Accommodation’s 3-A’s…The Triple Play for Reading and Learning


Even after practicing for 30 years in the optometric specialty of developmental vision, working with and helping thousands of children in  vision therapy,  I’m always touched by the children who make their way to a level of success in school and academics in spite of  the burden of an unaddressed visual deficiency. My last exam yesterday was one of these children;  a bright and bubbly 11-year-old, 5th grade, homeschooled girl. Let’s call her Jenny. Jenny is a smart and highly verbal little girl who says she likes to  read. Yes…and her mother reports that Jenny is a capable reader too. But there is more to Jenny’s story.

Jenny was referred to me for a visual evaluation by her primary care optometrist who identified a vision  problem causing Jenny to have chronic frontal headaches after reading for more than 30 minutes.  Her mother told me that after Jenny reads for a while she begins to squint, blink her eyes frequently and complain that her eyes  are hurting. What’s more, I learned that even though Jenny likes to read,  her mother states that her reading comprehension is poor. Her parents try to help her by orally reading aloud to Jenny. Of course, then she is only hearing the story read to her and not really reading it on her own.  Jenny’s  health history shows no problems and she has no allergies.  Jenny claims she has no blurred vision when reading, but when sewing she has trouble sometimes seeing the thread. Jenny’s referring eye doctor did not  find any refractive error, the most common reason for prescribing corrective lenses, but did identify Jenny with some instability in her binocular vision, that looked like convergence insufficiency,  and eye-focussing difficulty.

So why would a smart 5th grader who likes to read (at least that’s what she says)  experience headaches, blink, squint and complain of her eyes hurting when reading IF she has normal healthy eyes, 20/20 eye sight at both far and near and no refractive error? What is Jenny’s visual problem that could not be addressed with just prescribing some eye glasses alone?

What my comprehensive visual assessment revealed was Jenny has a condition known as Accommodative Dysfunction which affects her ability to properly focus her eyes.   Accommodation, otherwise known as “eye focusing”,  is a vital visual function that provides the ability to adjust the lens system of the eye to see detail as an object is brought closer to the eyes.  To read this article requires your eyes to accommodate (focus) on the print. In addition, to read your eyes must stay “in focus” on the printed material for an extended period of time. What’s more you must do this with a high degree of precision in order to see the print clearly. And let’s not forget that we must periodically look away and then back to the printed material. Therefore,  for efficient reading and learning, our eyes must engage in the “triple play” of eye focusing or what can be called the 3-As of Accommodation:

A # 1. Amplitude of Accommodation: This refers to the strength ability of focus. The greater the amplitude of accommodation means an object can be held closer to the eyes and sustained in focus for a longer period  of time.

A # 2. Accuracy of Accommodation: This refers to the ability to adjust the lens system of the eyes with precision to maintain optimal clarity of the viewed object.

A #3. Agility of Accommodation: This refers to the ability to adjust and change focus from near to far rapidly and without effort.

Symptoms of  Accommodative Dysfunction usually involves some of the following:

  • Eye discomfort and/or headaches (often frontal headaches) with sustained close work like reading
  • Squinting, blinking and rubbing eyes
  • Trouble copying from the chalkboard
  • Blurred vision when reading small print
  • Vision becomes worse by the end of the day
  • Reduced attention for reading
  • Poor reading comprehension

Why is Jenny’s story important?  Largely because Accommodative Dysfunction is a relatively common visual deficiency that can have a significant impact on a child’s quality of life.  Accommodative Dysfunction has been studied and linked to an array of symptoms  associated with near visual work such as reading or computer based tasks.  It has also been linked to reading problems in children. Below are two interesting studies done within the last 5 years that shows there is scientific evidence to link Accommodative Dysfunction with serious negative consequences on the lives of children:

 

Accommodative Function in School Children with Reading Difficulties. Graefes Arch Clin Exp Ophthalmol (2008), 1769-1774

Therefore research shows that good eye focusing (accommodation function) is essential to reading, yet too often this area of visual dysfunction gains very little notoriety.   Currently the rave is all about 3-D vision, 3-D movies, 3-D  TV and 3-D games, but  there are no cool digital media devices like 3-D video games and movies that shed light on public awareness on Accommodation Dysfunction. What’s more, school vision screenings will typically exclude testing of this vital visual function, even though it is one of the most important “players” in your child’s “vision abilities team” for reading and learning.

What can be done to help children like Jenny with Accommodative Dysfunction? The best approach for patients like Jenny is a combination approach of vision therapy to help her visual brain learn and develop the essential “neural-software” for effective and effortless coordination of her accommodative system and properly prescribed reading glasses.  The best practices in  vision therapy approach for Jenny will be office-based, doctor supervised optometric vision therapy. The best prescription for Jenny’s reading glasses will be lenses with high-definition optics to maximize her ability to not only focus her eyes but also to expand her peripheral visual awareness. The importance of  prescription lenses plus office-based vision therapy will help Jenny develop her 3-As of accommodation so that her visual-stress related side effects involving frontal headaches go away and she will find the act of reading and doing classroom learning to be a visually effortless process.

