INTRODUCTION with history of excessive near work.Ocular examination

INTRODUCTION

                Accomodative spasm (AS) is an aesthenopic
condition due to involuntary spasm of ciliary musclesa1 . It is commonly caused by psychological stress,excessive near work
or due to certain topical drugs.Cycloplegic refraction is the key modality to
unmask accommodative spasm presenting as pseudomyopia along with asthenopia. Management options for AS include bifocal
glasses/Plus glasses,orthoptic exercises and cycloplegia or atropinisation.But
recurrence is the major problem associated with AS.Slow weaning of atropine
might help to reduce the recurrence.In this study,we used cycloplegic
refraction in case of pseudomyopia with presence of aggravating factors and
observed the effect of slow weaning effect of atropine eye drops along with
avoidance of aggravating factors to prevent its recurrence.

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PURPOSE

•      
The purpose of study  was to highlight importance of cycloplegic
refraction to detect accommodative spasm.

•      
To evaluate role of
atropinisation for its management and effect of slow weaning on recurrence.

SETTINGS

This retrospective study was carried in a tertiary eye care hospital
in Chennai,India.

Sample size: 8
eyes of 4 patients.

All the patients
diagnosed as transient myopia along with presence of aggravating factors were
asked to undergo cycloplegia with cyclopentolate eye drops.If there was  shift from myopia to hypermetropia after
cycloplegia, patients were started on bifocal or plus glasses along with  atropine(1%) or homatropine(2%)  eye drops on weekly twice basis and were
evaluated two weekly.Eye drops were tapered every month gradually over three  months and patients were observed upto six
months.

 

SUMMARY OF
MATERIAL AND METHODS:

Presenting
complaints:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                    

 

Case 1:

An 11 year old
female was presented with complaints of sudden onset blurring of vision for
distance and near and headache with history of excessive near work.Ocular
examination including extra ocular movements was normal.

 

VISION
(corrected)

SPHERICAL POWER
DIOPTERS

Precycloplegia

OD:

20/40,N6

-2.00

 

OS:

20/63,N6

-1.75

Post cycloplegia

OD:

20/20,N6

+1.75,+3.00

 

OS:

20/20,N6

+2.00,+3.00

Management:

Patient was
managed with bifocal glasses with cycloplegic correction and +3.00 add for near
vision. She was started on atropine on weekly twice basis(1% eye drops) and was
tapered over three months.On subsequent visits there was symptomatic relief and
condition resolved.No recurremnce was noted over six months.

Case 2:

A 12 year old
female presented with complaints of sudden onset blurring of vision for
distance and headache with history of psychological stress.Ocular examination
including extra ocular movements was normal.

 

 

VISION
(corrected)

SPHERICAL POWER
DIOPTERS

Precycloplegia

OD:

20/40,N6

-1.25

 

OS:

20/20,N6

-0.25

Post cycloplegia

OD:

20/20,N6

+0.50

 

OS:

20/20,N6

+0.50

Management:

Patient was
managed with plus power  glasses with
cycloplegic correction and +3.00 add.She was started on homatropine 2%w/v eye
drops  on weekly twice basis and was
tapered over three months.On subsequent visits there was symptomatic relief and
condition resolved.No recurremnce was noted over six months.

Case 3:

13 year old male
presented complaints of sudden onset blurring of vision for distance and near
and headache with history of psychological stress.Ocular examination including
extra ocular movements was normal.

 

 

 

VISION
(corrected)

SPHERICAL POWER
DIOPTERS

Precycloplegia

OD:

20/40,N6

-2.25

 

OS:

20/40,N6

-7.00

Post cycloplegia

OD:

20/32,N6

+1.25,+2.50

 

OS:

20/32,N6

+0.75,+2.50

Management:

Patient was
managed with bifocal glasses with cycloplegic correction and +2.50 add for near
vision. He was started on atropine on weekly twice basis(1% eye drops) and was
tapered over three months.On subsequent visits there was symptomatic relief and
condition resolved.No recurremnce was noted over six months.After six months
there was again similar episode which was managed with similar protocol.

Case 4:

A 12 old male
presented complaints of sudden onset blurring of vision for distance and near
and headache with history of psychological stress.Ocular examination including
extra ocular movements was normal.

 

VISION
(corrected)

SPHERICAL POWER
DIOPTERS

Precycloplegia

OD:

20/20,N6

-1.25

 

OS:

20/20,N6

-4.00

Post cycloplegia

OD:

20/20,N6

+1.00,+2.50

 

OS:

20/20,N6

+0.75,+2.50

Management:

Patient was
managed with bifocal glasses with cycloplegic correction and +2.50 add for near
vision. He was started on atropine on weekly twice basis(1% eye drops) and was
tapered over  three months.On subsequent
visits there was symptomatic relief and condition resolved.

