Convergence Paralysis & Spasm

Question 1

What is convergence paralysis

Answer 1

Inability to converge
(some convergence is possible in convergence paresis)

Question 2

Signs and symptoms of convergence paralysis

Answer 2

Crossed diplopia at middle to near
Exotropia at near
Possible involvement of accommodation and pupils

Question 3

Convergence paralysis aetiology

Answer 3

head trauma
neurological disease e.g. MS and encephalitis
may be associated with dorsal midbrain syndrome
primary
functional overlay/ psychogenic

Question 4

Management of convergence paralysis

Answer 4

-Investigations e.g. MRI scan
-Base in prisms
-Occlusion
-Convex/hypermetropic lens (if accomm affected)
-Referral for psychological/psychiatric assessment (if functional overlay)

Question 5

Convergence spasm definition and symptoms

Answer 5

Definition- Usually spasm of near reflex due to
contraction of medial recti muscles and contraction of ciliary muscles

Symptoms- uncrossed diplopia and blurred vision (if accomm spasm also)

Question 6

Signs of convergence spasm

Answer 6

Esotropia - could be variable in size
Miosis
Observe consistency of convergence spasm and miosis throughout testing
Spasm on lateral gaze gives appearance of LR palsy - test abduction, doll’s head
Macropsia
Pseudomyopia

Question 7

According to Hyndman (2018), what is the most common cause of spasm of the near reflex?

Answer 7

Head injury

Question 8

Aetiology of convergence spasm

Answer 8

Head injury

Functional (aka psychogenic)
Stress and anxiety
Observation/ dynamic ret if accomm spasm too

Neurological disease
Encephalitis
Multiple sclerosis
Arnold Chiari malformation
Tumours (posterior fossa, pituitary)
Cerebral aneurysm (Weber et al., 2008)

Following CI exercises

Question 9

Management of convergence spasm

Answer 9

Avoid treatment
Botulinum toxin (Kaczmarek et al, 2009)
Single or repeated injections
Limited success, but some find it helpful
Occlusion
Atropine with convex lenses
Refer for psychological/psychiatric assessment
Refer for neurological investigation if needed

Question 10

Assessing if patient has a genuine convergence defect is important

Answer 10

Convergence to near point is reduced, but the patient is making a great fuss about this and you are not sure if they have a genuine problem.

Question 11

45y/o head trauma during RTA
Symptoms: Diplopia and blurred vision
Findings: Up to 45^E(T) at near, orthophoric in dist

Diagnosis: Convergence spasm
Management?

Answer 11

Atropine and readers - disliked
BT to MR – short lasting exo – disliked
Pt keen on Sx but little evidence on success

Question 12

Cyclo

Answer 12

induces the need to converge to focus

Question 13

Miotics

Answer 13

e.g. Pilocarpine increase depth of focus and reduces drive to convergence

Question 14

Tell patient to

Answer 14

Learn to stop driving spasm

Question 15

Functional/Pyschogenic

Answer 15

up-front with patients/parents in an understanding, non-confrontational way
Revealed underlying sig family event prior to symptoms
Refer for CBT (cognitive behaviour therapy)/Clinical psychologist

Question 16

How to assess if patient has a genuine accommodation defect

Answer 16

The patient reports accommodation to a level much worse than that expected for their age

Question 17

When accommodation is reduced…

Answer 17

the patient may stop converging at the point where the image blurs

Question 18

What is the Holmes Adie pupil?

Answer 18

• A rare neurological disorder affecting the pupil of the eye.

In most patients the pupil is larger than normal (dilated) and slow to react in response to direct light.

Absent or poor tendon reflexes are also associated with this disorder.

Usually unilateral can be bilateral and more frequent in young women

Question 19

Differentiating between Holmes Adie pupil and accommodative anomalies

Answer 19

Holmes adie has one enlarged pupil in response to light

Holmes adie is usually unilateral but can be bilateral in young females

Differential for holmes adie is CN3 palsy