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Pseudomyopia
Pseudomyopia
Pseudomyopia
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Pseudomyopia
SpecialtyOphthalmology Optometry
SymptomsBlurring of vision, asthenopia

Pseudomyopia (from ψεῦδο, "pseudo": false; and μυωπία "myopia": near sight) occurs when a spasm of the ciliary muscle prevents the eye from focusing in the distance, sometimes intermittently; this is different from myopia which is caused by the eye's shape or other basic anatomy. Pseudomyopia may be either organic, through stimulation of the parasympathetic nervous system, or functional in origin, through eye strain or fatigue of ocular systems. It is common in young adults who have active accommodation, and classically occurs after a change in visual requirements, such as students preparing for an exam, or a change in occupation.

Signs and symptoms

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The following symptoms may be seen in patients with pseudomyopia

  • Blurring of distance vision: Intermittent blurring of distant vision after prolonged near work is the main symptom of pseudomyopia.
  • Asthenopia
  • Headache
  • Eyestrain
  • Photophobia[1]
  • Esotropia: Acute onset esotropia may occur in accommodative spasm, which is the common cause of pseudomyopia.[2]
  • Diplopia: Diplopia may occur due to esotropia or convergence spasm

The diagnosis is done by cycloplegic refraction using a strong cycloplegic like atropine or homatropine eye drops. Accommodative amplitude and facility may be reduced as a result of the ciliary muscle spasm.[citation needed]

There is a close correlation between unaided distance visual acuity and myopia; however, this correlation is not maintained in the presence of pseudomyopia, while pseudomyopia maybe presented as decrement of distance visual acuity.[citation needed]

Diagnosis

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Treatment

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Treatment is dependent on the underlying aetiology. Organic causes may include systemic or ocular medications, brain stem injury, or active ocular inflammation such as uveitis. Functional pseudomyopia is managed through modification of working conditions, an updated refraction, typically involving a reduction of a myopic prescription to some lower myopic prescription, or through appropriate ocular exercises.[citation needed]

See also

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References

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Revisions and contributorsEdit on WikipediaRead on Wikipedia

Pseudomyopia

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from Grokipedia
Pseudomyopia is a transient refractive condition characterized by an apparent increase in nearsightedness due to excessive or spasmodic accommodation of the ciliary muscle, leading to temporary blurring of distance vision without permanent structural changes to the eye's axial length or corneal curvature. Unlike true myopia, it is fully reversible with relaxation of accommodation, often confirmed by a reduction in myopic refractive error of at least 0.50 diopters (D) or more following cycloplegic agents that paralyze the ciliary muscle. This condition primarily affects children and adolescents, with prevalence rates of around 24% in 6-year-olds and 18% in 13-year-olds in a Chinese school-based study, potentially linked to increased near work such as prolonged screen time. Recent studies have shown pseudomyopia as a risk factor for developing true myopia, with progression rates up to 21% in 6 months, and increased prevalence during the COVID-19 pandemic linked to excessive screen time. Common causes include functional factors like intense near-vision tasks (e.g., reading or digital device use), uncorrected hyperopia, and emotional or psychological stressors, including anxiety disorders that may exacerbate ciliary . Organic triggers can involve head trauma, certain medications (e.g., antipsychotics like ), or neurological conditions, though functional etiologies predominate in pediatric cases. Symptoms typically manifest as variable blurred distance vision, , headaches, , and ocular fatigue, which may be unilateral or bilateral and episodic or constant, often mimicking progressive if undiagnosed. Accurate diagnosis is crucial to prevent overcorrection with glasses, which could hinder visual development in children; it involves non-cycloplegic and cycloplegic showing a significant "gap" (e.g., >1.00 D), alongside assessments and checks for accommodative lag. Management focuses on addressing underlying triggers through cycloplegic drops (e.g., 1% or atropine) to break the spasm, combined with environmental modifications like reducing near work, exercises, and, in anxiety-related cases, multidisciplinary psychiatric support. First described in , pseudomyopia underscores the importance of cycloplegic refraction in pediatric eye exams to distinguish it from true and avoid unnecessary interventions.

