Smith 1. the accommodative and vergence systems are tightly correlated. A 5-year-old female initially presented for a strabismus and amblyopia evaluation. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and help make average daily distance tasks more manageable with less frequent symptoms. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. Of the 15 patients with secondary divergence insufficiency, an underlying neurologic or systemic disorder was either known or initially suspected in all based on the initial history and physical examination. NADivergence paralysis. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. Diagnosing convergence insufficiency J AAPOS. Reference: 1. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. It is an unusual form of strabismus with esotropia and diplopia only at distance and single binocular vision at near. Pencil pushups may be effective in some cases. A Maddox rod was also used to determine the near point of orthophoria in most patients. CI affects children and adults. All rights reserved. This is the brain's answer to coping with double vision and the stress of eyes not working as a . R. London. At the follow-up examination after nine weeks of patching and vision therapy for amblyopia, her visual acuities were equal in both eyes, and all testing showed normal correspondence. I prescribed glasses (+3.00 sph OD, +2.25 sph OS) for the patient, and she returned for follow-up care, eventually patching and undergoing vision therapy for her amblyopia. If a patient does not have good potential for sensory fusion, then the assistance that prism gives to the motor system wont allow for normal fusion, and it doesnt make sense to prescribe it. ACSanders Eye - Diplopia following cataract surgery . Primary divergence insufficiency is generally a benign condition. Patients presenting with a greater eso deviation at distance than at near, a concomitant deviation, and diplopia pose a challenging and critical diagnostic and therapeutic puzzle for . One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. Results: In high-myopia patients with divergence insufficiency, ocular axis measurements ranged from 24.8 to 31.0 (mean SD: 27.6 1.6) mm. Terms of Use| All Rights Reserved. Divergence insufficiency is the opposite problem of convergence insufficiency. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. 2012;130:12801284. Heavy Eye vs. If you can remember the old newspaper comics that had a green image with a red image overlying it that would turn into a 3-D image if you put on red/blue 3-D glassestranaglyphs are made similarly. 2005;89(10):1318-23. At the follow-up examination, she reported no diplopia in her glasses, and, eventually, she was able to see 250 seconds of arc RDS stereoacuity. In some circumstances, individuals with convergence insufficiency will also suffer from high exophoria or, In many cases, individuals with convergence insufficiency will notice that their symptoms worsen as they get tired or after attempting to do near tasks for a prolonged. American Journal of Ophthalmology, Volume 209, January 2020, Pages 55-61. EDivergence insufficiency: characteristics, diagnosis, and treatment. Rather, treatment for a secondary vertical deviation should aim to improve horizontal sensory and motor fusion through vision therapy so the patient is not in the strabismic position as often, thus eliminating the vertical deviation. Different cards with different images will require different amounts of negative and positive fusional vergence. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Convergence Insufficiency. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). PCBurian In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. J Neuroophthalmol. Patients with non-strabismic binocular vision disorderssuch as divergence insufficiency, basic esophoria and vertical heterophoriacan often benefit from treatment with prism, particularly relieving prism, while othersincluding those with convergence excess, convergence insufficiency, divergence excess or basic exophoriaare better managed with other treatment modalities, such as vision therapy or lenses.1 An option for prism patients is prescribing prism to relieve diplopia and asthenopia and concurrently having the patient do vision therapy to attempt to decrease or eliminate the amount of prism needed. Supported by One patient was followed up for only 1 month, but her esotropia resolved during that time. Patients in the study population shared the following symptoms: double vision when viewing distant objects, full-appearing ocular ductions, and esotropia identified during cover testing while fixing a distant target. 2014;18(4):309-15. If you have not read the previous portions of the vision therapy series it is highly advisable that you check them out first as they cover basics not explained here. This patient continued with vision therapy to help improve her sensory and motor fusion with the hope of eventually titrating down the amount of prism she wears. Common symptoms include: headaches; blurred vision ; double vision Tamler These questions are archived at https://neuro-ophthalmology.stanford.eduFollow https://twitter.com/NeuroOphthQandA to be notified of new neuro-ophthalmology questions of the week.Please send feedback, questions, and corrections to tcooper@stanford.edu. Individuals with convergence insufficiency often have a low AC/A ratio and a low near point of convergence. Define divergence insufficiency. Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. with a stereo image already pre-made onto the card. