Binocular Vision and Accommodation: Assessment and Treatment

CLINICAL CASE

Questions:

1. Identify the case.

My initial diagnosis is “Accommodative excess “as there are some signs related to
it such as:
 fails + Flipper mono and difficulty in bino flippers.
 Esophoria at near and at distance.
 the normal AA.
 Fluctuating of VA.
 fatigue at work as well as itchy eyes.
 High PRA

2. Which test would you do to confirm the case?

 MEM : its lowered or even negative value.
 Vergence Amplitude test show: BI blur at near may be low
 Cyclo Refraction.
 In the subjective, a vertical negative cylinder may appear due to tensional
causes.
 Slit lamp exams, to rule out dryness and allergy from SCL.

3. Is there any test that does not fit with the clinical signs of this case?
 YES, the NRA usually will be reduced in cases of AE.

 Also the Retinoscopy usually has a higher value than subjective. But this may
happen because the pt is overcorrected ! the cyclo refraction will give us the
accurate refractive status regardless the excess of accommodation.

 Some myosis can be observed in its performance, and also a fluctuating reflex
or difficult identification
 Binocular Vision and Accommodation: Assessment and Treatment

4. Which general recommendations would you indicate to this patient?

The common treatment options that may be recommended:

Reducing Near Work: Accommodative excess is often caused by excessive near

work activities as he is a bank teller he deals with numbers and near work for
extended periods. Reducing near work activities and taking frequent breaks can
alleviate symptoms and prevent the condition from worsening. The rule of 20/20/20
will be helpful.

Corrective Lenses: Prescription glasses or contact lenses of accurate refraction

(least minus more plus) can help to reduce the demand on the eyes to focus. Bifocals
or progressive lenses may also be prescribed to help the patient see clearly at
different distances.

Vision Therapy: to improve the patient's visual function and reduce symptoms. This
may include exercises to improve eye tracking, convergence, and accommodative
function. Such as hart chart and flippers.

Prism Lenses: Base IN Prism can be prescribed to help correct any underlying
binocular vision issues, such as excessive convergence or esophoria.

Lifestyle Changes: Practicing good visual hygiene habits such as taking frequent
breaks, adjusting lighting, and maintaining proper posture can help reduce symptoms
and prevent the condition from worsening.

Medications: In rare cases, medications such as atropine or cyclopentolate may be

prescribed to temporarily paralyze the ciliary muscles and reduce accommodative
spasm.
 Binocular Vision and Accommodation: Assessment and Treatment

5. Prepare a brief report for the patient

Dear
Thank you for visiting our clinic. Based on your symptoms and exam findings, it
appears that you may have accommodative excess, a condition where the eyes over-
focus on near objects, leading to symptoms such as eye strain, headaches, and
blurred vision.
The clinical exams showed a fluctuated Visual acuity which is related to your excess
near work.
Treatment for accommodative excess depends on the underlying cause and severity
of the condition. Treatment options may include reducing near work activities,
prescribing corrective lenses such as reading glasses or bifocals, vision therapy,
prism lenses, lifestyle changes, and in rare cases, medications.
We recommend that you take regular breaks from near work, adjust your lighting,
and maintain good posture when using digital devices. It's also important to follow
any prescribed treatment plan to alleviate symptoms and prevent the condition from
worsening.
If you have any further questions or concerns, please don't hesitate to contact us. We
are here to help you maintain optimal eye health and visual function.

Best regards,
[Atheer Alharby, Optometry Doctor]