Overview

Definition

Pseudomyopia is a transient characterized by apparent nearsightedness due to or overstimulation of the , which maintains the crystalline lens in an accommodated state, thereby increasing the eye's refractive power and causing blurred distance vision. This condition mimics but lacks the permanent structural alterations of the eye, such as axial elongation or corneal steepening. Unlike true , pseudomyopia is reversible upon relaxation of the , often resolving with appropriate intervention or rest from near work. Key features of pseudomyopia include its temporary nature, variability in severity, and association with symptoms like intermittent at distance and sometimes headaches from sustained accommodation. It typically occurs without changes in the eye's axial length or corneal curvature, distinguishing it as a functional rather than organic refractive disorder. estimates among school-aged children vary by population, with studies reporting rates from approximately 8% to 37% in non-myopic youth during routine examinations, highlighting its commonality in pediatric eye care. The condition was first linked to accommodative spasm in the mid-19th century, with Albrecht von Graefe describing cases of pseudomyopia induced by contraction in 1856. It was more formally defined in the , with J. P. Spencer Walker coining "pseudomyopia" in to describe this across various age groups. At its core, pseudomyopia stems from the 's role in accommodation: normally, this contracts to reduce zonular tension, allowing the lens to thicken for near focus, but in spasm, it fails to relax fully for distant vision, locking the lens in a more convex, hyperopic-adjusted form.

Distinction from True Myopia

Pseudomyopia differs fundamentally from true in its etiology and underlying pathophysiology. True , also known as genuine or axial , arises from permanent structural alterations in the eye, such as axial elongation of the eyeball or excessive of the or lens, resulting in a consistent that focuses light in front of the . In contrast, pseudomyopia is a transient, functional condition caused by excessive or sustained contraction of the , leading to accommodative that temporarily increases the refractive power of the lens without any permanent anatomical changes; this relaxes with appropriate intervention, restoring normal . A key diagnostic distinction lies in refractive error assessment. In pseudomyopia, non-cycloplegic typically reveals a myopic spherical equivalent (SE) of ≤ -0.50 diopters (D), but cycloplegic —using agents like tropicamide to paralyze accommodation—shifts the SE to > -0.50 D, often revealing or underlying hyperopia. True , however, shows persistent myopic (SE ≤ -0.50 D) even after , confirming the structural basis of the error. This difference underscores the importance of cycloplegic testing to avoid misdiagnosis and unnecessary correction in pseudomyopia cases. The long-term implications further highlight their divergence. True myopia, particularly when progressive or high (≥ -6.00 D), carries risks of ocular complications such as , , , and cataracts due to the mechanical stress from elongated ocular structures. Pseudomyopia, being reversible, does not inherently lead to these structural complications if the accommodative spasm is addressed promptly; however, untreated cases may contribute to the onset of true over time. Clinically, pseudomyopia often presents with fluctuating , such as variable distance blur exacerbated by stress or prolonged near work, reflecting the intermittent nature of spasm. For instance, a child experiencing emotional stress may report inconsistent near-clear and far-blurry vision that improves with relaxation, whereas true manifests as stable, unchanging distance blur regardless of circumstances.

Causes and Pathophysiology

Etiology

Pseudomyopia arises primarily from triggers that induce excessive and sustained contraction of the , leading to transient myopia-like refractive changes. The most common precipitant is prolonged near work, such as extended reading or screen use, which overstimulates the accommodative system and is particularly prevalent among children and young adults engaged in educational or digital activities. Organic etiologies include head trauma, neurological conditions, and certain medications, which can induce spasm. Psychological factors, including anxiety and stress, can play a significant role; for instance, one study of adolescents found 71.4% of pseudomyopia patients had underlying psychiatric diagnoses, with 23.8% specifically linked to . Environmental contributors further exacerbate ciliary overactivity, including poor lighting conditions that strain the eyes during near tasks, uncorrected hyperopia requiring constant accommodative effort, and certain medications such as antipsychotics like or other agents (e.g., topiramate, sulfa drugs) that can paradoxically induce accommodative spasms despite their varied pharmacological profiles. Demographically, pseudomyopia shows a higher incidence in school-aged children (ages 6-15 years), with rates around 18-24% in this group due to intense academic demands and near-work strain, while it is rarer in adults absent comorbidities like psychiatric conditions or medication use.

