ACCOMODATION Accommodation:- Parallel rays of light are brought to a focus on the retina by the refractive system of the eye

without any effort, thus enabling distant objects to be seen clearly. If the eye is to function adequately, it must be able to vary its focus so that it can adapt its refractive mechanism to allow objects which are near at hand to be seen clearly. In the emmetropic eye rays from infinity are brought to a focus upon the retina at R., when a near object, A, is looked at, a focus is formed behind the retina at A (the conjugate focus) and the large diffusion circles at the level of the retina will allow only a blurred image to be seen. It increasing the converging power of the eye would bring the image so that the focus would lie on the retina (from A to R) a district image could still be retained. This power of changing the focus is called accommodation. Mechanism of Accommodation Natural State of Capsule ACCOMMODATION Form * Reflexed Form Accommodated

The lens in accommodation. To show the deformation of the lens in the normal and accommodated state due to the opposing factors of the elasticity of the lens matrix and the capsule. Essential feature is an increase of the curvature of the lens, which affects mainly the anterior surface. It can be shown that in the state of rest the radius of curvature of this rays surface is 10mm while during accommodation it decreases to 6mm. Helmholtz Theory (Modern Version):- During accommodation the ciliary muscle contracts, the suspensory ligament relaxes and the elastic capsule of the lens than acts unrestrainedly to deform the lens substance into the more spherical, perhaps conoidal, accommodated shape that its own natural elasticity resists. With increasing age, inspite of unimpaired power of the ciliary muscle, changes in the lens capsule leave it with less ability to alter the mass of increasingly resistant lens substance. With increasing age, inspite of unimpaired power of the ciliary muscle, changes in the lens capsule leave it with less ability to alter the mass of increasingly resistant lens substance. Physical Accommodation:- is an expression of the actual physical deformation of the lens and it is measured in dioptres. Thus if the converging power of the lens is increased by I D - we speak of the expenditure of I D of accommodation . Physiological component unit myodioptre contractile power of the ciliary muscle required to raise the refractive power of the lens by I D. Physical accommodation fails in later life when the lens becomes hard in the condition known as presbyopia. Failure of physiological power of the ciliary muscle may occur in states of debility at any age distressing symptoms of astenopia and eyestrain from exaggerated ciliary effort.

Range and Amplitude of Accommodation:Far Point furthest distance at which an object can be seen clearly (meters), r metres, R refractive power of the eye (minimal accommodation). Near Point Nearest point which the eye can see clearly is called the near point (maximum accommodation), p distance of the near point. P refractive of the eye in accommodation. Amplitude of Accommodation:- Difference between the refractivity of the eye when at rest with minimal refraction and when fully accommodated with maximum refraction amplitude of accommodation. a = r p (range of accommodation) A = amplitude = P R. I dioptre = focal distance of 1 metre. Refractive power = reciprocal of the focal distance in meters. r = 1 m, then P = 100/10 or 10D. Thus in order to focus an object at 10cm (10/100m) we require 10x as much accommodation as is required to focus it at 1 meter. Emmetropia r = R = 1/ = 0. If near point is 10cm away. P = 10. Hypermetropia:- Amplitude of accommodation is greater than enumetropia. To see an object at 10cm he must add to this an amount of 10D to put him on an equality with the emmetrope. Distance behind the eye is negative. If he has a hypermetropia of 5D, so his far point is 1/5. The eye can adjust to bring near objects into focus. When the eye is adjusted for near vision, it is said to be accommodated. In distant vision accommodation is relaxed. Depth of Field and Depth of Focus. Depth of field refers to the range of distance from the eye in which an object appears clear without change of accommodation. The depth of clear zone is the depth of field. Depth of Focus:- range at the retina in which an optical image may move without impairment of clarity. Explanation of the range of clear vision Retinal receptors are discrete units of finite diameter. Depth of field and depth of focus are related to each other by the formula for distance of object and image from a lens. P distance of the object from the lens q distance of image from the lens f focal length of the lens. 1/p + 1/q = 1/f when distance are given in metres, then 1/p = p diopters, then formula in diopters P+Q=F. The depth of field (and of focus) is markedly influenced by the diameter of the pupil. Larger pupil cone of light with a more obtuse apex to reach the retina and shallows the fields.

