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Accommodation spasm and light-near dissociation

  • 1.  Accommodation spasm and light-near dissociation

    Posted 11-04-2025 10:15
    Edited by Michel Van Lint 11-04-2025 10:18

    I was wondering if anyone could help with this:

    A 44-year-old man presented in June this year for bilateral loss of vision. He presented to the neurologist, who suspected an optic neuritis. He was admitted for IV steroids but to no avail. An opthalmological examination was requested and eventually plasma exchange was suggested as there was no improvement. 

    Visual acuity was hand movements in both eyes and both visual fields were "black" (MD -20).

    During follow-up, visual acuity improved to snellen 18/20, but he did not find his vision better.

    Goldmann visual fields were constricted (30 degrees).

    Further examination revealed an accommodation spasm (along with pupillary miosis) and also a light-near dissociation.

    Serum was negative for treponema and anti-GQ1b.

    Today he reports having more headaches since two weeks and his diplopia tends to be markedly better when wearing sunglasses. The sunglasses appear to prevent the accommodation spasm.

    As for his diplopia, I was wondering about Botox, as atropin and prisms are not helping.

    Kind regards,

    Michel



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  • 2.  RE: Accommodation spasm and light-near dissociation

    Posted 11-04-2025 12:33
    Dr Van Lint, hope you are not implying that the patient was plexed for Accomodative spasm..
    There are reports of accomodative spasm being misdiagnosed as optic neuritis .
    I am a little confused with the history. 
    Pt had a double negative NMOSD phenotype optic neuritis for which was treated with plex and thereafter developed an accommodative spasm? In that case was there a history of trauma ,stress etc. that can precipitate an accomodative spasm.
    Otherwise cannot connect the two.
    Atropine has been prescribed for months ,homatropine too, with glasses/VT etc.
    But Botox isn't going to take care of the headache and blurred vision so wonder if it's eventually going to make the pt happy.
    It took me months to get out of my own pseudo myopia secondary to the AS.
    I had fallen off a moving train as a kid and had sustained a mild head trauma. In retrospect I attribute my pseudomyopia to it. I wore glasses till 36, then developed an early onset presbyopia at which point my pseudomyopia was diagnosed.Tried homatropine ou and got back my near vision.
    Mine was a slow mo kind of AS without diplopia etc, I guess:)

    Dr Shikha Bassi
    Sankara Nethralaya 
    Chennai
    India



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  • 3.  RE: Accommodation spasm and light-near dissociation

    Posted 11-04-2025 12:51
    I think that neuro imaging must be considered also dilated Fundus for possible pars planitis as a cause of miosis and accommodation spasm , this can happen in MS patients 
    Also VEP should be considered 



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  • 4.  RE: Accommodation spasm and light-near dissociation

    Posted 11-04-2025 13:56
    Did you do several isopters on the Goldmann to make sure this is not non-physiologic?
    Sent from my iPhone



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  • 5.  RE: Accommodation spasm and light-near dissociation

    Posted 11-04-2025 15:07

     

    When evaluating patients with unexplained visual loss, I believe it's essential to maintain the assumption of an underlying organic process.  Even in patients with a demonstrable non-organic component to their presentation, the possibility of coexistent real disease must be considered.  That said, when a patient presents with clinical features that appear to be inconsistent or contradictory, a functional etiology (e.g. psychogenic, malingering, etc.) must also be kept in mind.

     

    This 44-year-old man presented with bilateral HM vision, yet the clinical information provided to the group includes no objective evidence of an organic etiology.  Subsequent visual fields demonstrated bilateral symmetrical constriction.  And more recently, the patient presents with convergence spasm that's reportedly relieved by sunglasses.  Some degree of suspicion would appear to be warranted in this case.

     

    I would suggest beginning the analysis by reviewing the original history, the examination findings, and the neuroimaging results.

     

    HISTORY

     

    Did the patient report pain on eye movement prior to or coincident with the onset of visual loss?

    Did the patient give a history of other neurological symptoms?

    Did the patient drive himself to his appointment?

    Has the patient asked for documentation of disability?

     

    EXAMINATION

     

    On initial examination, when acuity was measured as HM in both eyes, how brisk were the DIRECT pupillary responses?  (Although the absence of an APD could have been explained by bilateral, symmetrical involvement, both pupils should have been very sluggish to direct stimulation).

     

    What were the fundus findings?  In particular, was there any disc swelling at onset?  If not, did optic atrophy and loss of the nerve fiber layer develop bilaterally after four to six weeks?

     

    Was color vision tested?  (Any color perception using standard testing methods would be inconsistent with HM vision from optic nerve disease).

     

    What was the response to testing with the OKN drum?  (With acuities below CF at 2 feet, the OKN response should have been absent).

