Pseudomyopia is a myopic shift in the refractive power of the eye due to overstimulation of the mechanism of accommodation. It is most common among children and may occur in all types of refractive errors, especially in hyperopia. The usual symptoms of pseudomyopia include asthenopia, intermittent blurry vision and sometimes diplopia. The management starts with recognition, which involves a high index of suspicion, cycloplegic refraction and relaxation of accommodation. This case series describes the management of three young adult female patients who presented with clinical features of pseudomyopia, with a focus on identifying predisposing risk factors and establishing the diagnosis.

Pseudomyopia refers to an apparent myopic shift caused by accommodative overactivity that resolves after cycloplegia and may occur as an isolated accommodative spasm or within the broader spasm of the near-reflex spectrum. Because the refractive component is functional rather than structural, cycloplegic refraction is essential to confirm reversibility and avoid misclassification as true myopia. A 47-year-old male police officer presented with a 1-month history of persistent, dull headaches associated with ocular discomfort. Symptoms were accompanied by intermittent nausea and visual strain, more pronounced during prolonged near tasks and smartphone use. Prior to an ophthalmologic assessment, he underwent a comprehensive neurological evaluation at a local hospital, including a computed tomography scan of the brain, which revealed no intracranial abnormalities. Cycloplegic refraction was performed in a staged manner across two visits due to occupational and driving requirements. At the initial visit, pre-cycloplegic autorefraction of the left eye demonstrated -0.75 -0.75 × 159° OS, with post-cycloplegic refraction of +1.25 -1.00 × 165° (+1.87 D hyperopic shift). At the two-week follow-up, pre-cycloplegic autorefraction of the right eye demonstrated plano -1.50 × 9° OD, with post-cycloplegic refraction of +1.75 -1.50 × 8° (+1.75 D hyperopic shift), suggesting a bilateral accommodative spasm. Near-addition spectacle correction was prescribed, and the patient was advised to limit prolonged near work, implement the 20-20-20 rule, and optimize workplace ergonomics. Cycloplegic refraction remains central to the diagnosis of accommodative spasm and pseudomyopia, and a marked shift toward reduced myopia or hypermetropia after cycloplegia supports the diagnosis. In this patient, optical management with near-addition correction was preferred over pharmacologic cycloplegia because of occupational and driving requirements.

This review aims to provide a summary of the present knowledge in the assessment and classification of accommodative dysfunctions in non-presbyopic patients, with special emphasis placed on the impact of the assessment techniques and protocols employed in the measurement of the dysfunctions. The most commonly employed clinical and objective techniques in the assessment of accommodative dysfunctions are discussed, in addition to the major limitations and diagnostic biases associated with the techniques. The major accommodative dysfunctions include insufficiency, infacility, spasm, fatigue, and paresis, while the most striking limitations in the assessment of these dysfunctions include inconsistencies in the assessment techniques and protocols employed, as well as the diagnostic criteria and norms. A pragmatic approach for the diagnosis of the dysfunctions is proposed with the aim of enhancing the specificity of the diagnostic techniques employed in the assessment of the dysfunctions. Standardization of the techniques and protocols employed in the assessment of the dysfunctions, in addition to the integration of objective dynamic techniques in the assessment of the dysfunctions, may help in the elimination of the diagnostic biases associated with the assessment techniques employed. This narrative review was developed using recent peer-reviewed articles retrieved from major scientific databases, including PubMed, ScienceDirect, Wiley Online Library, and Scopus, with emphasis on clinically relevant and recent publications.

As an optical system, the eyes function in line with the basic principles of refraction. Visual clarity depends on the ability to bring incident light rays to a point focus at the fovea centralis. Schematically, the cornea and crystalline lens provide the requisite total dioptric power (about +60 diopters; the cornea makes up about + 40 to + 48 diopters). Accommodation is the adaptative faculty that enables clear vision with subjective variation in the linear distance of visual targets. This is accomplished by the autonomic adjustment of crystalline lens dioptric powers to provide focus on the presented stimuli. The main stimulus is 'blur.' The focusing powers of the crystalline lens are directly proportional to the increase or decrease in lens convexity. At the near point of accommodation, the ciliary muscles contract and relax zonular tension, thus enabling increased convexity and focusing power. For the far point of accommodation, the ciliary muscles relax and exert greater tension on the zonules (of Zinn), thus reducing lenticular convexity.  Under typical conditions, the healthy eye responds to near-point (linear) stimuli by activating the near triad, which includes accommodation, convergence, and miosis. These mechanisms are synergistically engaged to enable single, clear binocular vision. Inhibition in one of these reflexes can most likely lead to dysfunction of accommodative response. Concerning the near reflexes, accommodation and convergence are most closely intertwined. This interrelationship can be reported as the 'accommodative convergence to accommodation (AC/A)  ratio. Depending on the underlying accommodative dysfunction, the ac/a ratio may be either low, normal, or high. The accommodative mechanisms can be subject to functional anomalies in maintaining visual clarity. Based on the Duke-Elder classification, these include: Accommodative insufficiency (AI). Accommodative spasm. Accommodative inertia. Ill-sustained accommodation. Accommodative infacility. AI is a functional vision anomaly characterized by the inability to sustain focus at near. With this condition, the accommodative response is often suboptimal compared to expected normal ranges.

Background: Mild traumatic brain injury (mTBI) is a prevalent neurological condition that results in various physical, emotional, and cognitive impairments. The most common are visual impairments, which affect vision's perceptual, motor, and sensory aspects. Objective: This paper analyzes the pathophysiology of mild traumatic brain injury (mTBI) and its effects on visual and oculomotor functions, focusing on the deficits of the accommodative system and their underlying mechanism. Findings: mTBI frequently causes diffuse axonal injury, resulting in abnormalities of the neurometabolic cascade that impact the brain's visual regions. Accommodative anomalies, including insufficiency, infacility, and spasm, are markedly more common in mTBI patients than in the general population. These deficiencies present as a notable delay in accommodation response, diminished peak velocity, and compromised dynamic responses, possibly due to sensory and motor disturbances. Conclusions: Accommodation disorder is a significant but under-examined component of visual sequelae related to mTBI. Future research should concentrate on the sensory and motor factors contributing to these deficiencies to enhance diagnostic precision and customize rehabilitative strategies.

We report improved symptoms in an adult patient with accommodation disorder and convergence spasm following a combination of in-clinic and at-home orthoptic therapies, including vergence training, non-prism spectacles to relax accommodation, cycloplegic eye drops, and anti-suppression exercises.

The human eye can see any object placed at a variable distance from it by altering its structure (by altering the anterior lens surface). This phenomenon is called accommodation. Accommodative dysfunction is a common vision disorder among the pediatric population with or without visual disturbance and binocular dysfunction. Accommodative dysfunction is either accommodative insufficiency or accommodative excess. Accommodative excess (AE) or excessive accommodation can be defined as a condition when the subject uses more accommodation effort or power than required for the stimulus at a particular distance or cannot relax the accommodation. Spasm of accommodation or accommodative spasm (AS) is defined as 'prolonged contraction of the ciliary muscle, most commonly causing pseudomyopia to varying degrees in both eyes by keeping the lens in a state of short-sightedness.'  AS falls in the spectrum of AE. AE is characterized by blurred vision at a distance, especially after prolonged near work, and difficulty refocusing from near to far. In the case of AS (also known as pseudomyopia), it always manifests. Headache, eye ache, and asthenopic symptoms are common in most cases.