FirstRanker Logo

FirstRanker.com - FirstRanker's Choice is a hub of Question Papers & Study Materials for B-Tech, B.E, M-Tech, MCA, M.Sc, MBBS, BDS, MBA, B.Sc, Degree, B.Sc Nursing, B-Pharmacy, D-Pharmacy, MD, Medical, Dental, Engineering students. All services of FirstRanker.com are FREE

📱

Get the MBBS Question Bank Android App

Access previous years' papers, solved question papers, notes, and more on the go!

Install From Play Store

Download MBBS Ophthalmology PPT 15 Convergence Accommodation Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 15 Convergence Accommodation Lecture Notes

This post was last modified on 07 April 2022


ACCOMMODATION

AND CONVERGENCE

--- Content provided by FirstRanker.com ---

Department of Ophthalmology

1

Learning Objectives

--- Content provided by FirstRanker.com ---


At the end of the class, students shall be able to
? Understand the basic mechanism of

accommodation and clinical importance of

--- Content provided by FirstRanker.com ---

anomalies of accommodation

? Understand the pathway for the near reflex and

importance of convergence insufficiency.

--- Content provided by FirstRanker.com ---


2


ACCOMMODATION

--- Content provided by FirstRanker.com ---


? Definition: Accommodation is the mechanism by which the

eye changes its refractive power by altering the shape of the
lens in order to focus objects at variable distances.

--- Content provided by FirstRanker.com ---


3

Mechanism of accommodation

--- Content provided by FirstRanker.com ---

? Increase in the curvature of the lens affects mainly the

anterior surface.

? Radius of curvature of anterior surface :10 mm

--- Content provided by FirstRanker.com ---

During accommodation



6 mm

--- Content provided by FirstRanker.com ---

This alteration in shape increases the converging power of the

lens.

4

--- Content provided by FirstRanker.com ---



RELAXATION THEORY OF HELMONTZ
? He considered that lens was elastic and in normal state is

--- Content provided by FirstRanker.com ---

stretched and flattened by the tension of the suspensory
ligament.

? During accommodation:
Ciliary muscle contracts causing the lens zonules to slacken,

--- Content provided by FirstRanker.com ---


lens assumes more spherical form increasing thickness and

decreasing diameter,

--- Content provided by FirstRanker.com ---

protrusion forwards at the centre and a relative flattening at the

periphery.

5

--- Content provided by FirstRanker.com ---


6


NEAR REFLEX

--- Content provided by FirstRanker.com ---


? It has 2 components :
? Convergence reflex comprising convergence of the visual

axes of the eyes and associated constriction of pupil.

--- Content provided by FirstRanker.com ---


? Accommodation reflex includes increased

accommodation and associated constriction of pupil.

--- Content provided by FirstRanker.com ---

? The near reflex comprises :

Accommodation , convergence and miosis.

7

--- Content provided by FirstRanker.com ---


ACCOMODATION REFLEX

? Af erent impulses-from

--- Content provided by FirstRanker.com ---

the retina to the

parastriate cortex

? Internuncial fibres relay

--- Content provided by FirstRanker.com ---


impulses from parastriate

cortex to Edinger

--- Content provided by FirstRanker.com ---

westphal nucleus of both

sides

? Ef erent fibres ?from

--- Content provided by FirstRanker.com ---


Edinger westphal

nucleus the ef erent

--- Content provided by FirstRanker.com ---

impulses travel along the

3rd nerve and reach the

sphincter pupil ae and

--- Content provided by FirstRanker.com ---


ciliary muscle

8
Physical and physiological

--- Content provided by FirstRanker.com ---


accommodation

Two factors in accommodation
q Ability of lens to alter its shape

--- Content provided by FirstRanker.com ---

q Power of the ciliary muscle

1.Physical accommodation- Expression of the actual
physical deformation of the lens, measured in dioptres.
2. Physiological accommodation- Contractile power of the

--- Content provided by FirstRanker.com ---

ciliary muscle required to raise the refractive power of the
lens , measured in myodioptres.

