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Spasm of Accommodation Associated with Closed Head Trauma
Abstract and Figures
Spasm of accommodation, creating pseudomyopia, is generally associated with miosis and excess convergence as part of spasm of the near reflex. It may also exist as an isolated entity, usually attributed to psychogenic causes. We present six cases of accommodative spasm associated with closed head injury. All patients were male, ranging in age between 16 and 37 years. The degree of pseudomyopia, defined as the difference between manifest and cycloplegic refraction, was 1.5 to 2 diopters. A 3-year trial of pharmacologically induced cycloplegia in one patient did not lead to reversal of the spasm when the cycloplegia was stopped. All patients required the manifest refraction to see clearly at distance. The pseudomyopia endured for at least 7 years following head trauma. This phenomenon may represent traumatic activation or disinhibition of putative brain stem accommodation centers in young individuals.
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... For example, some lesions may interfere with inhibition, while others interfere with activation of the accommodative portion of the parasympathetic (Edinger-Westphal) sub nucleus of the third cranial nerve. Accommodative spasm tends to occur in young individuals, because they have such strong accommodative reserve [23]. ...
... Stimulation of this area also produces convergence and miosis, but accommodation may be selectively activated. Experimental accommodative spasm has not been demonstrated [23]. ...
Background: Visual disturbances may result in a long-term complication after mild traumatic brain injury (mTBI) in children. These problems may affect both near work and reading, and thus affect activities of daily life and the child’s return to school activity. The purpose of the study was to assess the visual acuity disturbances and refractive status in children with persisting symptoms after mild traumatic brain injury. Material and methods: Forty-eight patients with persisting symptoms after mild traumatic brain injury and anomalies of visual acuity were included. Visual symptoms and refractive status were assessed during the eye examination. Results: Thus, in the mTBI group the visual acuity for the right eye was of 0.09-0.5 in 83.7% (40 patients), in 16.3% (8 patients) – right eye 0.6-0.8, comparing to the control group, where 62% patients had the visual acuity ranged almost in 1.0, just 14% (7 patients) ranged 0.09-0.5 and in 24% (12 patients) – 0.6-0.8. The visual acuity for the left eye in the research group was of 0.09-0.5 in 89.8% (43 patients), in 10.2% (5 patients) – for the left eye was 0.6-0.8, comparing to the control group, where 66% patients had the visual acuity ranged almost in 1.0, just 24% (12 patients) it ranged 0.09-0.5 and in 14% (5 patients) – 0.6-0.8. Conclusions: Visual acuity (VA) is affected primary after head trauma although it has big chances to get better with a vision therapy in a time period ranged between 3 and 6 months after the trauma. In most of the cases, we speak of a blurred vison in the near work and relative unclear perception at far. Autorefraction data usually will reveal a slight hyperopia with a possible astigmatic component ranged between 1D to 3D, and in 4.1%-8.2% of cases a slight myopia referring to the spherical compound and 18.4%-32.7% astigmatic compound, also ranged between 1D and 3D.
... Additional ocular examinations include a constricted pupillary reflex and extraocular movement to detect episodes of esotropia and exotropia. A thorough evaluation of orthoptics simplifies the accommodative excess or spasm diagnosis in all instances [29]. A low plus in the monocular estimation method, adequate performance with minus lenses, and inferior performance with plus lenses signify over-accommodation, which can lead to accommodative spasm and pseudomyopia, as recommended by Mitchell Scheiman. ...
... Manifest refraction can also treat this disorder by reducing distance blur. Chan et al. [29] prescribed eyeglasses to their patients based on their apparent refractive error. It was noted, however, that this treatment was not as effective as cycloplegia. ...