Small pupil or pinhole disc small blur circles few cones of fovea overrides minor refractive errors improves image of retina. On clinical testing diffraction disturbances overtake the benefit of the small aperture, at pinhole diameters of less than 0.75mm. Even if the emmetropic eye is sharply focused, pupil diameters of less than 2.4mm reduce visual acuity because of diffraction. Changes in Accommodation The pupil contracts during accommodation and convergence. (synkinesis). The anterior pole of the lens moves forward carrying the iris with it. The posterior pole does not change its position to any extent. The anterior surface of the lens becomes more convex. The posterior surface increases its curvature slightly. Since the posterior pole remains fixed forward, and the anterior pole moves the thickness of the lens at the centre increases. As the lens increases in axial thickness, it diminishes in diameter. Changes occur in the tension of the lens capsule. During accommodation the lens sinks in the direction of gravity. Changes within the lens substance create a change in refractive power of the lens, in addition to the changes in curvature of the surface when the ciliary muscle contracts. These internal changes are brought about by changes in curvature of the various position of the lens having different indices of refractions. The total dioptric power of the lens has been found to be greater during maximal accommodation than could be accounted for on the basis of changes in the curvature of the surface. Mechanism of Accommodation Active contraction of the ciliary muscle, passive change of the shape of the lens. The young lens is a soft easily molded material contained in an elastic capsule. The lens capsule tends to mould the lens to a spherical shape, but this is opposed by the tension of the zonular fibers that suspend the lens from the ciliary body. Traction of the zonule on the lens capsule flattens the lens. The ciliary body is stretched backward and outward along the sclera by the elastic choroid. Contraction of the ciliary muscle pulls the choroid forward and the ciliary attachment of the zonule inward towards the lens, reducing the tension in the zomule and allowing the lens to increase in convexity. As the index of refraction of the lens (about 1.39) is greater than the indices of aqueous and viterous (1.334), increase in the convexity of the lens increases its dioptric power and allows near objects to be imaged clearly on the retina required to produce a given change in curvature. This force can only be applied by greater contraction of the ciliary muscle. In middle life when near vision becomes difficult or impossible the condition is called presbyopia. Presbyopia:- The amplitude of accommodation gradually recedes in eye. 8yrs - 14D. 20yrs - 11D

30yrs - 9D 50yrs - 2D. Near point closest to the eye in young and gradually recedes until age 45 years. Accommodation completely lost at age 60 years. Presbyopia is the normal recession of the near point with age. 2 Explanation:- (1) lens nucleus Accommodation with Age Amplitude of Accommodation. Early years of life - 14D - Near point/7.00cm 36 years - 7D 14cm 45 years - 4D 25cm 60 years 1D 25cm Pharmacology:- ciliary muscle is under the control of the parasympathetic nervous system. Pilocarpine muscle contraction system and accommodative spasm. Cholinesterase inhibitors eg. physostigmine (eserine) Disopropryl fluorophosphate Ecothiopate iodide. Atropine paralyze ciliary muscle, cycloplegics. Tropicamide. Anomalies of Accomodation IN CREASED ACCOMODATION Excessive Accomodation. Eg young hypermetropes, myopes A large amount of near work especially in young subjects, production of artificial myopiaeven in hypermetropes.blurred vision , vision improved by concave lenses but it should not be prescribed. Diagnosis cycloplegia with atropine but difference greater than 1D Prognosis is good. TREATMENT; Refraction under full cycloplegia then correction is found by deducting about 1 D , treat general condition. Holiday etc. b. Spasm of accommodation Comparable to that brought about by miotics such as eserine, rare usually out of control of the patientand the amount may reach 10D or more,. Patients with functional neurosis.dental lesion, iridocyclitis, toxic reactions to drugs. TREATMENT

