Spasm of the Near Reflex After Traumatic Brain Injury: A Case Report

Spasm of the near reflex (SNR) is an uncommon disorder in which accommodation, convergence, and miosis are inappropriately sustained, and it may mimic neurological conditions.We report the case of a 14-year-old girl who developed diplopia at near, reduced near visual acuity, a large-angle esotropia, and a bilateral abduction deficit after a frontal traumatic brain injury (TBI), initially suggesting bilateral abducens nerve palsy.Neuroimaging and neurological evaluation were unremarkable.Monocular ductions were full, and the oculocephalic reflex was normal, which excluded a sixth nerve lesion.Autorefraction showed high myopia (approximately -8.00 D), which shifted to +2.00 D after cycloplegia.The esotropia and abduction deficit persisted under cyclopentolate and after one week of atropine.With +5.00 D spherical lenses, ocular motility and orthotropia were fully restored.A +3.00 D near addition, later incorporated into progressive spectacles, led to marked symptomatic improvement.At 18 months, she remained orthotropic and asymptomatic with progressive spectacles, but the esotropia persisted without correction.SNR with accommodative and convergence components can follow TBI and simulate bilateral sixth nerve palsy.Cycloplegic refraction and monocular ductions allow the diagnosis, and plus lenses may control the convergence component when cycloplegia fails.