Definition of accommodation

 Unique mechanism
 Focus diverging rays from a near object to
make it fall on the retina
 Clear focus
 Increase in the power of the physiological
crystalline lens

Ms.B.M.S. Deepa
Department of Optometry
 Accommodation

miosis
convergence

Ms.B.M.S. Deepa
Department of Optometry
 Far point
• The farthest object point for which an image
point will be formed on the retina of an
emmetropic or uncorrected ammetropic eye

Ms.B.M.S. Deepa
Department of Optometry
 Near point
• The nearest object for which an image point
will be formed on the retina of an
emmetropic or uncorrected ammetropic eye

Ms.B.M.S. Deepa
Department of Optometry
Amplitude of accommodation

– The difference between the dioptric power

required to focus at a near point (P) and to focus
at a far point (R)
A=P-R

Ms.B.M.S. Deepa
Department of Optometry
 Range of accommodation

– The linear distance between the far point of

accommodation & the near point of
accommodation

Ms.B.M.S. Deepa
Department of Optometry
Mechanism of accommodation

– ciliary muscle contracts, acting as a sphincter

muscle,
– releases the tension on the zonular fibres,
– allowing the elastic lens capsule to increase its
curvature
– allows the lens to become thicker & more nearly
spherical

Ms.B.M.S. Deepa
Department of Optometry
 Lag of accommodation

– Accommodation beyond the plane of regard

– Expressed in diopters

Ms.B.M.S. Deepa
Department of Optometry
 Depth of focus

– The extent of which the optical image of the eye

may be located in front of / behind the retina &
still appears to be acceptably clear with no
change in accommodation
– Influenced by the diameter of the pupil

Ms.B.M.S. Deepa
Department of Optometry
 AC/A
• To determine the change in accommodation
convergence that occur when the patient
accommodates or relaxes accommodation bt
a given amount.
• It is used to determine the appropriate
management sequence for a condition.

Ms.B.M.S. Deepa
Department of Optometry
• Eg: a patient has esophoria at near associated
with high AC/A ratio – respond well to + lens.
• Same degree of esophoria with normal or
low AC/A ratio – recommended Tx which
includes prism correction or vn therapy or
both.
• Rule of thumb : high AC/A ratio will result in
more eso or less exo at near, and low AC/A
ratio leads to less eso or more exo at near.
Ms.B.M.S. Deepa
Department of Optometry
 Calculated method AC/A ratio

– Full optical Rx – dist & near, Ipd in cms

– NFD- near target distance in meters
– Hn- near phoria ( eso is plus & exo is minus )
– Hf- far phoria ( eso is plus & exo is minus )

– Formula:
• AC/A = IPD (cm) + NFD (m) (Hn-Hf)

Ms.B.M.S. Deepa
Department of Optometry
• Eg: IPD :60mm
• 2 exophoria @distance
• 10 exophoria @ near(40cm)

• AC/A=?

Ms.B.M.S. Deepa
Department of Optometry
• AC/A = 6 + 0.4 (- 10 + 2 )
• = 6 + 0.4 ( -8 )
• = 6 + ( -3.2 )
• =2.8

• Sign of esophoria & exophoria have to be

remember.
Ms.B.M.S. Deepa
Department of Optometry
 Gradient method
• It is used to determined by measuring phoria
second time using -1.00 or -2.00 lenses. The
change in phoria with additional minus lens,
is the AC/A ratio.
• There is a significant difference between
2methods determining the AC/A ratio

Ms.B.M.S. Deepa
Department of Optometry
Eg:1
• Divergence excess and convergence excess
patients both have high calculated AC/A ratio
– but many of the pt approx. have normal
gradient AC/A ratio.
• Eg:2
• The same - one patient has convergence
insufficient. The clculated AC/A ratio will be
low, but the gradient AC/A may be normal.

Ms.B.M.S. Deepa
Department of Optometry
• The reason for the difference is the effect of
proximal convergence and the lag of
accommodation.
• The calculated AC/A ratio is usually larger than
the gradient because of the effect of proximal
convergence which affect the near phoria
measurement.so the gradient method of near
phoria tested twice, proximal vergence held
constant & theortically does not alter the
results. Ms.B.M.S. Deepa
Department of Optometry
 Gradient method
– Based on the fact that minus lenses placed in front of the eyes
stimulate accommodation & plus lenses relax accommodation
– Formula: AC /A = ΔL – ΔO
D
• ΔL – deviation with additional lenses,
• ΔO –original deviation without additional lenses
• D – dioptric power of additional lenses

Ms.B.M.S. Deepa
Department of Optometry
Eg:1 If ΔO=2Δ, ΔL=10Δ, D= +3.00, then

• AC/A = 2 – (-10) = 4Δ/D

3
Eg:2
Near phoria =2 esophoria , subjective finding
with -1.00 is 7 esophoria
AC/A = 7-2/1
=5:1
Ms.B.M.S. Deepa
Department of Optometry
 CA/C ratio
• To determine the change in accommodation that occur
when the patient converges or relaxes convergence by
given amount.
• Less commonly measured in practice
• It is also important to determine the final diagnosis.

• Eg: divergence excess and other cases of high exophoria at

distance may benefit from the use of added minus lens.
Analysis to the CA/C rato help to identify this.

Ms.B.M.S. Deepa
Department of Optometry
 RELATIONSHIP BETWEEN CONVERGENCE
ACCOMMODATION AND AC/A
 The disparity vergence and accommodative vergence change in opposite
directions when the stimulus to accommodation is held constant. When
disparity vergence increases, accommodative vergence decreases.
 Disparity vergence and the dissociated heterophoria are influenced by
the response AC/A and the response CA/C. Assuming that proximal
vergence is held constant in the measurements, consider two situations:
 1. When CA/C and AC/A are weakly related, the amount of disparity
vergence required will be much larger than predicted from measures of
the dissociated heterophoria.
 2. When the AC/A and CA/C are strongly related, the disparity vergence
used be in a direction opposite to the dissociated heterophoria.

Ms.B.M.S. Deepa
Department of Optometry
 Case discussion 1
• When a 35/F came with the complain of
blurring of vn for both Distance and Near*1yr
• She has the past ocular history of using
glasses(PAL’s)*2yrs and she told that 1st she
had trouble with only near vn for that she
used +1.00 later the vn was get worsed for
both D&N.

Ms.B.M.S. Deepa
Department of Optometry
 Case discussion 2
A 6 yrs old child came to clinic with c/o
headache and eye strain her OU: Distance vn is
- 6/6 OU: near vn is n6
But the AR power show OD: +2.75/-0.75*85
OS: +2.50/-0.50*90.?

Ms.B.M.S. Deepa
Department of Optometry
 MOST AWAITED SLIDE
THANK YOU..............

Ms.B.M.S. Deepa
Department of Optometry