Guideline:
Care of the patient with accommodative and vergence dysfunction
Bibliographic Source(s)
- American Optometric Association. Care of the patient with accommodative and vergence dysfunction. 2nd ed. St. Louis (MO): American Optometric Association; 1998. 89 p. (Optometric clinical practice guideline; no. 18). [160 references]
Guideline Status
This is the current release of the guideline.
According to the guideline developer this guideline has been reviewed on a biannual basis and is considered to be current. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.
Guideline Category
Diagnosis
Evaluation
Management
Treatment
Intended Users
Health Plans
Optometrists
Guideline Objective(s)
- To identify patients at risk for developing accommodative or vergence dysfunction
- To accurately diagnose accommodative and vergence anomalies
- To improve the quality of care rendered to patients with accommodative or vergence dysfunction
- To minimize the adverse effects of accommodative or vergence dysfunction and enhance the quality of life of patients having these disorders
- To inform and educate other health care practitioners including primary care physicians teachers parents and patients about the visual complications of accommodative or vergence dysfunction and the availability of treatment.
Target Population
Patients of all ages with accommodative and vergence dysfunction
Interventions and Practices Considered
Diagnosis
- Patient History
- Ocular Examination
- Visual Acuity
- Refraction
- Ocular Motility and Alignment
- Near Point of Convergence
- Near Fusional Vergence Amplitudes
- Relative Accommodation Measurements
- Accommodative Amplitude and Facility
- Stereopsis
- Ocular Health Assessment and Systemic Health Screening
- Supplemental Tests
- Accommodative Convergence/Accommodation Ratio
- Fixation Disparity/Associated Phoria
- Distance Fusional Vergence Amplitudes
- Vergence Facility
- Accommodative Lag
- Assessment
- Graphical Analysis
- Zones of Comfort
- Comparison to Expected Values
- Fixation Disparity and Vergence Adaptation
- Comparison of Methods of Analysis
Treatment
- Optical Correction
- Vision Therapy
- Lens and Prism Therapy
- Medical (Pharmaceutical) Treatment
- Surgery
Major Outcomes Considered
Not stated
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
The guideline developer performed literature searches using the National Library of Medicine's Medline database and the VisionNet database.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not applicable
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
The Reference Guide for Clinicians was reviewed by the American Optometric Association (AOA) Clinical Guidelines Coordinating Committee and approved by the AOA Board of Trustees.
Major Recommendations
Diagnosis of Accommodative and Vergence Dysfunction
The evaluation of a patient with accommodative and vergence dysfunction may includebut is not limited to the following areas. The examination components described are notintended to be all inclusive. Professional judgment and the individual patient's symptomsand findings have a significant impact on the nature extent and course of the servicesprovided. The potential components of the diagnostic evaluation for accommodative andvergence dysfunction include the following areas:
- Patient history
- Ocular examination
- Visual acuity
- Refraction
- Ocular motility and alignment
- Near point of convergence
- Near fusional vergence amplitudes
- Relative accommodation measurements
- Accommodative amplitude and facility
- Stereopsis
- Ocular health assessment and systemic health screening
- Supplemental tests
- AC/A ratio
- Fixation disparity/associated phoria
- Distance fusional vergence amplitudes
- Vergence facility
- Accommodative lag
Management of Accommodative and Vergence Dysfunction
Management of the patient with an accommodative or vergence dysfunction is based onsuch interpretation and analysis of the examination results.
The general goals for treating accommodative and/or vergence dysfunction are:
- To assist the patient to function efficiently in school performance at work and/or in athletic activities
- To relieve ocular physical and psychological symptoms associated with these disorders.
The frequency and composition of evaluation and management visits for accommodative orvergence dysfunction is summarized in the table below.
