REFRACTIVE ERRORS

AND
ACCOMMODATIVE
ANOMALIES IN
CHILDREN
Dr. Paula Eunice C. Felix
 Astigmatism Management
● Before 4–6 years:
○ Symmetrical astigmatism >1.5 D and oblique astigmatism ≥1.0D
should be corrected early to prevent amblyopia.
● After 7 years:
○ Full correction is necessary to support higher visual functions and
prevent asthenopia.
 Anisometropia
● Threshold for Amblyopia:
○ ≥1.0 D hyperopia, ≥2.0 D myopia,
and ≥1.5 D cylindrical anisometropia
can cause amblyopia in young
children.
● Age-Related Shift:
○ After 6 years, a shift toward myopia
increases anisometropia prevalence,
reflecting different eye growth
rates.
○ Hyperopes can also develop
anisometropia, though the
mechanism is unclear.
 Anisometropia
● Prevalence:
○ Global variations exist, affecting
treatment approaches.
○ A U.S. study on the Indian population
found a 15% prevalence.
○ Anisometropia can develop between
6–12 years, even if absent at age 6.
● Correlation with Eye Structure:
○ Anisometropia is linked to axial length
differences, not corneal curvature.
○ Even 0.5 D anisometropic myopia
should be corrected, as it may trigger
progressive myopia and worsening
anisometropia.
 Anisometropia
● Types:
○ Anisohypermetropia
○ Anisomyopia
○ Anisoastigmatism
○ Aniseikonia
 Anisometropia
Amblyopia & Anisometropia:

● Anisometropia is the sole cause of amblyopia in

37% of cases and coexists with strabismus in 24%
(PEDIG study).
● Treatment of anisometropia is crucial for
amblyopia management.

Effects in Older Children (6–7+ Years):

● Not necessarily amblyogenic, but impacts

stereoacuity and contrast sensitivity.
● Even minor anisometropia can cause eye strain
and headaches, requiring cycloplegic refraction for
proper diagnosis.
 Antimetropia
● Antimetropia in children is a
type of anisometropia where
one eye is myopic
(nearsighted) and the other is
hyperopic (farsighted).
 Antimetropia
Key Points & Important Notes:
1. Prevalence and Causes:

●
●

2. Association with Amblyopia:

●
●
 Antimetropia
Key Points & Important Notes:

3. Impact on Binocular Vision:

●
●

4. Management & Treatment Approaches:

● Correction with Glasses or Contact Lenses:

○
○
● Amblyopia Therapy:
○
○
● Refractive Surgery (in older children or adults):
○
 Will Early Prescription of
Spectacles Improve Visual
Function or Functional Vision?
● Visual Function:

● Functional Vision:
 Early Spectacle Correction &
Amblyopia Management
● Research Findings:
○ Spectacle correction between 6 months and 4 years reduces strabismus and amblyopia.
○ Improved VA to 6/12 or better by age 4.
○ Children with high isometropic hyperopia show VA improvements (6/9 or better) over time.
● Practical Challenges:
○ Most children do not seek consultation before 3–4 years.
○ Wearing spectacles is difficult for children under 3 years.
○ Strabismus is often the only reason for early consultation.
● Alternative Management:
○ If uniocular amblyopia due to hyperopia is detected early but spectacles are not feasible,
■ Occlusion therapy (patching the good eye) is recommended until the child accepts
spectacles.
Importance of Early Diagnosis
● Photo Screening:
○ A highly effective method for early detection of refractive errors.
○ Helps in early amblyopia management, though spectacle compliance
remains a challenge in young children.
● Impact of Uncorrected Hyperopia & Astigmatism on Functional Vision:
○ Children (4–5 years old) with:
■ Hyperopia >4.0 D or Astigmatism ≥1.5–2.0 D show poor visuomotor
and visuocognitive skills.
■ These skills improve significantly after wearing glasses.
ACCOMMODATIVE
ANOMALIES IN
CHILDREN
Basics of Accommodation
● Anatomical Structures involved:
○ Ciliary Muscles (Circular and Meridional)
○ Zonules
○ Crystalline Lens
○ Iris

● Accommodative Stimuli
○ Blur of the Object
○ Proximity of the Target
○ Changing Target Size
○ Convergence of the Eyes
○ Spatial Frequency
 Accommodation
● Accommodation is the ability to focus on
objects at varying distances.

● Present at birth but improves rapidly

within the first 6 months of life .

● Infants have a high level of

accommodation , allowing them to focus
from infinity to very close distances .
Basic Accommodation Process
 Amplitude of Accommodation
● Amplitude of Accommodation:
a. Donder ’s AOA Chart
b. Hofstetter ’s AOA:
i. Maximum: 25-0.4 (Age)
ii. Average: 18.5-0.3(Age)
iii. Minimum: 15-0.25(Age)
 Amplitude of Accommodation
● Definition: The amount of accommodation (in diopters)
required to focus from infinity to the nearest possible
point.
● Though accommodation and convergence are related,
they do not develop together from birth.
● The accommodative system is complex—beyond just
amplitude, other functions contribute to visual performance.

