Accommodation Disorders: Clinical Guidelines

List of Abbreviations

AA – amplitude of accommodation

AC/A – accommodative convergence-to-accommodation ratio

BAR – binocular accommodative response

D – diopter

NRA/PRA (FRA) – relative accommodation reserves

MAR – monocular accommodative response

ICD – International Classification of Diseases

AAA – absolute amplitude of accommodation

OAR – objective accommodative response

ORA – amplitude of relative accommodation

A-P axis – anterior-posterior axis

HIAE – habitually excessive accommodation effort

PD – prism diopter

APT – habitual accommodation tone

RPT – resting point of accommodation

CNS – central nervous system

Terms and Definitions

Accommodation — the ability of the eye to clearly see objects at various distances by changing refraction.

Clinical refraction of the eye — the position of the focus of its optical system relative to the retina.

Static refraction of the eye — the clinical refraction of the eye under conditions of inactive accommodation.

Cycloplegic refraction of the eye — the same as static refraction.

Dynamic refraction of the eye — the clinical refraction of the eye under conditions of active accommodation.

Manifest (non-cycloplegic) refraction of the eye — the same as dynamic refraction.

Absolute amplitude of accommodation — the difference in refraction of a single eye when focused on the near and far points of clear vision, expressed in diopters.

Amplitude of relative accommodation — the difference in refraction under conditions of maximum accommodation effort and relaxation during binocular fixation of a stationary object located at a finite distance from the eye, expressed in diopters.

Positive (unused) part of the relative accommodation amplitude (negative relative accommodation reserve, NRA) — the part of accommodation that can potentially be used.

Negative part of the relative accommodation amplitude — the used part of accommodation.

Accommodative response — the graded accommodation effort expressed in diopters, occurring in response to the presentation of a visual stimulus located at a finite distance.

Accommodation stability — the ability of the eye to maintain an adequate accommodative response for a prolonged period.

Accommodation instability — the inability of the eye to maintain an adequate accommodative response for a prolonged period.

Accommodation insufficiency — a condition characterized by decreased accommodation amplitude, reserves, and accommodative response.

Accommodation excess — a condition in which the accommodative response exceeds the accommodative demand.

Accommodation weakness — a long-standing condition of insufficient or unstable accommodation.

Resting tone of accommodation (RTA) — the state of the optical setting of the eye in the absence of a visual stimulus.

Habitual accommodation tone (HAT), tonic accommodation — the difference between manifest and cycloplegic refraction.

Pseudomyopia — a condition in which manifest refraction is myopic, while cycloplegic refraction is emmetropic or hyperopic.

Habitually excessive accommodation effort (HIAE) — a long-standing excessive accommodation tone that causes myopization of manifest refraction and does not reduce the maximum corrected visual acuity.

Accommodation spasm — an acute pathological excessive tone of accommodation that causes myopization of manifest refraction and reduces maximum corrected visual acuity.

Accommodation paresis (paralysis) — an acute or subacute accommodation disorder in which changing the optical setting of the eye to any distance by altering refraction temporarily becomes impossible.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

In children, 4 types of typical accommodation disorders are distinguished: accommodation spasm, habitually excessive accommodation effort (HIAE), accommodation paresis (paralysis), and accommodation weakness [1].

Accommodation spasm — an acute pathological excessive tone of accommodation that causes myopization of manifest refraction and reduces maximum corrected visual acuity [1].

Habitually excessive accommodation effort (HIAE) — a long-standing excessive accommodation tone that causes myopization of manifest refraction and does not reduce maximum corrected visual acuity (E.E. Somov, 1993) [1,2].

Accommodation paresis (paralysis) — an acute or subacute accommodation disorder in which changing the optical setting of the eye to any distance by altering refraction temporarily becomes impossible [1].

Accommodation weakness — a long-standing condition of insufficient or unstable accommodation [1].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Accommodation spasm. It develops most frequently in adolescents aged 12-18 years, but can also occur at an earlier age, and rarely in adults. As a rule, emotionally labile patients are affected. It is usually preceded by severe stress or prolonged emotional strain, sometimes combined with excessive visual workload. Accommodation spasm may be preceded by traumatic brain injury [3-4]; cases of accommodation spasm following refractive surgery [5-6] and in uncorrected hyperopia have been described [7]. The disease is more often bilateral, although cases of unilateral accommodation spasm are not uncommon, which is more characteristic of adults [8-10].

