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Accommodation-
Convergence
Insufficiency in Children
AGATHI KOURI,FRCS
EYE DEPARTMENT
CHILDREN’S HOSPITAL “P & A KYRIAKOU”
ATHENS
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Near Vision Complex
Accommodation: the refractive power of
the eye is altered to ensure a clear retinal
image
Convergence: the change in the relative
position of the visual axes
Pupillary constriction
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Accommodation is measured in diopters (D)
= the reciprocal of the fixation distance
Far Point of Accommodation (FPA) (infinity,0)
Near Point of Accommodation (NPA) (age)
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Amplitude of accommodation:
is the maximum increase in optical power that
an eye can achieve in adjusting its focus from
as far as possible (beyond infinity for a
longsighted eye) to the nearest possible.
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Accommodation
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Convergence
Near point of Convergence (NPC) ≈ 10cm
Unit of measurement = meter angle (MA)
the reciprocal of fixation distance in meters
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The Near Point Rule measures 50 cm long,
10 mm square, it is engraved with
Centimeters, Inches, Diopter Scales and
Duane Age (the mean of the near point of
accommodation at different ages according
to Duane) with sliding card holder.
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Accommodative convergence=
when a person exerts a certain amount of
accommodation a determined amount of
convergence is elicited
AC/A (normal 3-5)
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Convergence
insufficiency
One of the most common anomalies of binocular
vision
Prevalence : affects 5% of school aged children
Optom Vis Sci 2012
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Convergence
Insufficiency
Defined as an inability to obtain or, more
often, to maintain adequate binocular
convergence without undue effort
IOVS 2006
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Accommodative
Insufficiency
Accommodative insufficiency is a
condition in which the amplitude of
accommodation is less than expected for
a non presbyopic patient’s age
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Due to the link between accommodative
and vergence systems, a deficiency in
one system could cause an abnormality
in the other so that symptoms would
overlap
J Optom 2014
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Symptoms in children
Asthenopia (blurred vision, difficulty
focusing different distances, ocular pain,
ocular fatigue)
Headaches
Double vision during reading and close
work
Optom Vis Sci 2014
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Clinical Signs of CI
Exophoria at near>distance
Receded near point of convergence
(NPC)
Reduced positive fusional vergence (PFV)
at near
Low AC/A
Optom Vis Sci 2014
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Accommodative and
vergence dysfunctions
Interfere with child’s academic progress
Children can abandon a task due to inability
to maintain adequate accom./vergence
Children who perform extended periods of close
vision work (reading-computers), more likely to
report symptoms and signs
J Optom 2014
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Management
Home based/Office based
pencil push-ups
vision therapy
Base-in prism glasses
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Most commonly prescribed treatments for
accommodative dysfunction are:
a plus lens addition at near
(improve symptoms )
vision therapy/orthoptics
(eliminate the accommodative dysfunction)
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CITT study
2008
Compare effectiveness of various
treatments
221 children (9-17yrs) with symptoms of CI
12 weeks of treatment
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221 children with symptoms of CI
164 (74%) accommodative dysfunction;
63 (29%) decreased amplitude of
accommodation with respect to age,
43 (19%) had decreased accommodative
facility
58 (26%) had both.
Optom Vis Sci 2011
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Goal of CITT
find the most effective treatment
to improve symptoms and signs of CI and
increase the accommodative amplitude
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Pencil push ups
Pencil with 20/60 size letters and a white
index card
Move the pencil to within 2 to 3 cm of the
brow, just above the nose on each push-up.
15 minutes per day, 5 days per week
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Home Based Vision Therapy
HTS = Home Therapy System computer
software with Fusional vergence and
accommodative therapy procedures
(Home Therapy Systems, Gold Canyon,AZ)
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20 min per day 5days per week
(15min HTS + 5 min pencil push ups) The computerized therapy consisted of fusional vergence
and accommodative therapy procedures including
accommodative rock, vergence base in, vergence
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Office-based VT/orthoptics
Weekly 60-minute in-office therapy visit +
home therapy procedures 15min a day,
5 days per week.
Therapy consisted of a specific sequence
of standard vergence and
accommodative procedures
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CITT Results
Reduction of symptoms and signs of CI:
Office-based vision therapy = the most effective treatment
home-based computer software plus pencil push-ups was more effective than pencil pushups alone
base-in prism reading glasses the data did not support their use
Optom Vis Sci. 2010
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Base-in prism glasses should be reserved for
reduction of symptoms in the presbyopic
population
Curr Opin Ophthalmol 2010
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Increase in accommodative amplitude for
accommodative insufficiency:
Office-based orthoptic therapy was the most effective treatment
Optom Vis Sci 2011
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Most children aged 9 to 17 years who were
asymptomatic after a 12-week treatment
program of OBVAT for convergence
insufficiency maintained their
improvements in symptoms and signs for at
least 1 year after discontinuing treatment
Optom Vis Sci. 2009
Optom Vis Sci 2011
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In our “reality” :
Try push-ups with pencil or card
Try Home-video orthoptic excercises?
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Ευχαριστώ πολύ!!!