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. Intermittent convergence Always with accommodation and pupillary constrictionClassic causes of convergence spasm include the following: Most often nonorganic Excessive accommodation from uncorrected refractive error Lesions at the diencephalicmesencephalic junction (very rare)Convergence InsufficiencyConvergence insufficiency is a very common condition, characterized by the following: Exotropia greater at near than at distance (at least 10 prism diopters difference) Causes symptoms of asthenopia (fatigue with reading, diplopia at near, intermittent blurred vision when reading) Usually benign; may improve with orthoptic exercises Sometimes requires prisms in reading glasses or strabismus surgeryClassic causes of convergence insufficiency include the following: Idiopathic most often (in children or young adults) Head trauma Parkinson disease Progressive supranuclear palsyThe ability to converge can be measured (Fig. AJNR Am J Neuroradiol. of negative and positive fusional vergence. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. CHNuclear and infranuclear ocular motility disorders. Chaudhuri Z, Demer JL. Chaudhuri Z, Demer JL. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. Neuro-ophthalmology Illustrated-2nd Edition. They are low in cost and can be easily applied to a pair of spectacle lenses in-office to try out on a patient for several days or weeks, and refining the prism prescription is inexpensive and simple. MGeorge Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation Convergence insufficiency is an anomaly that causes the eye to under-converge at near. LRosenbaum Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. In fact, when the vergence system is struggling, the accommodative system often picks up the slack and becomes overworked, which can also play a role in some of the symptoms of eye strain, fatigue, and headaches. In addition, all patients underwent examination of ocular motility using a Maddox rod to demonstrate that the angle of uncrossed deviation increased as the viewing distance increased, remained the same or decreased in right and left gazes at distance, and decreased as the viewing distance decreased. Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). 2023 Stanford School of Medicine | Terms of Use | Barricks ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. MDavidoff Many patients were first evaluated within 1 month of the onset of symptoms, far sooner than the expected time course for the spread of comitance to convert a sixth cranial nerve palsy to a comitant esotropia. Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. Scheiman M, Wick B. The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. enlisted 100 patients without strabismus, and readers graded the LR-SR band visible in 95% of orbits on non-fat-suppressed coronal T1-weighted sequences, 68% on coronal STIR sequences. LDivergence insufficiency. Convergence Insufficiency Symptoms. Clin Exp Optom. Retrospective survey of patients with divergence insufficiency. This conclusion was recently confirmed by Wiggins and Baumgartner,22 who characterized a benign long-term prognosis in their cohort of patients with neurologically isolated divergence insufficiency. Since most of the patients have good fusional capacities they do not experience double vision for near with that said these patient can likely manage without the need for intervention. The most successful prism cases are often patients who have intermittent strabismus and good potential for normal fusion or patients with strabismus who have not developed any sensory anomalies. Bruce Prism is a powerful tool that can be used to successfully treat a variety of binocular vision conditions. Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. Prism in reading glasses or strabismus surgery may be required. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. 11. Tamhankar MA, Ying GS, Volpe NJ. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Stager DR, Sr, Black T, Felius J. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. Retrospective case reviews of patients with an acquired hyper deviation secondary to a superior oblique palsy found that 76% to 92% of participants were successfully treated with prism alone.5,6. The Apt Lecture. This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. What are the symptoms of Convergence Insufficiency? A near card is brought toward the patients nose until the patient sees double. doi:10.1136/bjophthalmol-2015-306783. Patients with divergence insufficiency may complain of intermittent double vision (diplopia) when looking at something in the distance, frequent "wandering" of the eyes, headaches, motion sickness, and eye fatigue that comes and goes and can vary from day-to-day depending on how tired the individual is. They include: double vision (diplopia) headaches blurry vision while reading squinting or closing one eye while reading words appearing to move around or float on the page while reading eyestrain or fatigue (asthenopia) FDDutton Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. The two prevalent hypotheses put forth so far include altered cerebrospinal fluid flow in the posterior cranial fossa, and involvement of the abducens nucleus or infranuclear portion. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. In some circumstances, individuals with convergence insufficiency will also suffer from high exophoria or exotropia, meaning the eyes like to sit in an outward position. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. RMTomsak use an approach called the SILO affect to work on increasing divergence or convergence ranges. If a patient sees four dots in free space or gives a diplopia response but is able to fuse with prism, perform a unilateral cover test. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). JLSharpe It is spasm of the near triad: 1. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. Fresnel membrane prisms can be very useful for many aspects of prescribing prism. Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. Home Vision Therapy Convergence Insufficiency Testing. This ocular misalignment has two main types: esotropia and exotropia. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. Abstract. Br J Ophthalmol. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. Customize your JAMA Network experience by selecting one or more topics from the list below. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. In 2005 Thacker NM et al. Effectiveness of base in prism for presbyopes with convergence insufficiency. When their medical records were reviewed at the time this study was being designed, I learned that they had since died of unrelated illnesses, so the course of their disorder could not be completely ascertained. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. The signs and symptoms with this condition are similar to convergence excess. The characteristics of the patients in this series who have an idiopathic disorder suggest that if certain rules of diagnosis are obeyed, divergence insufficiency can be distinguished from sixth cranial nerve palsy in most cases using clinical techniques. Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. On initial presentation, her best-corrected visual acuities were 20/40 OD and 20/25 OS. Blurred vision. Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. 2. If no movement is seen on the unilateral cover test, the patient has normal correspondence. 132. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. NJeds, Leigh . The opposite of divergence insufficiency is divergence excess. Divergence insufficiency esotropia (DIE), originally described by Duane in 1896, is an acquired condition characterized by an esodeviation that measures at least 10 prism diopters (PD) greater at distant rather than near fixation [].Patients with DIE complain about double vision at distance. None of these patients developed signs of an underlying neurologic disorder during follow-up. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. The LR-SR band vertically supports the LR pulley against the downward force of the inferior oblique muscle to maintain the LR pulleys vertical position. Demer JL. The following information was abstracted from the medical records: current medical history, past medical history, details of the ocular motor and general neurologic examinations, results of radiographic and laboratory tests, and long-term follow-up of those cases that were classified as idiopathic. It is idiopathic most often in children or young adults 2. The eyes deviate horizontally toward a cortical lesion, the eyes deviate horizontally away from a cortical seizure focus, and the eyes deviate horizontally away from a pontine lesion. Vertical Heterophoria. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. Histories reveal the possibility of a number of etiologic factors. Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency. Wall DIdiopathic intracranial hypertension: a prospective study of 50 patients. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. This page has been accessed 63,795 times. 2008;12(1):56. 2018 Jan 3:1-5. doi: 10.1080/09273972.2017.1421676. published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. What is divergence insufficiency? Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. Chang MY et al. GNCurrent concepts in giant cell (temporal) arteritis. Posted by . Sagging eye syndrome (SES) was first described by Rutar and Demer in 2009, as a potential leading cause of strabismus in older adult population as a combination of horizontal and vertical strabismus in addition to bilateral blepharoptosis (ptosis with high lid creases) and deepening of the sulcus. 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Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. Peripheral double pictures Usually double vision arises from a squint deviation of the eyes and is checked with a torch and a red glass before one eye to separate the pictures. 133. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. Near point convergence is the distance you can use both eyes without seeing double. . If the patient is still symptomatic, combining prism and vision therapy may help improve convergence and divergence ranges. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. Most trial lens sets come with prism lenses, but for larger angles of strabismus, it may be helpful to use a Fresnel prism trial set. It involves a specialty optical system and a uniquely created image book. Double vision. Privacy Policy| Since true paralysis of divergence generally cannot be documented in most affected patients,4 I prefer the term divergence insufficiency to describe this disorder, regardless of the severity of associated symptoms and signs. 13. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. Interestingly, they found that the relative proportion of SES was just 4.7% in patients younger than 50 years but it increased to 60.9% in patients older than 90. These studies were unrevealing in all patients. Effectiveness of prisms in relieving diplopia in superior oblique palsies. Although ophthalmoplegia associated with temporal arteritis has been rarely attributed to brainstem23 or ocular motor nerve injury,24 most cases are thought to result from extraocular muscle ischemia.25,26 The association of divergence insufficiency and temporal arteritis in these 2 cases emphasizes that the diagnostic signs of this ocular motor disturbance are not localizing and could occur in other disorders associated with local injury of extraocular muscles, such as myasthenia gravis, as was identified in 1 of the patients of Lepore.15, Divergence insufficiency was observed in 4 patients with pseudotumor cerebri.
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