 

 

 

 

 

 

 

 

DISCUSSION

Accommodative spasm is characterized by frontal
headache, blurred vision(pseudomyopia), miosis, acute acquired
concomittentesotropia(AACE),diplopia and sometimes macropsia.1,2,3Mostly
presents in children,young adolescents.It can be a part of spasm of near
reflex(SNR).2Ophthalmoplegic migraine needs to be differentiated
from it in presence of AACE and diplopia.1

Apart from psychological stress and excessive
near work certain conditions predispose to it:

Ø   Topical
miotics(parasympathomimetics, cholinergics)4

Ø  After refractive surgery :LASIK surgery, Photo
Refractive keratectomy5,6

Ø  After head trauma7

Ø  Due to central lesion involving dorsal midbrain
or idiopathic intracranial hypertension.8

Ø  Rare causes reported are :Bimatoprost induced9,
Secondary to long standing intermittent exotropia.10

The diagnosis of AS is clinical based on
presence aggravating factors and shift of refraction after cycloplegia.On open
field hartmann- shack wavefrontaberrometry it shows lead of accommodation and
negative spherical aberrations.11

Joseph H et al., showed  cases of AS 
a part of spectrum of spasm of near reflex and had described five such
cases.Accommodative spasm was graded as minimal when small minus and small plus
values were present and marked when small plus and high minus values were
present.12Hussaindeen JR et al., treated adult onset
concomittentesotropia associated with AS with cycloplegics for one year and condition
resolved completely without recurrence2Rutstein RP et al., studied
seventeen cases of accommodative spasm and treated them with plus
lenses,orthoptice exercise and psychologicalcounselling but only four cases
resolved completely.13In our study we found complete resolution of
condition without recurrence which is similar to observations of Hussaindeen et
al.Addition of glasses with cycloplegics gives comfortable working vision to
the patient.

In our case series, we had four cases which
were diagnosed on basis of hypermetropic shift after cycloplegia and presence
of predisposing factors like psychological stress and excessive near
work.Atropine(1%) eye drops provided powerful cycloplegia with symptomatic
relief one patient with milder symptoms was put on homatropine instead of
atropine. Atropine was started twice a week and was tapered over three months.
On sixth month followup recurrence were not noted in any of the patients.After
six months one patient presented again with similar complaints due to exposure
to psychological stress and was treated similarly.Larger sample size with
longerfollowup is required to reach to a definite conclusion.

CONCLUSION

Accommodative spasm can be easily misdiagnosed as myopia if
cycloplegic refraction  is not
done.Triggering factors also provides key to
diagnosis.Slow weaning of atropine prevents recurrence.

 

 

 

 

 

 

 

 

BIBLIOGRAPHY

1. Allegrini D, Montesano
G, Fogagnolo P, Nocerino E, De Cillà S, Piozzi E, Rossetti L, Stefini M, Pece
A. Transient Esotropia in the Child: Case Report and Review of the Literature. Case Rep Ophthalmol. 2017 Apr
24;8(1):259-264.

2. Hussaindeen JR, Mani R,
Agarkar S, Ramani KK, Surendran TS. Acute adult onset comitantesotropia associated with accommodative spasm. Optom Vis Sci. 2014 Apr;91(4
Suppl 1):S46-51. 

3. Iwasaki T, Akiya S,
Inoue T, Noro K. Surmised state of accommodation to stereoscopic
three-dimensional images with binocular disparity. Ergonomics. 1996
Nov;39(11):1268-72. 

4.  Zimmerman TJ, Wheeler TM. Miotics: side effects and ways to avoid them. Ophthalmology. 1982
Jan;89(1):76-80. PubMed PMID: 7070779.

5. .Shetty R, Deshpande K,
Kemmanu V, Kaweri L. The Role of Aberrometry in Accommodative Spasm After Myopic Photorefractive
Keratectomy. J
Refract Surg. 2015 Dec;31(12):851-3. 

6. Prakash G, Sharma N,
Sharma P, Choudhary V, Titiyal JS. Accommodative spasm after laser-assisted in situ keratomileusis (LASIK). Am J Ophthalmol. 2007 Mar;143(3):540; author reply 540-1. Epub
2006 Dec 28.

7.  London R, Wick B, Kirschen D. Post-traumatic pseudomyopia. Optometry.
2003 Feb;74(2):111-20.

8. Kawasaki A, Borruat
FX. Spasm of accommodation in a patient with increased
intracranial pressure and pineal cyst. Klin Monbl Augenheilkd. 2005
Mar;222(3):241-3. 

9.  Padhy D, Rao A. Bimatoprost (0.03%)-induced accommodative spasm and pseudomyopia. BMJ
Case Rep. 2015 Nov 23;2015. pii: bcr2015211820. 

10. Shanker V, Ganesh S,
Sethi S. Accommodative spasm with bilateral vision loss due to
untreated intermittent exotropia in an adult.Nepal J Ophthalmol. 2012 Jul-Dec;4(2):319-22. 

11.  Kanda H, Kobayashi M, Mihashi T, Morimoto T,
Nishida K, Fujikado T. Serial measurements of accommodation by open-field
Hartmann-Shack wavefrontaberrometer in eyes with accommodative spasm. Jpn J Ophthalmol. 2012
Nov;56(6):617-23. 

12. Goldstein JH, Schneekloth BB. Spasm of the
near reflex: a spectrum of anomalies. Surv Ophthalmol. 1996 Jan-Feb;40(4):269-78.

13. Rutstein RP, Daum KM,
Amos JF. Accommodative spasm: a study of 17 cases. J Am Optom Assoc. 1988
Jul;59(7):527-38. 

 a1Kindly add reference for all these statements

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