Accommodative Spasm and Presbyopia

Discussion in 'Optometry Archives' started by Neil_Brooks, Feb 4, 2004.

  1. Neil_Brooks

    Neil_Brooks Guest

    I have heard more about patients with accommodative excess/ciliary
    spasm/pseudomyopia on this NG than I have found anywhere else. I'm
    working with a couple of ophthalmologists who are proposing that I
    undergo two surgeries: 1) wavefront LASIK, and 2) a clear lensectomy,
    leaving me as a myope (probably -2.00d).

    Their theory is that this should break a recurrent and severe
    accommodative spasm that has just taken me out of work for the third
    time in 15 years. My concerns are:

    1) Is AS always a purely refractive issue (vs.
    psychogenic/neurologic/?)? If not, is it possible/probable that the
    spasm could recur post-operatively?

    2) Some have _theorized_ that presbyopia 'burns out' the
    accommodative mechanism; however, I have read material (Clyde Oyster's
    _The Human Eye: Structure and Function_) that indicate that presbyopia
    only decreases the response of the lens and the zonules. The
    innervation of the nerves, and the contraction of the ciliaries,
    continue even after presbyopia. Any thought about the concept of the
    spasm continuing post-presbyopia?

    3) Does anybody have any references that they can point me to that
    have tracked accommodative spasm patients through/after presbyopia??

    4) Any general thoughts on the pair of proposed surgeries?

    My specifics are below. I'd be grateful for any feedback.

    Thanks much,

    Neil

    ====================
    THE SPECIFICS
    ====================

    39 years old;
    male;
    congenital esotrope;
    congenital amblyopia OS - treated with patching;
    3X strabismus surgeries:
    age 2.5 yrs;
    age 25 yrs;
    age 35 yrs (following prism adaptive trials);
    no longer diplopic;
    non-comitant strabismus remains in all but primary gaze;
    DVD;
    hypertropia OS (~4d);
    slight IOOA (+1 or 2);
    virtually no stereopsis;
    high hyperope (app. 6.5d);
    moderate astigmatism (app. 2.25d);
    moderate-to-severe dry eyes;
    upper and lower puncta plugged;
    Rx prescribed is full (Atropinized x 4 days) cycloplegic refraction;
    currently in soft contacts (sph only) + over Rx glasses:
    cyl only (for distance);
    cyl, plus +2.25d sph (NVO);
    tenacious, recurring, severe accommodative spasm
    Was managed with nightly instillation of Mydriacyl or Cyclomydril,
    but no longer successfully.
    Now managed with nightly instillation of Homatropine 5% (leaving me
    dilated all the time)
    ====================
     
    Neil_Brooks, Feb 4, 2004
    #1
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  2. Neil_Brooks

    Neil_Brooks Guest

    Thanks much, Mike. Comments/questions below:

    So you _could_ see emmetropes whose accommodative amplitudes are
    normal for their age (let's assume their not presbyopes yet) who have
    AS?
    .. . . but not necessarily the spasm, correct? Do we _know_ whether AS
    _automatically_ ends with/after presbyopia?
    I think the reasons that they propose to do _both_ surgeries are:
    1) If we're trying to take a +6.50 hyperope down to a -2.00 myope,
    that's 8.50 of plus refractive surgery (in addition to the cyl) -- way
    out of range for current FDA parameters for wavefront lasik;
    2) Since there's a high degree of hyperopic correction, and a
    moderate degree of astigmatic correction necessary, it may be cleaner
    to put the sphere in the lens implant, then address the cyl with the
    lasik;
    3) It's not my understanding that implanted lenses correct (can they
    _induce_?) higher-order aberrations. Theoretically, the combination
    of the two procedures would render the best optical result (?).

    From what you say, Mike, if:

    - AS is primarily neurologic, and can be found (assuming) in
    emmetropes with otherwise normal accommodative systems, and
    - clear lens extraction does not stop the _mechanics_ of
    accommodation; it only renders it ineffective in changing the shape of
    the lens,

    then what do you think (WAG here, to be sure) is the likelihood
    that--if I proceed with both surgeries--I'll wind up a slightly myopic
    person with exacerbated dry eyes and AS?

