Project Report

On

"COMPARING THE ACCOMMODATION FACILITY

AMONG THE EMMETROPES, MYOPES AND HYPROPES
AND THE LEVEL OF RECOVERY AMONG THEM AFTER
VISION THERAPY"

Teerthanker Mahaveer University, Moradabad

Submitted for partial fulfillment of the requirement of the award of the

BACHELOR OF OPTOMETRY

Submitted by

ARVIND KUMAR

TPS1510006

Submitted To

Mr. ZAINUL ABIDEEN

Department of Optometry
Course-B.OPTOM

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 CERTIFICATE

This is to certify that the Project entitled "COMPARING THE ACCOMMODATION

FACILITY AMONG THE EMMETROPES, MYOPES AND HYPROPES AND THE

LEVEL OF RECOVERY AMONG THEM AFTER VISION THERAPY" which is

submitted by ARVIND KUMAR in partial fulfillment of the requirement for the award of

BACHELOR OF OPTOMETRY was carried out under my supervision.

Mr. ZAINUL ABIDEEN

Department of Optometry

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25*3

ACKNOWLEGMENT

No words can describe the gratitude, which I would like to express to all the

persons in making this present work successful.

First, I owe my heart full gratitude to my respected teacher guide of this Project

Mr (Dr. ASHISH CHANDER) for their interest, timely suggestions, invaluable

guidance and advice at every stage of this work .

I am also deeply indebted to (TEERTHANKER MAHAVEER MEDICAL

COLLEGE & RESEARCH CENTRE) MORADABAD.

I would like to thank all the ophthalmologist, optometrists, ophthalmic officers,

other technical and non- technical staff of the Hospital who has always been

helpful to me during my internship periods on completion of this project.

I am thankful to all my teachers of my college especially my guide

(MR.ZAINUL ABIDEEN)

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 CONTENTS
Page No.

INTRODUCTION 5

LITERAUTRE REVIEW 11

AIM AND OBJECTIVES 12

METHODOLOGY 13

RESULT 14

DISCUSSION 16

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 PREFACE

The process by which the refractive power of the eyes is adapted to ensure a

clear retinal image seen is known as accommodation. This division in refractive

power allows the retina to be conjugate with a variety of object distance.

INTRODUCTION:

Hypermetropia (hyperopia) or long sightedness-In this refractive condition

the parallel rays of light that are coming from infinity are focused behind of the

retina and the accommodation is being at rest

Myopia/Short sightedness-It is the type of refractive error in which the parallel

light rays coming from infinity are focused in front of the retina with

accommodation at rest

Astigmatism-In this refractive error rays of light are not focused at a single

point instead a line focused is formed

Accommodation :The human eye is provided by a special

mechanism by which a human eye can change the refractive power of

the lens focus on the object that are held at different distance

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Ocular structure concerned with the accommodation .

 Ciliary muscle

 Ciliary body

 Zonules

 Lens capsule

FAR positon/ PUNCTUM PROXIMUM: The farest point of an object

when its image clearly focus on retina with no effort of accommodation.

NEAR Position/ PUNCTUM REMOTUM: The nearest position of an

object at which it seems clear with maximum accommodation.

HOFSTETTER’S FORMULA:

A = 15 - 0.25 (X)

Where X= age of the patient

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MECHANISM OF ACCOMMODATION

Ciliary muscles contract

Zonules relax

Lens becomes more convex anteriorly

Result dioptric power increases

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 TYPES OF ACCOMMODATION

1. TONIC ACCOMMODATION

2. PROXIMAL ACCOMMODATION

3. REFLEX ACCOMMODATION

4. CONVERGENCEACCOMMODATION

1. TONIC ACCOMMODATION:This type of accommodation is due to

the tonus of the ciliary muscle and is active in the absence of a stimulus.

The value of tonic accommodation varies between individuals and

usually is 0.75D to 1.50D.

2. PROXIMAL ACCOMMODATION: This type of accommodation is

due to the awareness of the nearness of the target. This is independent of

actual dioptric power.

3. REFLEX ACCOMMODATION: It is an automatic adjustment

response to blur which is made to maintain a Clear and sharp retinal

image.

4. CONVERGENCE ACCOMMODATION: The amount of

accommodation stimulated or relaxed associated with convergence.

Clinically this is noted as the blur value when performing base out and

base in fusional reserves at near and BO at distance. The relation between

accommodative Convergence is clinically expressed as the AC/A ratio.

