Accommodation of eye
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Transcript of Accommodation of eye
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Theories & Anomalies Of Accommodation
Presented by Dr. Rohit Rao
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References • Duke-Elder’s practice of refraction by David
Abrams
• Optics & Refraction By A K Khurana
• Textbook of Ophthalmology by E Ahmed
• Clinical Optics By A R. Elkington
• Borish's Clinical Refracfion By W J. Benjamin
• Werner L, Trindade F, Pereira F,Werner L Physiology of Accommodation and Presbyopia, ARQ. BRAS. OFTALMOL. 63(6), December 2000.
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Definition Accommodation is the mechanism by which the eye changes refractive power by altering the shape of lens in order to focus objects at variable distances
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• Far point: Position of an object when its image clearly falls on retina with no accommodation.
• Near point: Nearest point clearly seen with maximum accommodation.
• Range of accommodation: Distance between far point and near point.
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• Amplitude of accommodation: Dioptric power difference between rest and fully accommodated eye.– A=P-R ( A: amplitude of accommodation;
P:dioptric value of near point; and R: dioptric value of far point.)
• Accommodative Convergence/Accommodation Ratio– To view near object: Accommodation for clear retinal
images, & convergence for binocular single vision.
– The number of prism dioptres of convergence which accompanies each dioptre of accommodation is (AC/A) ratio
– The normal range for the AC/A ratio is 3:1 to 5:1.
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Theories of accommodation
• The exact mechanism of accommodation is not known.
• In year 1801 YOUNG reported lens is responsible for accommodation.
“Principal fact that ACCOMMODATION is a feature of increase in the curvature of the lens which affects anterior surface mainly”
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Relaxation theory of HELMHOLTZ• Also known as the “Capsular Theory”.
• He considered that lens was elastic and in normal state it is stretched and flattened by tension of the suspensory ligaments.
• During accommodation, contraction of ciliary muscle shortens ciliary ring and moves towards the equator of the lens.
• Relax the suspensory ligaments, relieving strain.
• Lens assumes more spherical form, increasing thickness and decreasing diameter.
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Helmholtz Accommodation
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Points in favour of the relaxation theory• Imaging technique showed that ciliary
muscle move anteriorly & the equatorial edge of lens move away from sclera during accommodation.
• Gonio-videography show zonular fibers extending from ciliary processes to lens equator, are relaxed during accommodation
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Unaccommodated Pharmacologically stimulated
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Points against the theory• It is not clear how lens alters its shape
when tension in suspensory ligaments is relaxed?
• what is responsible for decline in power of accommodation with age?
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GULLSTRAND mechanical model of accommodation• It is based on HELMHOLTZ hypothesis
• GULLSTRAND devised a mechanical model to explain accommodation.
• It shows in unaccommodated state elasticity of choroid is stronger than lens. When accommodation comes into play weight i.e ciliary muscles contract to overcome elasticity of choroid.
• It helps lens to take accommodated shape.
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SCHACHAR’S theory• Presbyopia is due to
growth in equatorial diameter, leads to decrease in perilenticular space.
• Contraction of ciliary muscle cannot tense zonules and expand lens coronally.
• SCHACHAR introduced use of scleral expansion bands (SEB).
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TSHERNING’S theory• This theory attributed increased
curvature of capsule to increasing tension of the zonules.
• It states that contraction of ciliary muscle pulls zonules directly and increases tension of capsule at equator of lens, which leads to bulging of poles.
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COTENARY theory • COTENARY theory of accommodation
was proposed by COLEMAN.
• The COTENARY (hydraulic suspension) theory proposes that lens, zonules & anterior vitreous comprise a diaphragm between aqueous and vitreous.
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• As ciliary muscle contracts it forms a pressure gradient, causing anterior movement of lens zonules diaphragm and increasing anterior central curvature.
• Presbyopia is due to increase in lens volume, results in reduced response to pressure gradient created by ciliary body contraction.
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Types of Accommodation• Tonic accommodation
– It is due to tonus of ciliary muscle and is active in absence of a stimulus. The resting state of accommodation is not at infinity but rather at an intermediate distance.
• Proximal accommodation– Is induced by the awareness of the
nearness of a target. This is independent of the actual dioptric stimulus.
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• Reflex accommodation– Is an automatic adjustment response to
blur which is made to maintain a clear and sharp retinal image.
• Convergence-accommodation– Amount of accommodation stimulated or
relaxed associated with convergence.
– The link between accommodation and convergence is known as accommodative convergence and is expressed clinically as AC/A ratio.