Clinical Relevance:

● Underdevelopment of any part of the accommodative

system can lead to ocular symptoms in children.
● Understanding different aspects of accommodation is
essential for early diagnosis and treatment of vision
issues.
Accommodation vs Convergence
● During Neonatal Period:
a. Accommodation:
i. Fixed & Myopic (after birth)
ii. Gradual Improvement (4
months old)
b. Convergence:
i. Gradual Improvement (4
months old)
● Interconnected but distinct
development -> flexible & adaptable
visual system until maturity
 Different Facets of
● Amplitude of
Accommodation
accommodation
● Tonic accommodation (TA)
● Lag of accommodation
● Convergence
accommodation
● Accommodative facility
● Relative accommodation.
 Amplitude of Accommodation
● Definition: The eye's total
accommodative power (measured in
diopters).
● Test Methods:
a. Donders Push-up Method:
Uses the RAF ruler to measure
near point accommodation.
b. Sheard’s Method: Uses minus
lenses at a distance target to
determine amplitude.
● Clinical Importance: Commonly
tested in routine practice.
 Amplitude of Accommodation
● Definition: The eye's total
accommodative power (measured in
diopters).
● Test Methods:
a. Donders Push-up Method:
Uses the RAF ruler to measure
near point accommodation.
b. Sheard’s Method: Uses minus
lenses at a distance target to
determine amplitude.
● Clinical Importance: Commonly
tested in routine practice.
 Tonic Accommodation
● Definition: Passive state of
accommodation in the absence of
stimuli, often measured in darkness
or with a bright empty field.
● Measurement:
a. Cycloplegia (paralysis of
accommodation)
b. Infrared optometer
● Significance: Varies with refractive
errors.
 Lag of Accommodation
● Definition: The difference
between the accommodative
stimulus and the eye's
accommodative response.
● Measurement: Dynamic
retinoscopy
● Clinical Relevance: Helps
detect under-accommodation
in children.
Convergence Accommodation (CA/C Ratio)
● Definition: The amount of
accommodation induced
by eye convergence.
● Ratio: Dioptric change in
accommodation per prism
diopter of convergence.
● Clinical Use: Evaluates
binocular vision issues.
 Accommodative Facility
● Definition: The ability to rapidly
adjust focus between different
distances.
● Test:
a. Flipper Test using ±2D lenses
b. Cycles per minute (cpm) are
measured
● Normative Data:
a. Children (6–12 years): 4–5
cpm
b. Below 3 cpm indicates
accommodative dysfunction
 Relative Accommodation (PRA &
●
NRA)
Positive Relative Accommodation (PRA):
Maximum accommodation exerted beyond
convergence demand.
● Negative Relative Accommodation (NRA):
Minimum accommodation required to maintain
clear vision at a fixed distance.
● Test Method: Gradual increase of plus or minus
lenses while fixing convergence at 40 cm.
● Clinical Relevance:
a. Low NRA: Suggests accommodative
spasticity
b. Low PRA: Indicates fatigue in near work
 Accommodative Convergence (AC/A
● What it measures: Ratio)
The AC/A ratio quantifies how much accommodative convergence
is induced by each diopter (a unit of measurement for lens power)
of accommodation.
● Clinical Significance:
An abnormally high or low AC/A ratio can indicate binocular vision
problems, such as convergence excess or near esotropia (a
condition where the eyes turn inward when focusing on near
objects).
● Normal Range:
While the "normal" range is often cited as 3-5:1, it's important to
note that this range isn't based on data collected from a truly
"normal" population.
 Accommodative Convergence (AC/A
● High AC/A Ratio: Ratio)
A high AC/A ratio can be associated with certain types of strabismus (eye
misalignment) and may require treatment to address the underlying issue.
● Low AC/A Ratio:
A low AC/A ratio can indicate a deficiency in the ability to converge the eyes,
potentially leading to difficulty with near vision.
● Factors Affecting AC/A Ratio:
Several factors can influence the AC/A ratio, including orthoptic training, presbyopia,
cycloplegia, and refractive error.
● Treatment:
Treatment options for conditions related to an abnormal AC/A ratio can include
observation, bifocal glasses, vision therapy, and/or surgery.
● Clinical Methods:
Clinicians can use various methods to assess the AC/A ratio, including the gradient
AC/A and the clinical AC/A methods.
ACCOMMODATIVE
DYSFUNCTION IN
CHILDREN
 Symptoms of ACC Dysfunction
1. Asthenopia (Eye Strain): Red eyes,
frequent rubbing, irritation, disinterest in near
work.
2. Other Symptoms: Headaches, diplopia
(double vision), blurred vision, vertigo,
drowsiness.
3. Common Causes:
a. Accommodative insufficiency, infacility,
fatigue, spasm, and paresis.
b. Refractive errors (astigmatism,
hyperopia, anisometropia).
c. Neurological disorders, drug side
effects, ocular inflammation.
 Practical Dysfunctions
It is difficult to group together accommodative dysfunctions, as
the boundaries are often unclear. However, clinically it is useful to
separate anomalies of accommodation into five distinct syndrome
categories:
1. Insufficiency of accommodation
2. Infacility of accommodation
3. Fatigue of accommodation
4. Spasm of accommodation
5. Paresis of accommodation
 Accommodative Insufficiency
● Inability to achieve expected
accommodative amplitude for
age.
● Symptoms: Asthenopia,
headaches, difficulty reading,
double vision.
● Can occur in children, especially
those on psychological
medications.
 Accommodative Infacility

