CLINICAL REPORT. The Freedom to Choose an Unusual Case of Spasm of Accommodation

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1 CLINICAL REPORT The Freedom to Choose an Unusual Case of Spasm of Accommodation Robert Lederman BSc(Hons) Optom, FCOVD Owner and Managing Director at LedermanVision Abstract The expansion of free choice for a person, consequent to a successful therapeutic outcome is not unique to Optometric Vision Therapy. However, there are some conditions that limit free choice, which can be resolved only by Optometric Vision Therapy. In this essay, the prior limitation in free choice, the treatment process, successful outcome, and the consequence of the outcome for a 31 year old medical student is discussed. background In February 2016 Eric, a 31 year old male medical student, and someone who I have known well since he Correspondence regarding this article should be ed to Robert Lederman BSc(Hons) Optom FCOVD, at lederman66@gmail.com. All state ments are the author s personal opinions and may not reflect the opinions of the College of Optometrists in Vision Development, Vision Development & Rehabili tation or any institu tion or organization to which the author may be affiliated. Permission to use reprints of this article must be obtained from the editor. Copyright 2017 College of Optometrists in Vision Development. VDR is indexed in the Directory of Open Access Journals. Online access is available at Lederman R. The freedom to choose an unusual case of spasm of accommodation. Vision Dev & Rehab 2017;3(3): Keywords: accommodation, medical student, retinoscope, spasm, vision therapy was a child, attended my office, self-referred, for an examination. In the course of his studies, he had still not been required to make a final decision regarding the area of specialty that he would pursue, but due to a number of visual complaints, he felt anxious that the possibility of choosing a specialty that included surgery was becoming less of a realistic option. He held his hands in front of him as if he were about to perform a surgical procedure. My eyes are not quite talking to each other, he said, shaking his head in disappointment. He seemed quite forlorn. He described how hard his eyes were working and how they could suddenly ache. I had known Eric to be a very non-dramatic type. If he was complaining, then I knew that things were not good. Eric also complained of monocular diplopia from each eye that bothered him both at near and far, and that was worse at night. He d undergone an Ophthalmological exam that included an OCT and a corneal topography assessment. All was normal. Case Report The findings at the initial evaluation on are shown in Table 1. It was clear to us both that updating his glasses prescription would make a significant difference to his eyesight. Due to the unstable binocular fixation at far, as indicated by the Mallet unit, the low blur measurement on the test of positive fusional reserves, the reduced NRA finding and the failure to attain a single and clear image on the facility of accommodation test whilst looking through lenses, I recommended Optometric Vision Therapy (OVT) to help develop a more efficient and robust binocular response. In particular, it was obvious that Eric was accommodating in order to control his exophoria, and that developing vergence that was far more independent of accommodation, was going to be important in helping Eric to feel comfortable. Eric was living and studying many hours away. As a student of medicine, his schedule 188

2 Table 1. Findings at Initial Evaluation Currently Wearing Eye Prescription V.A. OD /-1.50 x /20-1 OS / x 10 20/30-1 Objective Refraction (Dry) OD / x 175 OS / x 10 Subjective OD / x 5 20/10-3 OS / x 9 20/15-2 Oculomotor Balance Phoria Fixation Disparity DV 4^ XOP 2^ left uncompensated exoslip (Mallet Unit) NV 2^ XOP None Near Point of Convergence 3cm to nose Jump Convergence Normal Amplitude of 9.0D Accommodation (RAF Rule) Facility of Accommodation RE +/- 2.00D 14cpm PASS LE +/- 2.00D 14cpm PASS Binoc: Fails NRA PRA Positive Fusional Reserves 9/57/55 Negative Fusional Reserves x/27/51 Fusional Reserves at 6m 4/20/18 was very intense and he was certainly already under enough pressure without having to try and incorporate weekly therapy sessions into his diary. I was confident that Eric was somebody who, given enough instruction, would be able to be responsible enough to practice his therapy procedures perfectly, and with regularity on a relatively independent program. In the examination, I had also probed Eric s ability to relax his accommodation sufficiently to blur an image of the 20/30 line on the Snellen chart, which he had made clear by accommodating through a -6.00D lens. Though he was able clear a lens, learning to relax his accommodation to an even greater degree would, I felt, help in preparing the ground for developing a more independent positive fusional vergence. He was scheduled for an hour therapy session in which he was given instructions about using the Bull s Eye target, with an emphasis on the letting go aspect of the procedure looking at a far Hart Chart, whilst maintaining peripheral awareness. In addition, he spent time learning to clear, then blur the image of a large Hart Chart viewed at far, through a -6.00D lens. I prescribed these exercises to be carried out for 10 minutes daily, for the duration of one month. Eric understood both the exercises and their rationale. In principle, I am opposed to a homebased program of Optometric Vision Therapy (OVT) because of the absence of one of the key elements that promotes a successful outcome to the treatment i.e. regular contact with the therapist. Beyond all the wonderful opportunities for a thoroughly enriching and engaging vision therapy session that are unique to the in-office session, I firmly believe that the weekly experience of the meeting is critical. The importance of the weekly interaction is that it helps to give context to what is going on in the patient s life right now. My experience is that Vision Therapists who work in a busy office may, almost paradoxically, need reminding of what a central figure they are in the life of their patients. They might find it difficult to imagine how one can be so essential to so many; but essential they are, and they have a pivotal role in the successful outcome of every OVT program. Occasionally, a patient will call the office to cancel their therapy appointment, having failed to find the time to do their OVT homework. Unless there are obvious reasons e.g. illness, my office policy is to strongly recommend that the patient come in anyway. The reasoning is that I want the patient to have an open discussion with their therapist regarding the reasons why they were unable to work the homework into their schedule. This itself is a vital part of the therapy and will increase the likelihood that the homework will be carried out during the following week. My experience is that nonattendance with an assurance to make up the 189