9

--- Content provided by FirstRanker.com ---

qThe far point of distinct vision is the position of an

object such that its image falls on the retina in the

relaxed eye, i.e. in the absence of accommodation.

--- Content provided by FirstRanker.com ---


The far point of the emmetropic eye is at infinity.

qThe near point of distinct vision is the nearest point

--- Content provided by FirstRanker.com ---

at which an object can be clearly seen when

maximum accommodation is used.

10

--- Content provided by FirstRanker.com ---

qThe range of accommodation is the distance between the

far point and the near point.

qThe amplitude of accommodation is the difference in

--- Content provided by FirstRanker.com ---


dioptric power between the eye at rest and the fully

accommodated eye.

--- Content provided by FirstRanker.com ---

11

? The amplitude of accommodation is given by

the formula

--- Content provided by FirstRanker.com ---


? A = P - R
? where A is the amplitude of accommodation in

dioptres

--- Content provided by FirstRanker.com ---


? P is the dioptric value of the near point distance
? R is the dioptric value of the far point distance.

12

--- Content provided by FirstRanker.com ---

? Applying this formula to the case of an emmetropic eye

with a near point of 10 cm,

? P = 10 D ( the reciprocal of 0.10 m )

--- Content provided by FirstRanker.com ---


? R = 0 ( the reciprocal of infinity is zero)

? A = 10 D

--- Content provided by FirstRanker.com ---

13

? Far point and near point of the eye vary with the

static refraction of the eye

--- Content provided by FirstRanker.com ---


? In a hypermetrope eye far point is virtual and lies

behind the eye

--- Content provided by FirstRanker.com ---

? In a myopic eye far point is real and lies in front of

the eye.

14

--- Content provided by FirstRanker.com ---

? In an emmetropic eye
? Far point is at infinity
? Near point varies with age
? About 7 cm at age of 10 years
? About 25 cm at age of 40 years

--- Content provided by FirstRanker.com ---

? 33 cm at age of 45 years

15

ANOMALIES OF ACCOMMODATION

--- Content provided by FirstRanker.com ---


DIMINISHED

INCREASED

--- Content provided by FirstRanker.com ---

ACCOMMODATION

ACCOMMODATION

1. PHYSIOLOGICAL

--- Content provided by FirstRanker.com ---


1. EXCESSIVE

(PRESBYOPIA )

--- Content provided by FirstRanker.com ---

ACCOMMODATION

2. PHARMACOLOGICAL

(Cycloplegia)

--- Content provided by FirstRanker.com ---


2. SPASM OF

3. PATHOLOGICAL

--- Content provided by FirstRanker.com ---

ACCOMMODATION

? Insufficiency of

accommodation

--- Content provided by FirstRanker.com ---


? Ill sustained accommodation
? Paralysis of accommodation

16

--- Content provided by FirstRanker.com ---

PRESBYOPIA

? Presbyopia is not an error of refraction but a

condition of physiological insufficiency of

--- Content provided by FirstRanker.com ---

accommodation due to reduced amplitude of
accommodation, leading to a progressive fall in near
vision.

? This begins between 40 years and 45 years.

--- Content provided by FirstRanker.com ---


17

? After the age of 40 years ,the NPA recedes beyond

--- Content provided by FirstRanker.com ---

the normal reading distance.

? This condition of falling near vision due to age

related decrease in the amplitude of accommodation

--- Content provided by FirstRanker.com ---

or increase in punctum proximum is presbyopia.

18
? Causes of presbyopia :

--- Content provided by FirstRanker.com ---

qAge related changes in lens which include

? Decrease in elasticity of lens capsule

? Progressive increase in size and hardness (sclerosis)

--- Content provided by FirstRanker.com ---


of lens substance.

qAge related decline in ciliary muscle power.

--- Content provided by FirstRanker.com ---

19

? Causes of premature presbyopia include

? Uncorrected hypermetropia

--- Content provided by FirstRanker.com ---


? Premature sclerosis of the crystalline lens

? General debility causing presenile weakness of ciliary

--- Content provided by FirstRanker.com ---

muscle

? Chronic simple glaucoma

20

--- Content provided by FirstRanker.com ---

? Symptoms

? Difficulty in near vision : patients start complaining of

inadequacy of vision for small print and finer objects at the

--- Content provided by FirstRanker.com ---


usual reading distance. Such problems start occurring in the

evening, and in dim light.

