Spasm of Near Reflex: Objective Assessment of the Near-Triad

PURPOSE. To characterize binocular steady-state accommodation, pupil and convergence responses (near triad) in spasm of near reflex (SNR) before and after optical and pharmacological intervention. To identify the putative source of SNR in the neural control schema of accommodation-vergence interaction using controls-engineering modeling. METHODS. Near-triad of 15 patients with SNR (9 to 23 years) was recorded using an infrared photorefractor at 2m viewing distance for 120s during clinical presentation, after optical fogging intended to relieve spasm, with cycloplegia, post-cycloplegia and longterm follow-up visits. Data were also collected without cycloplegia in 15 age-matched controls. Schor (1999) model was used to computationally simulate accommodation and vergence responses of controls and SNR. RESULTS. Both eyes of SNR exhibited significant myopia and refraction fluctuations (<1.0Hz) during clinical presentation [median (25th to 75th IQR) refraction: -1.7D (-3.2 to -0.8D); root mean squared (RMS) deviation: 1.1D (0.5 to 1.5D)], relative to controls [0.8D (-0.03 to 1.4D); 0.2D (0.1 to 0.3D)] (p < 0.001). These decreased after optical fogging, largely eliminated with cycloplegia and partially re-appeared in the postcycloplegia and follow-up visits. SNR responses could be modeled by increasing the gain and decay time of tonic accommodation, vis-a-vis, controls. Pupil and convergence responses in SNR were similar to controls at all visits (p > 0.1). CONCLUSIONS. Exaggerated fluctuations of steady-state accommodation may be a signature feature of SNR, even while their pupil and convergence responses may remain unaffected. These fluctuations may arise from the tonic accommodation controller, the properties of which could be potentially altered after optical fogging to relieve the disorder.