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Shirley H. Wray, MD, PhD, FRCP, Professor of Neurology, Harvard Medical School; Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Spasm of the Near Reflex;
Functional Convergence Spasm;
Spasm of the Near Triad;
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Episodic eye pain
This 17 year old boy presented with episodic eye pain.
He consulted an ophthalmologist for evaluation of his symptoms and also complained of periodic difficulty focusing.
On examination he had periodic spasms of abnormal eye movements, with impairment of full abduction.
His ophthalmologist considered the possibility of a tic or seizures and referred him to the Neurovisual Clinic.
Significant for a long history of behavioral disturbance including non-compliance at school and temper tantrums. He was an only child.
On examination he had intermittent spasm of convergence –
spasm of the near reflex.
Spasm of the near reflex may be a sign of:
1. An organic lesion or
2. A functional disorder
1. Lesions at the diencephalic-mesencephalic junction, for example, thalamic esotropia characterized by eyes peering at the nose associated with thalamic hemorrhage.
2. Cogan described convergence spasm elicited by extending the neck, in a patient with downbeat nystagmus.
3. Wernicke’s encephalopathy
4. Chiari malformation and other posterior fossa lesions
5. Multiple sclerosis
6. Metabolic disturbances
Spasm of the near reflex must be distinguished from convergence movements utilized by patients with horizontal gaze palsies to look laterally. In these cases, the pupils do not constrict with versional movements. (See ID936-4).
Spasm of convergence as a sign of a functional disorder is seen most commonly in adolescents and young adults with underlying psychological problems.
This case illustrates features typical of spasm of the near reflex.
This is a condition frequently misdiagnosed as bilateral sixth nerve palsy and there are times during this eye movement recording when the patient fails to abduct the eyes fully.
The features to watch for are:
1. Convergence spasms typically come and go.
2. The eyes are dysconjugate in primary gaze at the start of the exam, with an
3. Esotropia in primary position of the left eye
4. Each eye can move independently producing dysconjugate lateral movements
5. With both eyes viewing the patient limits abduction by imposing a strong convergence movement that causes accommodation, and most importantly, miosis.
6. With one eye patched, he has full abduction of both eyes
7. Careful examination shows full eye movements in all directions
8. Voluntary blinking of the eyelids accompanies the dysconjugate eye movements.
Spasm of the near reflex, characterized by intermittent convergence, accommodation and miosis, is a functional disturbance.
In 1976 we reported five patients with hysterical spasm of the near reflex erroneously diagnosed as a bilateral sixth nerve palsy.
The pupillary sign, intense miosis on attempted lateral gaze, is emphasized as an important clue to the correct diagnosis.
Despite extensive investigation, no disease of the central nervous system was found. Neurotic or hysterical features were evident in every patient.
(Griffin JF, Wray SH, Anderson DP. Misdiagnosis of spasm of the near reflex. Neurology 1976;26:1018-1020)
Spasm of the near reflex; Functional convergence spasms
Treatment in this case was directed towards the underlying psychological problems that this boy had.
(See also ref 8)
Psychloplegic eyedrops and refractive measures (positive or negative lenses) may be effective.