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I hope you can help me regarding this fairly rare matter. I…

Hello Doctor, I hope you can...
Hello Doctor,
I hope you can help me regarding this fairly rare matter.
I have been diagnosed with an accommodative spasm at both eyes. I am 28 years old.
Refraction with cyclopegia (Atropine) : + 0,50 (slight hyperopia)
Refraction WITHOUT cyclopegia : - 4,50 (pseudomyopia)
This constant spasm appeared right after a lasik surgery, 6 month ago.
However, before the surgery, there was no difference found between cyclopegic and non-cyclopegic refraction. I was hyperopic, +3,50 for the right eye and +2,00 for the left one
This situation causes me constant headaches and very blurry vision for targets near AND far.
I have to strain a lot to get images into focus which is exhausting. Of course I cannot hold accommodation all the time with such a big spasm, at rest everything is blurry.
To relieve the symptoms I had atropine for 3 months (1 drop per day in each eye), thanks to these drops my vision was perfect for targets far. During this time I used +3.00 readers for close vision.
My problem is : After 3 months i stopped the drops and when atropine wore off (2 weeks later which is quite long), accommodative spams came back.
My surgeon doesn't know what to do anymore. I have been to other ophtalmologists and unfortunately, they have no further idea.
I live in France and unfortunately, there are no neuro-ophtalmologists like in the US (I read that ciliary muscle contraction is linked to neurologic system)
I have got 2 questions in my mind :
1) Should I try atropine longer (1 year ?). Are there risks for the retina by having a long-term atropinization ?
2) In my case, as the 3-month atropine treatment didn't work, do you think that a clear lens extraction could be a good idea ?
I would be very grateful if you could advise me.
Thank you
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Answered in 1 hour by:
6/20/2013
Dr. Rick
Dr. Rick, Board Certified MD
Category: Eye
Satisfied Customers: 12,131
Experience: Ophthalmology since 1994 with Retina sub-specialty interest
Verified
Dr. Rick :

Hi. My name is***** and I have two decades of ophthalmology experience. I'm online and happy to answer your question today.

Dr. Rick :

Sorry to hear about all the difficulties you have been having. As a retina surgeon, let me go over your questions in order:

Dr. Rick :

1. Yes. I believe using the atropine for a year is a good idea. There are no significant risks to the retina from long term atropine use.

Dr. Rick :

2. I would not rush to a clear lens extraction, especially since you seem willing to give the atropine treatment a longer trial. Obtaining the correct post-operative refraction with clear lens extraction can be complicated after having had lasik surgery. You run the risk of making things worse....and you can not "undo" surgery.

Dr. Rick :

If things do not change after a year of atropine, then you might need surgical treatment...

Dr. Rick :

Is there anything else you would like to discuss at this point or have all your questions been answered to your satisfaction?

I hope this information was helpful for you. But I do work for tips so I want to make sure you are happy with me before rating me. If you have another question on this or a related issue feel free to fire away. You may also receive an email survey after our chat, if you don’t feel that I have earned a “10” rating in all areas, please let me know what I can do to meet your expectations.

Thanks in advance,

Dr. Rick MD FACS

Dr. Rick :

Hi. Are you there?

Customer:

Thank you for your answer

Customer:

Yes I am here

Dr. Rick :

My pleasure. Is there anything else you would like to ask me tonight?

Dr. Rick :

(it is 8 pm here in the USA

Customer:

I just would like some further information about point 2

Dr. Rick :

ok

Customer:

In France it's 3 am :D

Customer:

you say it's complicated to have a correct refraction for the implant after lasik surgery

Customer:

but i wonder why ?

Dr. Rick :

After lasik surgery it is hard to select the intraocular lens power after your natural lens is removed. If this were to happen you might need to use thicker glasses after the lens extraction than you did before lasik surgery. This is why I counsel patience.

Dr. Rick :

It has to do with the formula for calculating intraocular lens power....

Dr. Rick :

does this make sense to you?

Customer:

ok that's very clear, thank you. i don't care about having glasses again, i've been through a lot of pain with my spasm, especially when it was not diagnosed yet

Dr. Rick :

I can understand your pain and frustration :(

Dr. Rick :

I hope things get better soon.

Customer:

and would you advise to have clear lens extraction for both eyes if atropine doesn't work ?