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Accommodation Reflex
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• The afferent – Retina (with the retinal ganglion axons in
the optic nerve, chiasm and tract),
– Lateral geniculate body (with axons in the optic radiations)
– Visual cortex.
• Ocular motor control neurons are interposed between the afferent and efferent limbs of this circuit and include the visual association cortex
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• It determines the image is "out-of-focus” & sends corrective signals
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internal capsule and crus cerebri
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supraoculomotor nuclei (generates motor control signals)
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oculomotor complex.
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• The efferent
– Edinger-Westphal nucleus - oculomotor nerve - ciliary ganglion - short ciliary nerve - iris sphincter and the ciliary muscle/zonules/lens of the eye
– oculomotor neurons - oculomotor nerve - medial rectus, converge the two eyes.
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Anomalies of Accommodation
• Classification (by Duane with some modification):
– Accommodative insufficiency– Ill-sustained accommodation-
– Paralysis (or paresis) of accommodation
– Unequal accommodation
– Accommodative excess.
– Inertia of accommodation
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– Diminished or deficient accommodation– Physiological : Presbyopia
– Pharmacological : Cycloplegia
– Pathological
– Insufficiency of accommodation
– Ill sustained accommodation
– Inertia of accommodation
– Paralysis of accommodation
– Increased accommodation
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Presbyopia Presbyopia is a condition of physiological
insufficiency of accommodation leading to a progressive fall in near vision.
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Pathophysiology• In emmetropic eye far point is infinity and
near point varies with age (being about 7 cm at 10 years, 25 cm at 40 years and 33 cm at 45 years).
• We read from 25 cm. After 40 years, the near point recedes beyond normal reading or working range.
• Failing near vision due to age-related decrease in amplitude of accommodation is called presbyopia.
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Causes• Decrease in accommodative power of lens
with increasing age, leads to presbyopia, occurs due to:
– Age-related changes in lens:o Decrease in elasticity of lens capsule, and
o Progressive, increase in size and hardness (sclerosis) of lens substance which is not easily moulded.
– Age related decline in ciliary muscle power.
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Premature presbyopia:
• Uncorrected hypermetropia.
• Premature sclerosis of the crystalline lens.
• General debility causing pre-senile weakness of ciliary muscle.
• Chronic simple glaucoma.
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Symptoms• Difficulty in near vision.
• Patients complaint of difficulty in reading small prints
• Asthenopic symptoms due to fatigue of the ciliary muscle are also complained after reading or doing any near work.
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Presbyopia Rx
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Optical treatment• Prescription of appropriate convex
glasses for near work.
• A rough guide for providing presbyopic glasses in an emmetrope can be made from patient’s age.– About +1 DS is required at the age of 40-
45 years,
– +1.5 DS at 45-50 years,
– + 2 DS at 50-55 years,
– +2.5 DS at 55-60 years.
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Basic principles of presbyopic correction• Refractive error for distance is corrected first.
• Correction needed in each eye should be tested separately and add it to distant correction.
• Near point should be fixed according to the profession of patient.
• Weakest convex lens with which one can see clearly at near point should be prescribed, overcorrection will also result in asthenopic symptoms.
• Presbyopic spectacles may be unifocal, bifocal or varifocal.
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Surgical Treatment • Corneal procedures
– Non ablative corneal procedure
– Monovision CK
– Laser based corneal procedure
– Laser thermal keratoplasty (LTK)
– Monovision LASIK.
– Presbyopic bifocal LASIK
– Presbyopic multifocal LASIK C
Near Vision
Distant Vision
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• Intraocular refractive procedure– Refractive lens exchange
– Phakic refractive lens
– Monovision with IOLs
• Scleral based procedures– Anterior sclerotomy with tissue barriers
– Scleral spacing procedure
– Scleral ablation with erbium : yag laser
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Insufficiency of accommodation
• Condition in which accommodative power is constantly less than lower limit of normal range according to patient’s age.
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Etiology• Premature sclerosis of lens
• Weakness of ciliary muscle due to systemic causes: Debilitating illness, anemia, toxemia, malnutrition, diabetes mellitus, pregnancy, stress etc.
• Weakness of ciliary muscle due to local causes: PAOG, mild cyclitis as during onset of sympathetic ophthalmia.
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Clinical features• Features of eye strain and asthenopia. • Head ach, fatigue & irritability of the
eyes, while attempting near work.• Near work is blurred & becomes difficult
or impossible.• Disturbance of convergence :
intermittent diplopia.• It is stable condition, if due to
sclerosis of lens.• But is not stable in association with
ciliary muscle weakness.
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Treatment• Identification & treatment of any
systemic cause.
