How is pseudomyopia managed?

Management of Pseudomyopia

Pseudomyopia should be managed with cycloplegic eye drops as the primary treatment to relax ciliary muscle spasm and restore normal refractive status. 1

Understanding Pseudomyopia

Pseudomyopia is a condition characterized by a false or apparent myopia caused by ciliary muscle spasm that increases the refractive power of the eye. Unlike true myopia, pseudomyopia disappears under cycloplegia but returns when the cycloplegic effect wears off. This condition can cause:

• Blurred distance vision
• Fluctuating visual acuity
• Pain in the orbital region and head
• Progression to a chronic state if untreated

Diagnostic Approach

1. Compare manifest and cycloplegic refraction:

   • Significant difference (typically 1.5-2.0 diopters) between manifest refraction (myopic) and cycloplegic refraction (emmetropic or less myopic) confirms pseudomyopia 2
   • Document the degree of pseudomyopia as the difference between these measurements

2. Evaluate for underlying causes:

   • Prolonged near work and stress (most common functional causes) 1
   • History of trauma, particularly head trauma or whiplash injury 3, 4, 2
   • Paradoxical accommodation (rare cases where patients strain to see far and relax to see near) 5

Treatment Algorithm

First-Line Treatment:

• Cycloplegic eye drops to relax the ciliary muscle spasm 1, 3
  • Atropine sulfate 1% ophthalmic solution is effective 6, 3
  • Dosing: 1 drop in affected eye(s) once or twice daily as needed 6
  • Monitor for side effects: photophobia, blurred vision, dry mouth, flushing 6

Second-Line Approaches:

1. Vision therapy techniques to loosen the accommodative system 3

   • Near-far focusing exercises
   • Accommodative facility training

2. Refractive correction options:

   • Temporary prescription of the manifest refraction to provide immediate relief of symptoms
   • Progressive reduction in minus power as ciliary spasm resolves
   • Consider bifocal or progressive lenses if persistent

For Refractory Cases:

• Extended periods of cycloplegia (weeks to months) may be necessary 3
• Consider referral to a neuro-ophthalmologist if symptoms persist despite treatment

Special Considerations

• Post-traumatic pseudomyopia may follow one of three courses 3:

  1. Transient condition that resolves spontaneously
  2. Recalcitrant condition that resolves with cycloplegics but returns when medication wears off
  3. Progressive myopia that increases over time

• Warning signs requiring further investigation:

  • Unilateral presentation
  • Associated neurological symptoms
  • No improvement with cycloplegics
  • History of significant trauma

Patient Counseling

• Explain the functional nature of the condition
• Discuss the expected timeline for improvement
• Advise about potential side effects of cycloplegic medications
• Set realistic expectations based on the natural history of pseudomyopia

Monitoring

• Regular follow-up to assess response to treatment
• Repeat cycloplegic refraction to evaluate true refractive status
• Gradual tapering of cycloplegic medications as symptoms improve
• Adjustment of corrective lenses as needed

The management approach should be persistent, as pseudomyopia can be stubborn and may require prolonged treatment, especially in post-traumatic cases where the condition may persist for years 2.