Spasm of the Near Reflex Associated With Organic Disease Linda Rabinowitz Dagi, M.D., Georgia Antonakou Chrousos, M.D. and David C. Cogan, M.D. Spasm of the near reflex is characterized by transient attacks of convergence, accommoda- tion, and miosis. It is usually observed in young individuals and considered functional. We studied seven patients with spasm of the near reflex who had associated neurologic dis- orders or head trauma. Two patients had pos- terior fossa abnormalities (cerebellar tumor, Arnold-Chiari malformation), two patients had pituitary tumors, one patient had a ves- tibulopathy, and two patients had a history of antecedent head trauma. SPASM of the near reflex, defined as intermit- tent episodes of convergence, accommodation, and miosis, is generally considered functional in origin. 18 Patients with this condition fre- quently exhibit signs of hysteria, malingering, or a personality disorder. They may have tubu- lar visual fields 58 and respond to placebo thera- py, 7 or demonstrate significant personality dis- turbances. We examined a series of seven patients with spasm of the near reflex, each with a history of neurologic disease or head trauma, and none with signs or symptoms of a personality disorder, hysteria, or malingering. Case Reports Casel A 15-year-old girl was referred to one of us (D.G.C.) for examination; she had a history of intermittent episodes of visual blurring. At 8 years of age, she had been noted to be ataxic; at Accepted for publication Jan. 16, 1987. From the Neuro-ophthalmology Service, Center for Sight, Georgetown University, Washington, D.C. (Drs. Dagi and Chrousos), and the Neuro-ophthalmology Section, National Eye Institute, National Institutes of Health, Bethesda (Drs. Dagi, Chrousos, and Cogan). This study was supported in part by Research to Prevent Blindness, Inc. Reprint requests to Linda Rabinowitz Dagi, M.D., Center for Sight, Georgetown University, 3800 Reser- voir Rd. N.W., Washington, DC 20007. 14 years of age, neurologic examination showed downbeat nystagmus, truncal ataxia, extensor plantar reflexes, and adiadochokine- sis. Pneumoencephalography at 8 years of age had demonstrated herniation of the cerebellar tonsils, confirming the diagnosis of Arnold- Chiari malformnation. Her best corrected visual acuity was 20/25 bilaterally, and there was downbeat nystagmus in primary position. During the examination, the patient had several short episodes of spasm of the near reflex with miosis, convergence, and accommodation (confirmed by retinosco- py). Follow-up examination several months later showed a persistence of this disorder. Case 2 A 22-year-old woman was referred for oph- thalmologic examination because of failing vi- sion as previously described. 1 Best corrected visual acuity was hand motions bilaterally, and visual fields were severely constricted bilateral- ly. Ophthalmoscopic examination disclosed chronic papilledema. Horizontal gaze-evoked nystagmus was present in right and left gaze. Vertical gaze upward or downward caused a spasm of the near reflex. Subsequent cranioto- my disclosed a neurofibroma of the posterior fossa extending from the midline to the right cerebellar hemisphere. Case 3 A 27-year-old woman with a three-year histo- ry of amenorrhea and galactorrhea was re- ferred for evaluation of episodic visual blurring and diplopia. Computed axial tomography demonstrated a hypolucent area within the pituitary gland. Hormonal studies, and ulti- mately biopsy, confirmed a diagnosis of prolac- tin secreting pituitary microadenoma. Visual acuity was 20/20 bilaterally. Pupils and color vision were normal and Goldmann visual fields were full. Motility disclosed a small intermittent exotropia that could be traced back to childhood. Results of ophthal- moscopic examination were normal. During the examination, however, vertical saccades, espe- 582 ©AMERICAN JOURNAL OF OPHTHALMOLOGY 103:582-585, APRIL, 1987