HIAE develops more frequently in children and may precede the development of axial myopia; cases of HIAE in adults engaged in intense visual work are not uncommon. It is frequently preceded by colds, emotional and/or visual strain. The condition develops gradually, initially presenting with a fluctuating course — symptoms are more pronounced at the end of the day, at the end of the working week, and after visual workload [8-10].

Accommodation paresis (paralysis) is the opposite condition to its spasm. It is less common than accommodation spasm. It develops predominantly at the age of 7-15 years, more often in girls, and rarely in adults. Emotionally labile adolescents are frequently affected. Paresis is usually preceded by stress, a general acute illness, diagnostic atropine instillation**, or anesthesia. The disease can also be induced by pathological processes in the central nervous system: trauma, tumor, inflammation [11]. The condition is more often bilateral, with symptoms more pronounced at the end of the day, the end of the working week, and after visual workload [8-10].

Accommodation weakness is frequently detected in school-age children (sometimes preschoolers), especially those who are debilitated and suffering from chronic or frequent colds [8-10].

1.3 Epidemiology of the Disease or Condition

Accommodation disorders are detected in 21.1% of patients with hyperopia who consult an ophthalmologist, of whom 5.8%-11.5% are found to have accommodation insufficiency [12]. The prevalence of accommodative insufficiency ranges from < 1.00% to 61.6% and depends on ethnicity, age, study methodology, diagnostic criteria, and the number of tests performed to establish the diagnosis [13].

1.4 Features of Coding the Disease or Condition

H52.5 – Disorders of accommodation.

1.5 Classification of the disease or condition

In modern foreign literature, with various modifications, most authors mention at least three types of accommodation disorders: accommodative insufficiency [13], accommodative excess, and accommodative infacility [14,15].

The domestic approach to the classification of accommodation disorders differs somewhat.

The following pathological conditions of accommodation in children deserve special description [9]:

– accommodation spasm;

– habitual excessive accommodation tension (HEAT);

– paresis (paralysis) of accommodation;

– accommodative asthenopia (accommodation weakness).

1.6 Clinical presentation of the disease or condition

Accommodation spasm. Complaints are reduced to a sharp deterioration of distance vision; the ability to read is usually preserved, but only at a very close range. Under natural conditions, myopic refraction is determined, usually higher than 5.0 D, often around 10.0 D. At the same time, uncorrected visual acuity is reduced to 0.2–0.3, indicating a discrepancy between the detected manifest refraction and visual acuity. The addition of minus lenses of increasing power very slowly improves visual acuity, while the maximum corrected visual acuity remains below 1.0 and is usually 0.6–0.8. A characteristic sign of persistent accommodation spasm is the discrepancy between the refraction detected under natural conditions and the values of the anteroposterior axis (APA) length of the eye. The amplitude of absolute accommodation cannot be determined—the far point of clear vision merges with the near point. The amplitude of relative accommodation is not determined. Following instillation of short-acting anticholinergic agents (tropicamide** 0.5%–1% and even cyclopentolate 1%), a small residual myopia of up to 2.0–3.0 D, not previously diagnosed, is revealed. After instillation of atropine** 1%, emmetropia or mild hyperopia is detected. After the effect of cycloplegia wears off, pseudomyopia completely returns. The neurologist notes functional disorders of the central nervous system (CNS) and diagnoses a neurotic disorder (F48). In accommodation spasm, binocular functions are preserved in most cases; convergent strabismus accompanied by diplopia is rarely detected. No changes in the anterior segment of the eye are detected [8–10].

HEAT. Patient complaints come down to periodic, and later persistent, bilateral decrease in distance vision; a decrease in visual acuity of one eye is less common. Difficulties with close-up work are often noted. Under natural conditions, myopic refraction is determined; its magnitude may not correspond to the decrease in uncorrected visual acuity. The addition of minus lenses increases visual acuity to 1.0 and higher, but blurring is often required to achieve this. The amplitude of absolute accommodation is usually reduced due to the far point of clear vision shifting closer to the eye; the near point may be moved away, brought closer to the eye, or have normal values. Relative accommodation reserves are almost always reduced, often to zero. Following instillation of anticholinergic agents (cyclopentolate 1%, atropine** 1%), mild hyperopia, emmetropia, or lower myopia than that detected under natural conditions is revealed, and uncorrected visual acuity increases compared to baseline. After the effect of cycloplegia wears off, refraction returns to baseline completely or almost completely. HEAT often progresses into true axial myopia. In HEAT, binocular functions are preserved in most cases. No changes in the anterior segment of the eye are detected [8–10].

