Accommodative Spasm: Case Series

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Case Series

Anjali Kavthekar, N. Shruti, M. Nivean, M. Nishanth Paediatric Ophthalmology Services, M.N. Eye Hospital Private Limited, Chennai, Tamil Nadu, India

Abstract

This study highlights importance of cycloplegic refraction to detect accommodative spasm(AS) patients and role of atropinisation for its management.This retrospective case series study was done at a tertiary care eye hospital in Chennai, India. Four patients, presented with complaints of sudden onset blurring of vision and asthenopic symptoms with history of aggravation of symptoms with prolonged near work and under stressful conditions.Refraction was initially showing myopic refractive error.After cycloplegia,there was hypermetropic shift and VA was 20/20 for distance in all patients with their hyperopic correction,and N6 with upto +3.00 dioptres for near.Diagnosis of AS was made. Bifocal glasses were prescribed and atropinisation(1%) with avoidance of aggravating factors was started . Patients were tapered gradually to prevent recurrence over three months and were observed for six months in which none had reccurence.Post cycloplegia,the condition resolved and asthenopic symptoms were improved.

Keywords: Accommodative spasm, atropinization, cycloplegia, pseudomyopia

Introduction started on bifocal or plus glasses along with atropine (1%) or homatropine (2%) eye drops on weekly twice basis and were Accommodative spasm (AS) is an asthenopic condition due evaluated two weekly. Eye drops were tapered every month to prolonged contraction of ciliary muscles.[1] Cycloplegic gradually over 3 months and patients were observed up to refraction is the key modality to unmask AS presenting as 6 months [Figure 1]. pseudomyopia along with asthenopia. Management includes determining its underlying etiology and inhibiting the Case 1 excessive accommodation and excessive convergence using An 11‑year‑old female was presented with complaints strong cycloplegic agents and bifocal lenses.[2] Recurrence of sudden onset blurring of vision for distance and near is sometimes associated with AS. In this study, we used and headache with a history of excessive near work. cycloplegic refraction in case of pseudomyopia with the Ocular examination including extraocular movements was presence of aggravating factors and observed the effect of normal [Table 1]. slow weaning effect of atropine eye drops along with the Management avoidance of aggravating factors to prevent its recurrence. The patient was managed with bifocal glasses with cycloplegic correction and +3.00 add for near vision. She was started on Case Reports atropine on weekly twice basis (1% eye drops) and was tapered This retrospective case series study was carried in a tertiary over 3 months. On subsequent visits, there was symptomatic eye care hospital in Chennai, India. relief and condition resolved. No recurrence was noted over 6 months. Sample size: The sample size was eight eyes of four patients. All the patients diagnosed as transient myopia along with the presence of aggravating factors were asked to undergo Address for correspondence: Dr. Anjali Kavthekar, cycloplegia with cyclopentolate eye drops. If there was shift M.N. Eye Hospital Private Limited, #781, T.H Road, Tondiarpet, from myopia to hypermetropia after cycloplegia, patients were Chennai ‑ 600 021, Tamil Nadu, India. E‑mail: [email protected]

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DOI: How to cite this article: Kavthekar A, Shruti N, Nivean M, 10.4103/tjosr.tjosr_4_18 Nishanth M. Accommodative spasm: Case series. TNOA J Ophthalmic Sci Res 2017;55:301-3.

Kavthekar, et al.: Accommodative spasm

Table 1: Case 1 Vision (corrected) Spherical power diopters Precycloplegia OD: 20/40, N6 −2.00 OS: 20/63, N6 −1.75 Postcycloplegia OD: 20/20, N6 +1.75, +3.00 OS: 20/20, N6 +2.00, +3.00 OD: Oculus dextrum, OS: Oculus sinister

Table 2: Case 2 Vision (corrected) Spherical power diopters Precycloplegia OD: 20/40, N6 −1.25 OS: 20/20, N6 −0.25 Postcycloplegia OD: 20/20, N6 +0.50 OS: 20/20, N6 +0.50 Figure 1: Protocol of management OD: Oculus dextrum, OS: Oculus sinister