Frequency and Composition of Evaluation and Management Visits for Accommodative or Vergence Dysfunction
| Dysfunction | Number of Evaluation Visits | Treatment Options | Prognosis | Number of Follow-Up Visits | Management Plan* |
| Convergence insufficiency (CI) | 1 | Vision therapy (VT); prism | Excellent | 15 to 20 | Provide in-office VT with supplemental home VT; use prisms if patient is not able to participate in VT; educate patient |
| Divergence excess (DE) | 2 | VT; prism; minus lenses; surgery | Good | 30 | Provide active VT; use passive VT including occlusion base-in prism and minus lenses for non communicative patient; surgery if VT is not successful or the deviation is too large; educate patient |
| Basic exophoria | 1 | Prism; VT | Good | 30 | Treat near problems like CI; treat distance problems like DE; educate patient |
| Convergence excess | 1 | Plus lenses; VT; prism | Excellent | 15 to 25 | Prescribe plus lens addition at near; provide VT for residual symptoms; increase plus acceptance; use prism for the nonresponsive patient; educate patient |
| Divergence insufficiency | 1 to 2 | Vision therapy; prism | Fair | 15 to 25 | Differentiate functional DI from acquired DI in children; refer patient for MRI if neurological; treat with VT or prismatic correct at distance; educate patient |
| Basic esophoria | 1 | Prism; VT | Good | 20 | Eliminate deviation by correcting hyperopia; prescribe prismatic correction; provide VT for residual asthenopia and to eliminate prism; educate patient |
| Fusional vergence dysfunction | 1 | VT | Excellent | 15 to 20 | Provide VT balanced between convergence and divergence; treat abnormal accommodative system; educate patient |
| Vertical phorias | 1 to 2 | Prism; VT | Good | 20 | Correct vertical deviation with prism; if vergence dysfunction proceed with horizontal vergence VT; educate patient |
| Accommodative insufficiency | 1 | VT; plus lenses | Excellent | 15 to 20 | Provide VT to build accommodative amplitudes and accommodative facility; prescribe plus lenses at near; educate patient |
| Ill-sustained accommodation | 1 | VT; plus lenses | Excellent | 10 | Treat with VT or plus lenses; educate patient |
| Accommodative infacility | 1 | Plus lenses; VT | Excellent | 10 | Improve speed of accommodation with plus lenses initially; proceed with vision therapy; educate patient |
| Paralysis of accommodations | 1 | Optical correction | Poor | --- | Determine underlying cause; correct with progressive lens when necessary; educate patient |
| Spasm of accommodation | 1 to 2 | Plus lenses; VT; cycloplegic drug | Fair | 10 | Begin with plus lenses and VT; if VT fails use cycloplegic agent temporarily; educate patient |
Note: VT = vision therapy
MRI = magnetic resonance imaging
* See original guideline document for other management strategies
Clinical Algorithm(s)
An algorithm is provided for Optometric Management of the Patient with Accommodative Dysfunction.
Type of Evidence supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Potential Benefits
Most accommodative and vergence dysfunction responds to the appropriate use of lenses prisms or vision therapy. It is medically necessary for the optometrist to diagnose the condition accurately discuss the diagnosis and the risks and potential benefits of existing treatment options with the patient and initiate treatment when appropriate. Treatment including lenses prisms and vision therapy is not age restricted. Vision therapy can be given at any age. In some cases the best treatment includes a combination of lenses prisms and/or vision therapy. Proper treatment usually results in rapid cost-effective and permanent improvement in visual skills.
Potential Harms
Not stated
Qualifying Statements
Clinicians should not rely on this Clinical Guideline alone for patient care and management. Please refer to the references and other sources listed in the original guideline for a more detailed analysis and discussion of research and patient care information.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Clinical Algorithm
Patient Resources
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- American Optometric Association. Care of the patient with accommodative and vergence dysfunction. 2nd ed. St. Louis (MO): American Optometric Association; 1998. 89 p. (Optometric clinical practice guideline; no. 18). [160 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
Funding was provided by the Vision Service Plan (Rancho Cordova California) and its subsidiary Altair Eyewear (Rancho Cordova California)
Guideline Committee
American Optometric Association Consensus Panel on Care of the Patient with Accommodative or Vergence Dysfunction
Composition of Group that Authored the Guideline
Members: 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.
AOA Clinical Guidelines Coordinating Committee Members: John F. Amos O.D. M.S. (Chair); Kerry L. Beebe O.D.; Jerry Cavallerano O.D. Ph.D.; John Lahr O.D.; Richard L. Wallingford Jr. O.D.
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
According to the guideline developer this guideline has been reviewed on a biannual basis and is considered to be current. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the American Optometric Association Web site.
Print copies: Available from the American Optometric Association 243 N. Lindbergh Blvd. St. Louis MO 63141-7881
Availability of Companion Documents
None available
Patient Resources
The following are available:
- Answers to your questions about eye coordination. St. Louis MO: American Optometric Association. (Patient information pamphet).
- Answers to your questions about vision therapy. St. Louis MO: American Optometric Association. (Patient information pamphet).
Print copies: Available from the American Optometric Association 243 N. Lindbergh Blvd. St. Louis MO 63141-7881; Web site www.aoanet.org.
Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.
NGC STATUS
This summary was completed by ECRI on December 1 1999. The information was verified by the guideline developer on January 31 2000.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions as follows:
Copyright to the original guideline is owned by the American Optometric Association (AOA). NGC users are free to download a single copy for personal use. Reproduction without permission of the AOA is prohibited. Permissions requests should be directed to Jeffrey L. Weaver O.D. Director Clinical Care Group American Optometric Association 243 N. Lindbergh Blvd. St. Louis MO 63141; (314) 991-4100 ext. 244; fax (314) 991-4101; e-mail JLWeaver@AOA.org.
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