--- Content provided by FirstRanker.com ---

? Asthenopic symptoms due to fatigue of ciliary muscle

? Intermittent diplopia at near may develop.

21

--- Content provided by FirstRanker.com ---


? Treatment
Optical correction of presbyopia
Done by supplementing accommodation with
convex lens of appropriate power.

--- Content provided by FirstRanker.com ---


The difference between the distance correction
and the strength needed for near vision is called
the add.

--- Content provided by FirstRanker.com ---

22
PRESBYOPIC ADD

? If the patient is presbyopic, calculate the likely

--- Content provided by FirstRanker.com ---

reading addition and add this to the distance lenses
in the trial frame. In practice the reading addition is
estimated from the patient's age.

AGE RANGE

--- Content provided by FirstRanker.com ---


READING ADDITION

45-50 YEARS

--- Content provided by FirstRanker.com ---

+1.00 D

50-55 YEARS

+1.50 D

--- Content provided by FirstRanker.com ---


55-60 YEARS

+2.00D

--- Content provided by FirstRanker.com ---

OVER 6O YEARS

+2.50 D

23

--- Content provided by FirstRanker.com ---


MODES OF PRESCRIBING PRESBYOPIC ADD

o SPECTACLES
o CONTACT LENSES FOR PRESBYOPIA

--- Content provided by FirstRanker.com ---


2.SURGICAL TREATMENT OF PRESBYOPIA

o refractive surgeries

--- Content provided by FirstRanker.com ---

24
? Insufficiency of accommodation

Accommodative power is significantly and
persistently below the normal physiological limits

--- Content provided by FirstRanker.com ---

for the patient's age

? Causes

?Premature sclerosis of lens

--- Content provided by FirstRanker.com ---


?Weakness of ciliary muscle due to systemic

causes such as diabetes mellitus.

--- Content provided by FirstRanker.com ---

25

Clinical features :

Treatment :

--- Content provided by FirstRanker.com ---


Headache

1.Treatment of the

--- Content provided by FirstRanker.com ---

Fatigue

systemic cause

Blurring of vision for near

--- Content provided by FirstRanker.com ---


2.Near vision spectacles

work

--- Content provided by FirstRanker.com ---

3.Accomodation exercises

Intermittent diplopia

26

--- Content provided by FirstRanker.com ---





Paralysis of accommodation

--- Content provided by FirstRanker.com ---


? Paralysis of accommodation ,also known as

cycloplegia, refers to complete absence of

--- Content provided by FirstRanker.com ---

accommodation.

27

Causes

--- Content provided by FirstRanker.com ---


? Drug induced
? Internal ophthalmoplegia
? Paralysis of accommodation as a component

--- Content provided by FirstRanker.com ---

of 3rd nerve palsy.

28
DRUG

--- Content provided by FirstRanker.com ---

MAXIMUM

MAXIMUM

DURATION OF

--- Content provided by FirstRanker.com ---


DURATION OF

MYDRIASIS

--- Content provided by FirstRanker.com ---

CYCLOPLEGIA

MYDRIASIS

CYCLOPLEGIA

--- Content provided by FirstRanker.com ---


ATROPINE 1% TID 30-40 MIN

1 DAY

--- Content provided by FirstRanker.com ---

7-10 DAYS

2 WEEKS

CYCLOPENTOLAT 15 MIN

--- Content provided by FirstRanker.com ---


15-30 MIN

1 DAY

--- Content provided by FirstRanker.com ---

24 HRS

E 0.5%-1%

HOMATROPINE

--- Content provided by FirstRanker.com ---


30-60 MIN

30-60 MIN

--- Content provided by FirstRanker.com ---

1-2 DAYS

1-2 DAYS

2%

--- Content provided by FirstRanker.com ---


TROPICAMIDE

15-30 MIN

--- Content provided by FirstRanker.com ---

20-25 MIN

4-6 HRS

5-6 HRS

--- Content provided by FirstRanker.com ---


0.5%-1%

29

--- Content provided by FirstRanker.com ---

? Clinical features

? Treatment

? Blurring of near vision

--- Content provided by FirstRanker.com ---


? Self recovery-drug induced

? Photophobia (due to

--- Content provided by FirstRanker.com ---

paralysis and in cases when

mydriasis )

systemic cause is treated.

