Optometry & Visual Performance 134 Volume 14 | Issue 2 | June 2026 accommodative insufficiency was diagnosed.14 Based on her BAF and MAF difficulty and poor NRA, the patient was diagnosed with accommodative excess.14 These discrepancies are further addressed in the discussion. The patient failed with plus and minus lenses on BAF, and both NRA and positive relative accommodation (PRA) results were abnormal. Based on the low near vergence facility and unstable distance phoria, the patient was diagnosed with fusional vergence dysfunction.13 Because of reading complaints, poor King Devick results, poor pursuits results, and increased symptoms during saccades and pursuits in the VOMS test, oculomotor dysfunction was diagnosed.14 Based on her complaints of headaches during the VOMS test, the patient was diagnosed with vestibulo-ocular dysfunction.4 Based on the low TVPS score, she was diagnosed with poor visual perception.13 The patient participated in twelve sessions of optometric vision therapy, which included accommodative, vergence, oculomotor, vestibuloocular reflex, and visual perceptual therapy. This patient was very symptomatic and used many medications for additional diagnoses. Despite her progress, she started to report improvement in her symptoms only after the 8th session. The patient reported feeling “less clumsy” with her distance prescription but discontinued its use following completion of vision therapy. She continued using reading glasses and distance prescription sunglasses, which she found beneficial. Reading performance improved, enabling her to engage with previously challenging texts. Improvements included an increase in amplitude of accommodation (from 6 to 10 D in the right eye and 4 to 10 D in the left eye, respectively), binocular and monocular accommodative facility (9 cpm and 11-12 cpm, respectively), NRA (increased by 0.75 D), PRA (increased by 1.00 D), vergence facility (from 6 cpm to 14 cpm), and King Devick (from normative age of 11 to 13 years). Symptom severity decreased, as reflected by the improved BIVSS scores (28, 55%), and visual processing performance increased on TVPS subtests: visual discrimination (age equivalent >18 years), visual memory (>15 years), and spatial relations (>16 years). A very small increase in dizziness was observed during vestibulo-ocular reflex testing. Case Report 3 A 34-year-old female sustained football-related concussions in 2017 and 2022, both involving head trauma from collisions with other players. Although she remained conscious, the second concussion caused disorientation and removal from play. Assuming symptoms would resolve as with the first injury, she did not seek immediate medical attention. Persistent symptoms led to a physiotherapy referral in August 2022. Ongoing complaints included reading difficulty, ocular misalignment, fatigue, emotional dysregulation, head pressure, motion sensitivity, headaches, and photophobia, prompting referral for a binocular vision evaluation. The patient was evaluated in January 2023. Table 4 summarizes the findings. Refraction revealed emmetropia with -0.08 D OD; 0.00+ OS LogMAR visual acuity. Cycloplegic refraction measured +0.50 D binocularly. Near point of convergence break was 5 cm, with fusion recovery at 7 cm. Cover testing showed orthophoria at distance and near. On associated phoria testing, the patient reported constant target movement. She had difficulty clearing +1.00 D in the monocular accommodative facility test and failed both plus and minus lenses binocularly. NRA and PRA were -1.50 D and +1.75 D, respectively. The KingDevick score was equivalent to a 10-year-old, and the BIVSS score was 61. During VOMS, symptoms of headache and dizziness increased during horizontal/ vertical VOR and visual motion tasks. Horizontal saccades involved undershoots, and pursuits were jerky. Spectacles were prescribed with +0.25 D OD and +0.50 D OS, as the patient reported immediate relief and visual comfort. An FL-41 migraine filter was incorporated into the distance prescription following successful in-clinic testing, initiated at the patient’s request after her own online research. Internal and external ocular surface examinations were unremarkable. A diagnosis of accommodative excess was made based on reduced binocular and monocular accommodative facility with plus lenses.14 Findings of low vergence reserves, reduced fusional vergence facility, poor binocular accommodative facility with both plus and minus lenses, decreased NRA and PRA, and unstable fixation during the associated phoria test supported a diagnosis of fusional vergence dysfunction.14 Increased symptoms during VOMS indicated vestibular-ocular dysfunction.14 Additionally, her impaired performance on oculomotor assessments was consistent with oculomotor dysfunction.14 OVT was recommended to alleviate accommodative excess, enhance vergence function, improve oculomotor function, and reduce symptoms.
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