Spasm of the near reflex is occasionally mistaken for paretic strabismus. A misinterpretation can be avoided, if one notes during examination of an esotropia with a variable angle between the eyes, whether the pupils constrict with increasingly convergent positions (see also Chap. 10, ■ Fig. 10.8). A characteristic feature of spasm of the near reflex is that diplopia is intermittent, and that lenses to correct the accommodative myopia improve acuity.

When faced with a patient who shows the signs of spasm of the near reflex, the examiner must first consider whether the problem is psychogenic, since the pattern if innervation being examined can be volitionally driven. Spasm of the near reflex is often accompanied by voluntary nystagmus, a small angle, high-frequency quivering motion of the eyes. Dissociated end-gaze nystagmus is also frequently associated with spasm of the near reflex. Such volitionally controllable behaviors should not be taken for signs of organic pathology.

Spasm of the near reflex can spontaneously disappear. Occasionally, however, it is a tenacious disorder. Psychotherapy is often ineffective. As a last resort, one can atro-pinize both eyes and fit the patient with a pair of progressive addition lenses, fogging one eye to eliminate the diplopic symptom.

Congenital Nystagmus

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