Accommodative Excess/Spasm

DEFINITION:

A non-presbyopic, non-refractive sensorimotor anomaly of the visual system characterized by reduced accommodative facility and/or flexibility, over-accommodation, or accommodative spasm.

SIGNS AND SYMPTOMS:

The signs and symptoms associated with accommodative excess are related to performance of prolonged visually demanding near-centered tasks. They may include, but are lot limited to, the following:

A) More common signs and symptoms

1. Transient blurred vision (ICD: H53.8)
2. Diminished accuracy
3. Abnormal postural adaptation/working distance (ICD: R29.3)
4. Inconsistent work product
5. Reduced efficiency and productivity
6. Diminished performance with time on task/difficulty sustaining near visual function
7. Difficulty shifting focus from near to far
8. Asthenopia (ICD: H53.149)
9. Pain in or around the eye (ICD: H57.13)
10. Headaches (ICD: R51)
11. Avoidance of visually demanding tasks
12. Distance blur after performing near work

B) Less common signs and symptoms

1. Inaccurate/inconsistent visual attention, concentration, and/or awareness
2. Distractibility while performing visually demanding tasks
3. General fatigue (ICD: R53.83)
4. Illusory movement (ICD: H53.10)

DIAGNOSTIC FACTORS:

Accommodative excess is characterized by one or more of the following diagnostic findings:

1. Low accommodative amplitude relative to age or latent hyperopia
2. Reduced accommodative facility (monocular)
3. Reduced accommodative flexibility
4. Reduced accommodative stability
5. Reduced ranges of negative relative accommodation
6. Lead of accommodation
7. Unstable accommodative findings
8. Unstable refractive findings
9. Unstable retinoscopic findings
10. Inconsistent vergence findings

THERAPEUTIC MANAGEMENT CONSIDERATIONS:

The doctor of optometry determines appropriate diagnostic and therapeutic modalities, and frequency of evaluation and follow-up, based on the urgency and nature of the patient’s conditions and unique needs. The management of the case and duration of treatment would be affected by:

1. the severity of symptoms and diagnostic factors, including onset and duration of the problem
2. the complications of associated visual conditions
3. implications of patient’s general health, cognitive development, physical development, and effects of medications taken
4. extent of visual demands placed on the individual
5. patient compliance and involvement in the prescribed therapy regimen
6. type, scope, and results of prior interventions as well as etiological factors

PRESCRIBED TREATMENT REGIMEN:

The goal of the prescribed treatment regimen is to address the diagnostic factors and alleviate the presenting signs and symptoms associated with the diagnosed condition. Most accommodative excess cases require optometric vision therapy which incorporates the prescription of specific treatments in order to:

1. enhance accommodative amplitudes relative to age
2. enhance ability to sustain accommodation
3. enhance relative ranges of accommodation
4. enhance accommodative facility, flexibility, and stability relative to age
5. integrate accommodation with ocular motor skills
6. enhance accommodative/convergence relationship
7. integrate accommodative function with information processing

DURATION OF TREATMENT:

The following treatment ranges are provided as a guide. Treatment duration will depend upon the particular patient’s condition and associated circumstances. When duration of treatment beyond these ranges is required, documentation of the medical necessity for additional treatment services may be warranted for third-party claims processing and review purposes.

1. The most commonly encountered accommodative excess may require 16 to 24 sessions of office therapy in addition to therapy provided for the concurrent conditions.
2. Accommodative excess requires 32 to 48 sessions of office therapy if complicated by associated conditions such as cerebral vascular accident, head trauma, and/or other systemic conditions.

FOLLOW-UP CARE:

At the conclusion of the active treatment regimen, periodic follow-up evaluation is required. Should the signs, symptoms, or other diagnostic factors recur, further therapy may be medically necessary. Therapeutic lenses may be prescribed during or at the conclusion of active vision therapy to assist in the maintenance of long-term stability.