ACCOMODATION AND ITS

ANOMALIES

Presenter : Kyamwenge Royal

Supervisor : Dr Ngalula MD, Mmed (ophthalmologist)
OUTLINE

 Introduction
 Applied anatomy
 Mechanism of accommodation
 Accommodation pathway
 Common terminologies
 Anomalies of accommodation
Introduction

 Accommodation is the mechanism by which the

eye changes its refractive power by altering the
shape of lens in order to focus the divergent rays
from near objects onto the retina
 This increase in the power of crystalline lens
occurs due to increase in curvature of its anterior
surfaces
Applied anatomy

 The crystalline lens

 Biconvex, transparent
 Refractive index 1.39
 Refractive power 15-16D
 Ant curvature r=10mm
 Post curvature r=6mm
 Cont.…

 Peripherally,
attached to the ciliary
body with zonules of
Zinn.
Mechanism of accommodation

 Helmholtz's capsular theory(most acceptable)

 Accommodation is achieved by change in shape of
the lens
 when the eye is unaccommodated the cilliary
muscle ring is large and keeps the zonules tense
hence the lens is kept compressed (flat) by the
capsules
Cont.…

 Contraction of ciliary muscle causes the ciliary

ring to shorten and release the zonular tension on
the lens capsule, this allows the elastic capsule to
act unstrained and deform the lens substance.
 The lens alters its shape to become more convex
(anterior capsule is thinner at center ,thicker at
periphery)
 Cont.…

Changes in the crystalline lens during accommodation

 Cont.…
 Accommodated eye vs unaccommodated eye
 Ciliary muscles are contracted.  Ciliary muscles are relaxed.

 Zonules are relaxed  Zonules are contracted

 Lens is more convex.  Lens is flattened.

 Common terminologies
 Near point(punctum proximum)
Nearest point at which a small object can be seen clearly,
It varies with the age ,being about 7cm at the age of
10yrs ,25cm at the age of 40yrs and 33cm at 45yrs.
 Far point(punctum remotum)
A distant point at which a small object can be seen
clearly, In an emmetropic eye far point is at infinity, in
an hypermetropic eye its virtual and lies behind the eye
while in myopia its real and lies in front of the eye
 Cont.…

 Range of accommodation
The distance between the far point and the near point

 Power of accommodation
measure of ability of the media to refract light, its is
measured in diopter (D) which is equal to 1/f, where f is
the focal length in metres.
Cont.…

 Amplitude of accommodation
The difference between the dioptic power needed to
focus on near point (P) and far point (R)
(A=P-R)
 It varies with the age being about 14D at 10yrs ,4D
at 40 yrs and 2D at 50 yrs
Cont.…
Accommodation reflex
Anomalies of accommodation

 Presbyopia
 Insufficiency of accommodation
 Paralysis of accommodation
 Spasm of accommodation
Presbyopia

 Decrease in accommodative power of the lens due

to process of aging.
 The far point remains at infinity while the Near
point varies with age.
 Causes of presbyopia

 The decrease in the accommodative power of crystalline lens

with increasing age, leading to presbyopia is due to:
1. Age-related changes in the lens
• Decrease in the elasticity of lens capsule
• Progressive, increase in size and hardness (sclerosis)
of lens substance which is less easily moulded
2. Age related decline in ciliary muscle power may also
contribute in causation of presbyopia.
Causes of premature presbyopia

 Hypermetropia.
 Primary open angle glaucoma.
 General debility ,causing presenile weakness of
ciliary muscle.
 Premature sclerosis of the crystalline lens .
 Excessive close work.
 symptoms
1.Difficulty in near vision
Complain of difficulty in reading small prints (to start
with in the evening and in dim light and later even in
good light),Difficulty in threading a needle
2. Asthenopic symptoms (eye strain)
fatigue
Pain around eyes
Headache
Blurred vision
3. Intermittent diplopia
 Treatment

 The treatment of presbyopia is the prescription of

appropriate convex glasses for near work
 Rough guide
 +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
 +3 DS at 60+ years
 Basic principals of presbyopia correction
 Always find out refractive error for distance and first
correct it.
 Find out the presbyopic correction needed in each eye
separately and add it to the distant correction
 Near point should be fixed by taking due consideration
for profession of the patient
 The weakest convex lens with which an individual can
see clearly at the near point should be prescribed, since
overcorrection will also result in asthenopic symptoms.
 Insufficiency of accommodation

 Accommodative power is significantly less than the

normal physiological limits for the patient's age
 it should not be confused with presbyopia in which the
physiological insufficiency of accommodation which is
normal for the patient's age
 Causes of insufficiency of accommodation
1. Premature sclerosis of the crystalline lens
2. General debility causing pre-senile weakness of ciliary
muscle, eg anaemia, toxaemia, malnutrition, diabetes
mellitus, pregnancy, stress,etc
3. Weakness of ciliary muscle associated with primary open
angle glaucoma
 Symptoms
Similar to presbyopia:-
 Difficulty in near vision
 Asthenopic symptoms (eye strain) → more prominent
- fatigue
-Pain around eyes
-Headache
-Blurred vision
 Intermitent diploplia
 Treatment
 The treatment is essentially that of the systemic cause
that affects ciliary muscle
 Near vision spectacles in the form of weakest convex
lens which allows adequate vision should be given till
the power of accommodation improves
 Accommodation exercises help in recovery, if the
underlying debility has passed.
Paralysis of accommodation

 Paralysis of accommodation also known as

cycloplegia refers to complete absence of
accommodation
 Causes

1. Drug induced cycloplegia e.g atropine, homatropine

2. Paralytic Internal ophthalmoplegia (paralysis of ciliary muscle
and sphincter pupillae)
 Infections like diphtheria, syphilis
 Non infectious disease like Diabetes
 Alcoholism
 cerebral or meningeal diseases
3. Paralysis of accommodation due to complete CNIII paralysis due
to lesions in the nerve such as traumatic, inflammatory or
neoplastic in nature
Clinical features

 Blurring of near vision in previously emmetropic

or hypermetropic patients
 Photophobia (glare) due to accompanying
dilatation of pupil (mydriasis)
 Treatment

 Self-recovery if cause is reversible therefore treat

underlying causes of the disease
 Dark-glasses are effective in reducing the glare
 Convex lenses for near vision may be prescribed if the
paralysis is permanent.
 Spasm of accommodation

 Spasm of accommodation refers to exertion of

abnormally excessive accommodation
 Causes

1. Drug induced spasm of accommodation eg use of

strong miotics agents like echothiophate
2. Spontaneous spasm of accommodation like in children
who attempt to compensate for poor illumination, bad
reading position, mental stress or anxiety
 Clinical features
1. Defective vision due to induced myopia.
2. Asthenopic symptoms are more marked than the visual
symptoms
 fatigue
 Pain around eyes
 Headache
 Blurred vision
 Treatment

 1. Relaxation of ciliary muscle by atropine for a

few weeks and prohibition of near work allow
prompt recovery from spasm of accommodation.
 2. Correction of associated causative factors
prevent recurrence.
 3. Assurance and if necessary psychotherapy.
THANK YOU
references

 Comprehensive ophthalmology by A.K Khurana

 UpToDate