Paresis (paralysis) of accommodation. The patient's complaints are reduced to the inability to read. Refraction is generally mild hyperopia. Distance visual acuity may be normal. Near visual acuity is significantly reduced at all times—the patient has difficulty reading the line on the near vision chart corresponding to a visual acuity of 0.1. Near visual acuity is well corrected with positive lenses. The addition of plus lenses that fully compensate for the paresis allows such patients to freely read text corresponding to a near visual acuity of 0.6–0.7. The amplitude of absolute accommodation cannot be determined—the near point of clear vision merges with the far point. The amplitude of relative accommodation is zero—even the negative (spent) part of relative accommodation cannot be determined. Concentric narrowing of the visual field, mydriasis, and convergence difficulties are often noted. The neurologist notes functional disorders of the CNS and frequently diagnoses a neurotic disorder (F48). In paresis (paralysis) of accommodation, binocular functions are preserved in most cases. No changes in the anterior segment of the eye are detected [8–10].

Accommodative asthenopia (accommodation weakness). Children complain of rapid fatigue during reading; they read and write with the book and notebook held very close to their eyes, and rub their eyes. Uncorrected distance visual acuity may be reduced, but is corrected with corrective lenses. Near visual acuity may be slightly reduced—the patient can read text corresponding to a visual acuity of 0.5–0.6. The addition of weak positive lenses compensating for accommodation insufficiency increases near visual acuity to normal values. Under natural conditions, mild hyperopia, emmetropia, or more frequently mild myopia is detected. The amplitude of absolute accommodation is moderately reduced, mainly due to the far point of clear vision moving away from the eye. The far point of clear vision is often brought closer to the eye. Relative accommodation reserves are sharply reduced, usually to zero. Convergence may be weakened. When examining accommodation using accommodatography, accommodation instability is determined. The accommodative response is reduced compared to normal values. After instillation of anticholinergic agents, refraction may remain stable, but a shift of refraction towards its weakening is more frequently determined—myopia changes to emmetropia, mild hyperopia, or lower-grade myopia, which indicates concomitant HEAT. Long-term monitoring of such children shows that the majority of them develop true (axial) myopia. Treatment of this pathology should be aimed primarily at developing accommodative capacity. In accommodation weakness, binocular functions are preserved in most cases. No changes in the anterior segment of the eye are detected [8–10, 13].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis of accommodation spasm: under natural conditions, myopic refraction is determined, usually higher than 5.0 D, often around 10.0 D. Uncorrected visual acuity is reduced to 0.2–0.3 — a discrepancy between the detected refraction and visual acuity. Maximum corrected visual acuity is less than 1.0. Following instillation of atropine** 1%, emmetropia or mild hyperopia is revealed [8–10].

Criteria for establishing the diagnosis of HEAT: under natural conditions, myopic refraction is determined that does not correspond to the decrease in uncorrected visual acuity. The addition of minus lenses increases visual acuity to 1.0 and higher. Under conditions of cycloplegia, mild hyperopia, emmetropia, or lower-degree myopia is revealed [2, 8, 9].

Criteria for establishing the diagnosis of paresis (paralysis) of accommodation: near visual acuity is significantly reduced — the patient has difficulty reading text corresponding to a visual acuity of 0.1. The addition of plus lenses that fully compensate for the paresis allows patients to read text corresponding to a near visual acuity of 0.6–0.7 [8, 9, 15].

Criteria for establishing the diagnosis of accommodation weakness: uncorrected distance visual acuity may be reduced, but is corrected with corrective lenses. Near visual acuity is reduced to 0.5–0.6. The addition of weak additional positive lenses compensating for accommodation insufficiency increases near visual acuity to normal values. Under natural conditions, mild hyperopia, emmetropia, or more frequently mild myopia is detected [8–10, 13].

2.1 Complaints and Anamnesis

Comments: in accommodation spasm, children complain of a sharp deterioration in distance vision; the ability to read remains, but at a very close distance. In transient accommodation insufficiency (TIA), children complain of periodic, late, and persistent bilateral decrease in distance visual acuity, as well as difficulties with near work. In paresis (paralysis) of accommodation, children complain of the inability to read. With accommodation weakness, they complain of rapid fatigue during reading. Children read and write while bringing books and notebooks very close to their eyes, and rub their eyes.

History of present illness: time of detection, when the first glasses were prescribed, when the last glasses were prescribed. Refraction dynamics (according to previous examinations, previously prescribed glasses, from the patient's words). What treatment was previously received.

