Accommodative and Vergence Dysfunction
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OPTOMETRY: OPTOMETRIC CLINICAL THE PRIMARY EYE CARE PROFESSION PRACTICE GUIDELINE Doctors of optometry are independent primary health care providers who examine, diagnose, treat, and manage diseases and disorders of the visual system, the eye, and associated structures as well as diagnose related systemic conditions. Optometrists provide more than two-thirds of the primary eye care services in the United States. They are more widely distributed geographically than other eye care providers and are readily accessible for the delivery of eye and vision care services. There are approximately 32,000 full-time equivalent doctors of optometry currently in practice in the United States. Optometrists practice in more than 7,000 communities across the United States, serving as the sole primary eye care provider in more than 4,300 communities. Care of the Patient with The mission of the profession of optometry is to fulfill the vision and eye Accommodative and care needs of the public through clinical care, research, and education, all of which enhance the quality of life. Vergence Dysfunction OPTOMETRIC CLINICAL PRACTICE GUIDELINE CARE OF THE PATIENT WITH ACCOMMODATIVE AND VERGENCE DYSFUNCTION Reference Guide for Clinicians Prepared by the American Optometric Association Consensus Panel on Care of the Patient with Accommodative or Vergence Dysfunction: Jeffrey S. Cooper, M.S., O.D., Principal Author Carole R. Burns, O.D. Susan A. Cotter, O.D. Kent M. Daum, O.D., Ph.D. John R. Griffin, M.S., O.D. Mitchell M. Scheiman, O.D. Reviewed by the AOA Clinical Guidelines Coordinating Committee: John F. Amos, O.D., M.S., Chair Kerry L. Beebe, O.D. Jerry Cavallerano, O.D., Ph.D. John Lahr, O.D. NOTE: Clinicians should not rely on the Clinical Richard L. Wallingford, Jr., O.D. Guideline alone for patient care and management. Refer to the listed references and other sources for a more detailed analysis and discussion of Approved by the AOA Board of Trustees March 20, 1998 research and patient care information. The Reviewed February 2001, Reviewed 2006 information in the Guideline is current as of the date of publication. It will be reviewed periodically © American Optometric Association, 1998 and revised as needed. 243 N. Lindbergh Blvd., St. Louis, MO 63141-7881 Printed in U.S.A. Accommodative and Vergence Dyxfunction iii iv Accommodative and Vergence Dyxfunction TABLE OF CONTENTS II. CARE PROCESS .............................................................................. 25 A. Diagnosis of Accommodative and Vergence Dysfunction......... 25 INTRODUCTION ............................................................................................. 1 1. Patient History.................................................................. 25 2. Ocular Examination.......................................................... 26 I. STATEMENT OF THE PROBLEM ................................................. 3 a. Visual Acuity.................................................................... 27 A. Description and Classification of Accommodative and Vergence b. Refraction................................................................ 27 Dysfunction .................................................................................. 4 c. Ocular Motility and Alignment............................... 28 1. Accommodative Dysfunction ............................................. 5 d. Near Point of Convergence..................................... 28 a. Accommodative Insufficiency .................................. 5 e. Near Fusional Vergence Amplitudes ...................... 29 b. Ill-Sustained Accommodation................................... 5 f. Relative Accommodation Measurements................ 30 c. Accommodative Infacility......................................... 5 g. Accommodative Amplitude and Facility ................ 30 d. Paralysis of Accommodation .................................... 6 h. Stereopsis................................................................ 30 e. Spasm of Accommodation ........................................ 6 i. Ocular Health Assessment and Systemic Health 2. Vergence Dysfunction ........................................................ 6 Screening................................................................. 31 a. Convergence Insufficiency........................................ 8 3. Supplemental Tests........................................................... 31 b. Divergence Excess .................................................... 8 a. Accommodative Convergence/Accommodation c. Basic Exophoria........................................................ 9 Ratio........................................................................ 31 d. Convergence Excess ................................................. 9 b. Fixation Disparity/Associated Phoria...................... 33 e. Divergence Insufficiency .......................................... 9 c. Distance Fusional Vergence Amplitudes ................ 33 f. Basic Esophoria ........................................................ 9 d. Vergence Facility .................................................... 33 g. Fusional Vergence Dysfunction................................ 9 e. Accommodative Lag............................................... 33 h. Vertical Phorias......................................................... 9 4. Assessment and Diagnosis................................................ 34 B. Epidemiology of Accommodative and Vergence Dysfunction .. 10 a. Graphical Analysis.................................................. 34 1. Accommodative Dysfunction ........................................... 10 b. Zones of Comfort.................................................... 35 a. Prevalence............................................................... 10 c. Comparison to Expected Values ............................. 35 b. Risk Factors............................................................ 10 d. Fixation Disparity and Vergence Adaptation.......... 37 2. Vergence Dysfunction ...................................................... 11 e. Comparison of Methods of Analysis....................... 37 a. Prevalence............................................................... 11 B. Management of Accommodative and Vergence Dysfunction .... 38 b. Risk Factors ........................................................... 12 1. Basis for Treatment .......................................................... 38 C. Clinical Background of Accommodative and Vergence a. Vision Therapy........................................................ 38 Dysfunction............................................................................... 13 b. Lens and Prism Therapy ......................................... 46 1. Accommodative Dysfunction ........................................... 13 2. Available Treatment Options............................................ 49 a. Natural History........................................................ 13 a. Optical Correction................................................... 49 b. Common Signs, Symptoms, and Complications..... 14 b. Vision Therapy........................................................ 51 c. Early Detection and Prevention .............................. 15 c. Medical (Pharmaceutical) Treatment...................... 52 2. Vergence Dysfunction ...................................................... 16 d. Surgery.................................................................... 53 a. Natural History........................................................ 16 3. Management Strategy for Accommodative Dysfunction.. 53 b. Common Signs, Symptoms, and Complications..... 19 a. Accommodative Insufficiency ................................ 53 c. Early Detection and Prevention .............................. 23 b. Ill-Sustained Accommodation................................. 53 c. Accommodative Infacility....................................... 53 d. Paralysis of Accommodation .................................. 53 e. Spasm of Accommodation ...................................... 54 Accommodative and Vergence Dyxfunction v 4. Management Strategy for Vergence Dysfunction............. 54 a. Convergence Insufficiency...................................... 54 b. Divergence Excess .................................................. 56 c. Basic Exophoria...................................................... 56 d. Convergence Excess ............................................... 56 e. Divergence Insufficiency ........................................ 57 f. Basic Esophoria ...................................................... 57 g. Fusional Vergence Dysfunction.............................. 58 h. Vertical Phorias....................................................... 58 5. Patient Education.............................................................. 58 6. Prognosis and Followup ................................................... 58 CONCLUSION ................................................................................................ 61 III. REFERENCES .................................................................................. 62 IV. APPENDIX ........................................................................................ 79 Figure 1: Control Theory of Accommodative and Vergence Interactions....................................................................... 79 Figure 2: Potential Components of the Diagnostic Evaluation for Accommodative and Vergence Dysfunction.................... 80 Figure 3: Optometric Management of the Patient with Accommodative