The presentation presents some treatment modalities as regards AI.This is to keep you thinking more on how to approach a case of AI in terms of management.

1. JOURNAL CLUB
ACCOMMODATIVE
INSUFFICIENCY…
Amrit
Pokharel

2. Accommodation Insufficiency in
Children: Are Exercises Better than
Reading Glasses?
Strabism 2008; 16:65–69.
us
Copyright _c 2008 Informa Healthcare USA, Inc.
ISSN: 0927-3972 print / 1744-5132 online
DOI: 10.1080/09273970802039763

3. Researchers
Rune Brautaset,
BSc (Optom), MPhil, PhD,
Marika Wahlberg,
BSc (Optom),
Saber Abdi, BSc, MSc
(Orthop), PhD,
and Tony Pansell,
BSc (Optom), PhD
Unit of Optometry, Department
of Clinical Neuroscience,
Karolinska Institute, Stockholm,
Sweden

4. Purpose:
 The aim of the study was to compare efficacy
of plus lens (+1.00D) reading addition (PLRA)
with that of spherical flipper (±1.50D) in the
treatment of accommodative insufficiency (AI).

5. INTRODUCTION
 The normal accommodative system is
often described as
resistant
flexible
to fatigue
 Accommodative dysfunction is a relatively
common visual anomaly in children and
young adults.

6. INTRODUCTION
 The prevalence of accommodative
dysfunction
not associated with
presbyopia
 probably affects at least 2–3% of the
population (Rutstein & Daum, 1998).

7. INTRODUCTION
 Accommodative dysfunction :
Near Work
Accommodati
ve
Insufficiency

8. INTRODUCTION
 AI is a condition in which the amplitude of
accommodation is
 chronically the lower limit of the
expected amplitude for the patient’s age
 as measured with push-up accommodative stimuli
(Mein & Trimbel, 1994; Benjamin, 1998)

9. INTRODUCTION
 AI subjects also demonstrate
 a reduced accommodation facility (Scheiman
&Wick, 1994)
 Sometimes an lag of accommodation
(Rutstein & Daum, 1998; Scheiman &Wick,
1994).

10. INTRODUCTION
 AI has been reported to be the most
common cause of asthenopia in
schoolchildren between 8 and 15 years of
age (Borsting et al., 2003).

11. INTRODUCTION
Vision
Therapy
 manifest a range of non-strabismic
accommodative and vergence disorders
(Abdi et al., 2006).

12. INTRODUCTION
 Visual therapy involves purposeful and
controlled manipulations of
 target blur,
 disparity and
 proximity, with the aim of
 normalizing the a c c o m m o d a tiv e s y s te m , the
ve rg e nc e s y s te m , a nd m utua l inte ra c tio ns (Griffin
& Grisham, 1995; Rutstein & Daum, 1998).

13. INTRODUCTION
 The two most important vision therapy
regimes for AI are
plus lens reading additions (PLRA)
(Daum, 1983b; Mazow et al., 1 989; Rutstein & Daum, 1998)

14. INTRODUCTION
PLRA
Passive mode of therapy
Gives a helping hand in getting a
clear retinal image

15. INTRODUCTION
PLRA
The amount of blur decreases when
wearing glasses
Role reduce blur to such an extent that the remaining blur is
recognized and within the subject’s accommodative
capacity.

16. INTRODUCTION
 The subject’s task is to recognise the remaining
image blur and to clear the image. However, by
being able to clear the image, the blur-driven
sensors and the adaptive mechanism within the
accommodative system will start to regain
normal capacity (Ciuffreda, 2002).

17. INTRODUCTION
the initial amount of blur
is not reduced
however, a controlled
amount of additional blur
(with the negative side of
the flipper)
a controlled amount of
reduction in blur (with the
positive side of the
flipper)

18. INTRODUCTION
 The subject’s task is to recognise the
change in defocus of the image and
 to try to respond by obtaining a clear
image.
By being able to recognise and respond
to the blurred image,
 the blur-driven sensors and the adaptive
mechanism within the accommodative system will
start to regain normal capacity (Ciuffreda, 2002).

19. Rationale
 To clarify the issue of whether PLRA or
orthoptic exercises are equally effective or
whether one method is more effective
than the other.