And yes Jenny’s story will have a happy ending but only because she was identified by her primary care optometrist who made the referral. It is her primary care OD who is the hero! If left to the public provided visual screenings Jenny would still be enduring the headaches and eye discomfort because her problem would be unidentified. Her parents would have to continue to give assistance in any way they could, but ultimately Jenny would have to struggle and compensate for her success.

The Jennys’ of the world will continue to inspire me every time I see them. What if these kids didn’t have to struggle with an unaddressed visual deficiency of Accommodative Dysfunction? There is help available from doctors around the US and internationally, in private practice and University Clinics where optometric developmental vision and therapy services are provided.  But first, like in Jenny’s case, the primary care eye doctor is usually where the patient with Accommodative Dysfunction is diagnosed and then referred for proper vision therapy care.

Will you help? If you are a doctor, occupational therapist or other professional who works with children and have ideas or suggestions to  increase public awareness I welcome your thoughts and comments on my post. If you are a patient, concerned family member, or public advocate who is  interested in getting involved with others on this cause of vision advocacy, I encourage you to join Sovoto- The Vision Advocacy Network, take a look and contribute your thoughts to the discussion groups. Your involvement could make the difference in a child’s life!

Dan L. Fortenbacher, O.D., FCOVD

12 thoughts on “Accommodation’s 3-A’s…The Triple Play for Reading and Learning

  1. Dr. Fortenbacher,
    My name is Dan Fleischman and I have been reading Dr. Press’s and your posts for quite some time and after reading this blog post I was inspired to share my work with you. I am an Americorps volunteer and manage a new children’s vision care program at a children’s administration office in Washington State. Through this program I am not only screening all of our foster children but also setting up appointments for them with a developmental optometrist to have comprehensive examinations. Another key part to my program is community education about functional vision problems. By recruiting the assistance of some very dedicated optometrists in my community we have put on workshops to educate community members from foster parents to public health nurses to legal professionals and continue to schedule more. Americorps could be a vital resource on a national level to educate the public. It could even be possible to provide better vision screenings in schools if districts wrote the grants to get the volunteers and as long as federal funding continues of course. Americorps is a vital resource for the nation, with volunteers young and old ready to serve our country. Think of all the children that could be diagnosed and relieved of their suffering if we made vision care one of our priorities.

    • Dear Dan,
      I admire your commitment to serve as a volunteer in helping children, particularly in a program dedicated to provide children’s vision care. Thank you for sharing with us the work that you are doing. May I suggest another potential opportunity for you to gain additional insight from doctors as well as proactive individuals for vision advocacy…and that is to go to SOVOTO-The Vision Advocacy Network at: http://www.sovoto.com, join and start a discussion group. You may be surprised at amount of helpful information you will receive! Best regards,
      Dan L. Fortenbacher, O.D., FCOVD

  2. I just had a 4th grade girl in for a progress check who had an accommodative inflexibility problem. She came in with complaints of reading problems and getting D’s and F’s, reversing letters, and problems copying. I prescribed a stress-relieving lens of a very low power for indoor wear. She came back now making A’s, loving to read and no more reversals or other problems just 8 weeks later. She responded so well to the lenses, that we decided she would not need vision therapy at this time.

    • Dr. Scott,
      Thank you very much for sharing this example of how sometimes all it takes is a “nudge” from a correctly prescribed pair of reading glasses to make a huge difference for a child who is beginning to struggle with Accommodative Dysfunction. This correctly points to how important it is for a child with Accommodative Dysfunction to be first identified and second have appropriate treatment initiated. When there are no other co-existing visual problems, such as binocular or oculomotor dysfunction and if the Accommodative Dysfunction is relatively uncomplicated, reading glasses alone can be a “life saver”!

  3. Hello. I wanted to respond to your request for ideas. One of the things that has struck me with the 3-D games coming out is the number of people who have trouble seeing 3-D. (For instance, the people who had to watch the 2-D version of Avatar because the glasses made them dizzy.) The game companies must already know this and/or will have to estimate what percentage of their customer pool this is and how to handle it (at least on a legal basis (i.e. how to refund money)).

    So, my thought is, is there any way to talk one of these companies into putting a public service announcement into their game disclaimers?

    Something like: if you are having difficulties watching this movie, you should know about the field of developmental optomitry (please forgive me if that isn’t the exact right term) to have your ability to see 3-D evaluated. This is different from your ability to see 20/20 on an eye chart. Developmental optomitrists are uniquely trained to analyze this condition.

