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Unilateral Paralysis of Accommodation
NOTES, CASES, INSTRUMENTS U N I L A T E R A L PARALYSIS O F ACCOMMODATION PAUL A. H E I N , JR., M.D.
Saint Louis, Missouri A paralysis of accommodation is not rare. It can occur in a variety of toxic states—• diphtheria is the classic example—or as an isolated phenomenon, in which case the cause is probably nuclear, or within the eye itself. However, a paralysis of accommodation, clinically apparent in one eye only and in the absence of pupillary signs, seems sufficiently unusual to report.
at present and he was given the same glasses which he now wears. Three months prior to his first visit to the eye clinic, however, he had been hospitalized with an attack of acute sinusitis, with fever, head ache, and malaise. X-ray films then showed the left antrum to be obliterated, with some thickening of the mucosa of the right. The pupils were noted to be equal. The patient received antibiotics and made a prompt recovery. Since his first visit to the eye clinic, he has been seen at intervals, with no change in his refraction or vision. Last spring a bifocal of +3.0D. add was prescribed for the left eye. The boy is, gratifyingly, delighted with the results, and is doing better in school. COMMENT
Somewhat similar cases have been de scribed in the ophthalmic literature. Fuchs, in 1935, described an epidemic of paralysis CASE REPORT of accommodation in children from eight to A 15-year-old boy came to the Evanston Hos 16 years of age. The children were other pital Eye Clinic in April, 1960, complaining of blurred near vision in his left eye of indeterminate wise normal. This condition was bilateral duration. Externally, the eyes were normal. They and the accommodation was not absent but were orthophoric for distance and near. The pupils reduced to three or four diopters. Holmes were equal and responded briskly to light directly and consenually. Both pupils reacted to accommoda has reported congenital ophthalmoplegia tion, as did the right pupil tested by itself; how which can manifest itself as paralysis of ever, the left pupil tested alone did not react to ac accommodation. However, this is also bi commodation. Convergence was normal. The boy's vision without glasses was 20/20, R.E., and 20/200, lateral. Acquired paralysis of accommoda L.E. With a +0.5D. sph. it was 20/20, R.E., and tion is described by Etienne. The common a +2.7SD. sph., 20/30, L.E., Cyclogyl refraction est cause is syphilis. (The serology in the was: R.E., +0.75D. sph., L.E., +3.0D. sph. Near vision with glasses was Jl, R.E., and J7, L.E. The present case was negative.) fundi were negative. There was questionable venous In the syndrome of opticociliary neuritis, engorgement, especially inferiorly, of the retinal as presented by Mancall, there is pupillary vessels in the left eye. Attempts to measure the accommodative am paralysis but this condition can be unilateral. plitude gave conflicting results. The ordinary test Allen has described two cases in which the for accommodation, wherein a fine line is fixed as accommodation between the two eyes varied it is brought nearer the eye on a calibrated rod, was useless with the left eye; it could not be seen as much as six diopters. However, in these sharply even at its extreme position. The right eye cases, the weaker of the two eyes could ac showed over eight diopters of accommodation commodate. by this method. Placing minus lenses over the boy's A paralysis of accommodation in associa glasses while he read the Snellen chart at 20 feet gave poorer results. With the right eye alone, he tion with dental caries in an 18-year-old boy could read the 20/20 line with a —4.SD. sph. over his glasses but this required great effort; a —5.0D. was reported by Brownell. There was also a sph. rendered this line illegible. With his left eye low-grade sinusitis in his patient. The con alone, he could not read the 20/30 line even with a dition improved with treatment of the cari —0.5D. sph. in front of his glasses. ous teeth. It was bilateral. A review of the patient's chart showed that he It is tempting to assume that the difficult had first been brought to the eye clinic seven years before, when he was eight years of age, for a rou ies in my patient stem from his attack of tine examination. His vision then had been 20/20, sinusitis at the age of seven years. It would R.E.; 20/100—, L.E., without glasses. A homatropine refraction gave about the same results as be a singular sinusitis, however, which could 711
NOTES, CASES, INSTRUMENTS
712
paralyze accommodation without also para lyzing the pupil. If there were some clinical method of stimulating the ciliary muscle di rectly it would be possible to determine if
this boy's difficulty was due to failure of innervation or of the end-organ itself. 508 North Grand (3).