     

    Did the patient ambulate independently in the exam room and waiting area?

     

    NEURO-IMAGING

     

    What did the MRI show prior to treatment with IV steroids?  In particular, was there optic nerve enhancement unilaterally or bilaterally?  Also, were there any white matter lesions in the brain?

     

    Sharing the above data will greatly facilitate the diagnostic process.

     

                  Steve

     

    Stephen C. Pollock, M.D.





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  • 6.  RE: Accommodation spasm and light-near dissociation

    Posted 11-04-2025 15:39
    I have had over half dozen patients over the years with accommodative spasm treated successfully with biofeedback. If you find a good psychologist who does biofeedback and explain the "uncontrollable" meiosis and variable myopia and esotropia that occurs with this disorder they can design a biofeedback program to eradicate it. Works very well. 
    Only neurologists should confuse accommodative spasm with optic neuritis. !!
    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine













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  • 7.  RE: Accommodation spasm and light-near dissociation

    Posted 11-04-2025 18:13

    Was it sequential or simultaneous loss of vision? LHON?

    What does his RGC layer look like on OCT?
    I have seen a couple of men in their 40-50s with confirmed 11778 LHON recently...

    Deb

     




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  • 8.  RE: Accommodation spasm and light-near dissociation

    Posted 11-04-2025 19:14


    Although visual improvement can certainly occur in LHON patients, I know of no cases in which acuity improved from HM OU to nearly normal over a period of weeks.  Also recall that despite this dramatic improvement, the patient reported that he wasn't aware of any change in his vision!  And finally, bilateral, symmetric, peripheral field constriction is the inverse of what one would expect to see in LHON.

    As I mentioned earlier, we need OBJECTIVE data in order to carry out a reliable analysis of this case:  1) the direct pupillary responses when vision was HM;  2) the responses to OKN testing when vision was HM;  3) the fundus findings at presentation and six or more weeks later;  and 4) the MRI findings (optic nerves and brain) prior to initiation of steroids.

    I continue to suspect a strong functional component.

                 Steve

    Stephen C. Pollock, M.D.




    Original Message


  • 9.  RE: Accommodation spasm and light-near dissociation

    Posted 11-04-2025 19:18
    I agree with Dr Savino. I would do tangent screen fields at 1 and 2 meters to look for non-organic field abnormalities.

    Russ Edwards




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  • 10.  RE: Accommodation spasm and light-near dissociation

    Posted 11-05-2025 11:53
    When I was last practicing 4 years ago, not many ophthalmologists had tangent screens. Finger counting at different distances was just as practical, perhaps more so, since the finger targets were large and fast, unlikely to confuse a patient with no prior exposure to the tangent screen. Remember the old timers (i.e., J. Lawton Smith) who just had a flashlight that projected a point source of light onto a wall while the patient sat in a chair at different distances. That could catch an unsophisticated patient who would show a greater field at near, since they erroneously reasoned that being closer should improve their peripheral vision. The main benefit of a tangent screen would be for reporting numbers in a medical-legal issue.
    Mickey Rosenberg


    Original Message


  • 11.  RE: Accommodation spasm and light-near dissociation

    Posted 11-05-2025 12:46
    Tangent screens are hard to find but easy to make. Black felt, black thread, some 1" by 2" pine. Dowel painted black only used mine to test for non-organic disorders so I used 5 mm test objects at 1 meter and 10 mm objects at 2 meters. Got them at a craft store.

    Russ Edwards




    Original Message


  • 12.  RE: Accommodation spasm and light-near dissociation

    Posted 11-05-2025 13:26
    Or, if you are a luddite and not good with a needle, Good-lite still sells them.




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  • 13.  RE: Accommodation spasm and light-near dissociation

    Posted 11-05-2025 13:33

    When I was looking for tangent screens for my new office, several of our colleagues happily offered to sell me theirs as they were no longer being used.

    Deb




    Original Message


  • 14.  RE: Accommodation spasm and light-near dissociation

    Posted 11-06-2025 15:30

    Many thanks for the numerous responses.

    Apologies if this story is confusing. It is to me, too.

    The neurologist sent the patient to us after the first treatment with suspicion of bilateral optic neuritis. He never had an eye exam with us before treatment..

    The OCT was normal at presentation and still is. Therefore, I don't believe it was an optic neuritis. 

    During follow-up, his visual fields improved. Five months into follow-up he developed an accommodation spasm. I am not sure how I would confuse this with an optic neuritis, as was suggested?

    His MRI is currently normal.

    I was inclined to consider functional causes, but his light-near dissociation is not compatible with that.

    In the meantime, I will look into the biofeedback. Sounds like a good suggestion. 

    Thank you everyone

    Michel

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    Original Message


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