Personal history, family history: characteristics of visual load, physical education, sports, and other activities. Characteristics of the place of residence. Time spent outdoors [8-10,22].

2.2 Physical Examination

Not used.

2.3 Laboratory Diagnostics

Not performed.

2.4 Instrumental Diagnostics

Comments: the amplitude of absolute accommodation (AAA) — the difference in refraction of one eye when adjusted to the near (punctum proximum, p.p., PP) and remote (punctum remotum, p.r., PR) points of clear vision, expressed in diopters. AAA is measured monocularly.

Relative accommodation volume (RAV) – the difference in refraction under conditions of maximum tension and relaxation of accommodation with binocular fixation of a stationary object located at a finite distance from the eye, expressed in diopters. RAV is measured binocularly, with the text positioned at a distance of 33 cm under conditions of full distance correction in the presence of binocular vision. A decrease in PRA indicates accommodation weakness and a high risk of myopia onset. Values of the negative part of relative accommodation of less than 3.0 D indicate myopia undercorrection or accommodation spasm, while values of more than 3.0 D indicate myopia overcorrection or CVA (condition of accommodative overstrain). In both cases, clarification of objective cycloplegic refraction is required [28]. Normal age-related values of PRA and RAV are presented in the table Appendix A3. PRA values greater than 5.0 D are always overestimated and indicate dissociation between accommodation and convergence, exclusion of one eye from the reading act, and subsequent recording of absolute rather than relative accommodation [29].

Comments: the methods are based on recording changes in dynamic refraction in response to a change in the accommodation task—the objective accommodation response (OAR). In patients with accommodation disorders, OAR is usually reduced. An increase in OAR is a favorable criterion when assessing treatment efficacy and the prognosis of accommodation disorders [30].

Methods of objective accommodometry, computer accommodography, and dynamic retinoscopy (skiascopy) are used [30,31].

Comments: habitual accommodation tonus (HAT), or tonic accommodation, is the difference between manifest and cycloplegic refraction. High HAT values indicate accommodation spasm and TIA and are associated with a potentially high rate of myopia progression.

Resting tone of accommodation (RTA) – the state of the optical setting of the eye in the absence of a visual stimulus; its assessment is used as an additional diagnostic method. High RTA values are associated with CVA (condition of accommodative overstrain) and a high risk of development and progression of myopia. A decrease in PTA and RTA as a result of treatment – a favorable criterion for predicting the further course of accommodation disorders or their relief [30].

Comments: determining the APA length of the eye has diagnostic significance in the differential diagnosis of myopia and accommodation spasm [8,9].

2.5 Other Procedures

Not used.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Optical correction

Comments: when prescribing optical correction, the following factors are taken into account: accommodation impairment, accommodation status, convergence and binocular vision, age.

Addition can be implemented in the form of reading glasses, progressive glasses, or bifocals.

The prescription for progressive and bifocals must indicate the distance correction and the addition power. The interpupillary distance is indicated for distance [37].

Comments: continuous low-myopic image defocus in a binocular spectacle format helps eliminate pseudomyopia and inhibits eye elongation and refractive shift toward greater power in children with emmetropia and mild hyperopia [40].

3.2 Functional treatment

Comments: systematic exposure to the accommodation apparatus in children with accommodation disorders helps normalize accommodation tone, increase ciliary muscle performance, enhance the metabolic activity of ciliary body cells, improve ocular hemodynamics, and completely or partially relieve accommodation disorders [41].

Comments: 1) The "Mark on Glass" exercise is performed while wearing glasses, daily, once a day, for 1 month. For the first three days, the duration of each exercise is - 3 minutes, for the next three days - 5 minutes, and for the remaining days - 7 minutes.

2) The exercise with a "Racket" or a medical apparatus for training eye accommodation is performed for 7-10 minutes for each eye with a 10-minute interval for 4 weeks [26].

Comments: 1) Training glasses contain optical elements in the form of aspheric lenses with zero (or other required) refraction in the geometric center, a gradual increase in refraction on one side of the center, and a decrease on the other. During reading, conjugate eye movements force the patient to look along the horizontal meridian of the lenses, where refraction alternately and smoothly increases and decreases, causing successive relaxation and tension of accommodation [44-46].

2) Optical des-accommodative training glasses containing sphero-prismatic elements are used, providing a training effect based on the principles of divergent des-accommodative training and micro-blurring [43,45].

Comments: accommodation training according to E.S. Avetisov – K.A. Mats, methods of optical micro-blurring and divergent des-accommodative training according to A.I. Dashevsky or their combination, and the "rocking" method according to V.V. Volkov – L.N. Kolesnikova are used. Training can be performed automatically using special devices.

