Bilateral blurred distance vision, fluctuating vision, blurred vision when shifting gaze from near to far, headache, and eye strain while reading. Diplopia may occur in severe cases. Often seen in teenagers under stress. Symptoms may occur after prolonged and intense periods of near work (e.g., reading, cell phone or tablet use, writing, etc.).

Critical

Cycloplegic refraction reveals substantially less myopia (or more hyperopia) than was originally found when the refraction was performed without cycloplegia (manifest refraction). Manifest myopia may be as high as 10 diopters. Spasm of the near reflex is associated with excess accommodation, excess convergence, and miosis and is in the differential diagnosis of sixth cranial nerve palsy (see 10.8, Isolated Sixth Cranial Nerve Palsy).

Other

Abnormally close near point of focus, miosis, and a normal amplitude of accommodation that may appear low.

• Uncorrected hyperopia: Increased plus power accepted during manifest refraction.

• Other causes of pseudomyopia: Hyperglycemia, medication induced (e.g., sulfa drugs and anticholinesterase medications), anterior displacement of the lens–iris diaphragm.

• Manifestation of iridocyclitis.

• Inability to relax the ciliary muscles. Involuntary and associated with stressful situations or functional neuroses.

• Fatigue.

• Prolonged reading or cell phone use may precipitate episodes.

1. Complete ophthalmic examination. The manifest refraction may be highly variable, but it is important to determine the least amount of minus power or the most amount of plus power that provides clear distance vision.

2. Cycloplegic refraction.

1. True refractive errors should be corrected. If a significant amount of esophoria at near is present, additional plus power (e.g., +2.50 diopters) in reading glasses or bifocal form may be helpful.

2. Counseling patient and parents to provide a more relaxed atmosphere and avoid stressful situations.

3. Counseling patients and parents about appropriate ergonomics when doing near work. Ensure proper lighting, seating, and book/screen distance to reduce eye strain.

4. Cycloplegics have been used to break the spasm but are rarely needed except in resistant cases.

Reevaluate in several weeks. More severe cases may require frequent follow-up.