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| CASE REPORT |
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| Year : 2022 | Volume
: 2
| Issue : 4 | Page : 875-876 |
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Cyclodamia fogging technique for unilateral accommodative spasm: A case study
Devanshi M Dalal1, Dhaivat Shah2
1 Department of Paramedical and Health Sciences, Faculty of Medicine, Parul University, Vadodara, Gujarat, India
2 Research and Academics Department, Choithram Netralaya, Indore, Madhya Pradesh, India
| Date of Submission | 09-Apr-2022 |
| Date of Acceptance | 04-Aug-2022 |
| Date of Web Publication | 11-Oct-2022 |
Correspondence Address:
Dr. Dhaivat Shah
53, 54 Choithram Netralaya Shirram Talawali, Indore – Dhar Rd, Indore - 453 112, Madhya Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijo.IJO_910_22
Cyclodamia is a technique used for the determination of accommodative spasms. A 20-year-old healthy female presented a complaint of frontal headache for 1 month. In a previous checkup performed elsewhere, she was diagnosed with unilateral high myopia associated with amblyopia. In routine practice, the classic fogging technique is performed during the procedure of subjective correction. In the case of accommodative spasms, there are different techniques of fogging that can be used. The cyclodamia fogging technique should be used in routine practice to differentiate between the cases of excessive accommodation.
Keywords: Accommodative spasm, cyclodamia, near induced transient myopia, pseudo-myopia
How to cite this article:
Dalal DM, Shah D. Cyclodamia fogging technique for unilateral accommodative spasm: A case study. Indian J Ophthalmol Case Rep 2022;2:875-6 |
Cyclodamia is a technique used for the determination of accommodative spasms. Accommodative excess is a condition in which the patient has difficulty with all tasks requiring relaxation of accommodation. There is some confusion and disagreement in the literature about this condition. Other terms that have been used interchangeably with accommodative excess are ciliary spasm, accommodative spasm, spasm of the near reflex, and pseudo-myopia.[1] The present case report described the use of the cyclodamia fogging technique in a case of unilateral accommodative spasm.
| Case Report | |  |
A 20-year-old healthy female complained of a frontal headache for 1 month. In a previous checkup performed elsewhere, she was diagnosed with unilateral high myopia associated with amblyopia. She was not comfortable with the glasses prescribed and complained of blurring and headache with spectacles. The unaided visual acuity in the right eye (OD) was 6/9 and that in the left eye (OS) was 3/60, which was improving with pinhole to 6/6 and 6/18, respectively. Retinoscopy was OD -1.00Ds and OS -6.00 Ds, a highly fluctuating glow. Subjective acceptance with the classic fogging technique showed OD -0.50Ds 6/6; N6 and OS -5.50Ds 6/18; N12 at 40 cm.
In order to prescribe a balanced prescription, the cyclodamia fogging technique was tried. The left eye subjective acceptance after cyclodamia was -3.00Ds with vision 6/9. This indicated the presence of high response of accommodation. Because the starting point of cyclodamia was a retinoscopy value and the visual acuity difference in both eyes was only 1 line, a Borish delayed fogging technique was performed to confirm with the finding of accommodative spasm. Acceptance after the Borish delayed technique showed OD -0.50Ds and OS -0.75DS with vision 6/6; N6 in both eyes. Fundus evaluation was performed after using tropicamide and phenylephrine eye drops. The fundus of both the eyes (OU) was within normal limits. The patient was on follow-up after 3 days, post mydriatic test. The unaided visual acuity OD was 6/9 and OS 6/12, which was confirmed with three different visual acuity charts. Acceptance after the Borish delayed technique showed OD -0.50Ds and OS -0.75DS with vision 6/6; N6 in both eyes.
Monocular estimation method retinoscopy showed a high lead of accommodation -1.25DS. Worth four dot test at a distance and near showed fusion. The cover test at both distances was orthophoria. Maddox rod test performed to re-confirm phoria showed orthophoria. Non-strabismic evaluation showed tests probing ability to relax accommodation to be low. Unilateral accommodative spasm was diagnosed. The patient was explained about visual hygiene and the need for cycloplegic drops.
On first-week follow-up, the spasm was relieved without the use of cycloplegics. History revealed that the patient had stopped excessive near work and followed the 20-20-20 rule. Thus, only visual hygiene was sufficient to manage case.
On first-month follow-up, the unaided vision was OD 6/9 and OS 6/12 and the vision with glasses was OU 6/6 and N6. Retinoscopy was OD -0.50Ds and OS -1.00Ds. Monocular estimation method retinoscopy showed -0.50 DS. Other tests for non-strabismic binocular vision evaluation were within normal limits. The patient was advised to continue with the same glasses and maintain visual hygiene, and 2 months follow-up was given.