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 ACCOMMODATIVE ANOMALIES:

ACCOMMODATION INFACILITY

Accommodative infacility is a condition in which the patient feel difficulty to

change the accommodative response point.

An important characteristic of accommodative infacility is that it is the latency

& speed of the near point focused are abnormal.

CLINICAL FEATURES -

Symptoms:

These symptoms are generally related to the eyes for reading or other near tasks:

 Blurring of vision, particularly when looking from near to far or

far to near object.

 Headaches

 Eyestrain

 Reading problems

 Fatigue,& sleepiness

 A pulling sensation around the eyes

 Avoidance of reading and other close work

Signs:

 Direct measure of accommodative facility

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  Difficulty clearing -2.00 and +2.00(flipper) with monocular

accommodative facility

 Indirect measures of accommodative facility

 Difficulty cleaning -2.00 and +2.00 with binocular

accommodative facility

Differential diagnosis of Accommodative infacility.

Function disorder to rule out:

Convergence excess

Basic esophoria

Accommodative insufficiency

Accommodative infacility

INVESTIGATION:

 Case history: Blurring of near vision with general

asthenopicsymptoms

 Visual acuity: Distance vision is normal but near vision is poor

 Cover test: An exophoria is demonstrated for near fixation, with

good recovery becoming esophoria on extreme effort to

accommodate.

 Refraction:Cycloplegic refraction.

 Ocular Motility: In all nine gaze

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 NPC/NPA: done with RAF rular.

 Amplitude of accommodation: By Hofstetter’s formula

 Accommodative Facility: with help of flipper of +/-2.00DS

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 AIMS AND OBJECTIVE

 This study is basically aimed to analyze the comparisionof the

accommodative facility between emmetropes,myopes and hypropes and

the improvement level after giving therapy to them for the given period of

time

 To briefly determine the risk factor that are the major leading problem of

accommodative infacility.

 To understand the need of correcting of the accommodative infacilityin

different age of groups

 Giving them the best exercise which are going to help in management of

accommodative infacility and decreasing the problem.

 To determine in which patient the recovery is earlier and better(i.e. either

in myopes ,hyperopes ,emmetropes)

 To note down the recovery after doing the exercise with the help of

flipper and to subjectively analyze the patient response in terms of

reduction of problems

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 STATEMENT OF PROBLEM

In this project, accommodative infacility show long time easurement technique

and the patient fell fatigue and try to solved the patient problem for correct

measurement in deferent patient easily.

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 LITERATURE REVIEW
The data on the comparing the accommodation facility among the

myopes,hypropes and emmetropes presented by Duane in 1912 , still used as

reference values today. Duane’s data were compared with the ,accommodative

infacility data of Donders (1864) in a revaluation by Hofstetter (1944). In the

analyse by Duane (1912) many essential issues are found that are unclear detail

include the studied population , how age was calculated, a description of the

methodology, the number of measurements, and whether one or both eyes were

studied in each individual. The measuring technique used (flippers

technique)was discussed in later analyse (Sheard, 1957, Woodruff, 1987).

Absolute data of the comparing the accommodation facility among the

myopes,hypropes and emmetropes are consequently based on data from old

studies.

The difference between the power needed to focus at near object and the far

object of eye is known as amplitude of accommodation. The measurement of

the accommodation infacilityis a part of routine examination. In clinical

subjective techniques are commonly used to measure accommodationinfacility.

The commonly used subjective techniques for comparing th accommodative

facility among the myopes,hyperopes and emmetropes and importance after the

vision therapy with fllipers. the present study has examined the accommodation

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infacility using flippers technique in a range of subjects between 12 to 30 years

of age.

Many clinicialhave observed that patients shighest accommodation infacility

with the flippers method. This study quantifies the difference between the

techniques the comparing the accommodation facility with flippers method.

This study showed that flippers method result comparing in

emmetropes,myopes,hypermetrops.

The difference between the methods is proclaim according to the type

accommodative stimulation in the pushup technique, the angular size of the

retinal image increases. Hence the flippers method gives highest

accommodative facility.

In flippers method the subjects viewed the target at a distance of approx 33 cm

and foused on 6/12.

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 METHODOLOGY

1. Study Design

A cross-sectional study was madeand randomly selection of sample was made

to determine the accommodative facility using various subjective techniques in

patient between age of (10-30 years) in Venu Eye Institute & Research Centre,

New Delhi.