3 homework will, in most cases, not increase the compliance. However, as I stated, it seemed that being firm about this principle, would prevent Eric from receiving the treatment he needed, and he would continue to suffer. In Eric s case, time would show that my decision to use a home-based program had been the correct one. After a month, Eric returned. He had changed his prescription, significantly improving his eyesight, especially at night. He had mastered the therapy techniques but, unsurprisingly, did not report much improvement in his symptoms. At this visit, Eric was shown how to perform the Eccentric Circles therapy procedure, localizing both in front of and behind the circles. Clarity was emphasized as well as the need to work in 9 positions of gaze. In addition, Eric was issued with large Eccentric Circles (EC1 from Bernell) for working to develop his positive fusional vergence at far. I emphasized how essential it was to maintain perfect clarity whilst converging in front of the targets, simultaneously experiencing the illusion of three circles. I also invited Eric to become aware of the full stereo experience of the central set of circles that this procedure potentially provides. Maintenance of perfect clarity is essential in the Eccentric Circles activity to ensure that the patient is not driving convergence by accommodating, but that convergence skills are being developed independently of accommodation. Eric was to practice using the small Eccentric Circles at 35cm. When he felt he was thoroughly competent in maintaining the desired three circles, with clarity and depth on the central circle, he was to progress to the larger circles working from near to far. One month later, in April, Eric was in my office for his progress assessment. He could now clear the plus lenses binocularly on the test of accommodative facility. His NRA score had normalized and he no longer had an uncompensated exophoria at far. But most importantly he felt great. He told me that his symptoms had gone. I recommended that he continue to maintain using the Eccentric Circles from far, and slowly reduce the frequency of practice. Eventually, I said, You can check yourself weekly, then fortnightly and then monthly. I told him that this way he could selfmonitor if things were staying stable. I discharged Eric as a very satisfied patient. His glasses had taken care of his monocular diplopia and the therapy had taken care of his symptoms. It s January 2017 and I find myself looking at Eric who is sitting in my chair. Things are still not quite right. I feel my heart sink with disappointment. I d wanted to help Eric for a few reasons; primarily because he was a fellow human who was suffering. However, seeing as Eric was a potential Doctor of Medicine, I felt that if I could solve his visual issues through OVT, he would surely become an advocate and help break down negative perceptions towards OVT. I asked him to describe what he was feeling. I sometimes feel like I just want to relax my eyes, and I do. I close my eyes to relax them but then I experience a lot of pain. I listened as he continued, Sometimes I get the same pain when I m not trying to relax, and then my vision becomes blurred. Reaching for my trustworthy AO spot retinoscope, I asked Eric to look at a distant fixation target and instructed him to relax and just to space out. And there, in a fraction of a second, the reflex became so dull and as I drove the reflex across his pupil, the against movement was enormous. Clearly, Eric was having a spasm of accommodation each time he relaxed, and at other times too. So I understood then that Eric did not know what it meant to relax. I had to create the opportunity in which he could learn to become familiar with what relaxing accommo dation means. Wachs Mental Plus seemed to be the perfect therapeutic technique as a means to re-educate Eric about accommodation. Through the visual learning experience that this technique provides, he would come to recognize what relaxing accommodation actually feels like. 190

