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 Table of Contents    
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 403-406  

Accommodative insufficiency in post-COVID-19 case with refractive error

Department of Ophthalmology, College of Medicine, Qassim University, Buraydah, Al Qassim, Saudi Arabia

Date of Submission15-Jan-2022
Date of Decision12-Jun-2022
Date of Acceptance04-Jul-2022
Date of Web Publication02-Nov-2022

Correspondence Address:
Sultan H Alrashidi
Associate Professor, Department of Ophthalmology, College of Medicine, Qassim University, Qassim
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.ojo_19_22

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The aim of the case report is to present refractive error with accommodative insufficiency as a possible postinfectious manifestation of coronavirus disease-2019 (COVID-19). Three weeks after the COVID-19 infection, a 22-year-old subject presented with blurring of distance and near vision with a frontal headache after prolonged near work. The patient was not using any refractive correction before the COVID-19 infection. This case report describes the diagnosis, management, and treatment of accommodative dysfunction in a patient with a history of COVID-19 infection.

Keywords: Accommodative facility, accommodative insufficiency, amplitude of accommodation, fusional vergence, post-COVID syndrome, refractive error

How to cite this article:
Alrashidi SH. Accommodative insufficiency in post-COVID-19 case with refractive error. Oman J Ophthalmol 2022;15:403-6

How to cite this URL:
Alrashidi SH. Accommodative insufficiency in post-COVID-19 case with refractive error. Oman J Ophthalmol [serial online] 2022 [cited 2023 Jan 27];15:403-6. Available from: https://www.ojoonline.org/text.asp?2022/15/3/403/360400

   Introduction Top

Coronavirus disease-2019 (COVID-19) is an infection caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Nearly 10%–35% of people affected by SARS-COV-2 showed persistence of symptoms after recovered from acute phase of the disease. Hence, it is termed post-COVID syndrome (PCS) where the symptoms extending beyond 3 weeks from the onset of the first symptom and chronic COVID-19 as extending beyond 12 weeks.[1] The common systemic findings of the PCS are cough, fever, fatigue, shortness of breath, chest pain, headache, neurocognitive difficulties, muscle pains and weakness, gastrointestinal upset, rashes, metabolic disruption, thromboembolic conditions, depression, and other mental health conditions. The ocular manifestations of COVID-19 are conjunctivitis, chemosis, hyperemia, epiphora, photophobia, dry eye, optic neuritis, cranial nerve palsies, nystagmus, retinal lesions, and panuveitis.[2],[3]

Here, reporting a case of accommodative insufficiency (AI) with refractive error as a possible PCS. AI is an anomaly that occurs when the amplitude of accommodation (AA) is lower than the expected patient's age and is not associated with crystalline lens changes due to aging. AI is characterized by an inability to focus or sustain clear near vision for period of time, asthenopia, diplopia, poor reading comprehension, and headache while reading.[4] This case has not been reported previously and written informed consent has been obtained from the patient.

   Case Report Top

On November 22, 2020, a 22-year-old healthy subject presented with complaints of blurry vision for distance and near, pain in and around the eyes, and experiencing a frontal headache after 20–30 min of near work for a week. The patient was tested positive for real-time reverse transcription-polymerase chain reaction (rRT-PCR) for SARS-CoV-2 from a nasopharyngeal swab on October 15, 2020. The patient neither required any hospitalization nor specific treatment because there is only a dry cough and fever that lasted for a week. On November 1, 2020, the patient was tested negative for COVID-19 by rRT-PCR testing. Three weeks later, the patient developed the abovementioned ocular complaints and visited the clinic. Otherwise, the patient had no remarkable ocular, systemic, or family history and never had an eye examination or attended clinic before.