Accommodation is a process that allows a sharp focus on the fovea by relaxing the ciliary muscle, decreasing the lens's diameter, and increasing its thickness and curvature. The midbrain supranuclear impulse produces the motor command, leaves the Edinger Westphal nucleus and creates the near-triad synkinesis. An accommodative spasm occurs when the near triad reflexes fail. Common causes of accommodative spasms include excessive near work, psychological stress, head trauma, and strabismic and non-strabismic conditions. This review conducted a comprehensive analysis to comprehend the clinical characteristics, aetiology, diagnostic markers, and treatment alternatives. The most common symptoms of accommodative spasm include reduced distance and near vision, frontal headache, sensitivity to light or glare, and eyestrain during close work. In addition, the signs of accommodative spasm are a variation in visual acuity at a distance, a decreased retinoscopic reflex, and a smaller pupil. Despite its many limitations, cycloplegia is the primary method for accurately identifying the accommodative spasm. It includes increased intraocular pressure, blockage of the lacrimal duct, macular oedema, an allergic reaction, discomfort, and blurs vision. This mini-review focuses on non-invasive treatment alternatives, such as regular cycloplegic drugs, bifocals for near work, manifest prescription, the modified optical fogging approach, and vision therapy. The objective is to relax the accommodation and eradicate the symptoms associated with pseudomyopia.
... All subjects in the case series improved with cycloplegia except one subject. 16 The cycloplegic agent is one of the mainstay in the treatment of accommodative spasm, and accommodative facility exercises with a combination of plus/plus flippers are found to avoid recurrence of the condition by improving the ability to relax accommodation. The magnitude of flipper power was advised based on the previous report. ...
... In AS, this forward displacement of the crystalline lens continues and could result in inflammation of ciliary muscles. 12,13,[16][17][18] Pharmacologically inflamed ciliary body can also lead to spasm of accommodation. 18 On average, it is reported that the change in the lens thickness is 0.063 mm in an emmetrope, for a unit diopter of accommodation. ...
Spasm of accommodation refers to constant contraction of the ciliary muscles of the eye, which fail to relax. Neurological issues, head injury, and psychogenic factors can lead to spasm of accommodation , which is generally bilateral. This case report describes the clinical presentation of traumatic, unilateral accommodative spasm in an army person. A 26-year-old male presented with complaints of diminution of near vision in the left eye noticed accidentally. History revealed a blunt injury in the eyebrow region of the left eye two months back. His best corrected visual acuity was 6/6, 0.8 M (N6) in the right eye and 6/9, 2.5 M (N18) in the left eye. Accommodative response was documented using an open-field autorefractometer that showed asymmetry in the accommodation response and pupillary diameter between the two eyes. One percent Atropine sulfate eye ointment-twice a day for 3 days-was prescribed. On the fourth day, the spasm was resolved in the left eye. Pre-and post-Atropine administration, lens thickness measurements were documented , which showed significant changes. Accommodative facility exercise was initiated after the pharmacological management. Unilateral accommodative spasm is rare and needs careful investigations. Objective assessment of accommodative response and lens thickness measurement play a vital role in confirming the diagnosis. ARTICLE HISTORY
... Visual field deficits were identified in 35% of patients with visual changes after TBI [2,3]. Certain patients could benefit from using embedded prisms, such as Fresnel or Peli prisms [2,4]. The training should include the stimulation with light targets of both the deficient sector and the entire visual field. ...
Introduction. Brain injury may affect both afferent and efferent visual pathways. In children it is quite difficult to determine visual disturbances since they are often non cooperative. Visual field examination is an objective evaluation method that can outline visual pathway alteration in the acute period of head trauma. Materials and methods. Forty-eight patients with persisting visual symptoms after mild traumatic brain injury were examined. A control group of the same size has been evaluated. Results. Patients in the research group showed an obvious alteration of the fixation capacity of more than 20% in 91.7%95.8%, while in the control group the fixation capacity was up to 20% in 68.7%-70.8%. The ability to fix false positive points was up to 20% in 43.8%-45.8% patients in the research group and 70.8%-83.3% in the control group. The rate to fix false negative points was within the range of up to 20% for the research group in 93.7%-95.8% and the control group 91.7%-97.9%. The index of localized defects was up to 3dB in 62.5%-70.8% in the research group and predominantly 91.6%-95.8% for the control group. The average elevation index was within the range of < -3dB, 3dB> in 12.5%-20.8% research group and respectively 54.1%-56.2% control group. The graphic interpretation of changes in the visual field revealed a prevalence of the incidence of diffuse retinal depression with relative paracentral scotomas in 64.6%-68.7%. Conclusions. Based on the results, we can conclude that perimetric examination in the case of brain injured pediatric patients fulfils the requirements of credibility. Perimetric examination could be a landmark in the initial phase of settling post brain injured visual disturbances.