Physiological Mechanism

Pseudomyopia arises from a sustained of the , which disrupts the normal accommodative process. In typical accommodation, parasympathetic stimulation via the (cranial nerve III) activates the , leading to its contraction. This contraction reduces tension on the zonular fibers, allowing the lens to become more convex and increase its refractive power for near vision. In pseudomyopia, this state persists abnormally, resulting in an apparent myopic shift of 1-3 diopters without any structural elongation of the eyeball. The underlying this spasm involves overactivity in the parasympathetic system, particularly the Edinger-Westphal nucleus in the . This nucleus serves as the preganglionic parasympathetic center, sending signals through the to the , where postganglionic fibers release onto muscarinic receptors in the . Persistent release maintains , overriding the usual relaxation required for distance vision and preventing the balanced interplay with sympathetic influences that normally facilitate disaccommodation. Ocular changes in pseudomyopia include temporary anterior displacement of the lens and diminished zonular tension due to the ciliary spasm, which collectively enhance the lens's optical power and mimic myopia. Unlike true myopia, these alterations are functional and reversible, with no change in axial length or permanent corneal curvature. This pseudomyopic shift occurs because the unrelaxed ciliary muscle keeps the lens in a near-focus configuration, blurring distance vision while potentially sharpening near tasks. Studies demonstrate the functional nature of pseudomyopia through the use of cycloplegic agents like atropine, which block muscarinic receptors and interrupt parasympathetic signaling to the . Administration of atropine induces full relaxation, often revealing a hyperopic that confirms the spasm's role, with differences between non-cycloplegic and cycloplegic refractions typically ranging from 1 to 5 diopters. This reversal underscores that pseudomyopia stems from transient accommodative excess rather than anatomical defects.

Clinical Presentation

Signs and Symptoms

Pseudomyopia primarily manifests through visual disturbances related to sustained accommodative effort, with patients commonly reporting intermittent blurring of distance vision that occurs after prolonged near work and may improve temporarily with brief rest or cessation of near tasks. This blurring arises from the inability to fully relax the ciliary muscle, leading to variable refractive shifts, and is often accompanied by asthenopia, or eye strain, particularly following extended periods of close-up activities such as reading or screen use. Ocular examination typically reveals normal fundoscopy, with no structural abnormalities in the retina or optic disc, distinguishing it from pathological conditions. In some cases, miosis, or constriction of the pupils, may be observed due to associated accommodative spasm, contributing to the pseudomyopic appearance without true pupillary pathology. Systemic symptoms frequently include frontal headaches, often exacerbated by visual effort, along with photophobia and difficulty sustaining focus at distances beyond approximately 30 cm, reflecting the persistent ciliary muscle contraction. The symptoms of pseudomyopia tend to wax and wane, fluctuating over hours to days depending on the intensity of the accommodative and triggers like stress or near work, with episodes potentially resolving partially during periods of reduced visual demand.

Associated Factors

Pseudomyopia is frequently associated with psychological factors, particularly anxiety disorders, which can trigger accommodative spasms through dysregulation. Studies have reported that up to 71% of pseudomyopia patients exhibit comorbid psychiatric conditions, with being the most prevalent, showing a positive between anxiety-somatization scores and the degree of accommodative excess (r = 0.621, p = 0.010). This link is exacerbated in high-stress environments, such as during academic examinations or prolonged near work, where psychological pressure activates the parasympathetic response, leading to sustained ciliary muscle contraction. Comorbid depressive disorders are also more common in these cases, with symptom severity influencing the intensity of pseudomyopic episodes. Ocular comorbidities often accompany pseudomyopia, including uncorrected hyperopia, where accommodative excess masks latent and induces transient myopic shifts. Convergence insufficiency is another frequent associate, contributing to binocular stress that sustains accommodative s and mimics pseudomyopic refraction. Lifestyle influences play a notable role in exacerbating pseudomyopia, with digital from prolonged screen exposure promoting accommodative fatigue and . Nutritional factors, such as deficiencies in , serve as minor contributors by impairing general ocular health and potentially reducing resilience to accommodative stress, though evidence is indirect and primarily linked to broader refractive issues. Epidemiologically, pseudomyopia shows higher among urban children engaging in over 4 hours of daily , correlating with increased near-work intensity during periods like the . The condition is generally gender-neutral overall, but stress-related cases exhibit a slight predominance, attributed to higher anxiety in women.

