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Grand Rounds Conference

Grand Rounds Conference. Eric Downing MD University of Louisville Department of Ophthalmology and Visual Sciences. Subjective. CC : “Can’t control my eye movements”

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Grand Rounds Conference

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  1. Grand Rounds Conference Eric Downing MD University of Louisville Department of Ophthalmology and Visual Sciences

  2. 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.

  3. History POH: none PMH: none Eye Meds: none Meds: Cyclobenzaprine, Nortriptyline

  4. Objective OD OS VA: 20/70 20/40 Pupils: 3->1 3->1, no rAPD IOP: 24 23 (squeezing) EOM:

  5. Clinical Video

  6. Refraction • M -1.75 +0.25 x 005 20/20 -2.00 +0.25 x 170 20/20 • C -0.75 +0.25 x 016 20/20 -0.75 +0.75 x 010 20/20

  7. Objective SLE: All WNL DFE: All WNL Imaging: CT head: WNL

  8. Additional example

  9. 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

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

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

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

  13. 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

  14. 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: • Cerebral cortex • Pretectum of the midbrain • Oculomotor nuclear complex

  15. 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

  16. History & Physical • History • Decreased VA • Blurry vision/horizontal diplopia, especially at near • Eye strain • HAs • Physical • Variable esotropia, convergence overaction • Accommodative spasm • Miosis

  17. 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

  18. 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

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

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

  21. 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.

  22. 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

  23. Summary Varied treatments leads one to the conclusion that the natural history of the disease may be toward spontaneous resolution.

  24. References 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

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