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Show }. elin. Neuro-ophthalmol. 4: 71-72, 1984. Minus or Plus Lenses in the Therapy of the Convergence Spasm? To the Editor: The interesting case report of Dr. Schwartze and co-workers on convergence spasm in Volume 3, number 2, pp. 123-125, prompted me to ask a couple of questions. First: The description of the patients "regular glasses" is lacking, which is of utmost importance since it is known that the refraction in accommodative spasm is often expressed as pseudomyopia instead of hypermetropia, and the patient seems to need minus glasses instead of plus lenses. l As the handbook of Duke-Elder states, this situation is too often missed.2 Second: I do not understand the ground for using two controversial types of treatments, cycloplegic eye drops and minus lenses! We know that, if (e.g., in orthoptics) convergence insufficiency is treated with concave lenses and if this is done incompetently, it tends to induce a spasm of accommodation.! In general, when dealing with the convergence spasm, it is reasonable to use the method of powerful fogging3 in trying to reveal the accommodative spasm. This may be do to long-lasting hypermetropic accommodative strain which, in turn, may result in "hysterical symptoms." It is clear that all relaxing treatments release spasm, but among them plus lens addition is of long-acting nature. Kaisu Viikari, M.D. Turku, Finland References 1. Lyle and Jackson: Practical Orthoptics in the Treatment of Squint (4th ed.). The B1akiston Co., Philadelphia, Toronto, 1953, pp. 201; 225-226. 2. Duke-Elder, S.: System of Ophthalmology, Vol. 3. Kimpton, London, 1970, p. 470. 3. Duke-Elder, S.: Practice of Refraction (8th ed.). J.&A. Churchill, London, 1969, p. 237. Reply: The thoughtful letter from Dr. Viikari is certainly appreciated-particularly since it shows us that a copy of the Journal of Clinical Neuro-oph~ halmology made its way over to Turku, Finland! [n the paper Schwartze et aI., the authors stated .,convergence spasm is also known as ocular ipasm, spasm of accommodation, and (most de-v1arch 1984 scriptively), spasm of the near reflex." Dr. Viikari has presented an important point. The particular clinical entity that is being referred to here is really best known as "spasm of the near reflex." The classic paper by Cogan and Freese, which appeared in Arch. Ophthalmol. 54: 752, 1955, really should be reviewed by all interested parties in this syndrome. In that paper, Dr. Cogan stated-"The entity which we have called spasm of the near reflex has been infrequently described in the literature, and then under such names as spasm of accommodation, ocular spasm, and convergent spasm." Dr. Cogan also pointed out" Spasm of the near reflex is a distinct entity, not to be confused with convergence excess or isolated 'spasm of accommodation.''' In addition, he stated-"Specific treatment consisted in either atropinization or the use of minus lenses for as long as necessary." Dr. Cogan then documented 15 cases which responded to either minus glasses or cycloplegia. When I heard Dr. Cogan tell me about this syndrome during the year with him a~ a fellow (1958-1959), I asked the same question in my mind that Dr. Viikari did. If the patient is accommodating too much, one might inhibit that with a cycloplegic-but one would actually be flagellating that with a pair of minus one spheres given to an otherwise apparent emmetrope. The point of the matter, however, is that one can break up this functional syndrome with either the minus lenses (which relieve the blurring at distance from excessive accommodation) or, better yet, with a transient course of cycloplegics. I usually put these patients on 5% homatropine drops-and give them one drop at bedtime every night for a week-then every other night for another week-then every third night for another week. That usually breaks up the cycle of this functionally induced problem, and often relieves the patient. I believe that spasm of the near reflex is virtually always a functional problem, and is easily managed in this way. I think that is a different clinical entity from functional accommodative spasm which usually has a refractive substrate (as a large cylinder against which the patient has learned to accommodate actively), and must be handled by entirely different refractive means (often changing their glasses gradually and reducing the minus over two to three different pairs of lenses during a few months of time). Convergence excess is a different situation in which one has an esodeviation that is greater in degree at near than at distance. Therefore, if one is a purist, 71 |