... Pseudomyopia may have either organic causes, due to stimulation of the parasympathetic nervous system (common causes include head trauma, encephalitis, intracranial mass, and cerebrovascular disease), or functional causes, as a result of eye strain caused by prolonged near distance focusing (e.g. after continuous hours of studying for a test or overuse of tablets and smartphones). Pseudomyopia may present with one of the following symptoms: blurring of distance vision, asthenopia, headache, eyestrain, photophobia, accommodative esotropia, and diplopia [1,2]. ...
A teenage female patient visited the ophthalmology emergency department reporting blunt ocular trauma from a stretched elastic band, accompanied by blurred vision. At presentation, uncorrected visual acuity (VA) was 6/60 in the affected eye, improving to 6/7.5 with pinhole. A slit lamp examination showed a mild anterior chamber reaction and iridoplegia with pupil shape irregularity. Gonioscopy revealed partial cyclodialysis with angle recession. Fundoscopy revealed focal commotio retinae with blot hemorrhages. B-scan ultrasonography yielded no pathology. Follow-up examination, the day after the injury, included detailed refraction, which showed a myopic shift in the affected eye. Uncorrected VA improved to 6/15 and the patient achieved 6/7.5 with correction. Clinical findings indicated myopia, which resolved within one week from the incident, and refractive error rapidly decreased to prior emmetropic values.
... These more pronounced cases resolved within two weeks, but other cases have shown to persist (Hughes et al., 2017). Other proposed mechanisms (in the absence of biomicroscopy findings) include damage to the accommodative portion of the parasympathetic third nerve subnucleus or disinihibtion of brain stem centres (Chan & Trobe, 2002), but this has not been scientifically investigated and remains unsubstantiated. ...
Mild traumatic brain injury (mTBI, or concussion), results from direct and indirect trauma to the head (i.e. a closed injury of transmitted forces), with or without loss of consciousness. The current method of diagnosis is largely based on symptom assessment and clinical history. There is an urgent need to identify an objective biomarker which can not only detect injury, but inform prognosis and recovery. Ocular motor impairment is argued to be ubiquitous across mTBI subtypes and may serve as a valuable clinical biomarker with the recent advent of more affordable and portable eye tracking technology. Many groups have positively correlated the degree of ocular motor impairment to symptom severity with a minority attempting to validate these findings with diffusion tract imaging and functional MRI. However, numerous methodological issues limit the interpretation of results, preventing any singular ocular biomarker from prevailing. This review will comprehensively describe the anatomical susceptibility, clinical measurement, and current eye tracking literature surrounding saccades, smooth pursuit, vestibulo-ocular reflex, vergence, pupillary light reflex, and accommodation in mTBI.
Physiological adaptation of the eye to the visual perception of near objects consists of the “near triad”: convergence, accommodation, and pupil miosis. Normally, these tend to revert when one stops fixating on a near object. Spasm of the near reflex (SNR) is a pathological phenomenon, which manifests itself by the persistence of the above-mentioned adjustments, which prevents the eye from returning to its relaxed state. In this narrative review, we aim to summarize the etiology, diagnostics, treatment, and prevention of SNR. The literature review was performed by searching online databases. The clinical presentation of SNR is diverse; it presents as isolated accommodative spasm more frequently than impairment of all three components of the near triad. Patients usually present with fluctuations in visual acuity, blurred vision, diplopia, and asthenopia. The etiology is not fully understood. Potential causes include neuroanatomic, organic, and psychogenic disorders. The diagnosis is clinical, based on the constellation of symptoms and assessment of the near triad. The diagnostic golden standard is a cycloplegic examination of refraction, preferably using cyclopentolate hydrochloride (1%, 0.5%, or 0.1% solution). The first-line treatment requires the administration of a cycloplegic drug in combination with plus lenses, flipper lenses, optical fogging, or miotics. For secondary cases, causal treatment should be implemented. Prevention of SNR should be based on eliminating modifiable risk factors. We propose including screening for SNR symptoms in every ophthalmic examination, especially among patients with psychogenic or neural disorders, after brain trauma, or young adults spending much time in front of computer screens.