20. MATERIALS AND METHODS
 Partly blind study
 Consisted of assessments by three
examiners.
Inclusion
criteria
E1 E2
E3

21. MATERIALS AND METHODS
 Inclusion Criteria:
 Symptoms revealing uncomfortable vision
and/or
 refractive error less than 1 . 0 0 D o f hy p e rm e tro p ia
and less than 0 . 5 0 D o f m y o p ia , and/or
a s tig m a tis m le s s tha n 0 . 5 0 D m e a s ure d in
c y c lo p le g ia

22. MATERIALS AND METHODS
 Inclusion Criteria:
 distance heterophoria between 2 p d of exophoria
and 2 p d of esophoria
 near (40 cm) heterophoria between 6 p d of
exophoria and 4 p d of esophoria
 near point of convergence of 10 cm or better on
the RAF (Royal Air Force) rule

23. MATERIALS AND METHODS
 Inclusion Criteria:
 fusional reserve at least twice the near phoria
 near point of accommodation worse than (100/
(15D-(0.4 age))) on the RAF rule
 distance Snellen visual acuity of 0.8 or better both
monocularly and binocularly
 normal ocular motility

24. MATERIALS AND METHODS
 Inclusion Criteria:
 full stereo vision on the Lang II test
 no ocular pathology
 no history of ophthalmologic treatment
 not taking any drugs with a known effect on visual
acuity and/or binocular function and
accommodation.

25. MATERIALS AND METHODS
 E1 asked the subjects to consecutively
participate in the study.
24 subjects with AI
(age: 10.3 ±2.5 )
24
10 14
10 subjects-8 weeks of PRLA
9 subjects-8 weeks of
treatment
Flipper treatment
Age : 10.3 years ±2.74
5 drop outs
Age: 10.3 years ±2.41

26. MATERIALS AND METHODS
 If the subject met the inclusion criteria, the
subject was seen by a second examiner (E2)
who, without knowing the results of the inclusion
examination, performed measurements of the
study variables.
E2

27. MATERIALS AND METHODS
 Study variables:
E2
 Accommodative amplitude
 Accommodative facility
 Lag of accommodation
 Visual Analogue Scale (VAS) score

28. MATERIALS AND METHODS
 were those assessed?
 AA- three measurements were taken
 AF- accommodative facility at 40 cm with a ±2.00D
flipper while fixating a vertical row of letters equivalent
to 6/9 visual acuity (measured binocularly and in the
dominant eye; dominance was tested with the Miles
test (Michaels, 1975))

29. MATERIALS AND METHODS
 were those assessed?
 lead/lag of accommodation as measured with
N tt d y na m ic re tino s c o p y while fixating a vertical
o
row of letters equivalent to 6/9 visual acuity at 40
cm
 subjective grading of the degree of asthenopia on
a Visual Analogue Scale (VAS)

30. MATERIALS AND METHODS
 A visual analogue scale (VAS) is a
psychometric response scale which can be
used in questionnaires. It is a measurement
instrument for subjective characteristics or
attitudes that cannot be directly measured.
 Numbering from 0-10.

31. MATERIALS AND METHODS
 If 0 equals no problem when doing near work
and 10 equals the worst degree of problems,
what number would you grade your problems at
near work to be now?”
 These four measures were repeated after the 8
weeks’ treatment period.

32. MATERIALS AND METHODS
E3
 The subject was then seen by a third examiner
(E3) who, according to a randomization list and
without knowing the results obtained by E1 and
E2, assigned the subjects to either flipper or
PLRA treatment.

33. MATERIALS AND METHODS
E1 examination E2 performed
Included in study examination
Mixed samples
who met inclusion
criteria
E3 assigned glasses E3 assigned flipper
randomly treatment randomly
E2 performed follow up
examination at 8 weeks

34. MATERIALS AND METHODS
E3
24 subjects with AI
(age: 10.3 ±2.5 )
24
10 14
10 subjects-8 weeks of PRLA
9 subjects-8 weeks of
treatment
Flipper treatment
Age : 10.3 years ±2.74
5 drop outs
Age: 10.3 years ±2.41

35. MATERIALS AND METHODS
After 8 wks, re-
examination by E2
without knowing the kind
of treatment.

36. Flipper PLRA
 ±1.50D flipper lenses  +1.00 lenses
 Two sessions of nine
minutes each day
 To be done when not
tired or not feeling
asthenopia
 Done at 40 cm
 Done as many flips a
minute.