4 The Wachs Mental Plus exercise is quite similar to the Mental Minus but emphasizes increasing awareness and control of decreasing accommodation rather than increasing accommodation. In this procedure, the patient occludes one eye and initially holds a lens in front of his eye whilst standing close to, and viewing a small Hart chart affixed to a wall at eye level. He should then move back slowly from the target until it starts to blur, then move slightly closer, only until he sees the letters clearly. He should then remove the lens and try and maintain this relaxed state of accommodation. If he has done this, then the letters on the chart should appear blurred. When returning the lens, it should immediately appear clear. Next, he is invited to relax his accommodation and blur the letters without the help of the lens. If this cannot be achieved, then the lens is used once again to help him relax his accommodation. The goal in this part of the procedure is that the patient can clear and then blur the target (by relaxing accommodation) at will. When competency is achieved, then the sequence is repeated, this time with a lens. The entire procedure is then repeated with the other eye. Eric started the procedure with a lens and, once again, I ensured that Eric under stood the important elements of this procedure. In particular it was confirmed that he understood how, after having achieved clarity on a near (small) Hart Chart through the lens, he then needed to remove it from in front of his eye and maintain the accommodative posture. He was then required to return the lens and instantly see the chart clearly once again through it. It emphasized to Eric that only after he feels fully competent with the lens, should he then move up to the lens and repeat the procedure. Two weeks after our meeting I received this note in my inbox. Dear Robert, I m writing you this with tears of joy and almost disbelief. A week after beginning the exercises with the +3 lens I began to feel a change. The spasm stopped and my eyes are relaxed -- it feels great and like nothing that I can remember. I know I m not through yet, it doesn t totally feel stable, but I am able to maintain the relaxed state for the most part and to be aware of it. I started working with the +5 and will let you know how it goes. I wanted to let you know, and to say thank you. I feel like I got my eyes back. It s amazing. I met Eric a month after that and his issues were totally resolved. The most important thing for me he said, is that though after much consid eration I have decided that I would like to specialize in pediatric psychiatry, I wanted to know that I was making that choice when all the options were a real possibility. I feel that you brought me to that place and that I was able to make a free choice. And I want to thank you for that. Discussion There are a number of interesting elements to this case. 1. Eric had mentioned that his eyes might suddenly ache. I had erroneously as cribed this as being part of his asthenopia. He certainly had not mentioned this problem as his chief complaint. In a case where there are a number of symptoms, asking the patient what their chief complaint is essential. However, it is not clear to me that Eric would necessarily have mentioned this as his chief complaint. 2. This case highlights the indisputably fundamental role of the retinoscope in diagnosing accommodative spasm and is a reminder that recent Opto met ric graduates should be en- 191

5 cour aged to continue to use the ret in o- scope in practice despite the ubiq ui tous presence of auto-refrac t ors. It may just provide unexpected benefits. 3. It would appear to me that Eric s habitual tendency over many years, to overaccommodate to maintain fusion was persisting even after he had further stabilized his binocular gaze both at near and far. However, in this case there are two features that are very remarkable indeed. Firstly, that Eric actually believed he was relaxing his eyes when in fact he was going into accommodative spasm. The second is the power of the Wach s Mental Plus technique in re-educating Eric about what relaxation means regarding accommodation, and perhaps beyond it too. Optometric Vision Therapy: A Hidden Benefit Many of us are aware that as we improve a patient s vision skills, we are expanding possibilities for them. Most often, our patients feel it because they can now achieve where previously they were struggling. What is unusual in Eric s case is that he did not have the prior experience of actually struggling to perform surgery and then, only post-ovt, enjoy a successful resolution to his difficulty as a direct outcome of the treatment. He just intuited post-ovt how an obstacle that would have prevented him from becoming a successful surgeon, had now been removed. For Eric, over and above the visual comfort that he enjoyed post-ovt, was the peace of mind he experienced from having the freedom to choose. CORRESPONDING AUTHOR BIOGRAPHY: Robert Lederman BSc(Hons) Optom, FCOVD Robert Lederman is in private practice in Jerusalem, Israel, where he leads a team of six Vision Therapists. He became Israel s first board-certified Fellow of the College of Optometrists in Vision Development in 2001, and is a clinical associate of the Optometric Extension Program. Robert is on the Professional Advisory Group of the Kabuki Syndrome Network, is the Israel Director of the Special Olympics Opening Eyes Program and is a visiting lecturer at the Safra Brain Research Center for the Study of Learning Disabilities, University of Haifa. Dr. Lederman has lectured extensively over the last 25 years both in Israel and Internationally. 192