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Dr-Trace
Dr-Trace, Board Certified Ophthalmologist
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Experience:  Board Certified in General Ophthalmology
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[Great appreciation and Huge tip payment if you resolve my vision issu

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[Great appreciation and Huge tip payment if you resolve my vision issue]

A little over 3 years ago I started getting headaches and found I was having to strain to get images into focus. This started out just being when in a movie theater or spending long periods on the computer, but as the months went on, it became more pronounced and more frequent, until it became fairly constant and Excedrin could no longer fight back the tension/bruise pain in the area above my nose.

I went to two different eye Dr. to see about Lasik or contacts, and they found hardly no Sphere/power and only a slight astigmatism in each eye. I now realize that power was not found because during the test I was straining to achieve accommodation.

Eventually the severity of the issue progressed to the point where I could not hold accommodation all the time, and vision would go blurry unless I concentrated on straining again to regain at least partial focus. This blurred state is equal for both eyes, and for targets near and far. (my personal estimation is that at rest, the eyes are accommodating (and thus converging) to a point about 11 inches away) The “feeling” is as though my accommodative system no longer knows how to dial into the appropriate distance, and I have to make an exerted effort, as if my accommodative muscles were weak.

I went to a neuro-opthalmologist who didn't know what to make of my case. I had an MRI that showed up clean. I’ve had 5 Cycloplegic Refrections and each time, my vision (for all distances) goes blurry and they cannot find any setting on the phoropter to get the vision clear. So I go more than 3 days without being able to see. It seems I can only see (far/near) when undilated and straining, so I'm wondering what this tells us. The last Dr. I saw proposed the possibility of accommodative spasm, where my ciliary muscles are locked in a tensed near-point state.

I’m hesitant about this theory for the following reasons (please consider in detail and give your response to each):

1. I feel maybe my near-point or inaccurate ability to focus is due to some reason other than tensed muscles? There must be other causes of focusing problems besides spasm of ciliary muscles, right? (maybe equatorial zonular tension, the brain’s control of the accommodation system, etc?) Because if it were due to tensed accommodative muscles, I would expect the various muscle relaxing drops tried to relieve the spasm causing near-point accommodation, but that’s not what happens. (or Is my expectation of the drops’ effect inaccurate?)

2. The other puzzling aspect of the spasmed muscle theory is that to obtain clear vision, it does not feel like I’m relaxing the over-tensed muscles. It feels like great tension of muscles (with headache) and the ability fatigues over time. So, maybe when I “strain” I’m not relaxing the muscles, but instead creating some other change to compensate for the spasmed accommodative muscle? (just like what was observed when I tried -3.5 lenses)? It doesn’t seem logical that tensing causes relaxing.

3. If we're trying to determine if the accommodation system is working properly, it seems like knocking them out of the picture with drops would be the opposite thing we would want to do, because then we could no longer observe their action and acuity when I switch between relaxed and strained state. I would understand dilating if the case was that their tension was preventing me from seeing far away, and by forcing them to relax it would clear up my distance vision, but this is the opposite of what happens when I'm dilated, so it doesn't seem like that's what's going on.
Submitted: 2 years ago.
Category: Eye
Customer: replied 2 years ago.
Relist: I still need help.
Expert:  Camille-Mod replied 2 years ago.

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Customer: replied 2 years ago.
I still need help.
Expert:  Camille-Mod replied 2 years ago.

Thank you. Sometimes, finding the right Expert can take a little longer than expected and we thank you greatly for your understanding. We’ll be in touch again shortly:-)

Expert:  Dr-Trace replied 2 years ago.
Hi- I am Dr. Lewis and it sounds like what your are experiencing is most definitely accomodative spasm. I have seen multiple cases like yours and the reason you are not getting good answers is because this is not a common condition.

First, let me say that the problem tends to occur in people who are type A personalities, and very well keyed into their medical health. Listening to your explanations of what you perceive is happening is interesting but you are not one hundred percent correct in your understanding of accomodative spasm.