Case 2 A 12‑year‑old female was presented with complaints of sudden Table 3: Case 3 onset blurring of vision for distance and headache with a Vision (corrected) Spherical power diopters history of psychological stress. Ocular examination including Precycloplegia OD: 20/40, N6 −2.25 extraocular movements was normal [Table 2]. OS: 20/40, N6 −7.00 Postcycloplegia OD: 20/32, N6 +1.25, +2.50 Management OS: 20/32, N6 +0.75, +2.50 The patient was managed with plus power glasses with OD: Oculus dextrum, OS: Oculus sinister cycloplegic correction and +3.00 add. She was started on homatropine 2%w/v eye drops on weekly twice basis and was tapered over 3 months. On subsequent visits, there was Table 4: Case 4 symptomatic relief and condition resolved. No recurrence was Vision (corrected) Spherical power diopters noted over 6 months. Precycloplegia OD: 20/20, N6 −1.25 Case 3 OS: 20/20, N6 −4.00 Postcycloplegia OD: 20/20, N6 +1.00, +2.50 A 13‑year‑old male was presented with complaints of sudden OS: 20/20, N6 +0.75, +2.50 onset blurring of vision for distance and near and headache OD: Oculus dextrum, OS: Oculus sinister with a history of psychological stress. Ocular examination including extraocular movements was normal [Table 3]. Discussion Management AS is characterized by frontal headache, blurred The patient was managed with bifocal glasses with cycloplegic vision (pseudomyopia), miosis, acute acquired concomitant correction and +2.50 add for near vision. He was started on esotropia (AACE), diplopia, and sometimes macropsia[3‑5] and atropine on weekly twice basis (1% eye drops) and was tapered mostly presents in children and young adolescents. It can be over 3 months. On subsequent visits, there was symptomatic a part of spasm of the near reflex (SNR).[4] Ophthalmoplegic relief and condition resolved. No recurrence was noted migraine needs to be differentiated from it in the presence of over 6 months. After 6 months, there was again similar episode AACE and diplopia.[3] which was managed with similar protocol. Apart from psychological stress and excessive near work, Case 4 certain conditions predispose to it: A 12‑year‑old‑male was presented with complaints of sudden • Topical miotics (parasympathomimetics and cholinergics)[6] onset blurring of vision for distance and near and headache • After refractive surgery: LASIK surgery and with a history of psychological stress. Ocular examination photorefractive keratectomy[7,8] including extraocular movements was normal [Table 4]. • After head trauma[9] Management • Due to central lesion involving dorsal midbrain or idiopathic intracranial hypertension[10] The patient was managed with bifocal glasses with cycloplegic • Rare causes reported are bimatoprost induced,[11] correction and +2.50 add for near vision. He was started on secondary to long‑standing intermittent exotropia.[12] atropine on weekly twice basis (1% eye drops) and was tapered over 3 months. On subsequent visits, there was symptomatic The diagnosis of AS is clinical based on the presence aggravating relief and condition resolved. factors and shift of refraction after cycloplegia. Kanda et al.

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Kavthekar, et al.: Accommodative spasm