On ocular examination, the distance visual acuity was measured using E chart at 3.6-m distance with Electronic Visual acuity System-SAVE APRAMED and near acuity was measured with Snellen standard rotating near-point chart in the phoropter. The preliminary eye examination findings are shown in [Table 1].
Table 1: Preliminary eye examination findings

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Cycloplegic refraction was carried out 40–50 min after the instillation of the first drop with pupillary dilation of more than 6 mm. The postmydriatic test and a complete assessment of the patient's binocular vision were performed after 3 days of a cycloplegic refraction, and the findings are shown in [Table 2].
Table 2: Initial Binocular vision examination findings

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The patient was diagnosed to have compound myopic astigmatism with AI. Hence, flat top bifocals with add +1.00Ds was prescribed. The patient was advised to use glasses and called for a follow-up (f/u) after a month.

In December 2020 (f/u visit # 1), the patient reported comfortable distance and near vision with correction, however, the patient complained that still cannot see smaller prints at 30 cm without glasses and occasional episodes of headache after prolonged near work. In-office vision therapy was initiated due to reduced AA, positive relative accommodation (PRA), and lag in monocular estimation method (MEM) retinoscopy was seen in the f/u binocular vision assessment [Table 3]. Each therapy session lasted for 45 min where monocular accommodative training was initiated followed by binocular activities. This included with Hart chart, lens sorting, and loose lens rock, accommodative flipper ±1.50Ds lenses with 0.8 reduced Snellen target at 40 cm, and brock string for the first three sittings and followed by a change in training for accommodation facility with ±2.00DS lenses and computer vergence training for 12 sittings for 15 days. Accommodative facility assessment was done at the end of the therapy sessions. After 15 days of vision therapy, the patient was advised to continue his spectacles combined with daily 15-min home-based vision therapy consisting of ±2.00D lens flipper facility and far-near letter chart accommodative rock. The patient was asked to come for f/u after 4 weeks.
Table 3: Comparison of first follow-up visit and postvision therapy examination findings

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The patient did not report on the set date, however, revisited the clinic on February 15, 2021 (f/u visit # 2), and reported that there was an improvement after doing the vision therapy that was prescribed. Hence, the patient was encouraged to continue the home-based vision therapy and the visit was rescheduled to April 15, 2021 (f/u visit # 3). The binocular vision assessment findings on February and April 2021 are shown in [Table 3].

The single vision spectacles were prescribed as shown in subjective refraction and the patient was asked to report after 8 weeks. The patient visited the clinic (f/u visit #4) on July 2021 and reported complete relief of symptoms for near and there was no headache with current spectacles. His ocular examination and binocular vision assessment parameters were within normal limits.

   Discussion Top

AI is a nonstrabismic binocular vision anomaly characterized by AA always two diopters lesser than Hofstetter's minimum expected amplitudes for age, monocular accommodative facility of <6 cpm with ±2.00 D lenses, binocular accommodative facility less than 3 cpm with ±2.00 D lenses, lag of accommodation more than 0.75 D in MEM retinoscopy, and a PRA <1.25 D.[4],[5] The patient has shown the entire abovementioned characteristics with difficulty in clearing minus lenses during monocular and binocular accommodative facility testing. The sequential management for the case of AI began with the correction of ametropia, added near lenses, and then optometric vision therapy.[6],[7]

Several systemic findings and factors are found to be associated with accommodative dysfunction such as neurasthenia, emotional factors, toxic conditions, dental infections, endocrine disturbances, nasal obstruction, decompression sickness, menopause, alcohol, and medications such as stimulants, phenothiazine, antihistamines, cycloplegics, and diseases such as malaria, glandular fever, influenza, anemia, mumps, measles, diabetes mellitus, multiple sclerosis, arteriosclerosis, and myotonic dystrophy.[8]

The underlying cause of AI is not well understood; however, studies suggest that AI is caused by reduced action in the phasic mechanism of accommodation and possible abnormalities in the tonic mechanism of accommodation. Similarly, Liu et al. and Gottlieb et al. also agreed on this suggested cause and showed that the phasic mechanism of accommodation improves with treatment.[9],[10] The patient's symptoms are predominantly related to reading difficulty, the sequential management approach of AI treatment such as correction of ametropia, added lenses, and vision therapy was considered. The patient got benefitted from the near addition of + 1.00 Ds lenses for near activities which was determined from patient's AA, MEM retinoscopy, and by balancing the PRA and negative relative accommodation. However, the patient showed symptoms and signs of AI on the first f/u visit but showed progressive improvement in symptoms with vision therapy.

