An accommodation spasm is defined as
inadequate protracted contraction of the ciliary muscle.
Accommodation spasms arerare.
They may occur asfunctionalimpairment or
they may occur iatrogenically when
treating young patientswith parasympathomimetic agents (miotic agents). The
functional impair-ments are frequently attributable to heightened sensitivity
of the accommo-dation center, which especially in children (often girls) can be
psychogenic. Rarely the spasm is due
to organic causes. In these cases, it
is most oftenattributable to irritation in the region of the oculomotor nuclei
(from cerebral pressure or cerebral disorders) or to change in the ciliary
muscle such as in an ocular contusion.
Patients complain of deep eye pain and blurred distance
The diagnosis ismade on the basis of
presenting symptoms and refraction testing, including measurement of the range
of accommodation. This is done with an accom-modometer, which determines the
difference in refractive power between the near point and far point. A differential diagnosis should exclude
latent hyperopia. In children, this will frequently be associated with
accommoda-tive esotropia and accommodative pupil narrowing.
This depends on the underlying disorder. Cycloplegic therapywith
agents such as tropicamide or cyclopentolate may be attempted in the presence
of recurrent accommodation spasms.
Iatrogenic spasms are completely reversible by discontinuing
theparasympathomimetic agents. The prognosis is also good for patients with
functional causes. Spasms due to organic causes require treatment of the
un-derlying disorder but once treatment is initiated the prognosis is usually
Failure of accommodation due to palsy of the
This rare disorder is
primarily to one of the following causes:
❖Iatrogenic drug-induced palsy due to parasympatholytic agents such asatropine, cyclopentolate
scopolamine, homatropine, and tropicamide.
❖ Peripheral causes: Oculomotor palsy, lesions of the ciliary ganglion, or theciliary
❖ Systemic causes: Damage to the accommodation center in diphtheria, dia-betes
mellitus, chronic alcoholism, meningitis, cerebral stroke, multiple sclerosis,
syphilis, lead or ergotamine poisoning, medications such as isoniazid or
piperazine, and tumors.
The failure of accommodation leads to blurred near vision andmay
be associated with mydriasis where the sphincter pupillae muscle is also
involved. The clinical syndromes listed below exhibit a specific constellation
of clinical symptoms and therefore warrant further discussion.
❖ Post-diphtheria accommodation palsy: This transitory palsy is a toxicreaction and
occurs without pupillary dysfunction
approximately four weeks after infection. Sometimes it is associated with palsy
of the soft pal-ate and/or impaired motor function in the lower extremities.
❖ Accommodation palsy in botulism: This is also a toxic palsy. Itdoesinvolve the pupil, producing mydriasis, and can be the first symptom of botulism. It is
associated with speech, swallowing, and ocular muscle dys-function accompanied
by double vision.
❖ Tonic pupillary contraction is associated with tonic accommodation.
❖ Sympathetic ophthalmia is characterized by a decrease in the range ofaccommodation,
even in the unaffected eye.
Measurement of the range of accommodation is
indicated whenever sympathetic ophthalmia is suspected.
In addition to measuring the range of accommo-dation with an
accommodometer, the examiner should inquire about other ocular and general
This depends on the underlying disorder.
The clinical course of tonic
pupillary contractionis chronic andresults in irreversible loss of
accommodation. The toxic accommodation
pal-sies are reversible once the underlying disorder is controlled.