REFERENCES
Allen, T. D.: Anamolies of accommodation. Arch. Ophth., 4:84-89, 1930. Brownell, M. E.: Paralysis of accommodation in association with dental caries. Arch. Ophth., 26:105710S8, 1941. Duke-Elder, W. S.: Textbook of Ophthalmology. St. Louis, Mosby, 1949, v. 4, pp. 4431-4438. Etienne, M.: Paralysis of accommodation. Ann. ocul., 187:817-824, 1954. Fuchs, A.: An epidemic of bilateral paralysis of accommodation in children. Wien. klin. Wchnschr., 48:1547,1935. Holmes, W. J.: Hereditary congenital ophthalmoplegia. Am. J. Ophth., 41:615-618, 1956.
A NEAR-VISION T E S T FOR PRESCHOOL CHILDREN* HENRY F. ALLEN,
M.D.
Boston, Massachusetts Experience with a series of calibrated pic tures 1 for testing the vision of preschool chil dren has been accumulated over a period of eight years in private practice and five years in the hospital Orthoptic Clinic. The results indicate that these pictures are a valid means of comparing the visual acuity of a child's two eyes and that recognition of three or * From the Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, and the Harvard Medical School. The Preschool Vision Test is manufactured by Ophthalmix, Inc., Box 102, LaGrange, Illinois.
* M *
more of them at a given distance approxi mates the ability to identify the four cardinal positions of a 30-foot illiterate E at the same distance. By means of the pictures it has been possible to test the vision of many chil dren two and one-half years and older who for any reason could not be tested with the illiterate E. Retarded children up to nine years of age have been successfully tested in this way. Two practical points have evolved in our experience with testing the visual acuity of very young children by means which vary the distance rather than size of the object. After allowing the child to identify all the characters at close range and after occluding one of the child's eyes, the examiner should back away from the child while exposing one
aoo
INCHES
Saint Louis, Missouri A paralysis of accommodation is not rare. It can occur in a variety of toxic states—• diphtheria is the classic example—or as an isolated phenomenon, in which case the cause is probably nuclear, or within the eye itself. However, a paralysis of accommodation, clinically apparent in one eye only and in the absence of pupillary signs, seems sufficiently unusual to report.
at present and he was given the same glasses which he now wears. Three months prior to his first visit to the eye clinic, however, he had been hospitalized with an attack of acute sinusitis, with fever, head ache, and malaise. X-ray films then showed the left antrum to be obliterated, with some thickening of the mucosa of the right. The pupils were noted to be equal. The patient received antibiotics and made a prompt recovery. Since his first visit to the eye clinic, he has been seen at intervals, with no change in his refraction or vision. Last spring a bifocal of +3.0D. add was prescribed for the left eye. The boy is, gratifyingly, delighted with the results, and is doing better in school. COMMENT
Somewhat similar cases have been de scribed in the ophthalmic literature. Fuchs, in 1935, described an epidemic of paralysis CASE REPORT of accommodation in children from eight to A 15-year-old boy came to the Evanston Hos 16 years of age. The children were other pital Eye Clinic in April, 1960, complaining of blurred near vision in his left eye of indeterminate wise normal. This condition was bilateral duration. Externally, the eyes were normal. They and the accommodation was not absent but were orthophoric for distance and near. The pupils reduced to three or four diopters. Holmes were equal and responded briskly to light directly and consenually. Both pupils reacted to accommoda has reported congenital ophthalmoplegia tion, as did the right pupil tested by itself; how which can manifest itself as paralysis of ever, the left pupil tested alone did not react to ac accommodation. However, this is also bi commodation. Convergence was normal. The boy's vision without glasses was 20/20, R.E., and 20/200, lateral. Acquired paralysis of accommoda L.E. With a +0.5D. sph. it was 20/20, R.E., and tion is described by Etienne. The common a +2.7SD. sph., 20/30, L.E., Cyclogyl refraction est cause is syphilis. (The serology in the