Comments: it is advisable to use this method for its intended purpose - for the treatment of amblyopia. In cases of accommodation disorders, an increase in accommodation tone and even the development of accommodation spasm may occur after a course of training.

Comments: such training increases the dynamic refraction of the eye, increases positive relative accommodation and negative relative accommodation, inducing and enhancing accommodation spasm, CVIa, and the development and progression of myopia.

3.3 Medical treatment

Comments: medical treatment with phenylephrine is used in the complex treatment of accommodation insufficiency and CVIa alongside optical correction and functional treatment, and is usually administered in courses at home [41,45,47-50].

Comments: medical treatment with tropicamide in combination with other drugs is used in the complex treatment of CVIa alongside optical correction and functional treatment and is carried out in courses at home.

Comments: for the duration of cycloplegia, the patient is prescribed reading glasses, progressive glasses, or bifocals.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

5. Prevention and Dispensary Observation

Comments: a decrease in the amplitude of accommodation below minimum age-related values is an unfavorable prognostic criterion. An increase in the amplitude of accommodation after treatment is a criterion for treatment efficacy and a favorable prognosis for the further course of accommodation disorders.

Detection of a positive positive relative accommodation (PRA) of more than 0.5 diopters in spasm of accommodation is associated with the risk of developing myopia. A decrease in PRA after treatment – a criterion for treatment efficacy and a favorable prognosis for the further course of myopia [41].

6. Organization of Medical Care

Scheduled medical care is provided for accommodation disorders.

Primary physician-delivered primary health care for children with accommodation disorders is provided by ophthalmologists. An ophthalmologist in an ophthalmology office provides: consultative, therapeutic, and diagnostic care; dynamic follow-up; and, in the presence of medical indications, refers children to the children's vision conservation office or specialized ophthalmological medical institutions.

If signs of vision loss are suspected or detected in children, pediatricians, district pediatricians, and child and adolescent hygiene physicians refer patients for an initial ophthalmologist appointment (examination, consultation).

According to Order of the Russian Ministry of Health No. 211n dated April 14, 2025, "On Approval of the Procedure for Minors Undergoing Preventive Medical Examinations, Accounting Form No. 030-PO/u 'Minor's Preventive Medical Examination Card', the Procedure for Maintaining It, as well as the Form of Branch Statistical Observation No. 030-PO/o 'Information on Preventive Medical Examinations of Minors', and the Procedure for Filling It Out" (Registered with the Russian Ministry of Justice on May 22, 2025, No. 82300), during medical examinations of minors, including upon admission to and during their studies in educational institutions, an ophthalmologist examines children at the ages of 1 month, 12 months, 3 years, 6 years, 7 years, 10 years, 13 years, 15 years, 16 years, and 17 years.

7. Additional Information

Prevention of the development of accommodation disorders is of particular importance. Preventive measures include: compliance with the visual load regimen — ergonomic stereotypes for performing near-vision work; prescription of plus spectacles inducing myopia of 0.75–1.0 diopters for continuous wear in children with pseudomyopia [28]; home exercises for accommodation training, including the use of training spectacles; physical culture and sports; and spending at least 90 minutes a day outdoors during daylight hours [19,26].

Criteria for Evaluating the Quality of Medical Care

Criteria for assessing the quality of medical care for accommodation disorders in children are presented in Table 3.

Table 3. Criteria for assessing the quality of medical care for children with accommodation disorders

References

Appendix A1. Working Group Composition

1. Milash Sergey Viktorovich, Cand. of Med. Sci., Association of Ophthalmologists LLC;

2. Proskurina Olga Vladimirovna, Dr. of Med. Sci., Association of Ophthalmologists LLC;

3. Tarasova Natalya Alekseevna, Cand. of Med. Sci., Association of Ophthalmologists LLC;

4. Tarutta Elena Petrovna, Group Head, Dr. of Med. Sci., Professor, Association of Ophthalmologists LLC.

No conflict of interest is declared.

Appendix A2. Methodology for Developing Clinical Guidelines

The National Protocol for the Diagnosis and Treatment of Accommodation Disorders in Children was developed taking into account Order of the Russian Ministry of Health No. 614n dated October 9, 2025 (as amended on December 19, 2025) "On Approval of the Procedure for Providing Medical Care to Children Profiled in 'Ophthalmology'" (Registered with the Ministry of Justice of Russia on October 27, 2025, No. 83962), which sets forth the basic provisions for organizing ophthalmological care for children. Unlike the "Procedure", which outlines the main stages of providing ophthalmological care to children, the "Clinical Guidelines" are methodological guidelines for physicians that detail all stages of ophthalmological care and differentiated approaches in various situations based on evidence-based medicine principles.