--- Content provided by FirstRanker.com ---


? Micropsia

? Dark glasses ? reduce glare

--- Content provided by FirstRanker.com ---

? abnormal receding of near

? Convex lenses ?for near

point

--- Content provided by FirstRanker.com ---


vision if paralysis is

? Signs of 3rd nerve palsy

--- Content provided by FirstRanker.com ---

permanent.

30
Excessive accommodation

--- Content provided by FirstRanker.com ---

? A situation in which an individual exerts more than the

normal required accommodation for performing a

certain near work.

--- Content provided by FirstRanker.com ---


? Excessive near work is an important precipitating factor

especially when done in inadequate illumination.

--- Content provided by FirstRanker.com ---

31

? Clinical features

? Varying degrees of blurred vision

--- Content provided by FirstRanker.com ---


? Symptoms of accommodative asthenopia

? Near vision difficulty

--- Content provided by FirstRanker.com ---

32
? Treatment
1. Optical treatment : refractive error to be corrected
2. General treatment : Near work should be minimised

--- Content provided by FirstRanker.com ---

and when done should be in proper illumination.

3. The general health of the patient should be

improved.

--- Content provided by FirstRanker.com ---


33

CONVERGENCE

--- Content provided by FirstRanker.com ---

34
? Definition: Convergence is a disconjugate movement in

which both eyes rotate inward so that the lines of sight
intersect in front of the eyes.

--- Content provided by FirstRanker.com ---


? Allows bifoveal single vision to be maintained at any

fixation distance.

--- Content provided by FirstRanker.com ---

? Convergence does not deteriorate with increasing age.
? The power of convergence can be increased by

exercises.

--- Content provided by FirstRanker.com ---

35

Convergence reflex

? Afferent pathway ?the afferents from medial recti travel

--- Content provided by FirstRanker.com ---


centrally via the 3rd nerve to the mesencephalic nucleus
of the 5th nerve, to a presumptive convergence centre in
tectal or pretectal region.

--- Content provided by FirstRanker.com ---

? Internuncial fibres : from the convergence centre go to

the Edinger Westphal nucleus .

36

--- Content provided by FirstRanker.com ---



? Efferent pathway-

along the 3rd nerve.

--- Content provided by FirstRanker.com ---

From the 3rd nerve
efferent fibres of
convergence reflex
relay in the
accessory ganglion,

--- Content provided by FirstRanker.com ---

before reaching
sphincter pupillae.

37

--- Content provided by FirstRanker.com ---

? Angle of convergence

?It refers to the angle that is formed between the

primary lines of sight during convergence

--- Content provided by FirstRanker.com ---


?Its size depends on

? the fixation distance

--- Content provided by FirstRanker.com ---

and

interpupillary distance ( IPD )

38

--- Content provided by FirstRanker.com ---



Metre angle

? One metre angle

--- Content provided by FirstRanker.com ---


convergence is
exerted by each
eye when the eyes
are directed to

--- Content provided by FirstRanker.com ---

object at a
distance of 1 m of
the meridian line
between the two
eyes.

--- Content provided by FirstRanker.com ---


39

? In an emmetropic eye, the number of dioptres of

--- Content provided by FirstRanker.com ---

accommodation required to see an object clearly is

equal to the number of metre angles through which

each eye must converge to see the object singly.

--- Content provided by FirstRanker.com ---


? Thus 1D of accommodation is associated with 1 ma

of convergence of each eye

--- Content provided by FirstRanker.com ---

40
qThe near point of convergence is the closest point at

which an object can be seen singly during bifoveal
vision when maximum convergence is exerted.

--- Content provided by FirstRanker.com ---


qThe far point of convergence refers to relative

position of the eyes when they are completely at
rest, usually at infinity.

