Pseudomyopia with paradoxical accommodation: a case report

Abstract

Background Pseudomyopia is caused by increased refractive power by ciliary muscle spasm. Most patients cannot overcome pseudomyopia spontaneously; therefore, treatment of pseudomyopia is fastidious and needs a multidisciplinary approach. We report a case of unusual pseudomyopia with paradoxical accommodation, straining eyes to induce emmetropia at far distance and relaxing eyes to focus at near objects, contrary to physiological accommodation. Case presentation A 33-year-old woman experienced intermittent distant vision discomfort. This occurred at least a few hundred times daily. She could see near objects clearly; however, distant objects could be seen clearly only when she strained her eyes. Uncorrected distance visual acuity was 20/20 and manifest refraction (MR) in both eyes in the relaxed state was approximately − 2.5 D. MR changed to approximately − 0.5 D when she grimaced and strained her eyes when attempting to focus on distant letters. Her response was contrary to the physiological accommodative response. Cycloplegic refraction was approximately 0.0 D. Binocular autorefractor/keratometer was used to objectively evaluate her refractive response and pupil reaction according to accommodative stimulation. The IOL Master was used to evaluate the anterior chamber depth (ACD), lens thickness (LT), and pupil diameter with relaxed and strained eyes. For stepwise static accommodative stimuli (1–5 D), the refractive responses were correspondingly stepwise, similar to those elicited by healthy individuals. However, contrary to physiological accommodation, she strained her eyes to see distant objects and relaxed them to see near objects. There was no change in pupil diameter despite the accommodative stimuli being maximum. Biometry results showed that ACD deepened and LT flattened with eye strain, which were contrary to those during physiological accommodation. Conclusions We report a rare case with reverse of physiological accommodative response. When patients complain of unusual distant visual discomfort, pseudomyopia with paradoxical accommodation should be considered.

Pseudomyopia: A Review

“…The rest of the literature reviewed chooses less invasive treatment alternatives such as cycloplegic agents [ 14 , 16 , 17 , 18 , 22 , 25 , 26 , 36 , 38 , 39 , 40 ], plus lens additions for near work during cycloplegic treatment [ 14 , 17 , 18 , 20 , 36 ], prescriptions of manifest [ 18 , 25 , 36 , 40 , 55 ] or cycloplegic refraction for distance [ 36 ], base-in prisms [ 11 , 16 , 20 , 26 , 54 , 56 ] and vision therapies designed to relax accommodation [ 18 , 26 ] and improve fusional vergence ranges [ 17 ].…”

Efficacy and safety of acupuncture for patients with pseudomyopia

“…If empirical treatment for patients with pseudomyopia fails, [24][25][26][27][28] cycloplegic drugs (e.g., atropine and homatropine, homide, and tropicamide). [29] Cycloplegic drugs, though effective in improve vision, they are associated with systemic side effects and ocular discomfort. This required tapering of doses until these symptoms were manageable or required switching to weaker cycloplegics.…”

Pseudomyopia and Its Association With Anxiety

“…This psychological association was proven by the unstable refractive change seen with the large standard deviation of the manifest refraction during these periods of stress. The psychological stress stimulated a parasympathetic spasm which allowed the patient to control the pseudomyopia [ 3 ]. It is pertinent, that in response to stressors, the hypothalamus releases the corticotropin-releasing hormone that sends projections to the locus coeruleus of the brain stem.…”

“…Although stronger cycloplegics like atropine show better results compared to weaker cycloplegics like homatropine, homide, and tropicamide, they are associated with systemic side effects and ocular discomfort. This required tapering of doses until these symptoms were manageable or required switching to weaker cycloplegics [ 3 , 6 , 7 ].…”

“…Physiologically, when the eye wants to focus on a distant target, the ciliary muscles contract optimally to focus a clear image on the fovea. This reflex is known to have three components known as accommodation, convergence, and miosis and is mediated by a complex network of the parasympathetic nervous system (PNS) via the Edinger Westphal nucleus [ 1 , 3 ]. This reflex can malfunction for many reasons such as head trauma or excessive stress, resulting in an image of a near object to be projected in front of the retina instead of on the retina, which causes a blurred or distorted image [ 1 , 4 ].…”