Editor,—Asthenopia is characterised by ocular fatigue, frontal headache, and blurred vision, particularly during periods of sustained close work.1 It can be caused by accommodative insufficiency, a condition in which the effort required to maintain accommodation for near objects produces troublesome symptoms. This may be associated with a low accommodative convergence: accommodation (AC:A) ratio, which the patient has to overcome using positive fusional reserves. When fusion is insufficient symptoms of asthenopia can occur. In contrast, a high AC:A ratio would not normally be associated with asthenopia, but rather with overconvergence, potentially resulting in a convergence excess type of esotropia.2 We report two cases in which “pseudo-accommodative insufficiency” was identified as the cause of asthenopia and paradoxically associated with a high …