I think I am grasping from your explanation that you have been refracted to a -3.50 sphere. This doesn't necessarily mean that this is the correct prescription for your eyes, more likely it is what you have manifested on refraction.

it would be very important to obtain a cycloplegic refraction or streak retinoscopy to determine what your true refraction is in your eyes. My guess is that it would be close to plano or -1.00. That would mean that you are holding and accomodating about 2.00 diopters of myopia and this is why you are getting very bad headaches and straining with a loss of focus. You could even possibly be hyperopic and pulling in even more myopia with your ciliary muscles.

You asked for an answer to each question.

1. You feel your inability to focus is due to something other than your tensed muscles. Wrong. Accomodative spasm means that you are holding tension in your muscles even at distance. When you then try and focus up close, you use even more muscle power and you basically over strain your accomodative muscles and they tank out. If your accomodative complex was functioning normally, you would be holding no muscle contraction at distance and only using a small amount of muscle contraction at near. You are just in hyperdrive with your muscles. Putting in the muscle relaxing drops will tank your near vision completely so you can only see at distance. But even at distance you might be blurry for a while because you have trained your brain to see only well when you accomodate (even though it's not necessary). By doing this, you will have no muscle power to bring the focus in up close at all so the cycloplegic drops will cause your vision for a few days to be extremely blurry, at distance and especially up close. The only thing the drops should do is relieve the headache. Not the blurry vision.

2. You say that to obtain clear vision, it does not seem like you are relaxing but overstraining. This is typical for accomodative spasm. Your muscles have been in a constant strained state for such a long period of time that your brain does not know what to do. It keeps trying to do what it normally does to bring in focus - pull in muscle power. This doesn't work because the muscles are already overworked. It just makes the problem worse. To fix the problem, you need to complete paralysis or cycloplegia of the muscles for about a week. Along with this you might need a small amount of prescription for distance(for you it would be probably be only just astigmatism) and then use some cheater glasses up close to keep the muscles from needing to accomodate at all. You start with a +2.50 cheater pair of glasses to read with and a +1.50 for computer. Over a few weeks work your way down to less and less power. If the symptoms come back you go up on the cheater power. Over the counter glasses are cheap. You can go back and forth for a while to find what makes the vision clearest and gives the least headache. Finding the right strength will obviate the need for any accomodation.

3.You are confused because dilation makes your distance vision blurry too. This problem is short lived and is occurring because your brain is dishabituated to your real prescription at distance. You have gone so long in an accomodative state at distance that when accomodation is relaxed, you can't even see far away. This problem will go away after a week or so of cycloplegia because your brain will rehabituate to your normal non-refractive clear vision state. It takes time and doesn't happen right away.

So what I have told you is confusing but here is the botXXXXX XXXXXne.

Put in cycloplegic drops (preferably long acting like atropine or homatropine). Leave them working for two or three weeks. Remain blurry at distance for a bit and attempt to correct the distance with only a little astigmatism correction or slight hyperopic correction if your cycloplegia reveals hyperopia. Whatever your best cycloplegic refraction is, even if it's a little blurry, this is what you should wear for distance.

Buy a pair of over the counter +2.50 glasses for near work/reading and a pair of +1.50 glasses for the computer. Use them any time you need to read or use the computer.

After 2 weeks, stop the cycloplegic drops and see if your distance has improved to clarity. It should. Continue to use the close glasses for a few more weeks so you do not accomodate at all.

Gradually over weeks or months, go down on the reading and computer glass strength reading +1.50, computer +1.00.

Then eventually eradicate the cheater glasses.

This will allow the muscle strain to gradually abate.

The only caveate to this is your age. Nowhere does it state how old you are. If you are over forty, do not get rid of the reading or computer glasses at all. Any attempt to go without them will kick you back into accomodative spasm.
Customer: replied 2 years ago.
Dr. Trace,

Great answer! I'm happy you took the time to understand the situation and explain the clarifications to the points which puzzled me regarding the logic of what I'm experiencing. (To answer your question, I'm 35. They should have shown this at the bottom near the solutions I have tried thus far.)

