Journal of Neuro-Ophthalmology, September 1987, Volume 7, Issue 3

Persistent accommodative spasm nine years after head trauma.

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.

Journal of Clinical Neuro-ophthalmology 7(3):129-131, 1987. Persistent Accommodative Spasm Nine Years After Head Trauma Brian J. Bohlmann, B.S., and Thomas D. France, M.D. (9 1987 Raven Press, Ltd., New York 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. Key Words: Accommodative spasm-Traumatic head injury. Pediatric Eye Clinic University of Wisconsin Hospital and Clinics, Madison, Wisconsin. Address correspondence and reprint requests to Dr. Thomas D. France, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, Room F4/326, Madison, Wisconsin 53792 129 Spasm of the near reflex is a disorder character­ized by intermittent attacks of miosis, convergence spasm, and pseudomyopia (an increase in myopia over baseline established with cycloplegic refrac­tion). It is usually seen as a functional disorder in young patients with underlying emotional problems (1). Spasm of the near reflex can also occur following trauma; when present posttrau­matically, it rarely exceeds 1-2 years in duration. We report a patient who continues to experience accommodative spasm 9 years after a motor ve­hicle accident. CASE REPORT In August 1977, a woman, then 19-years-old, was struck by an automobile while riding her bi­cycle. On admission to the University of Wis­consin Hospital, she was unconscious and had a large hematoma in the right temporal region. Her eyes were deviated to the right. Her pupils were equal (3mm OU) and reactive to light. Skull, cer­vical spine, and chest radiographs were reported as normal. A computerized tomography (CT) scan showed a possible basilar skull fracture. She de­veloped marked respiratory insufficiency and re­quired intubation for several days following ad­mission. By the 17th hospital day, she was alert and responded well to commands but was disori­ented to time and place; at this time, a mild right­sided hemiparesis was noted. On the 18th hospital day, she was transferred to the Rehabilitation Medicine unit, for further care. Neuropsycholog­ical testing done on the 43rd hospital day revealed good intellectual functioning (full-scale IQ 94) with some impairment of spatial and visual memory. At the time of her discharge 2 months after the initial injury, the patient showed generally good intellectual functioning, with a mild residual memory deficit. 130 B. J. BOHLMANN AND T. D. FRANCE The patient first presented to the Ophthal­mology Clinic 3 months after injury, complaining of blurred vision for distant objects. Her uncor­rected visual acuity was 20/200 00 and 20/400 OS; visual acuity with a pair of recently prescribed glasses (-1.50 sphere OU) was 20/50 00 and 20/200 OS. Near vision was J2 OU with correction. Ductions, versions, and covertesting, with and without correction, were normal. The pupils were equal and reactive to light and accommodation. A cycloplegic refraction revealed a +0.25 refractive error in each eye and vision improved to 20/20 with this correction in place. Ophthalmoscopic ex­amination and Goldmann fields were normal. A diagnosis of accommodative spasm was made, and the patient was instructed to return in 1 month. At that time, the patient's visual acuity was 20/100 OU without correction, but, after cy­cloplegia with 1% cyclopentolate, improved to 20/20 OU, still without correction. The patient was begun on 1% atropine ointment OU every night, which was eventually tapered to once every fifth night. The patient did well on this regimen when compliant; when noncompliant, the patient's pseudomyopia returned. Hypnosuggestion therapy, by a physician therapist, was attempted on two occasions without success. Six years fol­lowing the accident, a high-resolution CT scan was done to rule out an organic basis for her com­plaints and revealed no abnormalities. Eight years following the accident, the patient stopped the atropine for a 5-month period, maintaining visual acuity of 20/25 OU with -1.00 sphere 00 and -1.50 sphere OS. Throughout the many examina­tions she has shown no sign of miosis or of con­vergence spasm. When last seen, 9 years after the initial injury, she complained that she had re­cently been unable to pass the visual acuity exami­nation for her driver's test. Vision without correc­tion was 20/300 00 and 20/200 OS. Her visual acuity was 20/70 OU with her old glasses; vision again improved to 20/20 OU without correction after administration of 1% atropine. The patient returned to using atropine every fourth night in conjunction with plano lenses and +2.00 bifocals. DISCUSSION Spasm of the near reflex is most commonly as­sociated with underlying emotional problems in young individuals. When this disorder occurs on a functional basis, miosis is always present and is accompanied by variable degrees of convergence .. "j.-l,.c·qrpd by" pphoria or esotropia and of ac- '1~, 'Ii, "orne pseudomyopia , Gill Neuro-ophlhalmol, Vol. 7. No.3. 