Our patient was a 12-year-old male with no past medical history who presented with difficulty reading at school. He described how words blurred together when reading at near. He denied difficulty with distance vision. He had no head turning and no reported history of behavioral problems at school or home, and no report of school and/or work issues apart from vision blurriness.

The patient started using reading glasses the previous year, but had been using them inconsistently. Other members of his family also have worn reading glasses.

Arriving at the diagnosis

In considering this patient’s symptoms, our differential diagnosis consisted of accommodative insufficiency, refractive error, convergence insufficiency and strabismus. This differential then helped us tailor our exam, with pertinent findings as follows:

• Distance VA without correction: 20/20 OU
• Near VA without correction: J3 OU prior to cycloplegia
• Objective refraction: OD + 0.50 OS + 0.25
• Motility: Full, no nystagmus
• Sensory exam: Fly positive, 3/3 animals, 7/9 circle, Worth-4-dot 4/4
• Cover/uncover/alternate cover: ortho in primary positions distance and near
• Near point of convergence: at nose
• Fusional amplitudes at near: broke 30 base-out, recovered 20 base-out.

Given his Jaeger score prior to cycloplegia, we diagnosed this patient with accommodative insufficiency and gave him a prescription for glasses with progressive add. The fact that a child his age should have no problem accommodating to J1 or 20/20 precycloplegia is what clinched our diagnosis.

The diagnosis of accommodative insufficiency is certainly one that could have been missed had we not checked near vision precycloplegia.

Discussion

Accommodative insufficiency (AI) is an inability to initiate or sustain near vision, presenting as diplopia, blurry vision, asthenopia, or headache.^1,2 While infrequently discussed in ophthalmologic literature, optometric studies have noted the incidence of AI to range from 2% to 3%.^3,4 AI is due to a congenital or acquired dysfunction of the ciliary body or any component of the accommodative reflex pathway.⁵

AI has important implications for pediatric patients in that it has been associated with increased frequency of performance and behavioral problems at school.^6,7 Though not measured in our patient, accommodative amplitude can be determined by either the push-up or spherical lens test.

Dynamic retinoscopy may reveal a sluggish or lack of return to neutrality of the red reflex when the patient refixates from distance to near. AI is typically treated with readers, though spherical flipper has been touted as having a larger effect on accommodative amplitude.⁸

The take-home point

When faced with a young patient who cannot read at near, ophthalmologists should consider accommodative insufficiency as a diagnosis. OM

REFERENCES

1. Bartuccio M, Taub M, Kieser J. Accommodative Insufficiency: A Literature and Record Review. Optometry and Vision Development. 2008. 39:35-40.
2. Glasser A , Kaufman PL. Accommodation and presbyopia. In: Kaufman PL, Alm A, eds. Adler’s Physiology of the Eye: Clinical Application. 10th ed. St Louis: Mosby; 2003:197–233.
3. Scheiman M, Gallway M, Ciner E, et al. Prevalence of visual anomalies and ocular pathologies in a clinical pediatric population. J Am Optom Assoc. 1996. 67:193-201.
4. Lara F, Cacho P, Garcia A, Megias R. General binocular disorders: prevalence in a clinic population. Ophthalmic Physiol Optom. 2001;21:70-74.
5. Kawaski A. 2005. Disorders of Accommodation. In: Miller N, Newman N, Biousse V, Kerrison J, editors. Walsh and Hoyt’s Clinical Neuro-Ophthalmology. Volume one. 6th ed. Philadelphia (PN): Lippincott Williams & Wilkins. pp. 739-809.
6. Grisham D, Power M, Riles P. Visual skills of poor readers in high school. Optometry. 2007; 78:542-549.
7. Borstig E, Rouse M, Chu R. Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency: a preliminary study. Optometry. 2005;76:588-592.
8. Brautaset R, Wahlberg M, Abdi S, Pansell T. Accommodation insufficiency in children: are exercises better than reading glasses? Strabismus. 2008 Apr-Jun; 16:65-69.

About the Authors

 

Claire Kiernan, MD, is resident physician in ophthalmology, Hamilton Eye Institute, University of Tennessee Health Science Center. She has a doctorate in medicine from Rush Medical College, where she received the 2015 William Hamlin Wilder, MD, endowed scholarship for ophthalmology. Her e-mail address is ckierna2@uthsc.edu.

 

Natalie C. Kerr, MD, FACS, FAAP, is the Roger L. Hiatt, senior professor of Ophthalmology, University of Tennessee Health Science Center in Memphis; residency program director; chief of pediatric ophthalmology at Le Bonheur Children’s Medical Center.