Grand Rounds Conference
Eric Downing MD
University of Louisville
Department of Ophthalmology and Visual Sciences
Subjective
CC: “Can’t control my eye movements”
HPI: 41M fell off a forklift suffered a concussion.
Complains of intermittent diplopia, blurry
vision, and uncontrollable blink reflex.
History
POH: none
PMH: none
Eye Meds: none
Meds: Cyclobenzaprine, Nortriptyline
Objective
VA:
Pupils:
IOP:
EOM:
OD
20/70
3->1
24
OS
20/40
3->1, no rAPD
23 (squeezing)
Clinical Video
Refraction

M -1.75 +0.25 x 005
-2.00 +0.25 x 170
20/20
20/20

C -0.75 +0.25 x 016
-0.75 +0.75 x 010
20/20
20/20
Objective
SLE: All WNL
DFE: All WNL
Imaging:
CT head: WNL
Additional example
Assessment

41M with h/o anxiety disorder, s/p concussion
with spastic eye movements, inappropriate
accommodation, pseudomyopia, and horizontal
diplopia at near > distance x 6 months.

Dx: Spasm of the near reflex
Plan


Referral to Neuro clinic
Trial of Atropine daily with reading glasses
Two week follow up



Patient reported no alleviation of symptoms
with Atropine
Addition of trial of Phospholine Iodide
Follow up again in 3 weeks
Convergence Spasm


First described by Cogan in 1955
Inappropriate occurrence of the near triad
1.
2.
3.

Convergence
Miosis
Accommodation
Diagnosis
1.
2.
3.
Intermittent episodes of sustained maximal convergence
Accommodative spasm
Pupillary constriction
Pathophysiology


Primarily a functional etiology, associated with
somatization disorders, such as hysteria or
neurosis
Organic causes: encephalitis, tabes, labyrinthe
fistulas, Arnold-Chiari malformation, posterior
fossa neurofibroma, trauma, or pituitary
adenomas
Organic

Jampel localized the near triad
to Brodmann areas 19 and 22,
but also there are at least 3
areas involved in the near
reflex:
1.
2.
3.
Cerebral cortex
Pretectum of the midbrain
Oculomotor nuclear complex
Epidemiology




Reported occurrence is very variable, and ranges
from 0.1-1%.
Most patients are young in age
2-3/1 Female to male predominance
Occurrence of visual symptoms occurs in ~16% of
patients with conversion disorder
History & Physical
History
Decreased
VA
Blurry vision/horizontal diplopia, especially at near
Eye strain
HAs
Physical
Variable
esotropia, convergence overaction
Accommodative spasm
Miosis
Work-up

Imaging and lab studies indicated in cases that
don’t have an antecedent event, other focal
neurologic signs, or absence of psychiatric
history
Treatment
 Atropinization
with reading glasses,
sometimes for up to one year
 Botox injection
 Miotics, such as Phopholine Iodide
 Antidepressants +/- psychological counseling
 Minus lenses
 Placebo drops


Retrospective study
17 pts
3 resolved with treatment
 14 were over-corrected
 7 needed continued treatment
 7 saw no benefit, and discontinued treatment






Case report
10 year old boy with convergence spasm
Given phospholine iodide and phenylephrine
Resolution within 8 weeks
Similar reports by Moore and Stockbridge



7 yr old girl with 10.5 diopters of pseudomyopia
Initial therapy with Atropine and reading glasses
with no resolution
She was placed on Sertraline and Diazepam, and
saw resolution within one month.
Summary

The varied range of disease entities and
nomenclature makes it difficult to present a
unified etiology

Variety of cases presented under the umbrella of
accommodation abnormalities and convergence
disorders.
With and without miosis
 With and without gaze paralysis of vertical gaze
 With and without accommodative spasm

Summary

Varied treatments leads one to the conclusion
that the natural history of the disease may be
toward spontaneous resolution.
References
1.
2.
3.
4.
5.
Goldstein JH, Schneekloth BB. Spasm of the Near Reflex: A Spectrum of
Anomalies. Survey of Ophthalmology. 1996;40(4):269-278
Weber KP, Thurtell MJ, Halmagyi GM. Teaching NeuroImage:
Convergence spasm associated with midbrain compression by cerebral
aneurysm. Neurology. 2008;70(15): e49-e50.
Hyun HJ, Chung US, Chun BY. Early Resolution of Convergence Spasms
Following the Addition of Antipsychotic Medications. Korean J Ophth.
2011;25(1):66-68
Christoff A, Christiansen SP. Spasm of the Near Reflex: Treatment with
Miotics Revisited. American Orthoptic Journal. 2013;63(1):110-113
Kaczmarek BB, Dawson E, Lee JP. Convergence Spasm treated with
botulinum toxin. Strabismus. 2009;17(1):49-51