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 OD OS OD OS VA: 20/7020/40 Pupils: 3->13->1, no rAPD IOP: 2423 (squeezing) EOM:

Clinical Video

Refraction M x 00520/20 M x 00520/ x 17020/20 C x 01620/20 C x 01620/ x 01020/20

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. 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 Dx: Spasm of the near reflex

Plan Referral to Neuro clinic Referral to Neuro clinic Trial of Atropine daily with reading glasses Trial of Atropine daily with reading glasses

Two week follow up Patient reported no alleviation of symptoms with Atropine Patient reported no alleviation of symptoms with Atropine Addition of trial of Phospholine Iodide Addition of trial of Phospholine Iodide Follow up again in 3 weeks Follow up again in 3 weeks

Convergence Spasm First described by Cogan in 1955 First described by Cogan in 1955 Inappropriate occurrence of the near triad Inappropriate occurrence of the near triad 1. Convergence 2. Miosis 3. Accommodation Diagnosis Diagnosis 1. Intermittent episodes of sustained maximal convergence 2. Accommodative spasm 3. Pupillary constriction

Pathophysiology Primarily a functional etiology, associated with somatization disorders, such as hysteria or neurosis 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 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: 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. Cerebral cortex 2. Pretectum of the midbrain 3. Oculomotor nuclear complex

Epidemiology Reported occurrence is very variable, and ranges from 0.1-1%. Reported occurrence is very variable, and ranges from 0.1-1%. Most patients are young in age Most patients are young in age 2-3/1 Female to male predominance 2-3/1 Female to male predominance Occurrence of visual symptoms occurs in ~16% of patients with conversion disorder Occurrence of visual symptoms occurs in ~16% of patients with conversion disorder

History & Physical History History Decreased VA Decreased VA Blurry vision/horizontal diplopia, especially at near Blurry vision/horizontal diplopia, especially at near Eye strain Eye strain HAs HAs Physical Physical Variable esotropia, convergence overaction Variable esotropia, convergence overaction Accommodative spasm Accommodative spasm Miosis 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 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 Atropinization with reading glasses, sometimes for up to one year Botox injection Botox injection Miotics, such as Phopholine Iodide Miotics, such as Phopholine Iodide Antidepressants +/- psychological counseling Antidepressants +/- psychological counseling Minus lenses Minus lenses Placebo drops Placebo drops

Retrospective study Retrospective study 17 pts 17 pts 3 resolved with treatment 3 resolved with treatment 14 were over-corrected 14 were over-corrected 7 needed continued treatment 7 needed continued treatment 7 saw no benefit, and discontinued treatment 7 saw no benefit, and discontinued treatment

Case report Case report 10 year old boy with convergence spasm 10 year old boy with convergence spasm Given phospholine iodide and phenylephrine Given phospholine iodide and phenylephrine Resolution within 8 weeks Resolution within 8 weeks Similar reports by Moore and Stockbridge Similar reports by Moore and Stockbridge

7 yr old girl with 10.5 diopters of pseudomyopia 7 yr old girl with 10.5 diopters of pseudomyopia Initial therapy with Atropine and reading glasses with no resolution Initial therapy with Atropine and reading glasses with no resolution She was placed on Sertraline and Diazepam, and saw resolution within one month. 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 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. Variety of cases presented under the umbrella of accommodation abnormalities and convergence disorders. With and without miosis With and without miosis With and without gaze paralysis of vertical gaze With and without gaze paralysis of vertical gaze With and without accommodative spasm 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. Varied treatments leads one to the conclusion that the natural history of the disease may be toward spontaneous resolution.

References 1. Goldstein JH, Schneekloth BB. Spasm of the Near Reflex: A Spectrum of Anomalies. Survey of Ophthalmology. 1996;40(4): Weber KP, Thurtell MJ, Halmagyi GM. Teaching NeuroImage: Convergence spasm associated with midbrain compression by cerebral aneurysm. Neurology. 2008;70(15): e49-e Hyun HJ, Chung US, Chun BY. Early Resolution of Convergence Spasms Following the Addition of Antipsychotic Medications. Korean J Ophth. 2011;25(1): Christoff A, Christiansen SP. Spasm of the Near Reflex: Treatment with Miotics Revisited. American Orthoptic Journal. 2013;63(1): Kaczmarek BB, Dawson E, Lee JP. Convergence Spasm treated with botulinum toxin. Strabismus. 2009;17(1):49-51