    I asked the ophthalmologist last night why we wouldn't use increased
    plus in my contacts to simulate making me myopic, taking care of the
    cyl temporarily in a pair of near specs, and the cyl and sphere in a
    pair of distance specs (or bifocals). He agrees with this. I have to
    imagine that a surgical result would be _at least_ as good as this
    trial, because a) the optics of cl's + specs can't be great, and b)
    elimination of HOA with the wavefront lasik.

    Again, grateful for your time, and any additional thoughts.

    Neil
     
    Neil_Brooks, Feb 4, 2004
    #2
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  3. Neil_Brooks

    Dan Abel Guest

    Would LASIK perhaps take care of the astigmatism? This is the case for
    me. I have had cataract surgery (which I assume is the same as the clear
    lens extraction) but still have 1.75D of astigmatism in one eye, which I
    correct by wearing a contact which has no sphere.
     
    Dan Abel, Feb 4, 2004
    #3
  4. Neil_Brooks

    Neil_Brooks Guest

    Dan Abel wrote (from a particularly beautiful part of my state):

    Dan,

    (Again, from the cheap seats) In my case, that's the idea. In your
    case, I would think, in theory, wavefront LASIK should/could eliminate
    your cyl.

    What you underwent sounds very similar to what they're considering for
    me. Do you know why they didn't try to implant a lens that knocked
    out your cyl, too? I know that some IOL's (e.g., the Artisan Lens)
    correct astigmatism quite handily . . . .

    I saw that you were -12d pre-surgery and ended up plano. Nice, huh?

    Best,

    Neil
     
    Neil_Brooks, Feb 6, 2004
    #4
  5. Neil_Brooks

    Dr. Leukoma Guest

    (Dan Abel) wrote in
    If there it nothing but astigmatism, then you can expect LASIK to introduce
    a slight amount of hyperopia at the same time it removes the astigmatism.

    DrG
     
    Dr. Leukoma, Feb 6, 2004
    #5
  6. Neil_Brooks

    Dr. Leukoma Guest

    (Neil_Brooks) wrote in
    With your prescription, I think that you would have to be certifiable - or
    your doctors would to perform LASIK on you. A clear lens extraction would
    leave you more hyperopic, not less. Hyperopic LASIK is only approved for
    up to +6, and it will make your eyes more dry than before. Perhaps you
    mean that they will perform a clear lens extraction with an implant, and
    then perform LASIK to correct the astigmatism. That makes more sense.

    Also, I believe that your non-comitant strabismus used to be comitant until
    you had your multiple surgeries. Do you still have amblyopia? Have your
    doctors tried blurring out the non-dominant eye with an over-plussed
    contact lens?

    DrG
     
    Dr. Leukoma, Feb 6, 2004
    #6
  7. Neil_Brooks

    Dan Abel Guest


    I belong to an HMO, and they are very conservative when it's their
    nickel. There was a poor soul on this group who got one of those and it
    rotated on him so he was actually worse off. The only fix for that is to
    go in again with surgery and rotate the lens back. I'm guessing that my
    HMO factored that possibility into the cost, and decided that since
    astigmatism can be fixed with glasses or contacts, that they wouldn't
    spend the money on these. I'm just as happy, because I'm not willing to
    risk it either. Furthermore, this surgery on my right eye was about 7
    years ago. I don't know if they had them back then. For my more recent
    surgery, I had no astigmatism in that eye.


    Very nice. I really like being able to see distance with no correction.
     
    Dan Abel, Feb 6, 2004
    #7
  8. Neil_Brooks

    Neil_Brooks Guest

    Many thanks for the response, Dr. G.
    Forgive me: I'm throwing around terminology as though I knew what I
    was talking about.... ;-)

    You're exactly right: the ophthalmologists' proposal is to 1) remove
    my lens and replace it with a lens to (over)correct the hyperopia,
    rendering me about a -2.00d myope, then 2) perform the wavefront LASIK
    to clean up any residual astigmatism.
    Interesting. If, as you suggest, the surgeries made the strabismus
    _non-comitant_, are there particular symptoms that you think this
    might cause (e.g., do you think that--other than in primary gaze
    (where I am ortho)--there may be some vergence-induced accommodation?
    Perhaps even as I try to read, moving my eyes across the page??)