    If they wouldn’t agree to this, maybe there would even be a way to talk one of the companies into creating a pre-video analysis “test” (on their website?) that would help viewers self-select into a range of “how well do you see 3-D?” The idea is that maybe they would like some market data to tell them what percentage of the population are ideal viewers. (For example, maybe it is worth devleoping a 3-D movie for those in the 60+ age range because they can see 3-D better than you’d guess.) The companies might be talked into putting some sort of public service announcement into this section.

    The end result wouldn’t really be to get people to vision therapy. The end result would really be just to get people to start talking about where they “see” on the 3-D vision range. Once the idea is in the public “mind,” they will eventually (through Internet research such as Google) give the developmental optomitry field credibility and come themselves to distinguish between vision therapy and opthomology.

    Suddenly, the stories you tell about patients being mislead, mistreated, or misdiagnosed will be big news. The public themselves will eventually get the opthomologists (and optomitrists and other vision care specialists who don’t believe in VT) to come around.

    I am betting that the game companies have a few key people who know a whole lot about the 3 As you’ve mentioned above. They must have big money invested in assuring people see 3-D. I’m hoping there’s a way to get a tiny, tiny bit of that money aimed in a more service-oriented manner.

  4. Pamela,
    You make some really important points about how it is a win-win situation to use the 3-D viewing technology potentially as a public health vision screening tool. When someone with “stereoblindness” is identifed and instructed how to find the correct treament, that means better vision for more people and that means more people can enjoy the 3-D movies and games. That would naturally lead to more customers for the companies who produce those products. Everyone wins!

    The American Optometric Association with the help of leaders in our profession like Dr. Dominick Maino are working to get this message out.

    Now that you, as a concerned patient, have taken the initiative to write your suggestions, hopefully your voice will be heard. If others will do the same there will be an even greater chance that 3-D Technology companies will be listening and take action to utilize this wonderful experience of 3-D – Stereovision- and use it to help those who don’t realize what they are missing!

    Thanks again for being a strong patient advocate for adult patients with strabismus on Sovoto – The Vision Advocacy Network. http://www.sovoto.com/group/adultstrabismicpatientsforum?xg_source=activity

  5. Hello,
    Thank you for your detailed explanation of Accommodative Dysfunction–my 8 year old daughter was diagnosed in January 2017 with Convergence Insufficiency, along with a host of other effects (suppression, reduced peripheral vision, accomodation dysfunction), and she has been participating in in-office vision therapy weekly since then, along with daily homework exercises. Her gains have been enormous, however, there is still an area of struggle: accommodation. She also still is experiencing frequent headaches (and in fact, wakes up in the morning with headaches a lot, lately–I suspect this is due to school work load). Do you have any suggestions? (When I discuss this with the doctor, whom I love dearly, I haven’t received a lot of concrete solution(s). We have modified the accommodation exercises–hart chart reduced, minimized, etc., but no real break through unlike with all the other exercises). My daughter has glasses for myopia, and we have never discussed the possibility of lenses for up-close assistance. Would this be a good option? Are there any other ideas?

    Thank you!
    Alison

    • Alison,
      Yes, it is very common for a patient in vision therapy to have near point lenses used as visual stress relief, especially those with accommodative dysfunction. For those children who have glasses for nearsightedness we often use a clip-on designed lens to apply during extended reading, homework, etc. Bifocals can also be prescribed with the near vision optics designed exactly for the patient’s needs. One other possibility to consider, when you mention she wakes up with a headache, is the possibility of sinus problems as visual headaches would not be typically seen first thing in the morning when waking up. Be sure to talk with your doctor about these concerns.
      Dr. Fortenbacher

      • Thank you so much for your ideas! I will discuss all of these points at our appointment 🙂
        Especially grateful,
        Alison

  6. By the way, I have goosebumps right now, as I’m so thrilled to have gotten a reply from you! I’ve seen many of your videos and have a secret desire to take my daughter to WowVision in the future (to see if a grand finale in her vision can be achieved).
    Another question, if I may:
    If we utilize clip-ons or bifocals, are we hindering her ability to achieve what vision therapy ultimately sets out to do? (Meaning, can we still achieve the goal of being able to read at length, do homework, etc. without glasses eventually?)

    Again, thank you with all my heart!

    Alison

    • Hi Alison,
      My pleasure to respond. The application of near point lenses can be therapeutic and preventative when applied judiciously. By using a “plus” lens for near work the patient will often have visual stress relief which can prevent a trend toward more myopia in addition to being a support in the process of working through an accommodative dysfunction. Think of it like wearing a glove to play catch in baseball. It makes it easier to catch the ball and easier on the hands, but does not teach you how to play the game. You need coaching on learning the game but using glove will still be better than without even after you are good in the game.

      I hope that helps!
      Dr. Fortenbacher

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