Customer:

or try just one eye ?

Dr. Rick :

I'd try one eye first and see how it goes.....

Customer:

okay

Customer:

do you also know if the ciliary muscle could "push" the implant ?

Customer:

because it couldn't change the shape of the implant, but i was thinking that maybe it could move it

Customer:

if the spasm is still active

Dr. Rick :

No. The ciliary muscle will not be able to move the implant. No worries there.

Customer:

that's at least one good news :-)

Dr. Rick :

Glad to be the bearer of good news :)

Customer:

would you recommend monofocal implant ?

Dr. Rick :

Yes...especially after all you have been through...keep it simple..

Customer:

that's what i think as well, i don't want to take further risks if long term atropinization doesn't work

Customer:

thank you for your answers

Dr. Rick :

My pleasure. Take care.

Dr. Rick :

It's safe for you to press the positive feedback button now if you so desire. And, never fear, even after you press that button I don't go up in a puff of smoke -- I'll still be right here to continue helping you, but, as I do work for tips, I want to make sure you are happy before rating me.

Dr. Rick
Dr. Rick, Board Certified MD
Category: Eye
Satisfied Customers: 12,131
Experience: Ophthalmology since 1994 with Retina sub-specialty interest
Verified
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Just one more thing: I do not think there is much, if any, long term risk to using atropine. I'd not worry about giving this a try, even for a year.
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Customer reply replied 5 years ago

I have got 3 more technical questions, if you think you would be able to answer them :-)

1. Is there any drop, or another possibility than atropine to paralyse accommodation, without having pupil dilated ?

Because I am always blinded when outdoors, even with sunglasses it is sometimes difficult to stand the light when it is very sunny.

For example, small quantities of botulinum toxin can be used to weaken some overactive muscles (for strabismus...). Is it possible to paralyse the ciliary muscle with this substance ?

2. How is it possible to get an accommodative spasm with such a huge amplitude (5 diopters) right after a lasik surgery ?

Because there are some cases of ciliary spasms released in scientific publications which lead to a difference of 0.25 or 0.50 diopters, sometimes 1 diopter, but my case seems to be nearly unique. All the lasik specialists I met since my surgery told me I was the first one to have a spasm of this amplitude (in france where there are however 150'000 lasik surgeries per year which is a lot).

I found some cases with the same amplitude as me, but for people who have got some head trauma after an accident.

3. Do you know if there is some medical research in the world about accommodative spasm ? Or regarding links between autonomic nervous system and ciliary muscle ?

From what I read in publications, the origin of this phenomenon is relatively unknown

Thank you.

1. Atropine is the best and, unfortunately, there is no drop that will stop accomodative spasm and, as the same time, not dilate your pupil.
2. That is a great question...and I don't know :(
3. The best place in Europe to get help and state-of-the-art care with this issue would be at Moorfields Eye Hospital. They are, without a doubt, one of the best eye hospitals in the world. If anyone can figure this out, it would be them :) Here is a link to their web page:
http://www.moorfields.nhs.uk/Home
Does this make sense to you?
It's safe for you to press the positive feedback button now if you so desire. And, never fear, even after you press that button I don't go up in a puff of smoke -- I'll still be right here to continue helping you, but, as I do work for tips, I want to make sure you are happy before rating me.
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Customer reply replied 5 years ago

Ok perfect,

I think we have examined the question from all sides.

Thank you very much for your accurate answers

My pleasure. I wish you the very best. :)
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Hi John,
I was just thinking about you today and wondering if you have had a chance to speak to the doctors at Moorfields. I hope you are on the road toward getting some solutions to your spam.
Let me know if there is anything else I can do to help you.
Dr. Rick MD FACS
Ask Your Own Eye Question
Customer reply replied 4 years ago

Thank you for your help.

No I didn't make an appointment at Moorfields yet, and I am not sure if my spoken english is good enough for that. I searched for e-mail contacts to ask some advice but it seems that it's only possible to make a new appointment.

I must see two more specialists my surgeon recommended to me, as wella as an eye hospital in Paris (Les Quinze Vingts), then if i have the feeling that i get no satisfactory answer i will get in touch with Moorfields

John,
You don't type with an accent lol!
I'm sure that there is an institute in France that can help, I just don't know much about your country -- you might ask around....
Let me know if there is anything else I can do to help.
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