Physical examination maneuver

Physical Exam

Accommodation

🔒
Subscribe to view — from $5/moSign in to watchAlready a subscriber? Videos are for subscribers. Subscriptions are not available in the app.At a school or residency?

How to Perform

Ask the patient to focus on a distant object, then hold a target such as your fingertip or a pen a short distance in front of the patient’s nose and ask the patient to shift focus to the near target. Observe both eyes turn inward and both pupils constrict as the patient focuses on the target, and ask whether the target remains clear. Then ask the patient to look back at the distant object and observe the eyes return to their resting position and the pupils dilate.

How to Interpret

Showing 1 of 8 findings

Concussion

Receded near point of convergence (5 cm or more from the nose)
Rule in
Helpful
Rule out
Not helpful
Evidence:Moderate

Related Bedside Tests

Pupillary Light ReactionMembers
Sign in
Pupillary Light Reaction
Rule in:VHSerious Eye Disease, HPoor Neurologic Outcome, HStructural Brain Lesion +11 more
Rule out:SHPoor Neurologic Outcome, SHSerious Eye Disease, SHStructural Brain Lesion +11 more
ConvergenceMembers
Sign in
Convergence
aka Near point of convergence (NPC) test
Rule in:VHSerious Eye Disease, VHVestibular Migraine, SHProlonged Concussion Recovery +1 more
Rule out:VHVestibular Migraine, SHProlonged Concussion Recovery, SHSerious Eye Disease +1 more
Extraocular MovementsMembers
Sign in
Extraocular Movements
Rule in:VHStroke, SHHyperthyroidism, SHMyasthenia Gravis +9 more
Rule out:HMyasthenia Gravis, SHHyperthyroidism, NHOrbital Fracture +9 more
OphthalmoscopyMembers
Sign in
Ophthalmoscopy
aka Fundoscopy
Rule in:VHGlaucoma, VHIncreased Intracranial Pressure, SHDiabetic Retinopathy +14 more
Rule out:SHGlaucoma, MHDiabetic Retinopathy, MHIncreased Intracranial Pressure +14 more
🎬Video coming soon
Visual Acuity
Rule in:VHRefractive Error, VHVisual Impairment, IEDiabetic Retinopathy
Rule out:HRefractive Error, HVisual Impairment, IEDiabetic Retinopathy
Alternate Cover TestMembers
Sign in
Alternate Cover Test
aka Cross-cover test, Test of skew
Rule in:VHSkew Deviation, VHVestibular Dysfunction, HStroke +1 more
Rule out:VHStroke, VHVestibular Dysfunction, HSkew Deviation +1 more

Related Systems / Regions

Head, Eyes, Ears, Nose, ThroatNeurological

Related Diagnoses

Adie Tonic PupilConcussionConvergence InsufficiencyDorsal Midbrain SyndromeFunctional Visual DisturbanceInternuclear OphthalmoplegiaNeurosyphilis

Related Chief Complaints

Blurred VisionBlurred Vision When ReadingDilated PupilDouble VisionDouble Vision When ReadingEye FatigueEye StrainHeadache with ReadingLight SensitivityUnequal PupilsVision Changes

References

  • Zhu Z, Gong H, Liu M, Zhang H, Yang L, Zhang X, Zheng H, Li Y, Li M, Li J. Diagnosing Tabes Dorsalis in HIV-Negative Patients: Clinical Features, Neuroimaging, and Laboratory Insights in the Modern Antibiotic Era. Infect Drug Resist. 2024;17:2567-2577. PMID: 38919834.
  • Keane JR. The pretectal syndrome: 206 patients. Neurology. 1990;40(4):684-690. doi:10.1212/WNL.40.4.684. PMID: 2320246.
  • Bremner FD, Smith SE. Bilateral tonic pupils: Holmes Adie syndrome or generalised neuropathy? Br J Ophthalmol. 2007;91(12):1620-1623. PMID: 17584996.
  • Shah SN, Chizuk HM, Fong HF, Hannon M, Mannix RC. Does This Child Have a Concussion?: The Rational Clinical Examination Systematic Review. JAMA. Published online April 6, 2026. doi:10.1001/jama.2026.1233. PMID: 41941197. PMCID: PMC13372223.
  • Moon BY, Kim SY, Yu DS. Receiver operating characteristic curve analysis of clinical signs for screening of convergence insufficiency in young adults. PLoS One. 2020;15(1):e0228313. doi:10.1371/journal.pone.0228313. PMID: 31978203. PMCID: PMC6980576. (Open access.)
  • Nij Bijvank JA, van Rijn LJ, Balk LJ, Tan HS, Uitdehaag BMJ, Petzold A. Diagnosing and quantifying a common deficit in multiple sclerosis: Internuclear ophthalmoplegia. Neurology. 2019;92(20):e2299-e2308. PMID: 31004067.
  • Dagi LR, Chrousos GA, Cogan DG. Spasm of the near reflex associated with organic disease. Am J Ophthalmol. 1987;103(4):582-585. PMID: 3565518.
  • Bickley LS, Szilagyi PG, Hoffman RM, Soriano RP. Bates' Guide to Physical Examination and History Taking. 13th ed. Philadelphia, PA: Wolters Kluwer; 2021.
  • Swartz MH. Textbook of Physical Diagnosis: History and Examination. 9th ed. Philadelphia, PA: Elsevier; 2025.

Research last updated September 9, 2026.