Diagnosis

Diagnostic Methods

Diagnosis of pseudomyopia begins with non-cycloplegic refraction, which typically reveals an apparent myopic error of -0.50 diopters or more, due to persistent accommodative spasm. Retinoscopy during this assessment often demonstrates unstable or "scissoring" reflexes, indicating variability in the accommodative response. Cycloplegic refraction serves as the gold standard for confirming pseudomyopia, employing agents like 1% tropicamide or cyclopentolate eye drops to paralyze the ciliary muscle and eliminate accommodative influence. This procedure, performed 30 to 60 minutes after instillation, reveals a significant reduction in myopic power—often shifting to emmetropia or hyperopia—distinguishing pseudomyopia from true refractive error. A discrepancy of more than 1.00 diopters between non-cycloplegic and cycloplegic findings is typically diagnostic. Additional confirmatory tests include measurement of accommodative amplitude using the push-up test, where amplitudes higher than expected for age may suggest underlying . Dynamic , assessing accommodative lag during near fixation, can further evaluate the response; a lead of accommodation (negative lag) supports the presence of . Imaging modalities such as anterior segment (OCT) are rarely required but can be employed to exclude lenticular or anterior segment abnormalities mimicking pseudomyopia.

Differential Diagnosis

Pseudomyopia must be differentiated from true , which represents a permanent resulting from elongation of the eyeball or increased corneal and lens power, leading to persistent myopic findings even after refraction. In contrast, pseudomyopia resolves completely with due to relaxation of the spasm. Confirmation of true myopia often involves axial length biometry, where values exceeding 24 mm indicate structural elongation beyond emmetropic norms (typically around 23-24 mm). Accommodative esotropia can mimic pseudomyopia through associated ciliary , presenting with inward deviation of the eyes () during near fixation, often accompanied by pseudomyopic blur and miotic pupils. Differentiation relies on orthoptic evaluation revealing intermittent linked to accommodation, which typically improves with bifocal correction to reduce near accommodative demand, unlike isolated pseudomyopia that lacks this strabismic component and responds primarily to . Conditions such as or cataracts may simulate pseudomyopia by inducing myopic shifts, but they feature distinct structural abnormalities absent in pseudomyopia. involves progressive corneal thinning and ectasia, resulting in irregular detectable via slit-lamp biomicroscopy and , with no resolution under . Cataracts, meanwhile, cause lenticular opacities visible on slit-lamp examination, leading to variable refractive errors including , but without the accommodative spasm hallmark of pseudomyopia. Neurological mimics, such as lesions causing tonic pupils or of the near , can produce persistent pseudomyopic symptoms unresponsive to standard cycloplegic agents. These often stem from trauma or vascular events affecting the or ciliary pathways, manifesting as fixed miotic pupils with accommodative excess. If symptoms persist post-cycloplegia, (MRI) is indicated to identify underlying lesions, distinguishing them from functional pseudomyopia.

Management

Treatment Approaches

The primary pharmacological intervention for pseudomyopia involves topical cycloplegic agents to induce paralysis of the , thereby relieving accommodative spasm and restoring . Atropine 1% , administered 1-2 times daily for 1-2 weeks, are particularly effective, with studies reporting complete resolution in affected cases after 15 days of use. Alternative cycloplegics, such as tropicamide 1% (twice daily, tapered to once daily after 30 days) or 1% (2-3 drops per day), have demonstrated similar efficacy when combined with monitoring, achieving full symptom relief within 45 days in clinical reports. Miotics are contraindicated, as they exacerbate the spasm by stimulating accommodation. Optical aids play a supportive role by minimizing accommodative demand during recovery. Plus lenses, such as +3.00 D for near tasks or with +2.00 D add, are prescribed following cycloplegic to facilitate clear vision without overworking the ; these can be worn full-time initially. Temporary under-correction of distance may be employed in select cases to avoid inducing further , though full correction is generally preferred post-stabilization to prevent visual fatigue. Vision therapy, particularly for chronic or persistent pseudomyopia, incorporates orthoptic exercises to enhance accommodative flexibility and fusional vergence. Techniques such as the Brock string for convergence training and accommodative flippers (±2.00 D) are performed under supervision or at home, typically over 4-6 weeks, leading to improved and reduced symptoms in case series. Accommodative rock exercises have also shown partial to complete resolution by normalizing reflexes. Addressing environmental triggers is essential to prevent recurrence during treatment. Recommendations include the 20-20-20 rule—taking a 20-second break every 20 minutes to view an object 20 feet away—along with reduced near work and increased outdoor time, which contribute to resolution when integrated with pharmacological or optical interventions. In cases linked to anxiety, brief psychological management may aid overall recovery.