--- Content provided by FirstRanker.com ---


41

qThe range of convergence is the distance between

--- Content provided by FirstRanker.com ---

the far point and the near point of convergence

qThe amplitude of convergence is the difference in

convergence power exerted to maintain the eye in a

--- Content provided by FirstRanker.com ---


position at rest and in a position of maximum

convergence.

--- Content provided by FirstRanker.com ---

42


Measurement of amplitude of convergence

--- Content provided by FirstRanker.com ---

1. Prism bar

2. Synoptophore

43

--- Content provided by FirstRanker.com ---


Anomalies of convergence

1) Convergence insufficiency
Inability to maintain adequate binocular

--- Content provided by FirstRanker.com ---

convergence for any length of time
without undue effort.

44
? Aetiology

--- Content provided by FirstRanker.com ---


A. Primary or idiopathic ? wide IPD,

general debility, overwork.

--- Content provided by FirstRanker.com ---

B. Refractive errors- uncorrected high hypermetropia

and myopia

C. Presbyopia

--- Content provided by FirstRanker.com ---


D. Muscular imbalances- exophoria,

intermittent exotropia and vertical muscle

--- Content provided by FirstRanker.com ---

imbalances.

45

Clinical features

--- Content provided by FirstRanker.com ---


1. Symptoms of

2. Symptoms due to

--- Content provided by FirstRanker.com ---

muscular fatigue

failure to maintain

binocular vision

--- Content provided by FirstRanker.com ---


? Eyestrain

? Blurred near vision

--- Content provided by FirstRanker.com ---

? Headache and eye

? Intermittent crossed

ache

--- Content provided by FirstRanker.com ---


diplopia

? Difficulty in changing

--- Content provided by FirstRanker.com ---

the focus from

distant to near

? Itching, burning and

--- Content provided by FirstRanker.com ---


soreness of eyes

46
Diagnosis

--- Content provided by FirstRanker.com ---


1. Remote NPC ? if NPC > 10 cm, Convergence

insufficiency is said to exist.

--- Content provided by FirstRanker.com ---

2. Decreased fusional convergence for near-when

measured on synoptophore, if there is difficulty in

attaining 30? of convergence.

--- Content provided by FirstRanker.com ---


3. Exophoria

47

--- Content provided by FirstRanker.com ---

Treatment
1. Optical treatment- Myopes are given full correction

and hypermetropes undercorrection to stimulate
their accommodation and simultaneously

--- Content provided by FirstRanker.com ---

convergence.

2. Orthoptic treatment- exercises to increase the near

point of convergence (NPC) and also to increase

--- Content provided by FirstRanker.com ---

amplitude of fusional convergence.

48
3. Prism Therapy
Base in ( BI ) prisms reading glasses or bifocals with prism

--- Content provided by FirstRanker.com ---


in the lower segment are useful.

4. Surgical treatment

--- Content provided by FirstRanker.com ---

? Last resort

? Medial rectus muscle resection can be performed.

49

--- Content provided by FirstRanker.com ---


Convergence paralysis

CAUSES
? Head injury

--- Content provided by FirstRanker.com ---

? Encephalitis
? Tabes dorsalis
? Narcolepsy
? Tumours

--- Content provided by FirstRanker.com ---

50
? Clinical features
? Convergence is completely absent
? Exotropia and crossed diplopia occurs on attempted

--- Content provided by FirstRanker.com ---

near vision

? Adduction is normal


--- Content provided by FirstRanker.com ---


51

? TREATMENT

--- Content provided by FirstRanker.com ---

qBase In (BI) prisms

qPlus lenses with BI prisms

52

--- Content provided by FirstRanker.com ---

Summary

? Accommodation is the mechanism by which the eye

changes its refractive power by altering the shape of the

--- Content provided by FirstRanker.com ---

lens in order to focus objects at variable distances.

? Convergence is a disconjugate movement in which both

eyes rotate inward so that the lines of sight intersect in

--- Content provided by FirstRanker.com ---

front of the eyes.

? The near reflex comprises : Accommodation ,

convergence and miosis.

--- Content provided by FirstRanker.com ---


53