was: R.E., +0.75D. sph., L.E., +3.0D. sph. Near vision with glasses was Jl, R.E., and J7, L.E. The present case was negative.) fundi were negative. There was questionable venous In the syndrome of opticociliary neuritis, engorgement, especially inferiorly, of the retinal as presented by Mancall, there is pupillary vessels in the left eye. Attempts to measure the accommodative am paralysis but this condition can be unilateral. plitude gave conflicting results. The ordinary test Allen has described two cases in which the for accommodation, wherein a fine line is fixed as accommodation between the two eyes varied it is brought nearer the eye on a calibrated rod, was useless with the left eye; it could not be seen as much as six diopters. However, in these sharply even at its extreme position. The right eye cases, the weaker of the two eyes could ac showed over eight diopters of accommodation commodate. by this method. Placing minus lenses over the boy's A paralysis of accommodation in associa glasses while he read the Snellen chart at 20 feet gave poorer results. With the right eye alone, he tion with dental caries in an 18-year-old boy could read the 20/20 line with a —4.SD. sph. over his glasses but this required great effort; a —5.0D. was reported by Brownell. There was also a sph. rendered this line illegible. With his left eye low-grade sinusitis in his patient. The con alone, he could not read the 20/30 line even with a dition improved with treatment of the cari —0.5D. sph. in front of his glasses. ous teeth. It was bilateral. A review of the patient's chart showed that he It is tempting to assume that the difficult had first been brought to the eye clinic seven years before, when he was eight years of age, for a rou ies in my patient stem from his attack of tine examination. His vision then had been 20/20, sinusitis at the age of seven years. It would R.E.; 20/100—, L.E., without glasses. A homatropine refraction gave about the same results as be a singular sinusitis, however, which could 711
NOTES, CASES, INSTRUMENTS
712
paralyze accommodation without also para lyzing the pupil. If there were some clinical method of stimulating the ciliary muscle di rectly it would be possible to determine if
this boy's difficulty was due to failure of innervation or of the end-organ itself. 508 North Grand (3).
REFERENCES
Allen, T. D.: Anamolies of accommodation. Arch. Ophth., 4:84-89, 1930. Brownell, M. E.: Paralysis of accommodation in association with dental caries. Arch. Ophth., 26:105710S8, 1941. Duke-Elder, W. S.: Textbook of Ophthalmology. St. Louis, Mosby, 1949, v. 4, pp. 4431-4438. Etienne, M.: Paralysis of accommodation. Ann. ocul., 187:817-824, 1954. Fuchs, A.: An epidemic of bilateral paralysis of accommodation in children. Wien. klin. Wchnschr., 48:1547,1935. Holmes, W. J.: Hereditary congenital ophthalmoplegia. Am. J. Ophth., 41:615-618, 1956.
A NEAR-VISION T E S T FOR PRESCHOOL CHILDREN* HENRY F. ALLEN,
M.D.
Boston, Massachusetts Experience with a series of calibrated pic tures 1 for testing the vision of preschool chil dren has been accumulated over a period of eight years in private practice and five years in the hospital Orthoptic Clinic. The results indicate that these pictures are a valid means of comparing the visual acuity of a child's two eyes and that recognition of three or * From the Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, and the Harvard Medical School. The Preschool Vision Test is manufactured by Ophthalmix, Inc., Box 102, LaGrange, Illinois.
* M *
more of them at a given distance approxi mates the ability to identify the four cardinal positions of a 30-foot illiterate E at the same distance. By means of the pictures it has been possible to test the vision of many chil dren two and one-half years and older who for any reason could not be tested with the illiterate E. Retarded children up to nine years of age have been successfully tested in this way. Two practical points have evolved in our experience with testing the visual acuity of very young children by means which vary the distance rather than size of the object. After allowing the child to identify all the characters at close range and after occluding one of the child's eyes, the examiner should back away from the child while exposing one
aoo
INCHES