Spasm of the Near Synkinetic Reflex
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Disease Entity
The spasm of the near synkinetic reflex, or spasm of the near reflex, is characterized by accommodation spasm, acute convergent strabismus and miosis.
Etiology
It can be divided in functional and organic.
Functional
Caused by anxiety or emotional distress, most common cause and most often seen in otherwise healthy individuals.
Organic
Head trauma, neurologic disease (multiple sclerosis, metabolic encephalopaties, Arnold-Chiari malformations, tumors).
Diagnosis
The diagnosis is commonly clinical. The presence of pseudo myopia with a hyperopic shift or lessening of the myopia after wet refraction, convergent strabismus and miosis is often diagnostic. Imaging studies are required when associated neurologic or systemic findings are present or the history of close head trauma.
History
The patient often complains of transient episodes of blurry vision, diplopia and asthenopia.
Physical examination
Variable acute esotropia is always present with limitation of abduction during the ophthalmologic exam. In the dry refraction pseudo myopia is present accompanied by miosis. It is recurrent in nature and commonly exacerbated by periods of anxiety.
A cycloplegic refraction is mandatory and always gives us a hyperopic shift or a lessening of the existent myopia which is characteristic of this entity.
Laboratory test
Imaging studies in cases were other neurologic or systemic findings are related to the onset of the disease or if there is history of head trauma.
Differential diagnosis
- Myasthenia gravis
- Multiple sclerosis
- Bilateral sixth nerve palsy
- Divergence insufficiency
Management
Medical therapy
The use of cycloplegic agents like atropine and the use of plus lenses and bifocals may be effective therapies.
References
1. Goldstein JH. Spasm of the near reflex: a spectrum of anomalies. Survey Ophthalmology 1996;40:269-278.
2. Hussaindeen JR. Acute adult onset comitant esotropia associated wth accommodative spasm. Optom Vis Sci 2014; Apr;91(4 Suppl 1):S46-51
3. Sitole S. Spasm of the near reflex in a patient with multiple sclerosis. Semin Ophthalmol 2007;Jan.Mar:22(1):29-31.
4. Rosenberg ML. Spasm of the near reflex mimicking myasthenia gravis. J Clin Neuroophthalmol. 1986 Jun;6(2):106-8.
5. Milea D. Atypical ocular myasthenia gravis. Rev Neurol (Paris) 2005 May;161(5):543-8.
6. Woillez JP. Acute strabismus caused by accommodative spasm. Bull Soc Ophthalmol Fr 1989 Dec;89(12): 1467-8.