1. So is the probability high that I arrived into this condition of spasm from long-term excessive daily computer work? Are you saying you don't think it's that my brain/vision system is being affected by my auto-immune disease?

2. I currently have Phenylephrine 2.5% drops, but I'm guessing they will not be strong enough? I have a script for Cyclogyl 1% 1 drop TID but have not filled yet (and they are expensive), should I ask for stronger atropine or homatropine instead?

3. I have contacts to correct my astigmatism, and the powers are only plano and +.5, so should/could I wear those during this period of drops?

4. When I've tried readers before (without drops) in an attempt to relaxe the spasm, but I could not see anything (unless I pulled them a few inches away from my face). Does this indicate anything regarding our plan? With drops, will it change things in a way that I'll be able to see out of them?

5. So for 2-3 weeks on the drops I will not be able to drive etc because I can't see in distance?

6. Your spasm theory makes a lot of sense, but I worry that if it’s not that, and my accommodative system is actually confused/weak, that putting them out of commission for weeks with drops will just make them that much more dysfunctional.. or maybe after the drops I may never be able to get focus back, no matter how much I strain.

(sorry for all the questions, it's important to be clear right? I think we’re making GREAT progress.)



Expert:  Dr-Trace replied 2 years ago.
I doubt very much that your accomodative spasm is related to your auto-immune disease. Especially if the disease does not affect your eyes (like episcleritis or iritis).

Phenylephrine 2.5% drops are definitely not strong enough. Atropine sulfate drops are cheap and you only need one or two drops to last over a week. Homatropine drops last 2-3 days.

I would definitely wear your contacts, especially the +.50 since the dilation will bring this prescription out and it will help you see more clearly at distance.

You should most definitely take it easy and not drive if possible because you will be blurry until you are done with the drops.

The problem with your accommodative system is not weakness, in fact it is the total opposite. Your system is like a spastic muscle, too strained and over-used. If you were an athlete with a muscle injury, resting and keeping the muscle immobile for two weeks would only improve the condition. If you've ever had a "charlie horse" or cramp, this is what your ciliary muscle is doing. You are blurry because it is overacting, pulling in too much prescription.

I want you to know that there are millions of people out there who no longer have the use of their ciliary muscle at all. After cataract surgery, the lens no longer accomodates. So your fear of never getting focus back is ungrounded. You can always recover focus with the use of prescription glasses, even if the ciliary muscle no longer works.

In the end, you may need to keep trying different combinations of glasses and drops to get you to a point where you are clear both at distance and near. The glasses may be different for differing focal points.

Let's try first to give your muscles a break. At thirty-five, they will kick back in after a short term of cycloplegia.

Feel free to respond back with any other concerns.

As always, remember to discuss this with your current ophthalmologist. Since I have not examined you, this cannot be considered a formal medical report. Rather our correspondence is for informational purposes only.

Thanks.

Dr. Trace
Expert:  Dr-Trace replied 2 years ago.
I also wanted to add that walmart has atropine 1% eye drops for 4 dollars. If you can't afford this, cyclogel 1% should be available from your ophthalmologist as a sample. You do not need much so a small bottle should do fine. I always give my patients samples when I need to prescribe cyclogel.
Expert:  Dr-Trace replied 2 years ago.
Oh and yes - the problem most likely occurred from your intensive use of the computer. If you can, enlarge your font. Working with larger print requires less need for accommodation.
Customer: replied 2 years ago.
Ok, great info. I'll see how she feels about changing the script to one of the other two drops.

To make sure I understand, in summary:

> Currently my near & far vision is blurry if I relax (e.g. if I close my eyes, relax my face, then open them). To get near or far vision clear, I need to "strain" my eyes.

> I'll use drops for a couple weeks to break their spasm, then after the drops wear off, my vision will be as clear without straining as they are now when I do strain? (I'll use readers as much as necessary to help prevent them from going back into spasm.)

