Journal of Neuro-Ophthalmology, March 2002, Volume 22, Issue 1

Spasm of Accommodation Associated with Closed Head Trauma

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.

ORIGINAL CONTRIBUTION Spasm of Accommodation Associated with Closed Head Trauma R. V. Paul Chan, MD Jonathan D. Trobe, MD Abstract: Spasm of accommodation, creating pseudo-myopia, 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 disinhibi-tion of putative brain stem accommodation centers in young individuals. ( JNeuro- Ophthalmol 2002; 22: 15- 17) Spasm of accommodation, creating pseudomyopia, typi­cally occurs in conjunction with miosis and inappropri­ate convergence as part of spasm of the near reflex, usually triggered by anxiety, depression, or malingering ( 1,2). In this setting, and rarely after head trauma ( 4), spasm of ac­commodation may also occur without the other two com­ponents of the near reflex ( 4). We describe six new cases of post- traumatic accommodative spasm that did not manifest miosis or esotropia. In these cases, the complaint of blurred distance vision, which was readily rectified with glasses, was initially attributed to other neuro- ophthalmic conse­quences of head trauma. METHODS We retrieved the cases by searching the files of the Neuro- ophthalmology Clinic, University of Michigan, The Departments of Ophthalmology ( Kellogg Eye Center) and Neu­rology, University of Michigan Medical Center, Ann Arbor, Michigan, USA. Address correspondence to Jonathan D. Trobe, MD, Kellogg Eye Cen­ter, 1000 Wall Street, Ann Arbor, MI 48105, USA from 1986 to 2000. Six patients met the criteria of ( 1) ante­cedent severe traumatic brain injury, ( 2) complaint of blurred vision, and ( 3) 1.00 diopter or more of myopia found on manifest than on cycloplegic refraction. The se­verity of the head injuries was based on coma for at least 1 week, elevated intracranial pressure, and neurologic find­ings consistent with brain stem and cerebral hemispheric damage. However, patients recovered enough to be aware that their vision was blurred for distance viewing. Cognitive function was sufficiently intact to allow accurate measure­ment of visual function. RESULTS Our six patients were male and ranged in age between 16 and 37 years. All complained of reduced distance vision. Post- traumatic pseudomyopia ranged from 1.50 to 2.00 diopters. Because the ophthalmologic examinations per­formed prior to our consultations had not included cy­cloplegic refractions, the pseudomyopia had not been rec­ognized. The visual complaints were vaguely attributed to consequences of brain injury. The single patient ( case 4) who was managed with long- term pharmacologic cyclople­gia did not show any resolution of the pseudomyopia when the cycloplegia was discontinued 3 years later. Pupils in dim illumination ranged in size between 3 and 6 mm, were equal in size, and constricted normally to direct light. Al­though eye movement abnormalities were present in all three patients, none had ocular misalignment at distance ( Table 1). DISCUSSION This case series affirms that spasm of accommoda­tion, without other components of the near reflex, may oc­cur following severe brain stem injury in young adults. The fact that this phenomenon has been so infrequently reported suggests that it is rare. However, it may also be overlooked, because debilitated patients are unable to clearly articulate their complaints. J Neuro- Ophthalmol, Vol. 22, No. 1, 2002 15 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. JNeuro- Ophthalmol, Vol. 22, No. 1, 2002 Chan and Trobe TABLE 1. Patient characteristics Patient Age, y/ ( case #) gender Date/ type of accident Imaging Neurologic abnormalities 1 30/ male 5/ 1/ 96/ fall from a roof; coma x 1 week CT: left frontal and parietal lobe hemorrhages 10/ 1999: left greater than right hemiparesis 2 20/ male 1/ 1990/ rollover accident; coma x 2 weeks 18/ male 8/ 1999/ two- car collision; coma x 1 week CT: multiple contusions of both frontal lobes and the brain stem; subarachnoid hemorrhage CT: subarachnoid and frontal lobe hemorrhage 9/ 1991: dystonic left hemiparesis 11/ 1998: cognitive impairment, limb and gait ataxia 17/ male 2/ 1986/ two- car collision; coma x 2 weeks Information not available 6/ 1987: spastic right hemiparesis 16/ male 1988/ hit by car while on bicycle; coma x 1 week 37/ male 1993/ assaulted, hit on head with lead pipe; coma x 2 weeks CT: frontal and temporal lobe hemorrhages CT: parieto- occipital skull