occurs, on average, at 40
years of age, the gradual onset of symptoms will become manifest. These symptoms
are as follows:
1.Vision at the customary near-work distance is blurred or can be sustained only with
excessive accommodative effort and some ocular discomfort.
2.Drowsiness after a short period of reading or near work.
3.Reading material must be held farther away(e.g., closer to the receding near point
and surrounding depth of field)to be seen more clearly. Thus, on average, smaller
individuals with proportionally shorter arms develop presbyopic symptoms at an
earlier age than do age-matched but proportionally taller persons. Some patients may
actually complain, "My arms aren't long enough to see up close any more.
4.Occasionally, especially in very early or incipient presbyopia, asthenopia related to
attempts at excessive accommodative effort is reported. It may even lead to an
accommodative spasm and pseudo myopia.
5.Transient diplopia and variable esophoria maybe experienced as a result of the
increased accommodative response/effort.
Presbyopia may be corrected by using supplementary lenses(in addition to any
correction for distance refractive error) to allow diverging rays from a near object of
regard to be focused upon the retina. Several standard clinical techniques are available
for determining the appropriate near vision addition namely
- dynamic cross- cylinder
- plus build up
- add based on patient's age
- proportion of amplitude
- dynamic retinoscopy
- NRA/ PRA balance

Dynamic cross cylinder

This test will provide an indication of the accommodative error. For a presbyopic
patient, the horizontal lines will be clearer .Plus lenses are added until equal clarity is
obtained for both lines. The binocular fused measurement is generally used as the
tentative near addition.
Plus build up
Plus spherical power is added to the distance refraction (in 0.25D steps) until the
patient is unable to achieve their optimal near visual acuity at the appropriate working
distance. The minimum plus power that gives clear vision at the required distances
places the proximal end of the depth of field coincident with the object of regard.
Thus additional plus power (typically an additional +0.25D) will be needed to place
the preferred reading position in the centre of the range of clear vision. The test is
generally performed binocularly.
Add based on the patient's age
The tentative add may simply be based on the patient's age. However, the required
addition may need to be adjusted appropriately due to variation in the required
working distance or if the amplitude of accommodation differs significantly from the
average for the patient's age.
Proportion of amplitude
A rule of thumb is that the patient should be able to sustain one- half of the
accommodative amplitude. Accordingly, the near add corresponds to the difference
between the required working distance (in dioptres) and one half of those amplitude.
For example, if the patient has an amplitude of accommodation of 3D and requires a
working distance of 40 cm, then the required add is equal to (2.50- 1.50) =+1.00D.
Dynamic retinoscopy
Dynamic retinoscopy can be used to determine to determine the accommodative
response for a given stimulus. Plus lenses are introduced over the distance
prescription while the patient views a near target at their preferred working distance
until an appropriate response is obtained. It is usual to leave the patient with a small
(0.25-0.50D) lag of accommodation to take advantage of the depth of field of the eye.
This allows the practitioner to prescribe the lowest possible add, thereby giving the
patient a wide range of clear vision.
NRA/PRA balance
Having determined a tentative add using one of the techniques described above,
negative relative accommodation and positive relative accommodation are measured
through this preliminary add. This add is then modified so that equal values of PRA
and NRA are obtained. The adjusted figure is the final tentative addition. For
example, if the initial tentative near addition was+100.D and sustained blur points
were found with a+2.00D and a +0.50D add, the NRA would be +1.00 (200-100) and
the PRA would -0.50 (0.50-100). A final tentative near addition of +1.25D would
equalise the NRA and PRA. The change suggested by the NRA is their algebraic sum
divided by two. In this example, that would be 0.50/2= +0.25D.

Range of accommodation
It is the last test performed after the plus lens to blur and the minus lens to blur tests.
The patient (using both eyes) is instructed to watch the 20/20 row of letters on the
near point card at a distance of 40cm and is asked to report when the 20/20 letters blur
as the card is moved toward the face along the reading rod. The examiner makes a
note of where the blur occurred, in centimeters and then moves the card back to the 40
cm position. The patient is then asked to watch the 20/30 letters and to report when
the letters blur as the card is moved away on the reading rod. Again the examiner
makes a mental note of the position of the card when the blur was reported and
subsequently measures the range (e.g 25-55cm). The patient is then informed that the
lenses will give him or her clear vision at a distance of 25-55cm. This gives the
patient the opportunity to consider whether or not this range of accommodation
encompasses his or her usual working or reading distance.