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Clues for the Diagnosis of Accommodative Excess and Its Treatment with a Vision Therapy Protocol

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Clues for the Diagnosis of Accommodative Excess and Its Treatment with a Vision Therapy Protocol Ophthalmology Research: An International Journal 13(3): 32-42, 2020; Article no.OR.60891 ISSN: 2321-7227 Clues for the Diagnosis of Accommodative Excess and Its Treatment with a Vision Therapy Protocol Carmelo Baños1,2, Eneko Zabalo3 and Irene Sánchez1,4,5* 1Departamento de Física Teórica, Atómica y Óptica, Universidad de Valladolid, Valladolid, Spain. 2General Optica, Burgos, Spain. 3Bidasoa Optika, Ikusgune Centro de optometría, Donostia-San Sebastián, Spain. 4Instituto Universitario de Oftalmobiología Aplicada (IOBA), Universidad de Valladolid, Valladolid, Spain. 5Optometry Research Group, IOBA Eye Institute, School of Optometry, University of Valladolid, 47011, Valladolid, Spain. Authors’ contributions This work was carried out in collaboration among all authors. Author CB designed the study, performed the statistical analysis, wrote the protocol, wrote the first draft of the manuscript and managed the literature searches. Author EZ collected the data, wrote the protocol, managed the literature searches and wrote the first draft of the manuscript. Author IS designed the study, performed the statistical analysis, wrote the protocol, managed the analyses of the study, managed the literature searches and wrote the first draft of the manuscript. All authors read and approved the final manuscript. Article Information DOI: 10.9734/OR/2020/v13i330171 Editor(s): (1) Dr. Tatsuya Mimura, Tokyo Women's Medical University Medical Center East, Japan. Reviewers: (1) Md. Abdul Alim, Rural Development Academy (RDA), Bangladesh. (2) Carlo Artemi, Minister of Public Education, Italy. (3) Prajakta Paritekar, Sankara Eye Hospital, India. Complete Peer review History: http://www.sdiarticle4.com/review-history/60891 Received 06 July 2020 Accepted 12 September 2020 Original Research Article Published 21 September 2020 ABSTRACT Introduction: Accommodative and vergence dysfunctions are the most common vision disorders in the pediatric population with a prevalence of up to 30%, and patients with these dysfunctions usually have symptoms at near distances that could affect academic results. This study is the retrospective assessment of accommodative excess cases and aims to find a pattern in optometric exams to help diagnose accommodative excess without cycloplegic drugs. Furthermore, this study assesses the utility of a vision therapy protocol as accommodative excess treatment. _____________________________________________________________________________________________________ *Corresponding author: E-mail: [email protected]; Baños et al.; OR, 13(3): 32-42, 2020; Article no.OR.60891 Methodology: A retrospective study was conducted with 24 patients who were diagnosed with accommodative excess and completed all sessions of the vision therapy protocol. The vision therapy protocol was organized into 8-12 sessions. Statistical analysis was performed using SPSS 23.0. Wilcoxon nonparametric paired tests were used to compare the clinical values between visits. Results: In total, 24 patients with accommodative excess were included in the retrospective study. The pairwise comparisons of sphere values obtained with the different refraction methods without cycloplegic drugs found statistically significant differences (P< 0.01). Statistically significant differences (P< 0.01) were shown in the sphere values obtained from subjective refraction, visual acuity tests, near point of convergence and stereopsis between the diagnosis visit and the post- vision therapy protocol visit, with better values post-therapy. Conclusion: Variations in the sphere values could be clues for accommodative excess if a double condition is given, the retinoscopy results are more positive than the subjective refraction findings (>0.60D) and are more positive than the values obtained with an auto refractor (>1.75D). Keywords: Accommodative excess; vision therapy; pseudomyopia; spasm of the near reflex; accommodative spasm. 