keeping the fun in dysfunction…

Accommodative Dysfunction is widely understood as an umbrella term for the more specific inadequacies with accuracy or stamina, facility and flexibility, amplitude, or sustainability. In layman’s terms, focusing on a near target either quickly or for a prolonged period is tough.  Symptoms of a focusing weakness can include headaches, red or sore eyes, inappropriate working distances (too close or too far) and a general aversion to any task within arms reach. Sound familiar?

Depending on the severity and origin, a Developmental Optometrist may choose to prescribe glasses to assist with near visual stress, in either the short or long term.  As I tell my patients, “reading glasses” are really intended to be used for any task you can “put your hands on”; not just reading. Many times the younger patients will report that they do not need their glasses because they can “see fine without them”.  I have to remind them that, unlike others they may know, the reason they were prescribed glasses is not because the world is blurry, but because their eyes have to work so incredibly hard to keep it clear.  The glasses are intended to reduce visual stress and promote comfort.  This relationship is similar to a pair of tennis shoes on the playground; a child could play barefoot all day, but it will be a much more comfortable and enjoyable experience with their shoes on. Vision Therapy activities also play a significant role in the treatment of these symptoms – near to far shifts and lens work to name a few.  But what do we do with the kids who cannot sit still long enough to work with lenses, or who don’t want to stand still to perform near far shifts?

Get creative, that’s what.

Most of us learn that accommodation is best worked on a monocular basis (one eye at a time). When faced with a child who cannot sit or stand still, I’ve found that instead of forcing them into a posture they struggle to achieve anyway (anything sitting still), it seems more effective to “use” their movement to my advantage.  For example, rolling a ball or playing catch in the hallway while they wear a patch. It’s not ideal, but is definitely a start. The level of difficulty can be increased with the use of a trial frame; an occluder one side and some low to mid level lenses over the non-occluded eye.  The lenses and occluder can be switched every few minutes to ensure balance.

Another fun task, again utilizing and encouraging the patient’s need to move, is to invent some sort of monocular walkaway task. One of my personal favorites is to play tic-tac-toe on a small piece of paper (usually an 8.5 x 11 cut in half) taped to the wall at the patient’s eye level. With a patch on, the patient must take 10 steps backward after each turn, meanwhile I am taking my turn, they will then return to the paper to take their next turn.  As they move back and forth between each turn, we passively work fixation but more directly assist with accommodation.  Again lenses can be added to increase difficulty.

There are many variations available in treating Accommodative Dysfunction as well as other accommodative challenges, and the sky is the limit.  Since near task avoidance can be a key behavior to overcome for these patients, forcing them to do “more of the same” right off the bat can be a losing battle.  Again, the suggestions I’ve made here are not intended to provide the level precision or strength we are looking for, but it is a start. Keep in mind that if a patient has trouble sitting still and focusing in the classroom, it stands to reason they will have similar challenges in your VT room. If they need to move, let them move.

Get creative and keep it fun!



Posted on November 10, 2013, in From My Perspective.... Bookmark the permalink. 2 Comments.

  1. Thanks Robert. As you say, accommodative activities can become tedious and boring, even to the therapist.
    One of my favorites that I learned from my days with Dr. Treganza is this: On the wall is a chart with letters/numbers/symbols at the patient’s acuity level at distance. The patient is seated at a small table at their maximum viewing distance. The patient has a manual typewriter with a blank sheet of paper in it. (yes you can still buy them – ours was non-electric!) The patient looks at the distance chart and remembers as many letters as he/she can. Then looks at the typewriter and finds the corresponding character and types it in. This activity has so many benefits in addition to accommodation: visual memory, eye-hand, scanning, etc. If you put the chart to be copied behind the patient you can add vestibular stimulation, as the patient looks over their shoulder to find what comes next. Many of our patients know how to keyboard, so you must get them to “hunt and peck” in this procedure.


  2. Linda and Robert:

    Thanks for the new ideas! I think there are lots of us who struggle with this one. I also have found that some of my patients who are either non-readers (too young) or really frustrated with letters enjoy starting with use of Dr. Hillier’s Matrix blocks. The kit comes with a chart that can be placed on the wall for distance (of the shapes) and then I use the white blocks in front of the patient for the close part of the task. I sometimes have them sit on the floor, on a Belgau board cross legged, or even stand next to a tall table or stand with the blocks on it. Then, we proceed to look up at the far chart, look down and find the matching shape on the small block, and place it in the correct position in that “line” of shapes on the table. You can also get some quick lens work in up close by having them turn all of the blocks shape-side up, while you have them look through a lens that you hold in front of their unpatched eye. (I generally find that I have to make that a game too…..something like, “while you do YOUR job of turning the blocks shapes up, I’m going to do MY job and occasionally hold a lens in front of your eye for you to look through. Sometimes there will be a lens, and sometimes not.”.

    At the end, (and this might be only two lines) I go and get the chart from the wall, hand it to the patient, and ask them to look and be sure everything is right where it’s supposed to be. This allows them to self evaluate, and to see any small differences/details that maybe they missed at distance. It seems that manipulating the blocks is calming, and helps add a little “movement” even if it’s not large movement. Jenni


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