INTRODUCTION Accomodative spasm (AS) is an aesthenopiccondition due to involuntary spasm of ciliary musclesa1 .
It is commonly caused by psychological stress,excessive near workor due to certain topical drugs.Cycloplegic refraction is the key modality tounmask accommodative spasm presenting as pseudomyopia along with asthenopia. Management options for AS include bifocalglasses/Plus glasses,orthoptic exercises and cycloplegia or atropinisation.
Butrecurrence is the major problem associated with AS.Slow weaning of atropinemight help to reduce the recurrence.In this study,we used cycloplegicrefraction in case of pseudomyopia with presence of aggravating factors andobserved the effect of slow weaning effect of atropine eye drops along withavoidance of aggravating factors to prevent its recurrence.PURPOSE• The purpose of study was to highlight importance of cycloplegicrefraction to detect accommodative spasm. • To evaluate role ofatropinisation for its management and effect of slow weaning on recurrence.SETTINGSThis retrospective study was carried in a tertiary eye care hospitalin Chennai,India.Sample size: 8eyes of 4 patients.
All the patientsdiagnosed as transient myopia along with presence of aggravating factors wereasked to undergo cycloplegia with cyclopentolate eye drops.If there was shift from myopia to hypermetropia aftercycloplegia, patients were started on bifocal or plus glasses along with atropine(1%) or homatropine(2%) eye drops on weekly twice basis and wereevaluated two weekly.Eye drops were tapered every month gradually over three months and patients were observed upto sixmonths.
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SUMMARY OFMATERIAL AND METHODS:Presentingcomplaints: Case 1:An 11 year oldfemale was presented with complaints of sudden onset blurring of vision fordistance and near and headache with history of excessive near work.Ocularexamination including extra ocular movements was normal. VISION (corrected) SPHERICAL POWER DIOPTERS Precycloplegia OD: 20/40,N6 -2.00 OS: 20/63,N6 -1.75 Post cycloplegia OD: 20/20,N6 +1.
75,+3.00 OS: 20/20,N6 +2.00,+3.00 Management:Patient wasmanaged with bifocal glasses with cycloplegic correction and +3.
00 add for nearvision. She was started on atropine on weekly twice basis(1% eye drops) and wastapered over three months.On subsequent visits there was symptomatic relief andcondition resolved.No recurremnce was noted over six months.Case 2:A 12 year oldfemale presented with complaints of sudden onset blurring of vision fordistance and headache with history of psychological stress.Ocular examinationincluding extra ocular movements was normal. VISION (corrected) SPHERICAL POWER DIOPTERS Precycloplegia OD: 20/40,N6 -1.25 OS: 20/20,N6 -0.
25 Post cycloplegia OD: 20/20,N6 +0.50 OS: 20/20,N6 +0.50 Management:Patient wasmanaged with plus power glasses withcycloplegic correction and +3.
00 add.She was started on homatropine 2%w/v eyedrops on weekly twice basis and wastapered over three months.On subsequent visits there was symptomatic relief andcondition resolved.No recurremnce was noted over six months.Case 3:13 year old malepresented complaints of sudden onset blurring of vision for distance and nearand headache with history of psychological stress.Ocular examination includingextra ocular movements was normal. VISION (corrected) SPHERICAL POWER DIOPTERS Precycloplegia OD: 20/40,N6 -2.
25 OS: 20/40,N6 -7.00 Post cycloplegia OD: 20/32,N6 +1.25,+2.
50 OS: 20/32,N6 +0.75,+2.50 Management:Patient wasmanaged with bifocal glasses with cycloplegic correction and +2.50 add for nearvision. He was started on atropine on weekly twice basis(1% eye drops) and wastapered over three months.
On subsequent visits there was symptomatic relief andcondition resolved.No recurremnce was noted over six months.After six monthsthere was again similar episode which was managed with similar protocol.Case 4:A 12 old malepresented complaints of sudden onset blurring of vision for distance and nearand headache with history of psychological stress.Ocular examination includingextra ocular movements was normal.
VISION (corrected) SPHERICAL POWER DIOPTERS Precycloplegia OD: 20/20,N6 -1.25 OS: 20/20,N6 -4.00 Post cycloplegia OD: 20/20,N6 +1.00,+2.
50 OS: 20/20,N6 +0.75,+2.50 Management:Patient wasmanaged with bifocal glasses with cycloplegic correction and +2.50 add for nearvision. He was started on atropine on weekly twice basis(1% eye drops) and wastapered over three months.On subsequentvisits there was symptomatic relief and condition resolved. DISCUSSIONAccommodative spasm is characterized by frontalheadache, blurred vision(pseudomyopia), miosis, acute acquiredconcomittentesotropia(AACE),diplopia and sometimes macropsia.
1,2,3Mostlypresents in children,young adolescents.It can be a part of spasm of nearreflex(SNR).2Ophthalmoplegic migraine needs to be differentiatedfrom it in presence of AACE and diplopia.1Apart from psychological stress and excessivenear work certain conditions predispose to it:Ø Topicalmiotics(parasympathomimetics, cholinergics)4Ø After refractive surgery :LASIK surgery, PhotoRefractive keratectomy5,6Ø After head trauma7Ø Due to central lesion involving dorsal midbrainor idiopathic intracranial hypertension.8Ø Rare causes reported are :Bimatoprost induced9,Secondary to long standing intermittent exotropia.10The diagnosis of AS is clinical based onpresence aggravating factors and shift of refraction after cycloplegia.On openfield hartmann- shack wavefrontaberrometry it shows lead of accommodation andnegative spherical aberrations.11Joseph H et al.
, showed cases of AS a part of spectrum of spasm of near reflex and had described five suchcases.Accommodative spasm was graded as minimal when small minus and small plusvalues were present and marked when small plus and high minus values werepresent.12Hussaindeen JR et al., treated adult onsetconcomittentesotropia associated with AS with cycloplegics for one year and conditionresolved completely without recurrence2Rutstein RP et al., studiedseventeen cases of accommodative spasm and treated them with pluslenses,orthoptice exercise and psychologicalcounselling but only four casesresolved completely.13In our study we found complete resolution ofcondition without recurrence which is similar to observations of Hussaindeen etal.
Addition of glasses with cycloplegics gives comfortable working vision tothe patient.In our case series, we had four cases whichwere diagnosed on basis of hypermetropic shift after cycloplegia and presenceof predisposing factors like psychological stress and excessive nearwork.Atropine(1%) eye drops provided powerful cycloplegia with symptomaticrelief one patient with milder symptoms was put on homatropine instead ofatropine. Atropine was started twice a week and was tapered over three months.On sixth month followup recurrence were not noted in any of the patients.Aftersix months one patient presented again with similar complaints due to exposureto psychological stress and was treated similarly.
Larger sample size withlongerfollowup is required to reach to a definite conclusion.CONCLUSIONAccommodative spasm can be easily misdiagnosed as myopia ifcycloplegic refraction is notdone.Triggering factors also provides key todiagnosis.Slow weaning of atropine prevents recurrence.
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