Convergence spasm (CS) is a rare disorder characterized by an involuntary state of convergence, miosis, and accomodation secondary to disconjugate gaze. It is a condition that occurs in younger patients and mostly arises from non-organic causes such as hysteria or conversion disorder. Organic causes of CS include encephalitis, and lesions within the lower brainstem, cerebellum, or pituitary. CS can often be mistaken to be a palsy of the abducens nerve, and as such, these patients have often be subjected to many unnecessary and invasive testing. Traditionally, convergence spasm has been treated with antidepressants and psychological counselling, placebo eye drops, atropine, and phospholine iodide. This case report describes a case of acute onset CS in a 12 year old patient, who was successfully treated with a combination use of cyclopentolate 1% and bifocal spectacles.
RM is a 12 year old female who presented to clinic reporting intermittent diplopia for approximately 3 months. RM described it as her eyes turning involuntarily inwards as she is looking at objects in close proximity. Medical and ocular history is unremarkable. Cover test at distance and near (40cm) revealed a flick exophoria. Upon testing the near point of convergence, RM started exhibiting a large angle esotropia. MEM at the moment of the convergence spasm revealed a high lag, and both of her pupils appeared constricted. Cycloplegic retinoscopy revealed a negligible refractive error. Treatment involved the use of cyclopentolate 1% 2 times a day with full time use of bifocals, along with patient reassurance. Followups occurred biweekly with gradual tapering of the cyclopentolate and bifocal use until the patient had a normal convergence response to near target with no corrective spectacles.
Combination of cyclopentolate use with bifocals and patient reassurance/counseling is a safe and effective treatment for children with acute onset convergence spasm.