Physical Exam

Accommodation

🎬

Video coming September 2026

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

Concussion

Receded near point of convergence (5 cm or more from the nose)

Rule in

HelpfulNo CI

Rule out

—

Evidence:Limited

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.
Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, Kontos AP. A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med. 2014;42(10):2479-2486. PMID: 25106780. PMC4209316 (free full text).
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.