1. INTRODUCTION because some studies include the same diagnosis for AE, accommodative spasm and New technologies have changed the way of life spasm of the near reflex [15,16]. in developed countries in the past 30 years. These technologies lead to higher use of visual This study follow the clinical criteria proposed by functions overall at near distances. In addition, Scheiman & Wick because this is the criteria the use of screens (smartphones, laptops, accepted by other authors [17]. AE could be computers, televisions, etc.) is present in both defined as a condition in which the subject exerts work and personal life and decreases the time more accommodation than required for the visual spent outdoors using visual functions at far stimulus or is unable to relax after the distances [1,2]. This fact could be related to an accommodation [15]. increase in the incidence of myopia in recent years, especially in urban environments [3-6], Diagnosing AE can be difficult without with an increase in asthenopia symptoms that cycloplegic drugs because many optometrists are related to accommodative and vergence around the world usually do not use cycloplegic dysfunction [2,7,8]. refraction. However, it is possible to find some clues from optometric exams that suggest a It is believed that these dysfunctions are more diagnosis of AE, such as variable visual acuity frequent today and are related to the extended findings, variable static and subjective refraction use of visual functions at near distances caused findings, low monocular estimate method or by the increase in the number of years spent at fused cross-cylinder findings, low negative school or the increase in indoor activities [2,9- relative accommodation values, high positive 11]. Accommodative and vergence dysfunctions relative accommodation values or failure of are the most common visual disorders in the monocular and binocular accommodative facility pediatric population, with a prevalence higher with +2,00 Diopters (D) [13,14,18,19]; than 30% depending on the study consulted pseudomyopia is also considered a variable sign [10,11]; the prevalence is between 13% and 30% of accommodative excess [15]. in the higher education population [12-14], usually with symptoms at near distances that In all accommodative and vergence dysfunctions, could affect academic results [9,13]. the first option of treatment must be refractive error prescriptions, even for mild refractive Accommodative excess (AE) is an errors. If the dysfunction still persists, sometimes accommodative dysfunction that is characterized vision therapy can be the primary treatment by symptoms such as headache, asthenopia, method [16,17,20]. A correct diagnosis of blurred vision after completing tasks at near accommodative or vergence dysfunction and a distances and other nonspecific symptoms correct prescription for the refractive error are [11,14,15]. AE has a prevalence that varies from necessary to choose a suitable combination of 0.8% to 10% depending on the study population exercises for vision therapy. A wrong [10-14]. The definition of AE can be confused combination of exercises could lead to the failure 33 Baños et al.; OR, 13(3): 32-42, 2020; Article no.OR.60891 of the vision therapy protocol, even when it is the phoropter VT-200 (Topcon, Japan) at a distance first option for treatment [16,21]. The goal of of 60 centimeters under scotopic conditions. vision therapy is to restore the balance in visual Refraction was measured with a phoropter and functions in order to lessen the symptoms during the Snellen chart. Stereopsis was measured with habitual visual activities [20]. a fusion of vectographic crosses at distance and with the TNO test (OOTECH Lameris, Holland) at For these reasons, the purpose of this study is to a distance of 40 centimeters with red-green retrospectively assess AE cases to find a pattern spectacles under photopic conditions. The cover from optometric exams to help in the diagnosis of test was measured at a distance of 6 meters with AE without cycloplegic drugs. Furthermore, this the Snellen chart and at a distance of 40 study assesses the utility of the vision therapy centimeters with the Snellen chart for near protocol for the treatment of AE. distance readings under photopic conditions; an esophoria (at far or near distance); or an 2. METHODOLOGY exophoria at far distance value equal or above 3 prismatic diopters (Δ) or an exophoria at near 2.1 Study Design distance above 6 Δ were considered out of the normal limits follow the Scheiman & Wick criteria A retrospective study was conducted with for horizontal phorias. Accommodation facility patients who were between 7 and 30 years old; was measured with flippers ±2.00 diopters at a were diagnosed with accommodative excess; distance of 40 centimeters under photopic inclusion criteria were of visual acuity below conditions as cycles per minute. NPC was 20/20 (Snellen chart) with the most positive measured with a pen torch at a distance of 40 subjective refraction findings without cycloplegic centimeters under photopic conditions [13]. drugs after discard any pathology and completed the vision therapy protocol. To verify the Complete optometric exploration was carried out accommodative excess diagnosis, a complete to verify the exclusion criteria: previous eye examination and binocular vision intraocular/strabismus surgery, ocular or head assessment were carried out, including a case- trauma and any systemic or eye pathology. history reflecting the full range of symptoms Refraction value is not an exclusion criteria. presented by the patient, visual acuity tests, Complete binocular
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