Accommodative Insufficiency: Prevalence, Impact and Treatment Options

Figures & data

Table 1 Summary of Selected Studies for AI Prevalence

Authors (Publication Year)	Sample Size	Diagnostic Criteria	Sample Characteristics	Country	Prevalence (%)	Standard Test Instruction Given (Yes/No)	Details of Refractive Correction Provided (Yes/No)	Tests Done for Diagnosis
Dwyer (1992)^Citation14	144	AI-5	School children (7–18 years)	USA	8	No	Yes	NPA, NRA, PRA, MAF, BAF, MEM
Scheiman et al (1996)^Citation15	2023	AI-7	School children (6–18 years)	USA	2	No	Yes	NPA, PRA MAF, BAF, MEM
Porcar and Martinez-Palomera (1997)^Citation10	65	AI-7	College students (18–19 years)	Spain	6.2	No	Yes	NPA, PRA, MAF, BAF, MEM, FCC
Rouse et al (1999)^Citation16	453	AI-2	Children (9–13 years)	USA	11.5	No	Yes	NPA, MEM
Cacho et al (2002)^Citation2	328^	AI-6	Symptomatic clinic population	Spain	12.5	No	Yes	NPA, PRA, MEM, MAF, BAF
Borsting et al (2003)^Citation29 ^$	392	AI-2	School children (8–15 years)	USA	10.5	No	Yes	NPA, MEM
Sterner et al 2006)^Citation9 ^$	72	AI-1	School children (5–10 years)	Sweden	33.3	Yes	Yes	NPA
Marran et al 2006)^Citation5 $	299	AI-1 and 4	Elementary school children (mean [SD] age: 11.5 [6.3] years)	USA	AI-1: 4.7 AI-4: 3.3	No	Yes	NPA
Hussaindeen et al (2016)^Citation8	920^	AI-8	School children (7–17 years)	India	0.2	No	Yes	NPA, MAF, MEM
Davis et al 2016)^Citation4 $	484	AI-1 and 4	School children (8–16 years)	USA	17.8	No	Yes	NPA
Wajuihian and Hansraj 2016)^Citation19	1201^	AI-6	High-school students (13–19 years)	South Africa	4.5	No	Yes	NPA, PRA, MAF, BAF, MEM
Hashemi et al 2019)^Citation18	726	AI-6	University students (18–22 years)	Iran	4.07	Yes	Yes	NPA, PRA, MAF, BAF, MEM
Nunes et al (2019)^Citation20 ^$	292	AI-3	School children (10–14 years)	Portugal	6.8	No	Yes	NPA, MAF
Abdi and Rydberg 2005)^Citation12	120	AI-1	School children (6–16 years)	Sweden	61.6	No	Yes	NPA

Notes: ^A priori sample size estimation. ⁹ Convergence Insufficiency Symptom Survey (CISS): Nunes et al (2019),²⁰ Davis et al (2016),⁴ Marran et al (2006),⁵ Borsting et al (2003); ^$Use of other symptom surveys: Sterner et al (2006).²⁹

Criteria for AI diagnosis: 1) Push-up monocular AA at least 2 D below Hofstetter’s calculation for minimum amplitude: 15–0.25 × age (years); 2) High values on monocular estimation retinoscopy >+0.75 DS; 3) Fails monocular AF testing with −2.00 D < 6 cpm; 4) AI with co-morbid CI; 5) Monocular AA below Hofstetter’s calculation for minimum amplitude: 15–0.25 × age (years); 6) PRA <−1.25 DS; 7) Push-up monocular AA below age-expected norms for the population: 16–0.3 × age (years) with complaints of near blur.

AI-1: Criterion 1 is used as the only diagnosis; AI-2: Criteria 1 and 2 are used together; AI-3: Criteria 1 and 3 are used together; AI-4: Criterion 1 is used for AI diagnosis along with a diagnosis of co-morbid CI; AI-5: Criterion 5 is used without additional details; AI-6: Three criteria are used (Criteria 1, 2 and 3); AI-7: Four criteria are used (Criteria 1, 2, 3 and 6); AI-8: Criteria are used as mentioned.

Abbreviations: NPA, push-up near point of accommodation; NRA, negative relative accommodation; PRA, positive relative accommodation; MAF, monocular accommodative facility; BAF, binocular accommodative facility; MEM, monocular estimation method; FCC, fused cross-cylinder testing.