1987 (2). Nirankari and Hameroff (3) reported two pa­tients, who, on attempted lateral gaze, experi­enced convergence spasm with miosis (pupillary constriction from 5mm to 2mm OU); between spasms, the patients' muscle ductions and ver­sions were full. One of these patients also had pseudeomyopia evidenced by changing visual acuity and variable, noncydoplegic, refractive error. The same authors reported a third patient who experienced attacks of varying visual acuity ("accordion vision") with an induced myopia of 2-3 diopters without convergence. Isolated convergence spasm has been reported with organic conditions including diphenylhydan­toin intoxication, (4) head injury (5,6), labyrinthine lesions (7), Wernicke's encephalopathy (8), basilar inflammation, in patients with hyperopia with ab­normality of the accommodative convergence/ac­commodation (AClA) ratio, and has been seen as a consequence of the Arnold-Chiari malformation (9). Convergence spasm due to organic causes is almost always seen without miosis and is often ac­companied by other signs and symptoms of neu­rological disease such as ataxia or nystagmus (4). When a patient presents with convergence spasm as one component of spasm of the near re­flex, the functional nature of the disorder may be overlooked, leading to an erroneous diagnosis of bilateral sixth-nerve palsy. Griffin et al. (2) report five patients in whom spasm of the near reflex was misdiagnosed as bilateral sixth-nerve palsy, re­sulting in extensive investigations including ca­rotid arteriography, pneumoencephalograms, and craniotomy. These authors conclude that "careful observation of the pupil size during attempted lat­eral gaze in these patients shows the presence of miosis, which establishes beyond doubt the diag­nosis of spasm of the near reflex." They also note that monocular excursions are full in spasm of the near reflex, which would not be the case with bi­lateral sixth-nerve palsy. The intermittent spasmic convergence move­ments of the eyes associated with vertical gaze paresis, retractory nystagmus, and abnormal pu­pillary responses seen in cases of sylvian aquaduct syndrome associated with pineal tumors, while not truly convergence spasm, may mimic this con­dition. Treatment for spasm of the near reflex usually includes cycloplegic eye drops and glasses for reading. In addition, some patients may benefit from simple reassurance or psychiatric counseling. Manor (10) describes a patient who was unrespon­sive to cycloplegics but who was successfully treated with special glasses containing an opaque ACCOMMODATIVE SPASM AFTER HEAD TRAUMA 131 inner third of each lens. Schwartze et al. (11) re­ported successful treatment of convergence spasm by narcosuggestion during an amobarbital sodium interview. Moore and Stockbridge (12) have reported the use of miotics and placebo eye drops in 17 patients with good success with either method of therapy. The patient presented here shows only accom­modative spasm with significant pseudomyopia without pupillary changes or convergence as evi­denced by the presense of an esodeviation in pri­mary gaze or on lateral gaze. While Nirankari and Hameroff (3) reported a patient who experienced accommodative spasm accompanied by miosis which developed following an automobile acci­dent, the patient showed no evidence of the dis­order 2 years after the accident. The patient in our report continues to experi­ence significant pseudomyopia 9 years after her initial trauma. The relationship of the onset of her visual problem to the severe head trauma, the long term course of her difficulty, and the lack of response to psychotherapy and placebos would seem to imply that her problem is due to an or­ganic cause rather than to a functional one. The significant head trauma resulting in coma, the presence of a basilar skull fracture noted on CT scan, and the long rehabilitation period following the injury implies a significant brain contusion. The resultant accommodative spasm could be due to an injury to the upper brainstem following trauma to the basilar skull. The normal high-reso­lution CT scan done 6 years after the accident does not necessarily rule out the presence of small brainstem lesions which could account for the pa­tient's continued problem. This patient is an ap-parent exception to the generalization that pa­tients with posttraumatic spasm of the near reflex tend to resolve spontaneously after 1-2 years. We feel it is important to recognize that some patients may experience a prolonged course of accommo­dative spasm after significant head trauma and to propose that all such cases may not be due to functional causes. REFERENCES 1. Miller NR, ed. Clinical neuro-ophthalmology, vol. 2. Balti­more: Williams and Wilkins, 1985:533-5. 2. Griffin JF, Wray SH, Anderson DP. Misdiagnosis of spasm of the near reflex. Neurology 1976;26:1018-20. 3. Nirankari VS, Hameroff SB. Spasm of the near reflex. Ann OphthalmoI1980;12:1050-1. 4. Guiloff RJ, Whitely A, Kelly RE. Organic convergence spasm. Acta Neurol Scand 1980;61:252-9. 5. DeMorsier G, Balavoine C. Spasms de la Convergence. Opthalmologica 1948;116:248-3. [Cited by Guiloff RJ, Whiteley A, Kelly RE. Organic Convergence Spasm. Acta Neurol Scand 1980;61:252-259.] 6. DeMorsier G, Balavoine C. Encephalopathie traumatique et spasms de la convergence. Revue Oto-Neuro-opthalmologie 1949;21:400-3. [Cited by Guiloff RJ, Whiteley A, Kelly RE: Organic Convergence Spasm. Acta Neurol Scand 1980;61: 252-259.) 7. Cogan 0, Freese CG. Spasm of the near reflex. Arch Oph­thalmoI1955; 54:752-9. 8. Herman P. Convergence Spasm. Mt Sinai J Med 1977; 44:501-9. 9. Hoyt WF, Daroff RB. Supranuclear disorders of ocular con­trol systems in man: Clinical, anatomical and physiological correlations-1969. In: Bach-y-Rita P, Collins Cc, Hyde JE, eds. The control of eye movements. New York: Academic Press, 1971:211-2. 10. Manor RS. Use of special glasses in treatment of spasm of the near reflex. Ann OphthalmoI1979;1l:903-5. 11. Schwartze GM, McHenry LC, Proctor RC. Convergence spasm-treatment by amytal interview. JClin Neuro Oph­thalmol 1983;3:123-5. 12. Moore S, Stockbridge L. Another approach to the treat­ment of accommodative spasm. Am Orthopt J 1973;23:71­72. J Clin Neuro-ophthalmol. Vol. 7, No.3, 1987