Prevention Strategies

Preventing pseudomyopia involves proactive measures to minimize accommodative stress and promote healthy visual habits, particularly in children and individuals with high near-work demands. modifications are foundational, emphasizing the reduction of prolonged near tasks to avoid ciliary muscle spasm. Recommendations include limiting continuous near work to no more than 30 minutes without breaks, following the 20-20-20 rule—every 20 minutes, look at an object 20 feet away for 20 seconds—and maintaining an ergonomic viewing distance of 50-70 cm for screens or reading materials. These practices help relax accommodation and reduce , with visual hygiene education shown to lower the incidence of accommodative excess. Environmental controls further support prevention by optimizing visual conditions. Adequate is essential, with levels of at least 300-500 recommended for reading and desk work to minimize glare and fatigue. Additionally, encouraging at least 2 hours of daily outdoor time promotes emmetropization and reduces the risk of pseudomyopia progressing to true in children, as exposure helps regulate ocular growth. Studies indicate that increasing outdoor activity by approximately 80 minutes per day can achieve a 50% reduction in myopia onset risk. Screening protocols enable early detection in at-risk populations, such as school-aged children engaged in intensive near work. Annual cycloplegic refractions are advised for students and others with heavy visual demands, using agents like 1% tropicamide to accurately differentiate pseudomyopia from true refractive errors. Early intervention is particularly crucial for children with uncorrected hyperopia exceeding +2.00 , as timely correction can prevent accommodative overload and subsequent pseudomyopia development. Educational campaigns play a key role in fostering awareness among parents and educators about digital hygiene and balanced activities. Promoting habits like alternating with physical play and monitoring near-work duration has been linked to significant risk reductions. These initiatives emphasize the importance of integrating and rest periods into daily schedules to safeguard long-term ocular health.

References

  1. https://pmc.ncbi.nlm.nih.gov/articles/PMC8950661/
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  5. https://www.myopiaprofile.com/articles/what-is-pseudomyopia
  6. https://bmcophthalmol.biomedcentral.com/articles/10.1186/s12886-021-01907-5
  7. https://bmcophthalmol.biomedcentral.com/articles/10.1186/s12886-024-03551-1
  8. https://pmc.ncbi.nlm.nih.gov/articles/PMC5803705/
  9. https://www.aao.org/eye-health/ask-ophthalmologist-q/how-can-you-tell-pseudomyopia-from-true-myopia
  10. https://www.aao.org/eyenet/article/is-pseudomyopia-a-risk-factor-for-myopia
  11. https://eyewiki.aao.org/Myopia
  12. https://www.ncbi.nlm.nih.gov/books/NBK592379/
  13. https://pmc.ncbi.nlm.nih.gov/articles/PMC8377937/
  14. https://pubmed.ncbi.nlm.nih.gov/21822161/
  15. https://jamanetwork.com/journals/jamaophthalmology/fullarticle/266191
  16. https://eyewiki.aao.org/Spasm_of_the_Near_Synkinetic_Reflex
  17. https://reviewofmm.com/case-study-pseudomyopia/
  18. https://www.cureus.com/articles/68472-pseudomyopia-and-its-association-with-anxiety
  19. https://www.pjms.org.pk/index.php/pjms/article/view/3991/991
  20. https://reviewofmm.com/myopia-management-binocular-vision-issues-treat-simultaneously-or-bv-first/
  21. https://eyewiki.org/Convergence_Insufficiency
  22. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0316438
  23. https://www.researchgate.net/publication/390216047_Rise_in_Pseudomyopia_in_Time_of_Covid-19_Pandemic-A_Possible_Correlation_with_Screen_Time
  24. https://www.nepjol.info/index.php/NEPJOPH/article/view/59178/59575
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  29. https://www.aoa.org/AOA/Documents/practice%20Management/Clinical%20Guidelines/Consensus-based%20guidelines/Care%20of%20patient%20with%20myopia.pdf
  30. https://pmc.ncbi.nlm.nih.gov/articles/PMC7902945/
  31. https://www.aaojournal.org/article/S0161-6420(22)00483-3/fulltext
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