spasm of the near reflex

Spasm of the near reflex is a disorder of intermittent episodes of convergence, miosis and accommodation.¹ During an episode the patient is esotropic, particularly at distance, has extreme miosis, and may report double or blurred vision.¹ Pseudomyopia accompanies the episodes, and abduction may be limited.²

The abduction deficit arises because the patient substitutes convergence for lateral gaze.¹ The diagnosis rests on finding the other features of the near reflex, mainly miosis, on attempted lateral gaze.¹ Ductions tested with the other eye covered are usually normal.¹ Uncorrected high hyperopia can mimic spasm of the near reflex, but a careful cycloplegic refraction reveals an accommodative esotropia instead.¹

Spasm of the near reflex is most often a functional disorder in patients with psychogenic disease or in malingerers.¹ Organic causes have been reported, including encephalitis, trauma, Arnold-Chiari malformation, pituitary adenoma and posterior fossa neurofibroma.³ Every patient with spasm of the near reflex should therefore have a neurologic evaluation to exclude them.³