37. Flipper PLRA
 followed by another  use the glasses as
one-minute trial of much as possible for
flipping and a one- all types of near
minute break. visual work.
 repeated until the
subject had done a
total of five minutes
of flipping
 Target

38. Statistical Methods
 The effect of treatment (before vs. after),
 the type of therapy regime (flipper vs. PLRA)
and
 the interaction effect between them were
analysed using multivariate analysis of variance.

39. Statistical Methods
 Bonferroni post-hoc analysis
 Planned comparison.
 Wilcoxon matched pair test was used for
analysis of the VAS score and the within-group
results
 A significance level of 0.05 was considered
significant.
 Dropouts have not been included in the
analysis.

41. RESULTS
 Accommodative Amplitude and
Accommodative Facility
 Significant interaction between the study
variables and the treatment [F(2,34) = 6.97, p =
0.003].
 The post hoc analysis showed a significant
change in accommodative amplitude [F(1,17) =
18.84, p < 0.001].

42. RESULTS
 Accommodative amplitude change over a
period.

43. RESULTS
 Accommodative facility change over a period.

45. RESULTS
 Flipper vs. PLRA
 The analysis did not reveal any statistically
significant difference between the two therapy
regimes [F(1,17) = 0.31, p = 0.58].
 With the accommodative response excluded, the
difference was still not significant [F(1,17) = 2.06,
p = 0.17].

46. RESULTS
VAS
Flipper PLRA
6.3 units lower 4.7 units lower
after treatment after treatment
[Z(n = 9) = 2.66; p [Z(n = 10) = 2.80;
= 0.008] p = 0.005]

47. DISCUSSION
 Visual therapy in AI involves
 Purposeful and
 controlled manipulations of
 target blur, disparity and proximity with the aim of
normalizing the accommodative system (Griffin &
Grisham, 1995; Rutstein & Daum, 1998).

48. DISCUSSION
 The two most commonly used regimes of
therapy for AI are fundamentally different.
 PLRA is a much more passive type of
treatment as compared with flipper treatment.
 However, in both regimes, the aim is
 to improve the response of the blur-driven
sensors and the adaptive mechanisms within the
accommodative system so that they can regain
normal capacity (Ciuffreda, 2002).

49. DISCUSSION
 The purpose of the present study was to
evaluate which mode of therapy
PLRA FLIPPER
 is a more

50. DISCUSSION
 Expected values for accommodative amplitude
in the age range tested in this study are
between 14.0 and 16.5D (Rutstein & Daum,
1998).
 This is less than the improvement found by
Abdi et al. (2007) over a 12-week treatment
period with the same +1.00D reading addition
and less than that found by Daum (1983b).

51. DISCUSSION
 The results of the present study show that
 both methods improve accommodative amplitude.
The improvement with PLRA was from 3.58D to
4.25D.

52. DISCUSSION
 With
accommodative amplitude improved from
5.16D to 7.82D, a significant improvement
which occurred due to good compliance.
Daum (1983)

53. DISCUSSION
Present study results Sterner et al. (2001).
The amount of treatment and the treatment time were
comparable to the treatment regime used in this
study.

54. DISCUSSION
 The expected binocular values for
accommodative facility are between
 6 and 10 cpm (Rutstein & Daum, 1998).Before
treatment, all subjects performed worse on
accommodative facility.
 After treatment, all subjects reached values
just within the normal range, irrespective of the
treatment regime. Despite this, the
improvement was small and not statistically
significant (p = 0.06).

55. DISCUSSION
VAS
 Before treatment, all subjects included had a
grading of much more than 2 (7.3 and 8.1 on
average in the PLRA and flipper groups,
respectively).

56. DISCUSSION
 The reduction in VAS score was significant in
both groups, but only in the flipper group was
an average VAS score below 2 achieved.
 The higher level of improvement in
accommodative amplitude and the lower VAS
score after treatment in the flipper treatment
group indicates that
 the treatment time needed will be shorter with
this type of treatment as compared with PLRA.

57. DISCUSSION
 On the other hand, the fact that dropout only
occurred in the flipper treatment group
indicates that
 it m a y be m o re d iffic ult to m o tiv a te s ubje c ts to d o
o rtho p tic e x e rc is e s a s c o m p a re d to we a ring
re a d ing g la s s e s .

58. CONCLUSION
 The results indicate that both methods
improve the accommodative amplitude, but
that overall accommodative function reaches
higher levels of improvement with spherical
flipper as compared with PLRA treatment.
 However, the accommodative function did not
gain normal values in 8 weeks of treatment
with either regime.

59. Thank You