2. Study team

The procedure was performed by well experienced and educated medical team

which consist one opthalmologistone intern optometrist two senior optometrist

all the team members are well trained about handling and using the instruments

that are required in this study

3.Logistic Material-

Following materials are used in this study which are given below

 Data collection sheet

 Projector chart

 Torches

 Cycloplegic eye drops

 Trial set with trial frame

 Retinoscope

 Prescription sheets

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  Slit lamp

 Flipper

4.Study Population :

In this crossectional study,100 subjects of age group from 10-30 years were

identified and then accommodative facility is measured in OPD with carefully.

5.Inclusion criteria:

Patients from age 10 to 30 years are included for measuring their visual acuity

the patients whose unaided or aided vison is 6/6 are included(i.e. subjects with

myopia ,hypermetropia,astigmatism ,emmetropia are included)

6.Exclusion criteria:

 Any ocular pathology (congenital or acquired) and structural deformity.

 Any anomaly of accommodation (lag of accommodation)

 Best corrected Visual acuity is less than 6/6

 Any ocular muscles paralysis.

 Disorder of the visual pathway.

3. Data Collection and Analysis:

Firstly, Data collection forms were prepared. All data forms were kept secretly

and with safety. The data collection form comprises of demographic data, visual

acuity, systemic and ocular history etc.

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 Data collection of every follow up is also considered. After data

collection, the data were analyzed by repeated measurement of analysis

of variance.

Procedure of screening

For the screening procedure a well illuminated room is required

 The projection chart is to be kept a 6 meter distance from the patient

 The optometrist firstly have to note down the complain of the patient and

then medical history is taken (systemic, ocular medication/surgeryetc)

 Then optometrist did the torch light examination and recorded visual

acuity with carefully.

 If the unaided visual acuity of the subject is less than 6/6 then the

optometrist have to do the refraction of the subject

 The refractive errors are initially determined by Retinoscope and have to

refined by subjective refraction and duchrome test

 After that accommodative facility of the subject is measured with the help

of flipper+/-2.00DS

 The measurmentof IOP is to be done along with the anterior segment and

posterior segment examination

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 If all the findings of anterior segment and posterior segment found to be

normal then themeasurment of accommodative facility of the patient take

place with the help ofFlipper(+/-2.00D).

 After the measurment of accommodative facility put value in the data

collection sheet

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 RESULT

 After evaluating 45patent(15 Emmetropes, 15 Myopes, 15 Hyperopes) it

was found that there is comparatively good accommodative facility in

Emmetropes & Hypropes.

 After 15 days of exercise good improvement was seen in maximum

subjects.

 In case of Hypropes show the highest values of improvement after the

vision therapy.

 Improvement in accommodative facility, Hyperopes shows maximum

improvement in comparison to Emmetropes & Myopes.

 Myopes shows significantly less improvement in accommodative facility

in comparison to Emmetropes & Hypropes.

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 CONCLUSION AND RECOMMENDATION

 Through the cross sectional study we found that the accommodative

facility plays a great role in my project.Some Abnormality in

accommodative facility leads to the significant problems in daily life. So

it is important to carried out the orthoptics examination in daily OPD.

 Abnormality in accommodative facility can be easily improve with

proper counseling &some Orthopticsexercise

LIMITATION

-Some limitation in my project are;

- Sample size is less.

- Age group may be different.

FUTURE SCOPE

In this project show importance of vision therapy with flipper. Flippers show

high level of recovery in myopic person.

BIBLIOGRAPHY

A.K Khurana .fifth edition( optics and refraction)

J.K Kanski .second edition(optics and reftaction)

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 APPENDIX-I

IN EMMETROPIC CASES:-

Improvement After
Right Eye Left Eye 1st day Evaluation
S.no Age/Sex Vision Therapy with
Vision Vision with flipper(in CPM)
flipper (in CPM)

1 18/M 6/6 6/6 4cpm 9cpm

2 19/M 6/6 6/6 3.5cpm 8cpm
3 21/F 6/6 6/6 2cpm 9cpm
4 15/F 6/6 6/6 5cpm 12cpm
5 16/M 6/6 6/6 6cpm 12cpm
6 17/M 6/6 6/6 5cpm 9cpm
7 26/M 6/6 6/6 7cpm 13cpm
8 24/F 6/6 6/6 2cpm 8cpm
9 22/M 6/6 6/6 4.5cpm 9cpm
10 27/F 6/6 6/6 2cpm 15cpm
11 15/M 6/6 6/6 1cpm 8cpm
12 28/M 6/6 6/6 5cpm 11cpm
13 17/F 6/6 6/6 4cpm 9cpm
14 15/M 6/6 6/6 2cpm 7cpm