Table 2 Symptomatology in AI as Reported by Various Authors

Authors (/Year)	Symptoms Reported in AI					Symptoms Related to Academic Performance
	Blurred Near Vision	Headache	Double Vision	Eye Strain	Facility Problem	Difficulty with Continuous Reading	Fatigue	Avoiding Reading	Downward Academic Progress
Marran et al (2006)^Citation5	√	√	√
Sterner et al (2006)^Citation9	√	√			√		√
Schieman and Wick2008)^Citation31	√	√		√		√	√	√
Borsting et al2003)^Citation29	√							√	√
Abdi and Ryderg 2005)^Citation12	√	√							√
Chase et al (2009)^Citation37								√	√

Table 3 Studies Assessing the Efficacy of Interventions for AI

Authors (Year)	Sample Size	Age Group (Years)	Treatment Groups and Comparisons	Control/Placebo Arm (Yes/No)	Treatment Period	Outcome Measures
Daum (1983)^Citation11	144	12–37	Monocular and binocular push-up accommodation training (3 times/day), accommodative flippers (± 1.50 DS) (3 times/day)	No	3–14 weeks	96% of subjects showed partial improvement in both symptom relief and AA 53% showed complete improvement in AA and symptom relief
Hung et al (1986)^Citation79	21; Only 6 had an accommodative dysfunction	18–24	In-office (±2.00 D flipper; jump focus and computer vergence training); Home orthoptic training(±2.00 D flipper)	No	30 minutes in-office orthoptic training + 15 minutes home orthoptic training/week	Increase in flipper rate (p<0.001) Improvement in tonic accommodation (p=0.011) Normalizing of near fixation disparity curve (p=0.0011)
Sterner et al (2001)^Citation80	13 (7 in orthoptic group and 6 in sham group)	6–17	Accommodative flippers (±2.00 D) (2 sessions of 9 minutes each day for each day for 3 weeks)	Yes	5 weeks	Orthoptic group showed improvement in accommodative flipper speed and relief in symptoms when compared to placebo
Wahlberg et al (2005)^Citation7	22; (11 (+1.00 D) and 11 (+2.00 D))	7–17	Plus lens (+1.00 D vs +2.00 D)	No	8 weeks	Improvement in AA by 3.28 D (+1.00 D group) and by +1.36 D (+2.00 D group) Improvement in visual analogue scale (VAS) for symptoms by 3.21 units (+1.00 D group) and by 5.57 units (+2.00 D group)
Abdi and Rydberg (2005)^Citation12	49	6–16	Plus lens of +0.75 D and +1.00 D	No	12 weeks	48 subjects were symptom free (97.95%) 1 subject had reduced symptoms
Abdi and Rydberg (2005)^Citation12	3 (AI with CI)	6–16	CI exercise (pencil push-up 5 times/day) with +0.75 D plus lens	No	12 weeks	2 subjects were symptom free 1 subject had reduced symptoms
Abdi et al (2007)^Citation72	12	8–16	Plus lens (+1.00 D)	Yes (3 control)	8 weeks	Significant improvement in AA in subjects when compared to controls (p<0.001) No change in reading speed with +1.00 D lens (p=0.28)
Brautaset et al (2008)^Citation82	19 (10 in plus lens group and 9 in vision therapy group)	7–14	+1.00 DS plus lens and accommodative flippers (±1.50 D)	Plus lens vs accommodative flipper	8 weeks	Both groups showed improved AA, accommodative flipper group showed greater improvement (F,2,34=6.97, p=0.003) Both groups showed improvement in facility, with accommodative flipper group showing better results [F1,17,=3.96, p=0.06]
Scheiman et al (2011)^Citation81	121 with accommodation dysfunctions (63 had a diagnosis of AI) (30 into office-based orthoptic, 27 into home-based orthoptic and 28 into placebo)	9–17	Home-based orthoptic therapy (pencil push-up, accommodative rock, jump duction); Office-based orthoptic therapy	Yes (compared with office-based placebo)	12 weeks	Improvement in AA by both office-based orthoptic (2.00 D, p=0.02) and home-based orthoptic (2.00 D, p=0.037) when compared to placebo Improvement in facility was noted in office-based orthoptic (4.4 cpm, p=0.0001) after 8 weeks of treatment and home-based orthoptic (2 cpm, p=0.002) when compared to placebo

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