    To the question of whether the amblyopia remains: not that I know of,
    but I'll inquire. We have tried blurring out an eye with an
    overplussed lens, under the guise of a monovision trial, adding ~2.25
    or 2.50d OS, then OD (~ a week at each eye). It threw off my
    alignment pretty badly, rendering me diplopic.

    With unstable alignment, I don't suppress. I alternate. We've also
    tried patching (in the last four years) for two weeks at a time. The
    AS did not diminish, but my subjective assessment of my vision did. I
    seem to be _slightly_ left eye dominant, but _do_ pick up "useful
    information" from the other eye.

    I keep thinking that the critical issue for me now is to get as much
    info as I can about the etiology of AS, generally, and in me,
    specifically. If it's basically neurological, then it seems more than
    likely that the AS will survive these two proposed surgeries _and_
    presbyopia. I have yet to find anybody who has tracked an AS patient
    through presbyopia, but I'm not sure why it would resolve until some
    time after my accommodative amplitudes naturally zeroed out (quite a
    few years out, I'm afraid).

    I will be seeing a neuro-ophth at UCSD's Shiley Eye in six weeks. We
    may do some imaging on my brain (my primary ophtalmologist assure it
    will only prove incontrovertibly that I don't _have_ one!) to see if
    there's anything glaring that might underlie the AS.

    Again, many thanks for your help. I'd be most grateful for any other
    suggestions as to avenues I might consider.

    Neil
     
    Neil_Brooks, Feb 6, 2004
    #8
  9. Neil_Brooks

    Dan Abel Guest

    Forgive me: I'm throwing around terminology as though I knew what I
    was talking about.... ;-)[/QUOTE]

    I'm not a professional, but I can't imagine any situation other than a
    severe myope whose myopic correction is exactly the power of the lens, who
    would have a clear lens extraction *without* an implant.

    Think of it this way: Let's say you have a finger that twitches randomly
    and the doctors say that it is neurological and there isn't anything they
    can do about it. Then you get a severe infection in that finger and it is
    amputated. It ain't agonna twitch no more!

    When they do a clear lens extraction, they're removing the ability of the
    lens to affect your vision. Your muscles in the eye can twitch all they
    want, they won't have any affect on your focusing. This also means that
    you will lose all ability to focus, or accomodate. Since you plan to
    leave your eyes nearsighted by two diopters, this means that you will need
    to wear glasses for distance.
     
    Dan Abel, Feb 6, 2004
    #9
  10. Neil_Brooks

    Dr. Leukoma Guest

    (Neil_Brooks) wrote in

    For a hyperope, the most common deviation would be esotropia, usually
    comitant, but not necessarily so. Unfortunately, strabismus surgery can
    change not only the angle, but also the type of deviation, and also make it
    comitant. Can I assume that you still have a horizontal component and it
    is an eso- deviation or is it exo-? I guess the AS comes in associaton
    with close work for you?

    You could be using accommodation to control vergence - not usually the
    other way around.

    I did have a 60 something presbyope in whom I diagnosed accommodative
    spasm. He was an attorney who worked in the same building. The pain was
    consistent with accommodative spasm, and it was promptly relieved with
    instillation of the cycloplegic agent. I can't remember if the vision was
    blurred also.

    I don't really have any better ideas at this time for your situation,
    unless your doctor might consider a stronger agent such as atropine. I
    feel for you, though.

    DrG
     
    Dr. Leukoma, Feb 7, 2004
    #10
  11. Neil_Brooks

    Neil_Brooks Guest

    Dan Abel wrote
    True enough, Dan, but to follow your analogy: what if the muscle that
    was spasming was actually located in the hand--not in the finger
    itself. Having the finger amputated would only eliminate the result
    of the spasm: the finger twitch. The muscle in the hand would
    continue to cramp from excessive tone.

    In this case, if the accommodative spasm is the result of excessive
    ennervation of the ciliary body, then presbyopic loss of elasticity in
    the lens could simply mean that no refractive change occurs as a
    result of the spasm. The ciliary body, however, _could_ continue to
    spasm as a result of inappropriate and ongoing ennervation. For that
    matter, rule of thumb seems to indicate that accommodative amplitudes
    really aren't gone until we're in our 60's or 70's.

