Grand Rounds

Grand Rounds ConferenceEric Downing MDUniversity of LouisvilleDepartment of Ophthalmology and Visual Sciences

SubjectiveCC: Cant control my eye movements

HPI: 41M fell off a forklift suffered a concussion. Complains of intermittent diplopia, blurry vision, and uncontrollable blink reflex.

Ptosis progressive over several years, OD > OS. Holds lids up to see. 2HistoryPOH: nonePMH: noneEye Meds: noneMeds: Cyclobenzaprine, Nortriptyline

FOH: GlaucomaFH: Cancer, stroke

3Objective OD OSVA: 20/7020/40Pupils: 3->13->1, no rAPDIOP: 2423 (squeezing)EOM: Levator function > 10 mm is excellent; < 5 is poor

4Clinical Video

RefractionM-1.75 +0.25 x 00520/20-2.00 +0.25 x 17020/20

C-0.75 +0.25 x 01620/20-0.75+0.75 x 01020/20ObjectiveSLE: All WNLDFE: All WNL

Imaging:CT head: WNLAdditional example

Assessment41M 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 reflexPlanReferral to Neuro clinicTrial of Atropine daily with reading glassesTwo week follow upPatient reported no alleviation of symptoms with Atropine Addition of trial of Phospholine Iodide Follow up again in 3 weeksConvergence SpasmFirst described by Cogan in 1955Inappropriate occurrence of the near triad ConvergenceMiosis AccommodationDiagnosisIntermittent episodes of sustained maximal convergenceAccommodative spasmPupillary constrictionPathophysiologyPrimarily a functional etiology, associated with somatization disorders, such as hysteria or neurosisOrganic causes: encephalitis, tabes, labyrinthe fistulas, Arnold-Chiari malformation, posterior fossa neurofibroma, trauma, or pituitary adenomasOrganic Jampel localized the near triad to Brodmann areas 19 and 22, but also there are at least 3 areas involved in the near reflex:Cerebral cortexPretectum of the midbrainOculomotor nuclear complex

EpidemiologyReported occurrence is very variable, and ranges from 0.1-1%.Most patients are young in age2-3/1 Female to male predominance Occurrence of visual symptoms occurs in ~16% of patients with conversion disorder15History & PhysicalHistoryDecreased VABlurry vision/horizontal diplopia, especially at nearEye strainHAsPhysicalVariable esotropia, convergence overactionAccommodative spasmMiosis

16Work-upImaging and lab studies indicated in cases that dont have an antecedent event, other focal neurologic signs, or absence of psychiatric history

17TreatmentAtropinization with reading glasses, sometimes for up to one yearBotox injectionMiotics, such as Phopholine IodideAntidepressants +/- psychological counselingMinus lensesPlacebo drops

Sjogren and Hashimoto thyroiditis; HIV18Retrospective study17 pts 3 resolved with treatment14 were over-corrected7 needed continued treatment7 saw no benefit, and discontinued treatment

Case report10 year old boy with convergence spasmGiven phospholine iodide and phenylephrineResolution within 8 weeksSimilar reports by Moore and Stockbridge

7 yr old girl with 10.5 diopters of pseudomyopiaInitial therapy with Atropine and reading glasses with no resolutionShe was placed on Sertraline and Diazepam, and saw resolution within one month.

SummaryThe varied range of disease entities and nomenclature makes it difficult to present a unified etiologyVariety of cases presented under the umbrella of accommodation abnormalities and convergence disorders.With and without miosisWith and without gaze paralysis of vertical gazeWith and without accommodative spasmSummaryVaried treatments leads one to the conclusion that the natural history of the disease may be toward spontaneous resolution.ReferencesGoldstein JH, Schneekloth BB. Spasm of the Near Reflex: A Spectrum of Anomalies. Survey of Ophthalmology. 1996;40(4):269-278Weber 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):66-68Christoff A, Christiansen SP. Spasm of the Near Reex: Treatment with Miotics Revisited. American Orthoptic Journal. 2013;63(1):110-113Kaczmarek BB, Dawson E, Lee JP. Convergence Spasm treated with botulinum toxin. Strabismus. 2009;17(1):49-51