Studies have shown that bilateral AI may accompany an acute illness or infection and it is a common nonpathological, nonspecific manifestation of a viral illness, also it does not represent damaged neural pathways that have insidious onset and resolves as the patient's systemic condition improves.[8],[11],[12] The patient also reported difficulty in near activities and signs of AI as a post-COVID-19 manifestation and eventually resolved with the prescription of spectacles and vision therapy. However, AI may co-occur with lesions in parasympathetic pathway, other systemic illnesses, neurological diseases, and ocular disorders. As with other viral diseases, AI is presumed to be self-limited PCS and can be managed with correction of ametropia, added near lenses, and/or vision therapy.

There is a significant improvement in AA using plus lenses at near and vision therapy and long-term improvements are seen with vision therapy. Hence, a detailed binocular vision assessment is mandatory before prescribing added lens and initiating vision therapy for patients who reports headache and near vision difficulty after acute illness or any systemic insult.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.


I would like to thank the patient who signed the informed consent and publication consent to write his ocular findings and management as a case report.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, et al. Post-acute COVID-19 syndrome. Nat Med 2021;27:601-15.  Back to cited text no. 1
Nasiri N, Sharifi H, Bazrafshan A, Noori A, Karamouzian M, Sharifi A. Ocular manifestations of COVID-19: A systematic review and meta-analysis. J Ophthalmic Vis Res 2021;16:103-12.  Back to cited text no. 2
Zhou Y, Duan C, Zeng Y, Tong Y, Nie Y, Yang Y, et al. Ocular findings and proportion with conjunctival SARS-COV-2 in COVID-19 patients. Ophthalmology 2020;127:982-3.  Back to cited text no. 3
Cacho P, García A, Lara F, Seguí MM. Diagnostic signs of accommodative insufficiency. Optom Vis Sci 2002;79:614-20.  Back to cited text no. 4
Hussaindeen JR, Murali A. Accommodative insufficiency: Prevalence, impact and treatment options. Clin Optom (Auckl) 2020;12:135-49.  Back to cited text no. 5
Russell GE, Wick B. A prospective study of treatment of accommodative insufficiency. Optom Vis Sci 1993;70:131-5.  Back to cited text no. 6
American Optometric Association Clinical Practice Guidelines. Care of the Patient with Accommodative and Vergence Dysfunction. St. Louis, MO: American Optometric Association; 2011.  Back to cited text no. 7
Hitch A. Persistent Systemic Failure of Accommodation in Young Adults. Australian Journal of Ophthalmology. Paper Read at the Annual Scientific Meeting of the Orthoptic Association of Australia in Singapore; 04 May, 1978. Available from: https://onlinelibrary.wiley.com/doi/pdf/10.1111/j. 1442-9071.1979.tb01468.x. [Last accessed on 2021 Aug 17].  Back to cited text no. 8
Liu JS, Lee M, Jang J, Ciuffreda KJ, Wong JH, Grisham D, et al. Objective assessment of accommodation orthoptics. I. Dynamic insufficiency. Am J Optom Physiol Opt 1979;56:285-94.  Back to cited text no. 9
Gottlieb GL, Corcos DM, Jaric S, Agarwal GC. Practice improves even the simplest movements. Exp Brain Res 1988;73:436-40.  Back to cited text no. 10
Charters L. Disorders of Accommodation can be Perplexing; August 15, 2004. Available from: https://www.ophthalmologytimes.com/view/disorders-accomoation-can-be-perplexing. [Last accessed on 2021 Aug 21].  Back to cited text no. 11
Thal LS, Phillips SR, Stark L. Paralysis of accommodation in infectious mononucleosis. Am J Optom Physiol Opt 1977;54:19-26.  Back to cited text no. 12


  [Table 1], [Table 2], [Table 3]


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