The abracadabra of cycloplegics in clinching the diagnosis of accommodative spasm

Shruthy Vaishali Ramesh; Prajnya Ray; Prasanna Venkatesh Ramesh; Meena Kumari Ramesh; Ramesh Rajasekaran

doi:10.4103/jcor.jcor_242_20

POST GRADUATE SECTION

Year : 2021 | Volume : 9 | 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

Correspondence Address:
Prasanna Venkatesh Ramesh
Department of Glaucoma and Research, Mahathma Eye Hospital Private Limited, No. 6, Tennur, Seshapuram, Tiruchirappalli - 620 017, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcor.jcor_242_20

Abstract

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.^[1],[2] It may start suddenly, manifesting unilaterally or bilaterally, constant or intermittent, and can occur at distance and/or near.^[3] 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.^[3] 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.^[1]

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.^{[1],[4],[5],[6],[7],[8],[9],[10],[11],[12]}

The differential diagnosis for AS are convergence excess, accommodative excess, pseudomyopia, anticholinesterase medication usage, iridocyclitis and hyperglycemia.^[13],[14]

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.^[1] 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.^{[1],[13],[15]}

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

Nil.

Conflicts of interest

There are no conflicts of interest.

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