Do I have the above correct?
The only part I still don't understand, is you're saying this "straining" is me compensating for accommodative spasm; but I don't understand how the eye could accomplish such a thing.... if the ciliary muscles are locked in a near-state, how could I be compensating for this, since I can't change the length of the eye, etc. ? (I know it can't be that I'm relaxing the ciliary muscles, because if that were the case, then the drops would have the same effect as me straining.)
Expert:  Dr-Trace replied 2 years ago.
Ok - Let me try to explain a little better. You are not straining to compensate or see through the accommodative spasm, you are feeling strained because your muscles are in accommodative spasm. If we break the spasm, the feeling of strain would go away.

Your distance vision, with your muscles completely relaxed (cyclopleged) is plano in one eye (with a little astigmatism and +.50 with a little astigmatism in the other). When they measured your distance vision without drops(cycloplegia), you were measuring -3.50. This means that your muscles at distance were holding in or straining in -3.5 and -4.0 diopters of accommodation at distance. Normally your ciliary muscles should be relaxed at distance without any constriction or strain at all. This wasn't happening. You were contracting at distance. Then when you went to see up close, the muscles contracted even more to focus at near. This is the reason for the headaches and feeling of strain, first when working up close then all the time.

The eye has a whole range of muscle contraction where it can see clearly. It has to do with infinite distances vs. 20 to 30 feet distances. I see kids all the time who function with holding in two or three diopters of accommodation at distance. They are perfectly clear at what they perceive as distance (20 to 30 feet). Maybe they aren't crystal clear looking at a horizon thousands of feet away but they don't know it or they easily relax their accommodation to see infinity. Their environment of distance is about 20 to 30 feet. They don't even know they are accommodating a little. In young kids, the muscles are so strong that it is no strain at all to do this.

In your case, as you get closer to 40, the lens stiffens in the eye (herald of cataract coming in your later years) and the muscles need to pull much harder to flex the stiffer lens. You probably have been accommodating a bit your whole life and now as you reach 35 and need to work on the computer so much, your ability to pull is not as good as it used to be. Welcome to the aging process.

So working these muscles to do what you have been used to doing your whole life has now become intolerable. The lens is stiffer. You need more muscle pull to get the same effect. Bingo, your muscles have cramped from overwork.

We now need to get your muscles to relax and get your brain used to seeing infinite distances, not 20 to 30 feet distances. It will happen. It just takes time.


I know this stuff is complicated. But it's worth fixing it.
Dr-Trace, Board Certified Ophthalmologist
Category: Eye
Satisfied Customers: 26
Experience: Board Certified in General Ophthalmology
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Customer: replied 2 years ago.
Ok, I will try the drops approach and we'll see what happens.

I'm really trying to understand this, I just wish I was able to totally grasp it.

1. I understand that I'm over-accommodated and that's why -4 lenses compensate for the blurriness at distance. (And if I'm assuming correct, this is why I can't see up close with those glasses on, because the ciliary muscles are already maxed out as is, so I can't compensate more on top of the power of the glasses in order to see close?)

2. I'm also assuming that because my accommodation is locked at near-point, my brain thinks I'm looking at something near, and this is why my eyes cross inward converging at a point pre-target, resulting in double vision?

3. So I'll try to rephrase the part I don't understand: My near/far vision is blurry because my ciliary muscles are spasmed, so how is it that I'm able to make the vision clear?? I'm not relaxing the ciliary muscles, and not changing the length of the eye, etc. so how am I doing it?


If I've been over accommodating my whole life, a 2 week break can cancel the habit?
Expert:  Dr-Trace replied 2 years ago.
1. Yes, yes, yes. You get the concept that you are over accommodating by -4 diopters at distance. When you put the glasses on, it makes you clear because the image focuses on your retina through the accommodating lens and glasses (like a telescope or the physics of double lenses).