showed excessive accommodation in AS objectively by given his/her/their consent for his/her/their images and other open‑field Hartmann–Shack wavefront aberrometry. There clinical information to be reported in the journal. The patients was an increase in negative spherical aberrations along with understand that their names and initials will not be published more negative average standard deviation refractive power in and due efforts will be made to conceal their identity, but patients of AS as compared to healthy individuals.[13] anonymity cannot be guaranteed. Goldstein and Schneekloth showed cases of AS a part of Financial support and sponsorship spectrum of SNR and had described five such cases. AS was Nil. graded as minimal when small minus and small plus values were present and marked when small plus and high minus Conflicts of interest values were present.[2] Hussaindeen et al. treated adult onset There are no conflicts of interest. concomitant esotropia associated with AS with cycloplegics for 1 year and condition resolved completely without References [4] recurrence. Rutstein et al. studied 17 cases of AS and treated 1. Lindberg L. Spasm of accommodation. Duodecim 2014;130:168‑73. them with plus lenses, orthoptic exercise, and psychological 2. Goldstein JH, Schneekloth BB. Spasm of the near reflex: A spectrum of counseling, but only four cases resolved completely.[14] In anomalies. Surv Ophthalmol 1996;40:269‑78. our study, we found complete resolution of condition without 3. Allegrini D, Montesano G, Fogagnolo P, Nocerino E, De Cillà S, Piozzi E, et al. Transient esotropia in the child: Case report and review recurrence which is similar to observations of Hussaindeen of the literature. Case Rep Ophthalmol 2017;8:259‑64. et al. Addition of glasses with cycloplegics gives comfortable 4. Hussaindeen JR, Mani R, Agarkar S, Ramani KK, Surendran TS. Acute working vision to the patient.[4] adult onset comitant esotropia associated with accommodative spasm. Optom Vis Sci 2014;91:S46‑51. In our case series, we had four cases which were diagnosed 5. Iwasaki T, Akiya S, Inoue T, Noro K. Surmised state of accommodation on basis of hypermetropic shift after cycloplegia and the to stereoscopic three‑dimensional images with binocular disparity. presence of predisposing factors such as psychological stress Ergonomics 1996;39:1268‑72. 6. Zimmerman TJ, Wheeler TM. Miotics: Side effects and ways to avoid and excessive near work. Atropine (1%) eye drops provided them. Ophthalmology 1982;89:76‑80. powerful cycloplegia with symptomatic relief; one patient 7. Shetty R, Deshpande K, Kemmanu V, Kaweri L. The role of aberrometry with milder symptoms was put on homatropine instead of in accommodative spasm after myopic photorefractive keratectomy. atropine. Atropine was started twice a week and was tapered J Refract Surg 2015;31:851‑3. th 8. Prakash G, Sharma N, Sharma P, Choudhary V, Titiyal JS. Accommodative over 3 months. On the 6 month follow‑up, recurrence was spasm after laser‑assisted in situ keratomileusis (LASIK). Am J not noted in any of the patients. After 6 months, one patient Ophthalmol 2007;143:540. presented again with similar complaints due to exposure to 9. London R, Wick B, Kirschen D. Post‑traumatic pseudomyopia. psychological stress and was treated similarly. Larger sample Optometry 2003;74:111‑20. size with longer follow‑up is required to reach to a definite 10. Kawasaki A, Borruat FX. Spasm of accommodation in a patient with increased intracranial pressure and pineal cyst. Klin Monbl Augenheilkd conclusion. 2005;222:241‑3. 11. Padhy D, Rao A. Bimatoprost (0.03%)‑induced accommodative spasm and pseudomyopia. BMJ Case Rep 2015;2015 pii: bcr2015211820. Conclusion 12. Shanker V, Ganesh S, Sethi S. Accommodative spasm with bilateral AS can be misdiagnosed as myopia if cycloplegic refraction vision loss due to untreated intermittent exotropia in an adult. Nepal J is not done. Triggering factors also provide key to diagnosis. Ophthalmol 2012;4:319‑22. 13. Kanda H, Kobayashi M, Mihashi T, Morimoto T, Nishida K, Slow weaning of atropine prevents recurrence. Fujikado T, et al. Serial measurements of accommodation by open‑field Declaration of patient consent hartmann‑shack wavefront aberrometer in eyes with accommodative spasm. Jpn J Ophthalmol 2012;56:617‑23. The authors certify that they have obtained all appropriate 14. Rutstein RP, Daum KM, Amos JF. Accommodative spasm: A study of patient consent forms. In the form the patient(s) has/have 17 cases. J Am Optom Assoc 1988;59:527‑38.

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