On follow-up, the best-corrected visual acuity in both eyes was 6/6; N6 at 40 cm. Monocular estimation retinoscopy showed +0.25DS. Tests for non-strabismic binocular vision evaluation were within normal limits. The patient was explained the importance of visual hygiene, and follow-up of 6 months was given.
| Discussion | | |
In routine practice, the classic fogging technique is performed during the procedure of subjective correction. In the case of accommodative spasm, there are different techniques of fogging that can be used. Dorland Smith[1] developed a technique for the determination of accommodative spasm, in which the correction for working distance was left before the eyes for a short time after the sphere and cylinder powers were determined by retinoscopy. The excess plus was brought first to a point when 20/200 (6/60) acuity was attained at a distance. The subjective result at this point was recorded by addition of -2.50 OS to the findings before the eyes. Then the excess plus was unfogged until 20/40 (6/12) acuity was reached at a distance.[1] This technique of cyclodemia is not used much during routine clinical practice. Ideally, Borish delayed fogging test is used, but in this case, cyclodamia was used first, as Borish delayed fogging test involves fogging and defogging binocularly. Therefore, in the case of anisometropia or a difference of visual acuity in both eyes more than two lines, Borish delayed fogging test could not be performed. Thus, cyclodamia is advantageous in such cases.
Usually, the symptoms are generally related to the use of the eyes for reading or other near tasks: Long-standing Blurred vision worsens after reading or other near tasks. Headaches, eyestrain, difficulty focusing from far to near, and sensitivity to light are signs that would be the direct measures of accommodative relaxation. The patient had difficulty clearing +2.00 with ±2.00Dsp flippers when measuring monocular accommodative facility, and the monocular estimation method retinoscopy finding was low. The indirect measures of accommodative relaxation reduced negative relative accommodation. On the measurement of the binocular accommodative facility with ±2.00Dsp flippers, the patient faced difficulty clearing +2.00D and the binocular accommodative facility was low with the fused cross-cylinder finding low base-in to blur finding at near.[2] Difficulty with a plus lens both monocularly and binocularly strongly suggests a problem in relaxation of accommodation.
Differential diagnosis of accommodative excess is important. Functional disorders to rule out are convergence excess, basic esophoria, accommodative insufficiency, and accommodative infacility. Non-functional causes of accommodative excess are bilateral drugs, cholinergic drugs, morphine, digitalis, sulfonamides, and carbonic anhydrase inhibitors. Unilateral spasms may be because of local eye diseases. General diseases in adults such as encephalitis, trigeminal neuralgia, syphilis, children influenza encephalitis, and meningitis may also present with a similar picture.[3]
The final treatment consideration is the use of vision therapy to restore normal accommodative functions. Vision therapy is generally necessary in the management of accommodative excess and accommodative infacility. In many cases, it is also critical in the treatment of accommodative insufficiency and ill-sustained accommodation.[4]
As differentially diagnosing the functional disorders is important, the cyclodamia technique was useful. Dorland Smith described that fogging by this technique is equivalent to the cycloplegic effect achieved by using homatropine.[5] Earlier studies suggest that this technique is the simpler and easier mode of achieving relaxation of accommodation.[6] Studies on vision screening of pre-school children show difficulties in refraction with an auto-refractometer because of active accommodation.[7] Thus, the use of cyclodamia, if implemented in routine practice of refraction, can overcome the need for using cycloplegics.
| Conclusion | | |
The cyclodamia fogging technique should be used in routine practice to differentiate between the cases of excessive accommodation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Benjamin WJ, Borish IM. Borish's Clinical Refraction. St. Louis: WB Saunders Co; 1998.  |
| 2. | Duane A. Anomalies of accommodation clinically considered. Trans Am Ophthalmol Soc 1915;1:386-400. |
| 3. | Barresi BJ. Ocular ASSESSMENT: THE Manual of Diagnosis for Office Practice. Boston, MA: Butterworth-Heinemann; 1984. p. 123-30. |
| 4. | Suchoff IB, Petito GT. The efficacy of visual therapy: Accommodative disorders and non strabismic anomalies of binocular vision. J Am Optom Assoc 1986;57:119-25. |
| 5. | Smith D. Refraction under cyclodamia. Am J Ophthalmol 1926;9:896-903. |
| 6. | Smith D. The estimation of the total refractive error without a cycloplegic. Am J Ophthalmol 1931;14:498-509. |
| 7. | Suryakumar R, Bobier WR. The manifestation of noncycloplegic refractive state in pre-school children is dependent on autorefractor design. Optometry Vis Sci 2003;80:578-86. |
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