Vision and Learning

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

Dan L. Fortenbacher, O.D., FCOVD

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. Your involvement could make the difference in a child’s life!