2. You are not locked at near-point. You are accommodating even at distance. You then are able to flex your accommodation even more to see up close. The reason why your eyes cross inward up close is because the accommodation/convergence reflex is coupled. When we accommodate, there is a reflex that automatically pulls the eyes inward (convergence).

In kids, there is an entity known as accomodative esotropia. Anytime they attempt to read, their eye crosses inward. We fix these kids by giving them bifocals so they can't accommodate at all. This keeps the reflex of eye crossing convergence from happening. It usually happens in kids that are very farsighted and see best at infinite distance. These kids use their accommodative muscles to see at 20 feet (functional distance) and then use even more muscle power to see close. Because they are driving their accommodation so hard, they converge (since the reflex is coupled) too much and their eyes cross.

The fact that your eyes cross inward up close is even more evidence that you are experiencing accommodative spasm (too much accommodation). You are accommodating so much that you converge too much also and your eyes cross at near (and you see double).

3. When you are rested, you see clearly at distance because you are accommodating some (even though you don't need to). When your muscles get fatigued, they give up. This is why your vision gets blurry at distance sometimes and you also get a headache. The muscles are giving up because of strain and where you normally accommodated to see at 20 to 30 feet distance, you no longer can. Your muscles should not be accommodating at distance at all but they are.

So we have got to stop your muscles from accommodating too much. Usually breaking a muscle spasm for a week or two will reset the muscle complexes and they will go back to functioning normally. But you will need to be careful. Anytime your eyes feel overworked or fatigued, you need to take a break. If you start to get a headache, you need to take a break. You can go back into the habit. But using reading glasses up close as needed can help. And getting plenty of rest, minimizing stress and not overworking your eyes can help too.
Expert:  Dr-Trace replied 2 years ago.
I actually mis-stated paragraph 3. What I meant to say in paragraph 3 is when you are rested, you see clearly at distance because you are accommodating some (even though you don't need to). When you have been doing up close work for a long time your muscles get fatigued but they don't give up. This is why your vision gets blurry at distance and you get a headache. The muscles won't give up because of strain and where you normally accommodated to see at 20 to 30 feet, you can't. You are too strained.
Expert:  Dr-Trace replied 2 years ago.
The only other thing I would double check is to see if your cycloplegic refraction is really plano and +.50 with some astigmatism. I suspect that you have a bit more hyperopia than your docs found just based upon your symptoms.
Customer: replied 2 years ago.
Ok, but to clarify, I was not saying my eyes cross inward when seeing up close. They cross inward when looking 2 feet away or 200 yards away. So in both cases the double objects are spread apart by the same ratio. Does this new information still fit into the theory and will be corrected post drop treatment?

The second thing to clarify: I was not saying I see clearly at distance when rested. I see clearly only when I strain. For example, I can switch between blurry and focused several times and each transition only takes about a second to accomplish.... so this is the action I was inquiring about in #3, what part of my eye am I manipulating if it's not the ciliary muscles?

(ps. I posted another question for you)
Expert:  Dr-Trace replied 2 years ago.
I think you are hyperopic and it was not fully measured by the docs who examined you. So you hold accommodation at distance and more at near. This is why you go from blurry to clear. You accommodate and things get clear. The muscles relax a little and things get blurry. Then you strain (accommodate) and things get clear again.

As far as the crossing is concerned - Was the crossing of the eyes measured by the neuro-ophthalmologist? I would question if the crossing was of the same ratio at distance as at near. But I am not examining you so I can't be sure. You may have perceived that the crossing was the same at distance and near but you probably crossed more at near.


I made a recommendation to you in your other question to see a good neurologist. I think there may be a few things going on here and the accommodative spasm is just part. Nothing to worry too much about as your MRI was normal but I think a neurologist might shed some light on all the factors.
Dr-Trace, Board Certified Ophthalmologist
Category: Eye
Satisfied Customers: 26
Experience: Board Certified in General Ophthalmology
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Customer: replied 2 years ago.
You may be right, but since the first neurologist wasn't any help, I'm going to start first by doing the two weeks with drops, and see what results come of it.