    This is where I'm hypothesizing, but many people seem to agree that
    the _effort_ of accommodation won't quit. Only the resulting
    lenticular accommodation will.
    Having -0- accommodative amplitudes doesn't scare me. As I type this,
    sitting before me are:
    a) the laptop computer, and
    b) eight different pairs of glasses, often worn piggyback to give me
    BCVA ;-)

    Many thanks for the response. I'd absolutely welcome further input on
    this matter.

    -Neil
     
    Neil_Brooks, Feb 7, 2004
    #11
  12. Neil_Brooks

    Dan Abel Guest


    But it would be better if I knew what I was talking about! I was assuming
    that the problem with AS is that it messed up your vision. That's where I
    was coming from. I would think (another assumption here!) that the two
    surgeries would fix your vision, at the price of losing whatever
    accomodation you now have. It sounds like you are saying that just the
    process of having a spasm causes problems. What else does it do besides
    muck up your vision?
     
    Dan Abel, Feb 9, 2004
    #12
  13. Neil_Brooks

    Neil_Brooks Guest

    I didn't make myself particularly clear, Dan. In my case, with my
    impressive collection of glasses that I can/do wear over my contacts
    when necessary, I have found workarounds for the blurred vision issue
    (though this smorgasbord of over-Rx glasses may well contribute to the
    spasm itself). All of that is merely a 'nuisance.'

    The real problem, in my case, is pain. Dull, aching,
    anywhere-from-two-Tylenol-to-flat-on-the-floor-nauseous-and-dizzy
    pain.

    With the mix of:
    noncomitant alignment issues;
    high hyperopia;
    moderate-to-high astigmatism;
    an inherently faulty (and/or unwittingly horribly abused)accommodative
    mechanism;
    congenital amblyopia;
    infantile esotropia (rather than adult- or early onset);
    commencing presbyopia, . . .

    .. . . when the spasm hits _me_ -- which it _always_ does at near, and
    _usually_ does at anything, even distant, requiring sustained
    accommodation (think movies, plays, sporting events) -- even though my
    Rx was confirmed yesterday to be effectively identical to my
    cycloplegic wavefront analysis Rx -- it locks my accommodative
    mechanism by cramping up those nagging ciliaries. So -- much like a
    charley horse in the thigh -- it's the pain that gets me. Relieving
    the cramp (cycloplegia)--while effective--leaves the soreness of the
    muscle that the cessation of the charley horse does. The cramp goes
    away, but it left the thigh muscle quite sore from _having been_ in a
    knot....

    I spoke Friday with a Dr. Robert Rutstein, Associate Professor of
    Optometry at University of Alabama - Birmingham. He, along with Kent
    Daum and John Amos, authored "Accommodative spasm: a study of 17
    cases." Interestingly, these 17 patients were emmetropic when
    refracted dry (no cycloplegia). That clearly answers my question
    about whether AS is _only_ a response to a refractive error: it
    doesn't _have to_ be. Folllowing treatment, resolution of AS was
    achieved in 4 out of 17 patients. Not great percentages for people
    who, basically, _didn't need glasses_. Doesn't bode well for my poor
    peepers.

    Dr. Rutstein agreed with my hypothesis -- which is unfortunately
    corroborated by Dr. G's 60-ish patient with AS -- that AS quite likely
    does not resolve with presbyopia. I speculate at this point
    that--even at age 70+, when accommodative amplitudes have typically
    reached zero, it may subside, but will likely not resolve. Sigh.

    Fortunately (??), this also indicates that it's probably not wise to
    risk exacerbating dry eyes by proceeding with a clear lens extraction
    and lens implants, followed by wavefront LASIK. We _did_ order new
    contacts yesterday, pushing me to a 1.50d myope, hypothesizing that
    this takes a _modicum_ of load off of the accommodative system at
    near. I will have _near_ glasses that are only cyl, and separate
    _distance_ glasses that are cyl and minus sphere.

    Meanwhile, I'm very glad I learned to type fairly quickly without
    looking at the screen ;-)

    Thanks again, Dan.

    Dan Abel wrote
     
    Neil_Brooks, Feb 10, 2004
    #13
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