This article is about the accommodation spasm. The primary rule for near vision is ciliary muscle constriction, synchronised convergence of both eyes, and pupil constriction. Any weaknesses in these components could result in an accommodative spasm. Variable retinoscopic reflex, unstable refractive error, and lead of accommodation in near retinoscopy are common causes of spasm. We conducted a thorough literature search in the PubMed and Google Scholar databases for published journals prior to June 2022, with no data limitations. This review contains twenty-eight case reports, six cohort studies, four book references, four review articles, and two comparative studies after applying the inclusion and exclusion criteria. The majority of studies looked at accommodative spasm, near reflex spasm, and pseudomyopia. The most common causes of accommodative spasm are excessive close work, emotional distress, head injury, and strabismus. Despite side effects or an insufficient regimen, cycloplegic drops are effective in diagnosing accommodation spasm. The modified optical fogging technique is also effective and may be an option for treating accommodative spasm symptoms. Bifocals for near work, manifest refraction, base-in prisms, and vision therapy are some of the other management options. As a result, it requires a comprehensive clinical treatment strategy. This review aims to investigate the various aetiology and treatments responsible for accommodative spasm and proposes widely implementing the modified optical fogging method and vision therapy in clinics as comprehensive management to reduce the future upward trend of accommodative spasm.
A bilateral sixth nerve palsy portends serious disease of the central nervous system and precipitates extensive patient studies. Spasm of the near reflex, characterized by intermittent convergence, accommodation, and miosis, is a functional disturbance. Five patients with hysterical spasm of the near reflex erroneously diagnosed as a bilateral sixth nerve palsy are reported. The pupillary sign, intense miosis on attempted lateral gaze, is emphasized as an important clue to the correct diagnosis. Despite extensive investigation, no disease of the central nervous system was found. Neurotic or hysterical features were evident in every patient.
The lateral suprasylvian (LS) area, an extrastriate visual area in the cat, has been suggested to play an important role in processing motion in 3-dimensional visual space. In addition, the LS area is related to all three components of the ocular near response, i.e. lens accommodation, pupillary constriction, and ocular convergence: microstimulation in this area evoked these intra- and extraocular movements, and neuronal discharges associated with these movements were also found. Anatomical pathways, direct and indirect, from this area to premotor nuclei in the brainstem are known to exist. The present paper reviews studies useful for assessing the functional roles played by the LS area in triggering and modulating component movements in the ocular near response.
Spasm of the near reflex is most often seen on a functional basis in young adults with underlying emotional problems. In particular, when convergence spasm is associated with miosis on attempted lateral gaze, a functional basis for the disorder should be suspected. Patients who experience spasm of the near reflex following trauma commonly follow a benign course with spontaneous resolution of their ocular complaints within 1-2 years. Accommodative spasm, manifested by pseudomyopia, or spasm of convergence, alone, or in combination with miosis, may be found as isolated signs of spasm of the near reflex. We report a patient who continues to demonstrate accommodative spasm 9 years after a motor vehicle accident.
The entity which we have called spasm of the near reflex1 has been infrequently described in the literature, and then under such names as spasm of accommodation, ocular spasm, and convergent spasm. It is characterized by intermittent and usually painful convergence, accommodation, and miosis. Although reported in association with neurologic * and vestibular † disease, it is generally attributed to hysteria. Nevertheless, the cases reported have been isolated instances, and, except for a collation of cases in Wilbrand and Saenger's text,7 no comprehensive series has been reported heretofore.
We have had the opportunity to study 16 cases. It is our purpose to summarize these cases with specific reference to signs and symptoms, age and sex, etiologic factors, and treatment. These cases are presented individually in the "Addendum." It was found impossible to review adequately the cases in the literature, for, while some clear-cut instances have been described, the majority
Disorders of Pupillary Function, Accommodation, and Lacrimation
- H S Thompson
- N R Miller
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