● Difficulty rapidly adjusting focus

between near and far.
● Vision eventually clears but
takes longer (>1 second).
● Common in students switching
between blackboard and notes.
 Fatigue of Accommodation
● Ciliary muscles fail to maintain
contraction for near work.
● Results in blurred vision
shifting to a farther point.
● Rare in children but may be
linked to undiagnosed
hyperopia or astigmatism.
 Spasm of Accommodation
● Involuntary, excessive
contraction of ciliary muscle.
● Symptoms: Distance & near blur,
brow ache, constant headaches,
sometimes diplopia.
● Dynamic retinoscopy shows no
accommodation change.
 Paresis of Accommodation

● Partial or complete failure of

accommodation.
● Causes: Cycloplegic drops,
neurological issues, medications
(sedatives, antipsychotics).
● May cause functional weakness
in ciliary muscles.
 Clinical Importance & Diagnosis
● Symptoms often misattributed to
refractive errors—proper tests needed.
● Accommodative dysfunction should be
diagnosed through multiple tests.
● Accommodative facility can be
deficient even when amplitude is
normal.
● Identifying & addressing these issues
early prevents academic and
vision-related struggles
 Asthenopia
● Can occur in the following conditions:
○ Accommodative insufficiency
○ Accommodative infacility
○ Accommodative fatigue
○ Accommodative spasm
○ Dyslexia
○ Hysteria
○ Ocular inflammations
○ Phorias-ocular motility disorders
○ Latent nystagmus
○ Aniseikonia
○ Refractive errors: Astigmatism; hyperopia;
and anisometropia, Accommodative paresis
 Accommodative Therapy
1. Accommodative Dysfunction in Children
2. Standard Treatment
3. Importance of New Vision Care in Children
 Accommodative Dysfunction in
Children
● Common in children, especially
during near work.
● Most frequent types:
Accommodative insufficiency &
infacility.
● Causes: Often not due to
neurological or general health
issues.
 Standard Treatments
A. Plus Lens Addition

● Used in cases of:

○ Accommodative insufficiency (difficulty
maintaining focus).
○ Excessive lag of accommodation (eye
response is slower than stimulus).
○ Low PRA (Positive Relative
Accommodation) (difficulty increasing
accommodation).
○ Fatigue of accommodation (eye muscles tire
quickly).
● Prescription:
○ Reading glasses or bifocals.
 Standard Treatments
B. Orthoptic Exercises

● Purpose: Strengthen accommodation and vergence.

● Techniques:

○ Push-up Exercise: Improves vergence and

accommodation.
○ Flipper Method: Uses alternating plus/minus lenses
to build accommodative flexibility.
○ Synoptophore Machine: Traditional but less
practical due to attendance issues.
○ Home-based exercises: Equally effective as
clinic-based therapy.
● Scientific Evidence: Facility therapy techniques improve
accommodative function.
 Importance of Near Vision Care in
Children
● Increase in near work complaints due to digital
screens (computers, mobile games).
● Asthenopia (eye strain) is a major problem in
schoolchildren.
● Even with correct glasses, symptoms may
persist due to underlying accommodative issues.
● Parental concern is high, but many cases stem
from accommodative deficiencies.
 Assignment: Deadline Mar
● Read the American Academy31
of Ophthalmology article: “Typical
and Atypical Development of Ocular Alignment and Binocular
Vision Infants - The Background” , and answer the following
questions:
○ What is the significance of Angle Kappa in diagnosing
strabismus?
○ Explain how Accommodation and Convergence develop
independently from each other.
○ In Figure 1B, explain how poor acuity affects OKN/motion
processing, absence of single binocular vision, presence of
refractive error, fixed overaccommodation, and and gross
misalignment of the eyes in developing infants.
 REFERENCES
● Typical and Atypical Development of Ocular Alignment and
Binocular Vision in Infants – The Background. (2019, June 5).
American Academy of Ophthalmology.
https://www.aao.org/education/disease-review/typical-aty
pical-development-of-ocular-alignment-b