accommodative insufficiency
Accommodative insufficiency is an amplitude of accommodation below the lower limit expected for the patient's age.1,2 A common lower limit comes from Hofstetter's formula, 15 − (0.25 × age), and an amplitude 2 D or more below that value is considered abnormal.2
Patients usually fail the ±2.00 D flipper test and have a positive relative accommodation (PRA) under −1.50 D.1 Many can make an appropriate accommodative response, but the effort is great enough to cause asthenopia, and they may complain of blur after sustained reading or at the end of the day.1 Other complaints include blurred vision, difficulty reading, irritability, poor concentration and headaches.1
Presbyopia produces the same symptoms, but the presbyopic amplitude is normal for the patient's age, so accommodative insufficiency is generally a diagnosis in pre-presbyopes.2 Accommodative insufficiency generally has a functional cause, but ocular disease, systemic and neurologic disorders, lesions of the parasympathetic supply to the ciliary body, and many ocular and systemic drugs can also produce the condition.2 The case history must rule these causes out before treatment.2 Vision therapy to build amplitude and facility is the most effective treatment, and plus lenses at near are the alternative for a patient who cannot meet the time demands of therapy.1
More detail
Accommodative insufficiency is the only accommodative disorder with a reduced amplitude.2 Patients with accommodative insufficiency struggle with every test that requires them to stimulate accommodation, patients with accommodative excess struggle with tests that require relaxing it, and patients with accommodative infacility struggle with both.2 Accommodative paralysis reduces the amplitude dramatically and usually has a local or systemic disease or a medication behind it.2 Some patients with accommodative insufficiency overconverge through the AC/A crosslink while trying to accommodate and are wrongly classified as having convergence excess.1
Sources (4)
- Care of the Patient with Accommodative and Vergence Dysfunction (AOA clinical practice guideline)
- Scheiman and Wick, Clinical Management of Binocular Vision, ch. 12
- American Academy of Ophthalmology (2020) 'Accommodative Insufficiency', Basic and Clinical Science Course, Section 3: Clinical Optics.
- Scheiman, M., Gallaway, M., Coulter, R., Reinstein, F., Ciner, E., Herzberg, C. and Parisi, M. (1996) 'Prevalence of vision and ocular disease conditions in a clinical pediatric population', Journal of the American Optometric Association, 67(4), pp. 193–202.
Reviewed October 2026