fracture; frontal hemorrhages 5/ 1989: anosmia, gait ataxia 8/ 2000: cognitive deficits, speech, extremity and gait ataxia The mechanism of the accommodative spasm is un­certain. In cats, accommodation is mediated by a pathway from the lateral suprasylvian cortex bilaterally to the ocular motor nuclei ( 5). Stimulation of this area also produces con­vergence and miosis, but accommodation may be selec­tively activated ( 5). Experimental accommodative spasm has not been demonstrated. Although overactive accommodation appears to be uncommon in brain lesions, accommodative paresis is not. It has been reported in Wilson disease, encephalitis, and left parietal infarct or hematoma ( 6). Among patients with le­sions of the dorsal midbrain, accommodative paresis may alternate with accommodative spasm ( 6). This suggests a linkage of the mechanisms involved in excess and deficient accommodation in brain stem damage. For example, some lesions may interfere with inhibition, while others interfere with activation of the accommodative portion of the para­sympathetic ( Edinger- Westphal) subnucleus of the third cranial nerve. Accommodative spasm tends to occur in young individuals, perhaps because they have such strong accommodative reserve. Based on our cases, and those previously reported, post- traumatic accommodative spasm appears to be an en­during phenomenon. In our single patient ( case 4) who un­derwent a 3- year trial of pharmacologic cycloplegia, the ac­commodative spasm did not disappear when the medication 16 © 2002 Lippincott Williams & Wilkins Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SPASM OF ACCOMMODAHON ASSOCIATED WITH CLOSED HEAD TRAUMA JNeuro- Ophthalmol, Vol. 22, No. 1, 2002 TABLE 1. Patient characteristics ( Continued) Pre- accident refraction Information not available OD- 3.25 OS - 3.25 Information not available OD - 0.50 OS - 0.50 Information not available Information not available Post- accident manifest refraction 10/ 1999: OD- 1.50 OS:- 1.50 9/ 1991: - 5.00 OU 3/ 2000: OD - 2.25 + 0.75 x003 OS- 3.00 + 0.50 x 5/ 2000: OD:- 2.00+ 1.00 x 180 OS- 3.50 + 0.50 x 2/ 1987: OD - 2.50 - 0.50 x OS - 2.50 4/ 1990: - 2.50 OU 5/ 1990: OD - 2.00 OS - 2.00 + 0.75 x 9/ 1997: 1.75 OU 8/ 2000: - 1.75 OU 174 180 10 145 Post- accident cycloplegic refraction 10/ 1999: OD Piano OS Piano 9/ 1991: - 3.25 OU 3/ 2000: OD- 9.75+ 1.50 x 180 OS- 1.00 + 1.25 x 160 5/ 2000: OD- 0.75+ 1.00 x 180 OS- 1.00 + 1.00 x 160 2/ 1987: OD- 1.00- 0.25 x 10 OS- 0.75- 0.25 x 150 6/ 1987: OD- 1.25 OS- 1.00 5/ 1990: OD- 1.25 OS- 1.25 + 0.75 x 145 8/ 2000: saccadic pursuit Other ophthalmic findings 10/ 1999: saccadic pursuit, dysmetric eye movements 9/ 1991: saccadic pursuit, comitant esotropia 11/ 1998: rotary nystagmus 6/ 1987: saccadic pursuit, hypometric saccades 5/ 1989: none 8/ 2000: saccadic pursuit Treatment 10/ 1999: manifest refraction ( provided 20/ 20 OU) 9/ 1991: manifest refraction ( provided 20/ 20 OU) 3/ 2000: prescribed cycloplegic refraction without cycloplegia 5/ 2000: patient could only see 20/ 50 with cycloplegic refraction; prescribed manifest refraction ( 20/ 20 OU) 6/ 1987: homatropine and bifocals 4/ 1990: patient could only see 20/ 50 with cycloplegic refraction; prescribed manifest refraction ( 20/ 20 OU) 5/ 1989: prescribed manifest refraction ( 20/ 20 OU) 9/ 1997: prescribed full manifest refraction ( 20/ 20 OU) was discontinued. In a previously reported case ( 3), it was still present after 6 years of topical atropine treatment. We suggest that patients be fitted with their full manifest cor­rection, together with a reading aid if necessary. REFERENCES 1. Cogan DG, Freese CG. Spasm of the near reflex. Arch Ophthalmol 1955: 54: 752- 9. Griffin JF, Wray SH, Anderson DP. Misdiagnosis of spasm of the near reflex. Neurology 1976; 26: 1018- 20. Bohlmann BJ, France TD. Persistent accommodative spasm nine years after head trauma. J Clin Neuroophthalmol 1987; 7: 129- 34. Sloane AE, Kraut JA. Spasm of accommodation. Doc Ophthalmol 1973; 34: 365- 9. Bando T, Takagi M, Toda H, Yoshizawa T. Functional roles of the lateral suprasylvian cortex in ocular near response in the cat. Neu-rosciRes 1992; 15: 162- 78. Thompson HS, Miller NR. Disorders of Pupillary Function, Ac­commodation, and Lacrimation. In: Miller NR, Newman NJ, eds. Walsh & Hoyt's Clinical 1\' euro- ophthalmology: 5th ed. Vol. 1. Bal­timore: Williams & Wilkins. 1998: 1011- 18. 17 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. [VBheadinjury]