15 14/M 6/6 6/6 6.5cpm 13cpm

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 IN MYOPIC CASES

1st day Improvement Subjective Test or

Right Left Evaluation After Vision PMT
S.no Age/Sex Eye Eye with Therapy with
Vision Vision flipper(in flipper (in Right Eye Left Eye
CPM) CPM)
22/M 6/6 3.5cpm -0.50DC180 -0.25DC120
1 6/6 8cpm
-2.50DS -0.50DS/-
20/F 6/6 2cpm
2 6/6 7cpm 0.75DC90
27/F 6/6 2.5cpm -0.25DS -0.50DC90
3 6/6 9cpm
-0.75DC180 -0.25DS/-
18/M 6/6 5cpm
4 6/6 10cpm 0.25DC90
-0.50DC160 -2.25DS/-
14/F 6/6 7cpm
5 6/6 13cpm 0.50DC50
19/M 6/6 4.5cpm -1.00DS/-0.50×90 -0.50DS
6 6/6 9cpm
27/F 6/6 1cpm -0.50DS -0.25DS
7 6/6 7cpm
25/M 6/6 5cpm -3.00DS/-0.75DC90 -1.00DC70
8 6/6 11cpm
22/F 6/6 5.5cpm -0.50DC60 Plano
9 6/6 10cpm
20/M 6/6 3cpm Plano -0.25DC90
10 6/6 8cpm
23/M 6/6 5cpm -1.00DS -0.50DS
11 6/6 9cpm
29/M 6/6 5cpm -0.75DC90 -0.50DC120
12 6/6 11cpm
27/F 6/6 6cpm -0.50DS -0.75DC70
13 6/6 13cpm
14/M 6/6 3cpm -0.75DC180 -0.25DS
14 6/6 8cpm
20/M 6/6 7cpm -1.00DS -0.75DS
15 6/6 12cpm

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 IN HYPERMETROPIC CASES
Improvem Subjective Test or
1st day -ent After PMT
Right Evaluation Vision
Left Eye Right Eye Left Eye
S.no Age/Sex Eye with Therapy
Vision
Vision flipper(in with
CPM) flipper (in
CPM)
26/F 6/6 5cpm +0.50DS +0.75DS
1 6/6 10cpm
24/M 6/6 4.5cpm +0.25DC180 +0.50DS
2 6/6 9cpm
19/F 6/6 5cpm +0.25DC120 +0.50DS
3 6/6 9cpm
25/F 6/6 4cpm +0.50DS +0.25DC90
4 6/6 13cpm
+1.00DS +1.50DS/
18/F 6/6 3cpm
5 6/6 10cpm 1.25DC40
17/M 6/6 4cpm +0.75DS +0.50DC90
6 6/6 9cpm
20/F 6/6 4cpm +1.50DS +0.0.75DS
7 6/6 09cpm
19/M 6/6 7cpm +0.50DS Plano
8 6/6 13cpm
16/F 6/6 5cpm +0.50DC170 +0.50DC90
9 6/6 12cpm
26/F 6/6 6cpm Plano +1.00DC90
10 6/6 14cpm
28/F 6/6 2.5cpm +0.75Ds +0.50DS
11 6/6 8cpm
13/F 6/6 4cpm +0.75DC140 +0.50DS
12 6/6 10cpm
22/F 6/6 5.5cpm +0.75DC80 +1.25DC70
13 6/6 12cpm
Plano +0.50Ds/+0.25
17/M 6/6 3cpm
14 6/6 9cpm DC90
+1.50DS/+0.50DC +0.50DS
16/M 6/6 5cpm
15 6/6 11cpm 170

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 APPENDIX-II

PERFORMA

DATE - REG NO -

NAME – ADD-

SEX/AGE –

B.P - SYSTEMIC

DISEASE – C/O –

VISUAL ACUITY - OD OS

UNAIDED –

WITH GLASS –

PIN HOLE –

IOPwih time –

COLOR VISION –

SUBJECTIVE TEST-

SLIT LAMP EXAMINATION –

LID –

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CORNEA

ANT.CHMB-

PUPIL-

LENS-

FUNDUS WITH I/O-

OTHER INVESTIGATION( if needed);-

1. OPTICAL COHARANCE TOMOGRAPHY

2.SPECULAR MICROSCOPY

3. PACHYMETRY

4. FFA

5. VISUAL FIELD

TREATMENT

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