What is the treatment for a patient with a right eye that lacks accommodation, but accommodates when the left eye is covered?

Accommodative Spasm of the Right Eye with Binocular Inhibition

This patient has an accommodative spasm of the right eye that is suppressed by binocular viewing but manifests when the left eye is covered—a rare phenomenon requiring cycloplegic refraction and treatment with cycloplegic agents to break the spasm. 1

Understanding the Clinical Presentation

This presentation represents a unique form of accommodative spasm where:

• The right eye maintains excessive accommodation (pseudomyopia) that only becomes apparent when tested monocularly 1
• Binocular viewing allows the normal left eye to suppress or inhibit the accommodative spasm in the right eye 1
• When the left eye is covered, the right eye's underlying accommodative spasm becomes unmasked and prevents proper distance vision 1

This differs from typical bilateral accommodative spasm and suggests a functional disorder with binocular interaction components 1, 2

Diagnostic Evaluation

Perform cycloplegic refraction to definitively diagnose and quantify the accommodative spasm:

• Use cyclopentolate or atropine to achieve complete cycloplegia, as these agents paralyze the ciliary muscle and reveal the true refractive error beneath the spasm 3
• In adults, cyclopentolate provides greater cycloplegia than tropicamide and allows more accurate refraction, though with longer duration of effect 3
• The difference between manifest (non-cycloplegic) and cycloplegic refraction will quantify the degree of accommodative spasm 3
• Dynamic retinoscopy prior to cycloplegia can assess accommodation and may show the accommodative spasm when the right eye is tested alone 3

Assess for underlying psychological factors:

• 83% of patients with accommodative anomalies are female, and 57% have previously diagnosed anxiety or are self-described "worriers" 2
• Accommodative spasms are frequently caused or exacerbated by anxiety and stress, similar to other somatic symptoms 2
• Prolonged near work and stress are common triggers for functional accommodative spasm 4

Treatment Approach

Initiate cycloplegic therapy to break the accommodative spasm:

• Atropine sulfate 1% ophthalmic solution is indicated for cycloplegia and can be used therapeutically 5
• The maximum cycloplegic effect occurs within 30-40 minutes, with effects lasting 7-10 days 5
• This prolonged action helps break the cycle of spasm and allows the ciliary muscle to relax 4
• Cycloplegic eye drops are the standard treatment for accommodative spasm 4

Address the binocular component:

• Once cycloplegia reveals the true refractive error, prescribe appropriate spectacle correction for any underlying hyperopia discovered 3
• The case report documenting this phenomenon showed low hyperopia in both eyes after cycloplegia 1
• Correcting even small amounts of hyperopia can reduce accommodative demand and prevent spasm recurrence 3

Provide psychological intervention:

• Use an evidence-based psychological approach to help the patient understand how stress and anxiety cause or worsen accommodative symptoms 2
• Explain that ocular symptoms are often a manifestation of anxiety rather than the primary problem 2
• Help patients recognize that some blur is normal in everyday life and break the vicious cycle of anxiety leading to symptom deterioration 2
• In one series, 83% of patients showed dramatic improvement within one session after discussion of the anxiety-accommodation relationship, with none requiring further treatment 2

Critical Pitfalls to Avoid

Do not rely solely on manifest refraction:

• Manifest refraction will be misleading because the accommodative spasm creates pseudomyopia that varies depending on whether testing is monocular or binocular 1
• A significant difference between manifest and cycloplegic refraction may require a post-cycloplegic refraction on a subsequent day after full accommodation returns 3

Do not focus exclusively on ocular treatments:

• Well-meaning professionals offering only ocular treatments can deflect attention from the real psychological cause and may inadvertently worsen the condition 2
• Inconsistency of responses is the rule in accommodative spasm patients, and responses are poorly related to visual stimuli presented 2

Do not assume bilateral symmetry:

• While most accommodative spasms are bilateral, this case demonstrates that unilateral or asymmetric presentations can occur, particularly when triggered by monocular occlusion of the fellow eye 1
• The contralateral (left) eye may also show accommodative spasm when occluded, even though it appears normal during binocular viewing 1

Expected Outcomes

• Cycloplegic treatment typically resolves the spasm within days to weeks 4
• Addressing underlying anxiety often leads to spontaneous resolution or significant improvement of symptoms 2
• Long-term management focuses on stress reduction and appropriate refractive correction to minimize accommodative demand 4, 2