• Any refractive error should be corrected & if vision for near work is seriously blurred then additional near correction has to be prescribed same as presbyopia.
• If associated with convergence excess then full spherical correction.
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• Convergence insufficiency is there, then base in prisms can be added.
• Prismatic correction added should bring near point of convergence to same distance as near point of accommodation.
• Weakest convex lenses should be prescribed, so as to exercise and stimulate accommodation.
• After recovery additional correction should be made weaker and weaker from time to time.
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• Accommodative exercises.
– While do exercises patient should wear correction for distance.
– Should be done simultaneously in both eyes, even if associated with convergence insufficiency.
– But with convergence excess then the exercise should done with one eye alternately.
– Accommodation test card exercise.
– Useless in generalized debility and sclerosis of lens.
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Ill-Sustained accommodation• Accommodation fatigue.
• It is a situation in which though range of accommodation is in normal range but it cannot sustain it for a sufficient period of time.
• Initial stage of insufficiency of accommodation.
• It occurs due to – Stage of convalescence from debilitating illness
– Stage of generalized tiredness
– When the patient is relaxed in the bed
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Clinical features• These symptoms are most commonly
reported at the end of the day
• Blurred vision after prolonged near work.
• Headaches
• Eyestrain
• Fatigue, sleepiness and a loss of comprehension with continued reading
• A dull 'pulling' sensation around the eye.
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Treatment• Near work should be curtailed during
debilitating illness.
• General tonic measures should be taken.
• The condition of illumination and posture while doing near work, should be improved.
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Inertia of accommodation• It is a condition in which patient faces
difficulty in altering the range of accommodation.
• Amplitude of accommodation is normal.
• Ability to make use of this amplitude quickly and for long periods of time is inadequate.
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Clinical features• Difficulty changing focus from one distance
to another
• Headaches
• Eyestrain
• Fatigue
• Difficulty sustaining near tasks
• Blurred vision
Treatment: correcting any refractive error and accommodative exercises.
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Paralysis of accommodation• Cycloplegia, refers to complete absence of
accommodation.
• Causes
– Atropine, homatropine or other parasympatholytic drugs.
– Internal ophthalmoplegia (paralysis of ciliary muscle and sphincter pupillae)due to neuritis associated with diphtheria, syphilis, diabetes, alcoholism, cerebral or meningeal diseases.
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– Complete third nerve paralysis due to intracranial or orbital causes.
– Systemic medications such as anti-hypertensive, antidepressants.
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Clinical features
• Blurred vision at near
• Photophobia or a 'dazzling' effect
• Diplopia
• Micropsia: objects may appear smaller than they are due to a false sense of distance
• Enlarged pupil.
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Treatment• An effort should be made to find out
the cause and try to eliminate it.
• Self-recovery occurs in drug-induced paralysis and in diphtheric cases (once systemic disease is treated).
• Dark-glasses effective in reducing glare.
• Convex lenses for near vision, if the paralysis is permanent.
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Excessive accommodation• Accommodative response is greater
than the accommodative stimulus.
• There is functional increase in tonus of ciliary muscle, results in a constant accommodative effect.
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Causes• Young hypermetropes frequently uses
excessive accommodation as a physiological adaptation
• Young myopes performing excessive near work, associated with excessive convergence.
• Astigmatic error in young patients
• Presbyopes in the beginning
• Use of improper and ill fitting spectacles
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Precipitating factors
• Excessive near work done, especially in dim or excessive illumination.
• General debility, physical or mental ill health
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Symptoms• Blurred vision at near is uncommon • Blurred vision at distance • Headaches • Eyestrain • Photophobia • Difficulty changing focus from distance to
near • Diplopia
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Treatment • It has a good prognosis.
• Refractive error should be corrected after carefully performed cycloplegic refraction.
• Near work should be stopped for some time, after that it should be done with proper illumination conditions.
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Spasm of accommodation
• Spasm of accommodation refers to exertion of abnormally excessive accommodation.
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Causes• Drug induced spasm of
accommodation is known to occur after use of strong miotics.
• Spontaneous spasm of accommodation: attempt to compensate for a refractive anomaly.
• Occurs when excessive near work is done with bad illumination, bad reading position, state of neurosis, mental stress or anxiety.
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Clinical features• Defective vision: due to induced
myopia.
• Asthenopic symptoms
• Precipitating factors like marked degree of muscular imbalance, trigeminal neuralgia, a dental lesion, general intoxication.
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Treatment• Relaxation of ciliary muscle by atropine
for 4 weeks or more and
• Prohibition of near work allow prompt recovery from spasm of accommodation.
• Elimination of the associated causative factors to prevent the recurrence.
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thank
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