|POST GRADUATE SECTION
|Year : 2021 | Volume
| Issue : 2 | Page : 93-95
The abracadabra of cycloplegics in clinching the diagnosis of accommodative spasm
Shruthy Vaishali Ramesh1, Prajnya Ray2, Prasanna Venkatesh Ramesh3, Meena Kumari Ramesh4, Ramesh Rajasekaran5
1 Medical Officer, Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Tiruchirappalli, Tamil Nadu, India
2 Optometrist, Department of Optometry and Visual Sciences, Mahathma Eye Hospital Private Limited, Tiruchirappalli, Tamil Nadu, India
3 Medical Officer, Department of Glaucoma and Research, Mahathma Eye Hospital Private Limited, Tiruchirappalli, Tamil Nadu, India
4 Head of the Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Tiruchirappalli, Tamil Nadu, India
5 Chief Medical Officer, Mahathma Eye Hospital Private Limited, Tiruchirappalli, Tamil Nadu, India
|Date of Submission||27-Oct-2020|
|Date of Decision||10-Feb-2021|
|Date of Acceptance||03-Mar-2021|
|Date of Web Publication||31-Jul-2021|
Prasanna Venkatesh Ramesh
Department of Glaucoma and Research, Mahathma Eye Hospital Private Limited, No. 6, Tennur, Seshapuram, Tiruchirappalli - 620 017, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Accommodative spasm (AS) is a rare involuntary asthenopic condition occurring in children, adolescents and young adults who engage more in near work. It presents as a repetitive condition of accommodation, which shows a tendency to maintain accommodation in the absence of a stimulus. Here, we discuss in brief about AS with reference to a patient who reported to us with such a condition.
Keywords: Accommodative spasm, asthenopia, cycloplegics
|How to cite this article:|
Ramesh SV, Ray P, Ramesh PV, Ramesh MK, Rajasekaran R. The abracadabra of cycloplegics in clinching the diagnosis of accommodative spasm. J Clin Ophthalmol Res 2021;9:93-5
|How to cite this URL:|
Ramesh SV, Ray P, Ramesh PV, Ramesh MK, Rajasekaran R. The abracadabra of cycloplegics in clinching the diagnosis of accommodative spasm. J Clin Ophthalmol Res [serial online] 2021 [cited 2023 Mar 24];9:93-5. Available from: https://www.jcor.in/text.asp?2021/9/2/93/322790
Accommodative spasm (AS) is a rare involuntary asthenopic condition where there is a greater than normal accommodative response elicited for the given accommodative stimulus, due to prolonged contraction of the ciliary muscle., It may start suddenly, manifesting unilaterally or bilaterally, constant or intermittent, and can occur at distance and/or near. Common symptoms include headache, photophobia, glare, and eye strain associated with near work. Eye strain associated with near work is frequently associated with convergent spasm and disappears with cycloplegics or may resolve spontaneously. Clinically, it is confirmed by refraction (accepting more minus in dry refraction and accepting plano or lesser plus in cycloplegic refraction). The treatment option for AS includes adding hyperopic lenses, vision therapy; and for severe cases, strong cycloplegic drugs such as cyclopentolate or atropine are prescribed and gradually weaned off.
| Case Report|| |
A 24-year-old female patient presented with blurring of distant vision with good near vision for the past 1 week duration. She also gave history of increase in her near-work activity recently. There was no history of spectacle usage, medication usage or head trauma recently. Best-corrected visual acuity (BCVA) was 20/20 with −3.00 dioptre sphere (DS) for distance with unaided N6 near vision in both eyes (OU). After instilling 1% cyclopentolate eye drops three times, 5 minutes apart, her refraction was −0.50 DS (OU) with BCVA of 20/20. Cycloplegic refraction helped in clinching the diagnosis of AS in this scenario. Indirect ophthalmoscopy done revealed a normal posterior pole OU, ruling out any signs of intermediate uveitis [Figure 1].
|Figure 1: (a and b) Normal fundus photography of OD and OS, respectively. (c and d) Optical coherence tomography of the macula of OD and OS showing normal findings, respectively|
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Orthophoria existed at both distance and near. Visual field testing revealed generalized constriction of fields OU [Figure 2]. All ocular health examinations including color vision, extra-ocular movements and optical coherence tomography were normal. The patient was also sent for a neurological consultation to rule out any midbrain lesions. Neurophysiological tests and magnetic resonance imaging were also normal [Figure 3]. The patient was then started with homatropine 1% eye drop twice weekly for 1 month, once weekly for the next 2 months, and then slowly tapered off over the next 3 months. On subsequent visits, symptomatic relief was noted with gradual resolution of signs. No recurrence was noted till the 12-month follow-up period post discontinuation of therapy, after the condition had resolved.