Complete cycloplegia with atropine and this should be kept up for a long time. Correcting spectacles. DIMINISHED ACCOMODATION INSUFFICIENCY OF ACCOMODATION Two types Lenticular due to lens sclerosis leads to early presbyopia. Weaknessof the Ciliary muscle eg debility, fatigue, anaemia, malnutrition, early glaucoma accompanied by excessive use of the eyes especially for close work andertaken under unfavourable surroundings. Symptoms and Signs Asthenopia, eye strain, headaches, fatigue, irritability, blurred near vision which may become difficult or impossible. Accommodative failure is frequently accompanied by a disturbance of convergence. TREATMENT Treat existing condition, refraction correct distance and near work in presbyopia. If there is convergence excess such glasses should be prescribed urgently. By relieving the effort to accommodate much of the stimulus to converge is removed. If there is convergence insufficiency then prisms base in may add considerably to the patients comfort. Only the weakest convex lense should be prescribed so that accommodation may be exercised and stimulated. As soon as recovery takes place the additional correction for reading should be made progressively weaker. Accomodation exercises using the accommodation test card. Black vertical line drawn on white card. Exercises only in cases of ciliary insufficiency. Treat the underlying course. Ill Sustained Accomodation.: Similar to above only less accentuated. Common in mild form in those who read in the evening when they are tired. Innertia of Accomodation ;rare condition.The patient experiences some difficulty in altering range fo accommodation.It takes sometime and involves some effort for him to ofcus on a near object after looking into the distance. Paralysis of Accomodation: Drugs eg Atropine, result of disease rg paralysis of the ciliary muscle or oculomotor nerve and may be sassociated with other paralytic lesions in the muscular apparatus of the eye. Accompanied by dilatation of the pupil. Cerebral syphilis, tabes, encephalitis lethargica, trauma, influenza, herpes zoster, diabetes, chronic alcoholism, food poisoning, belladonna poisoing, botulism. TREATMENT : treat the primary condition. CYCLOPLEGIA Paralysis of the ciliary muscle. Eg atropine, homatropine, scopolamine, also paralyses sphincter muscle of the iris and cause mydriasis. MIOTICS

Eg Pilocarpine, echothiopate, physostigmine, phospholine iodide stimulate ciliary muscle contraction and induce some degree of spasm. AC/A Ratio The AC/A ratio is the amount of convergence measured in prism dioptres/unit (dioptric) change in accommodation. The normal value is 4 D. This means that I D of accommodation is associated with 4 D of accommodative convergence. The AC/A ratio is independent of the state of refraction. Abnormalities of AC/A ratio are significant causes of strabismus. A high ratio may cause excessive convergence and may produce an exotropic during accommodation on a near object. A low ratio may cause an exotropia when the patient looks at a near object. Relation Between Accommodation and Convergence In normal binocular vision, accommodation and convergence operate in unison. The chief stimulus to accommodation is a change in the vergence of light striking the retina. The basic stimuli to binocular adjustment for near vision are: Change in the vergence of light reaching each fovea and Temporal disparity of the two images relative to the fovea. The relationship between these two functions is not strictly fixed, although under normal conditions a unit change in one is accompanied by a unit change in the second. Thus I D of accommodation is ordinary accompanied by 1 metre angle of convergence. A meter angle is the angle formed by each visual axis with a line perpendicular to the interpupillary line. Some latitude is possible between accommodation and convergence. There is an amplitude of accommodation corresponding to each convergence value and convergence can vary somewhat relative to a fixed condition of accommodation. The change in convergence produced by a change in accommodation is known as accommodative convergence. The change in accommodation produced by convergence is discussed below. Fincham and Walton found that in young subjects up to age 24 years, the convergence-induced accommodation is equal to convergence, but above this age it gradually diminishes. This is probably due to the sclerosis of the crystalline lens causing a reduced response to a given nerve discharge and contraction of the ciliary muscle rather than a change in the relative innervations of the 2 functions. Accommodation can be produced by convergence alone and up to 24 years of age the physiologic maximum can be produced by this stimulus. In older person, the rate of increase in accommodation with increasing convergence is reduced. This is caused by the need for greater ciliary force to produce a given amount of accommodation. Artificial paresis of ciliary muscle with homatropine causes the maximal accommodation to be reduced at all ages. \ Maximal accommodation requires maximal force of the ciliary muscle. Miotics enhance the contraction of the ciliary muscle accompanying convergence. This results in an increase of accommodation relative to convergence and the maximal accommodation is increased above the physiologic maximum