Methods used for evidence collection/selection: search in electronic databases; analysis of modern scientific developments on the problem of accommodation disorders in children in Russia and abroad; synthesis of practical experience of Russian and foreign colleagues.

When selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure its reliability. The result of this examination affects the level of evidence assigned to the publication, which in turn affects the strength of the recommendations derived from it.

A preliminary version of these guidelines was reviewed by independent experts who were asked to comment primarily on whether the interpretation of the evidence underlying the recommendations is reliable and accessible to practicing physicians and patients.

Comments were received from ophthalmologists specializing in accommodation disorders and primary care physicians regarding the clarity of presentation and the importance of the guidelines as a working tool in daily medical practice.

Comments received from experts were carefully systematized and discussed by the chairs and members of the working group. Every item was discussed. Changes and additions recommended as a result of the discussion were incorporated into the text of the guidelines.

Target audience for these clinical guidelines:

1. Ophthalmologists;

2. Pediatricians;

3. District pediatricians;

4. Child and adolescent hygiene physicians;

5. Physiotherapists.

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for assessing grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Order of the Russian Ministry of Health No. 614n dated October 9, 2025 (as amended on December 19, 2025) "On Approval of প্রজাতির Procedure for Providing Medical Care to Children Profiled in 'Ophthalmology'" (Registered with the Ministry of Justice of Russia on October 27, 2025, No. 83962).

2. Order of the Russian Ministry of Health No. 203n dated April 14, 2025 "On Approval of Criteria for Assessing the Quality of Medical Care" (Registered with the Ministry of Justice of Russia on May 28, 2025, No. 82382).

3. Decree of the Government of the Russian Federation No. 3867-r dated December 18, 2025 "On Approval of the List of Vital and Essential Medicines, as well as Lists of Medicines for Medical Use and the Minimum Assortment of Medicines Required for Medical Care".

4. State Register of Medicines (as of August 30, 2024).

5. Order of the Russian Ministry of Health No. 211n dated April 14, 2025 "On Approval of the Procedure for Minors Undergoing Preventive Medical Examinations, Accounting Form No. 030-PO/u 'Card of Preventive Medical Examination of a Minor', the Procedure for Its Maintenance, as well as Industry Statistical Observation Form No. 030-PO/o 'Information on Preventive Medical Examinations of Minors' and the Procedure for Its Completion" (Registered with the Ministry of Justice of Russia on May 22, 2025, No. 82300).

6. GOST 30808-2002 Spectacle Lenses. General Specifications.

7. Federal Law of the Russian Federation No. 323-FZ dated November 21, 2011 "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation".

Table 1. Normal age-related values of accommodation parameters

Appendix B. Physician Action Algorithms

Accommodation disorders

Appendix C. Patient Information

In children, 4 types of typical accommodation disorders are distinguished: spasm of accommodation, habitual excessive accommodation tension (HEAT), paresis (paralysis) of accommodation, and accommodation insufficiency. Accommodation disorders are detected in 21.1% of patients with hyperopia who consult an ophthalmologist, of which 5.8% to 11.5% have accommodation insufficiency. The prevalence of accommodation insufficiency ranges from < 1.00% to 61.6% and depends on ethnicity, age, research methodology, diagnostic criteria, and the number of tests performed to establish the diagnosis.

To treat various types of accommodation disorders, spectacle correction with addition or reading glasses with positive lenses are prescribed. Courses of home-based accommodation training are conducted.

In addition to optical methods, hardware-based treatment methods are widely used for treating accommodation disorders. A complex of hardware treatment is effective, including laser stimulation of the ciliary zone, optico-reflex training, magnetophoresis, acupuncture, and collar zone massage. After treatment, the tone and working capacity of the ciliary muscle normalize, and ocular hemodynamics improves.

Additionally, pharmacotherapy is performed for accommodation disorders. Eye drops are usually instilled in the evening before bedtime. Children with spasm and paresis (paralysis) of accommodation may require the assistance of a psychotherapist.

Accommodation disorders are usually resolved as a result of the prescribed treatment, but under unfavorable circumstances, they can recur.

Children with accommodation disorders usually require follow-up by an ophthalmologist at least once every 6 months.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not used.