Beyond the Classic Near Triad: Diagnostic Insights from a Case of Accommodative Spasm

BACKGROUND: Accommodative spasm (AS) is an involuntary condition characterized by excessive contraction of the ciliary muscle, leading to exaggerated accommodative response and fluctuating refractive error. The reported prevalence of accommodative spasm ranges from 2.6% in an Indian clinic cohort to 37.19% in Chinese school children. Since the COVID-19 pandemic, accommodative spasm has been reported in 20% of symptomatic patients associated with increased near work and digital screen exposure. It often presents with headache, photophobia, blurred distance vision, and eye strain. This case report describes bilateral accommodative spasm in a 14-year-old female who presented with blurred distance vision in left eye and headaches. CASE PRESENTATION: Best-corrected visual acuity was 20/20 in the right eye and 20/400 in the left eye; near acuity was N6 in both eyes. Objective refraction using an open-field autorefractor (WAM-5500) showed fluctuating myopia. Retinoscopy revealed a vacillating reflex, and a lead of accommodation on dynamic retinoscopy suggesting accommodative instability, which was further confirmed by excessive accommodative responses measured using open-field autorefractor. Baseline ocular biometry revealed axial length within the normal range, increased lens thickness, and reduced anterior chamber depth. The patient was treated with 1% atropine sulfate eye ointment, administered twice daily for three days. Cycloplegic refraction on day four showed resolution of the spasm with a stable retinoscopic reflex. RESULTS: After a 21-day atropine washout, repeat retinoscopy confirmed the absence of accommodative instability. Post-mydriatic ocular biometry showed no change in axial length but significant improvements in lens thickness and anterior chamber depth. CONCLUSION: This case highlights the potential role of objective ocular biometry as an adjunctive tool in accommodative spasm, providing additional structural insights that may aid clinical diagnosis and treatment monitoring.