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Show f. Gin. Neuro-ophthalmol. 3: 123-125, 1983. Convergence Spasm-Treatment by Amytal Interview A Case Report GEORGE MARK SCHWARTZE, M.D. LAWRENCE C. MCHENRY, JR., M.D. RICHARD C. PROCTOR, M.D. Abstract Convergence spasm is manifest by intermittent occurrence of ocular convergence, accommodative spasm, and miosis. It is usually due to hysteria but can have an organic basis. Treatment has included various ophthalmologic interventions. An amytal interview was used successfully to establish a nonorganic basis for the gaze palsy and, more importantly, concomitant narcosuggestion proved to be effective treatment. Convergence spasm is also known as ocular spasm, spasm of accommodation, and (most descriptively), spasm of the near reflex. It is usually a manifestation of an hysterical conversion, but has been reported in association with organic causes. Frequently, it is misdiagnosed. We report a patient in which the neuro-ophthalmologic exam, special maneuvers, and amytal interview helped to diagnose her convergence spasm. Case Report A 35-year-old woman, 6 months before admission, began noting intermittent bilateral esotropia which was relieved only by putting on her regular glasses. Four months prior to admission, she had sudden onset of severe headache, nausea, and vomiting accompaning the bilateral esotropia. She complained that the bilateral esotropia gradually became constant. During the next 4 months, she experienced intermittent severe pain in both eyes and horizontal diplopia. There was no diurinal variation of the diplopia and there was no clinical or laboratory evidence of endocrine abnormalities. Ophthalmological examination showed bilateral esotropia ranging from 350 to 40,0 showing signs of orthophoria. The greatest esotropia was noted when attention was directed to her visual problem From the Departments of Neurology and Psychiatry, Bowman Gray School of Medicine of Wake Forest University, WInston· Salem, North Carolina. June 1983 (Fig. 1). On attempted lateral gaze, with binocular vision, adduction was adequate in both eyes. Abduction was to midline or less in the corresponding eye (Fig. 2). The remaining ocular excursions could be demonstrated while one eye was covered (Fig. 3). Special maneuvers l such as passive rotation and optokinetic stimulation, showed good abduction in each eye. The pupils were miotic and remained so despite far or near binocular vision. When monocular vision was assumed, there was pupillary dilatation (Fig. 4). Skull radiographs and computerized cranial tomography were unremarkable. An amytal interview revealed that she recently became the family matriarch and reluctantly assumed the task of "looking over" various family affairs. The abreaction revealed aspects of her life that she"did not want to see." During the interview, it was noted that the patient was orthophoric and narcosuggestion was used successfully. Discussion In 1955, Cogan and Freese~ described convergence spasm as being manifest by intermittent occurrence of convergence, accommodative spasm, and miosis. Convergence is usually present intermittently because of the discomfort the patient experiences in attempting to maintain convergence. In some Cdses, the convergence is mdintained for surprisingly long periods. Miosis is the most important sign to be observed. During convergence, miosis is dlways present and usually extreme. The differenti.l1 di.lgnosis of convergence spasm includes bil.lteral sixth nerve palsy, divergence insufficiency, and divergence pdfalysis. The esotropia in bil<lteri.l sixth nerve palsy is constant at rest; monocular ductions will be abnormal and diplopia will increase on lateral gaze to either side.:l The causes of bilateral sixth nerve palsy dfe the same .lS those which cause unilateral sixth nerve pals/. In reports of pdrdlysis of cranial nerves III, IV, and VI, Rucker'" Ii and then Rush and Younge' found the sixth nerve to be most frequently affected. Neoplasm W.lS shown to be a common cause. It is 123 Convergence Spasm not unusual to see reports, especially from the precomputerized cranial tomography era, in which a posterior fossa craniotomy was done for convergence spasm, In divergence insufficiency and divergence paralysis, the esotropia is only present in distant vision, Diplopia disappears as the object is moved closer. Unlike abduction