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Brief Summary

GUIDELINE TITLE

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.

BRIEF SUMMARY CONTENT

 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Diagnosis of Accommodative and Vergence Dysfunction

The evaluation of a patient with accommodative and vergence dysfunction may include, but is not limited to, the following areas. The examination components described are not intended to be all inclusive. Professional judgment and the individual patient's symptoms and findings have a significant impact on the nature, extent, and course of the services provided. The potential components of the diagnostic evaluation for accommodative and vergence dysfunction include the following areas:

  1. Patient history
  2. Ocular examination
  3. Visual acuity
  4. Refraction
  5. Ocular motility and alignment
  6. Near point of convergence
  7. Near fusional vergence amplitudes
  8. Relative accommodation measurements
  9. Accommodative amplitude and facility
  10. Stereopsis
  11. Ocular health assessment and systemic health screening
  12. Supplemental tests
    1. AC/A ratio
    2. Fixation disparity/associated phoria
    3. Distance fusional vergence amplitudes
    4. Vergence facility
    5. Accommodative lag

Management of Accommodative and Vergence Dysfunction

Management of the patient with an accommodative or vergence dysfunction is based on such 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 or vergence 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.

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EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each recommendation.

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IDENTIFYING INFORMATION AND AVAILABILITY

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.

DATE RELEASED

1998 (reviewed 2006)

GUIDELINE DEVELOPER(S)

American Optometric Association - Professional Association

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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DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.
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