|Figure 2: (a and b) Visual fields of OD and OS showing generalized constriction, respectively|
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|Figure 3: (a) Axial section of magnetic resonance imaging brain showing normal findings. (b) Sagittal section of magnetic resonance imaging brain showing normal findings|
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| Discussion|| |
Accommodation involves the process of increasing the plus refractive power of the crystalline lens, particularly for viewing closer objects. In rare cases, accommodation does not relax, even when viewing distant objects. Such patients are said to have AS and typically exhibit myopia shift (pseudo myopia). Causes of AS are commonly psychological stress and excessive near work; local causes such as post refractive surgery laser-assisted in situ keratomileusis (LASIK), secondary to long-standing intermittent exotropia and iridocyclitis; rare causes such as bimatoprost utilization; systematic causes such as multiple sclerosis, blocked-ventricular-peritoneal shunt, acute respiratory disease, myasthenia gravis, disturbance to supranuclear control areas secondary to head trauma, encephalitis, intracranial masses, cerebrovascular disease, central lesion involving dorsal midbrain and idiopathic intracranial hypertensio.,,,,,,,,,
The differential diagnosis for AS are convergence excess, accommodative excess, pseudomyopia, anticholinesterase medication usage, iridocyclitis and hyperglycemia.,
Treatment of accommodative spasm
There are multiple protocols for managing AS depending on the cause and presentation. In this scenario, as the organic systemic and ocular conditions were ruled out, the patient responded well to a tapering dose of homatropine 1% eye drops over a 6-month period and remained stable even up to 12 months post stopping the medication. The other commonly used treatment modalities to re-establish accommodative stability are near addition to help reduce accommodative stress, vision therapy with simple eye exercises, or special lenses such as accommodative flippers to improve the accommodative facility. The clinician should also reinforce the importance of visual hygiene in the form of proper working distance, lighting, and appropriate rest period. Few more important treatment modalities suggested are modified fogging method and psychological counseling. Care should be taken not to abruptly stop strong cycloplegic drops such as atropine and emphasising on the gradual weaning of atropine, to prevent recurrence. Clear lens extraction and multifocal intraocular lens implantation have been suggested for recalcitrant cases of AS with non-organic etiology, who are not responding to medical therapy.,,
| Conclusion|| |
Considering the confounding presentation of AS and its variable causes, thorough knowledge of this disease is necessary for its timely diagnosis and management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Prerana S, Revathy M. Persistent accommodative spasm. Sci J Med Vis Res Foun 2013;31:435.
Kavthekar A, Shruti N, Nivean M, Nishanth M. Accommodative spasm: Case series. TNOAJ Ophthalmic Sci Res 2017;55:301-3.
Rutstein RP. Accommodative spasm in siblings: A unique finding. Indian J Ophthalmol 2010;58:326-7.
] [Full text]
Airiani S, Braunstein RE. Accommodative spasm after laser-assisted in situ
keratomileusis (LASIK). Am J Ophthalmol 2006;141:1163-4.
Shanker V, Ganesh S, Sethi S. Accommodative spasm with bilateral vision loss due to untreated intermittent exotropia in an adult. Nepal J Ophthalmol 2012;4:319-22.
Pillai G, Thajudeen A. Uveitis induced cyclospasm induced myopia-A unique case. Adv Ophthalmol Vis Syst 2017;7:00222.
Padhy D, Rao A. Bimatoprost (0.03%)-induced accommodative spasm and pseudomyopia. BMJ Case Rep. 2015 Nov 23;2015:bcr2015211820.
Sitole S, Jay WM. Spasm of the near reflex in a patient with multiple sclerosis. Semin Ophthalmol 2007;22:29-31.
Voon LW, Goh KY, Lim TH, Tan KK, Yong VS. Pseudomyopia in a patient with blocked ventriculoperitoneal shunt – A case report. Ann Acad Med Singap 1997;26:229-31.
Anokhina GD. Bilateral accommodative spasm in an acute respiratory disease. Oftalmol Zh 1983;38:252-3.
McMurray CJ, Burley CD, Elder MJ. Clear lens extraction for the treatment of persistent accommodative spasm after head trauma. J Cataract Refract Surg 2004;30:2629-31.
Kawasaki A, Borruat FX. Spasm of accommodation in a patient with increased intracranial pressure and pineal cyst. Klin Monbl Augenheilkd 2005;222:241-3.
Satgunam P. Relieving accommodative spasm: Two case reports. Optom vis perf 2018;6:207-12.
Gedar Totuk OM, Aykan U. A new treatment option for the resistant spasm of accommodation: Clear lens extraction and multifocal intraocular lens implantation. Int J Ophthalmol 2018;11:172-4.
[Figure 1], [Figure 2], [Figure 3]