weakness there is no increase in esotropia on lateral gaze, Divergence insufficiency is not associated with abnormal neurological findings and is presumed due to preexisting esophoria for distance that has become manifest.: J Divergence paralysis has been reported with a wide variety of neurological diseases, Most cases of divergence paralysis are secondary to nuclear or intranuclear involvement of the sixth nerve,8 Divergence paralysis may be an early sign or a late residual of bilateral sixth nerve palsies, In all the above-mentioned differential diagnoses, there is no pupillary changes as in convergence spasm, Convergence spasm is usually considered a manifestation of hysteria. Of the multiple neuroophthalmologic signs and symptoms of hysteria, the gaze defect is rare and difficult for the patient to sustain convincingly,9 Convergence spasm secondary to organic causes have been reported, The etiologies are varied and pupillary constriction is not a constant sign,1O In the top of the basilar syndrome, a hyperconvergence or convergence spasm without pupillary involvement may be seen, II This is a pretectal esotropia not related to the near reflex, The treatment of convergence spasm has included cycloplegic eye drops, minus lenses and glasses, with the inner third of each lens opaque,12 The usefulness of an amytal interview is limited, and its indication is not specific for any particular psychiatric condition,l:3 There has been only one other case of convergence spasm in which the amytal interview was used. The results established an hysterical origin, but the improvement did not persist,14 In our case, however, abreaction and then narcosuggestion during amytal interview resulted in apparent success, This technique has dual implication. First, it is of diagnostic significance in that an organic cause can be ruled out and possible expensive and invasive procedures are obviated, Second, narcosuggestion was of therapeutic aid in our case. Our patient had return of orthophoric gaze and full range of extraocular motion and normal conjugate movements in all fields of gaze, The miosis also reverted to appropriate pupillary size, Even though the initial results are encouraging, follow-up will be necessary to monitor the long-term effect of treatment. References I. Troost, B,T., and Troost, E.G.: Functional paralysis of horizontal gaze. Neurology 29: 82-85, 1979, 2. Cogan, D.G., and Freese, CG., Jf.: Spasm of the near reflex. Arch. OphthalmoJ. 54: 752-759, 1955, Figure 1. Patient fixing at a distance. Figure 2. Attempted lateral gaze to either side shows adequate adduction, abduction, however, is limited to midline or less bilaterally. Figure 3, Covering one lens partially restores the resting midline and monocular excursions. Some convergence is still present. Figure 4, Note the relative mydriasis and mid position with monocular vision (compare Figs. I and 3). 124 Journal of Clinical Neuro-ophthalmology 3. Griffin, J.F., et al.: Misdiagnosis of spasm of the near reflex. Neur%gy 26: 1018-1020, 1976. 4. Keane, J.R.: Bilateral sixth nerve palsy. Arch. Neural. 44: 501-509, 1977. 5. Rucker, C. W.: Paralysis of the third, fourth and sixth cranial nerves. Am. f. aphtha/mol. 46: 787-794, 1958. 6. Rucker, C. W.: The causes of paralysis of the third, fourth, and sixth cranial nerves. Am. f. aphtha/mol. 61: 1203-1298, 1966. 7. Ruch, J.A., and Younge, B.R.: Paralysis of cranial nerves III, IV, and VI. Arch. aphtha/mol. 99: 76-79, 1981. 8. Kirham, T.H., Bird, A.c., and Sanders, M.D.: Divergence paralysis with raised intracranial pressure. Br. Med. f. aphtha/mol. 56: 776-782, 1972. 9. Keane, J.R.: Neuro-ophthalmologic signs and symp- June 1983 Schwartze, McHenry, Proctor toms of hysteria. Neur%gy 32: 757-762, J982. 10. Guiloff, R.J., et al.: Organic convergence spasm. Acta. Neuro/. Scand. 61: 252-259,1980. 11. Caplan, L.R.: "Top of the basilar" syndrome. Neur% gy 30: 72-79, 1980. 12. Manor, R.: Use of special lens in treatment of spasm of the near reflex. Ann. aphtha/mol. 903-905, 1979. 13. Naples, M., and Hackett, T.P.: The amytal interview: History and current uses. Psychosomatics 2: 98-105, 1978. 14. Herman, P.: Convergence spasm. Mount Sinai f. Med. 44: 501-509, 1977. Write for reprints to: Lawrence C. McHenry, Jr., Department of Neurology, Bowman Gray School of Medicine, 300 South Hawthorne Road, Winston-Salem, North Carolina 27103. 125 |
