ACCOMMODATION
AND CONVERGENCE
--- Content provided by FirstRanker.com ---
Department of Ophthalmology1
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 theanterior surface.
? Radius of curvature of anterior surface :10 mm
--- Content provided by FirstRanker.com ---
During accommodation6 mm
--- Content provided by FirstRanker.com ---
This alteration in shape increases the converging power of thelens.
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 suspensoryligament.
? 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 theperiphery.
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 theparastriate cortex
? Internuncial fibres relay
--- Content provided by FirstRanker.com ---
impulses from parastriate
cortex to Edinger
--- Content provided by FirstRanker.com ---
westphal nucleus of bothsides
? Ef erent fibres ?from
--- Content provided by FirstRanker.com ---
Edinger westphal
nucleus the ef erent
--- Content provided by FirstRanker.com ---
impulses travel along the3rd 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 muscle1.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 thelens , measured in myodioptres.
9
--- Content provided by FirstRanker.com ---
qThe far point of distinct vision is the position of anobject 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 whenmaximum accommodation is used.
10
--- Content provided by FirstRanker.com ---
qThe range of accommodation is the distance between thefar 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 eyewith 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 ofthe 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 years15
ANOMALIES OF ACCOMMODATION
--- Content provided by FirstRanker.com ---
DIMINISHED
INCREASED
--- Content provided by FirstRanker.com ---
ACCOMMODATIONACCOMMODATION
1. PHYSIOLOGICAL
--- Content provided by FirstRanker.com ---
1. EXCESSIVE
(PRESBYOPIA )
--- Content provided by FirstRanker.com ---
ACCOMMODATION2. 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 ofaccommodation, 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 ---
22PRESBYOPIC ADD
? If the patient is presbyopic, calculate the likely
--- Content provided by FirstRanker.com ---
reading addition and add this to the distance lensesin 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 D50-55 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 ---
25Clinical features :
Treatment :
--- Content provided by FirstRanker.com ---
Headache
1.Treatment of the
--- Content provided by FirstRanker.com ---
Fatiguesystemic cause
Blurring of vision for near
--- Content provided by FirstRanker.com ---
2.Near vision spectacles
work
--- Content provided by FirstRanker.com ---
3.Accomodation exercisesIntermittent 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 ---
MAXIMUMMAXIMUM
DURATION OF
--- Content provided by FirstRanker.com ---
DURATION OF
MYDRIASIS
--- Content provided by FirstRanker.com ---
CYCLOPLEGIAMYDRIASIS
CYCLOPLEGIA
--- Content provided by FirstRanker.com ---
ATROPINE 1% TID 30-40 MIN
1 DAY
--- Content provided by FirstRanker.com ---
7-10 DAYS2 WEEKS
CYCLOPENTOLAT 15 MIN
--- Content provided by FirstRanker.com ---
15-30 MIN
1 DAY
--- Content provided by FirstRanker.com ---
24 HRSE 0.5%-1%
HOMATROPINE
--- Content provided by FirstRanker.com ---
30-60 MIN
30-60 MIN
--- Content provided by FirstRanker.com ---
1-2 DAYS1-2 DAYS
2%
--- Content provided by FirstRanker.com ---
TROPICAMIDE
15-30 MIN
--- Content provided by FirstRanker.com ---
20-25 MIN4-6 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 whenmydriasis )
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 thenormal 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 ---
35Convergence 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 tothe Edinger Westphal nucleus .
36
--- Content provided by FirstRanker.com ---
? Efferent pathway-
along the 3rd nerve.
--- Content provided by FirstRanker.com ---
From the 3rd nerveefferent fibres of
convergence reflex
relay in the
accessory ganglion,
--- Content provided by FirstRanker.com ---
before reachingsphincter 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 ---
andinterpupillary 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 adistance 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 isequal 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 ---
40qThe 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 convergenceqThe 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 ---
42Measurement of amplitude of convergence
--- Content provided by FirstRanker.com ---
1. Prism bar2. 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 timewithout 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 hypermetropiaand 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 fatiguefailure 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 fromdistant 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-whenmeasured on synoptophore, if there is difficulty in
attaining 30? of convergence.
--- Content provided by FirstRanker.com ---
3. Exophoria
47
--- Content provided by FirstRanker.com ---
Treatment1. 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) prismsqPlus 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