I've had cycloplegic refraction several times, but maybe while under the drops I'll ask someone to bring me in to have it re-checked.

I'll update you when I know more.
Customer: replied 2 years ago.
Forgive me, I truelly am trying hard to understand this.
You say my vision is blurry at distance because my ciliary muscles are tensing, though they shouldn't be, right? And that I'm then making my vision clear by tensing my ciliary muscles. If tensed ciliary muscles are the cause of going away from state of focus, how could increasing the problem be solving the issue, eg. making the vision clear?
Expert:  Dr-Trace replied 2 years ago.
Your vision is not always blurry at distance. When you strain, you make the vision clear. This is why I think you are a little farsighted. Because you do require (and probably have always required) some flexing of the ciliary muscles even at distance. But because you have overused and fatigued your ciliary muscle complex, you are aware of the strain now (the flexing) even at distance. And when you don't feel strain, your muscles are relaxed and your vision is blurry.

If you were functioning normally, you would not feel any strain at all at distance. Even though you held a little muscle contraction at distance, you would not be able to feel that strain.

But because you have worked on the computer so much and held near focus so long, your muscles are cramped and spasmed. So any use of these muscles makes you feel strain. And on top of this, they are cramping up on their own and occasionally freezing in a -3.5 diopter state.

Compare the situation to an athlete with a pulled or strained hamstring. When the muscle is overused or injured, it gets strained. After the injury, any use of the muscle at all hurts and causes it to spasm. Any use. Even just a little use is painful or feels strained. And occasionally, the muscle cramps or spasms on its own and holds too much contraction (like a charlie horse). In order to treat this, complete immobilization is necessary.

I hope this makes sense to you.
Dr-Trace, Board Certified Ophthalmologist
Category: Eye
Satisfied Customers: 26
Experience: Board Certified in General Ophthalmology
Dr-Trace and other Eye Specialists are ready to help you
Customer: replied 2 years ago.
I finally got the new prescription for Atropine in place of cyclogyl. If it were you, would you let it wear off after a week to see if vision had returned to normal, or go 2 weeks straight through without a break?

Do you typically prescribe a drop per day or per week?
Expert:  Dr-Trace replied 2 years ago.
One drop of atropine per day for 1 week and then let it wear off by itself. It may take up to a week to do so. Keep in touch with me (at no charge) and let me know if your symptoms go away.

Dr. T
Customer: replied 2 years ago.
Ok, let me walk through this reasoning with you now since I may not be able to see once I put these drops in.
Once my accommodation is knocked out with drops, then I should be able to see in distance (especially with the help of my contacts for slight astigmatism correction). If I'm not able, then I may be farsighted. If this is the case, then one of the several reader strengths I bought would correct for it? If a plus lens does not correct for distance, then it must be nearsightedness or some other issue?
Expert:  Dr-Trace replied 2 years ago.
When you first put the atropine in, you should buy a pair of +2.50 readers to read with (at the dollar store) if you see clearly at distance with your contacts. If you don't see clearly at distance, I would go back and ask your ophthalmologist to rerefract you at distance after two or three days on atropine. Since you've been on atropine there should be no accomodation left. When you were cyclopleged for testing in the office originally, they used a weaker drop and you were in accomodative spasm. The spasm did not allow full cycloplegia so you read plano with astig because your spasm was overriding the weaker drops. Now that atropine is being used, a cycloplegic refraction will determine your true prescription and it is probably farsighted with astigmatism. Then I would give that prescription at distance (in contact samples) and wear a pair of +2.50 at near for reading over the contacts. Which ever works I would use for two weeks while the atropine is on board. Then when the atropine wears off, I would go back to using nothing and see if the headaches and symptoms of spasm are gone.
Dr-Trace, Board Certified Ophthalmologist
Category: Eye
Satisfied Customers: 26
Experience: Board Certified in General Ophthalmology
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Expert:  Dr-Trace replied 2 years ago.
I am going to follow up with you in 14 days to see how your headaches and eye strain are doing.

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