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. What is congenital ocular motor apraxia? Convergence Insufficiency Symptoms. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? 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. FEDivergence paresis: a nonlocalizing cause of diplopia. Histologic studies showed that each rectus pulley consists of an encircling ring of collagen located near the globe equator in tenon fascia, coupled to the orbital wall, adjacent EOMs, and equatorial Tenon fascia by bands containing densely woven collagen, elastin, and smooth muscle. What is the cause of convergence spasm? With exercises that adapt to each patient and their specific needs, it is an ideal solution for problems such as lazy eye, strabismus, convergence insufficiency, double vision, or other binocular problems. The use of topical anaesthesia does not abolish this surgical risk. Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). To begin therapy, many therapists will focus first on normalizing the accommodative system. Patel SH, Cunnane ME, Juliano AF, Vangel MG, Kazlas MA, Moonis G. Imaging appearance of the lateral rectus-superior rectus band in 100 consecutive patients without strabismus. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. Extraordinary symptoms equivalent to diplopia 2.3.1. The cyclotorsion component of SES was present in 65% of patients. He usually volunteers the infor mation that he has no trouble in reading or close use of his eyes. [5], MRI measurements of horizontal EOM lengths in SES were approximately 40%, or 14 mm, longer than the EOMs of nonstrabismic younger and older controls. Reproduction in whole or in part without permission is prohibited. PMDivergence paralysis. Miller 2011;31(3):206-9. Convergence Insufficiency. "The term divergence insufficiency implies a problem at the level of the brainstem, suggesting that there is decreased neural output to the extraocular muscles," said Prem S. Subramanian, MD, PhD, at the University of Colorado in Aurora. 1995, St. Louis, Missouri: Mosby. Results from this study also supported previously published evidence of normal age-related connective tissue degeneration as there was a positive age effect in correlation to supero-temporal bowing of the LR-SR band.[9]. Similarly, the theories on mechanism of divergence itself have varied. The remainder of the neurological examination should be normal, without any cranial neuropathies. However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. In support of that hypothesis, some investigators have reported clinical-radiographic and clinical-pathologic correlations of patients with divergence insufficiency associated with focal lesions, usually of the pons and midbrain,7-10 but also in other locations, such as the craniovertebral junction.8,11 On the other hand, patients with divergence insufficiency and a variety of diffuse brain injuries have also been described.8,12-15 The site of this elusive region, if in fact such a region exists, remains undefined. 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 . Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. Stager DR, Sr, Black T, Felius J. EDivergence insufficiency: characteristics, diagnosis, and treatment. 632. Convergence Insufficiency Testing. Duane 2008;12(1):56. PJThompson In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. The distance at which diplopia occurs is noted (near point of convergence). JSLevy Of the 20 patients with primary divergence insufficiency, there were 10 women and 10 men, ranging in age from 24 to 90 years, with a median (mean) age of 74 (70) years. 2009;86(2):153-6. NParalysis of divergence. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. 5. 2016 May; 100(5): 648651. Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. 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. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre, 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 glasses, In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees, Different cards with different images will require different amount. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Br J Ophthalmol. Arch Ophthalmol. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. make average daily distance tasks more manageable with less frequent symptoms. A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. In the meantime, temporary paste-on and, if stable for several weeks, permanent ground-in prisms, were effective and conservative means of relieving symptoms in these patients. 2013;97(11):1415-9. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. This page has been accessed 63,795 times. 3. It is also possible that the 3 patients who died and did not undergo long-term follow-up had some unsuspected neurologic disorder at the time they were evaluated. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. From a practical point of view, it seems reasonable to defer further investigation, including neuroimaging, in an affected patient who has no other neurologic or systemic symptoms or signs. If the patient gives a fusion response with or without prism but movement on the unilateral cover test is seen, then anomalous correspondence is suspected and relieving or corrective prism is not an appropriate management option. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. In that study, strabismus surgery was performed in 50% of all SES cases. Results This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. Questions with answers: 125. Arch Ophthalmol. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. IRT. Prescribing relieving prism for horizontal, non-strabismic, binocular vision disorders can be done by calculating Sheards or Percivals criteria by using clinical data or analyzing fixation disparity and determining the associated phoria.1 At near, fixation disparity and the associated phoria can be found with a Wesson card. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. Although prescribing it can seem intimidating at first, with practice and a bit of trial and error, you can perfect your ability to prescribe prism for your patients in no time. Scheiman Dr. Jenewein is an assistant professor at Salus University, Salus Universitys Principal Site Investigator for the Pediatric Eye Disease Investigator Group, a Fellow of the American Academy of Optometry and a Diplomate of the Binocular Vision, Perception and Pediatric Optometry Section of the Academy. Teitelbaum B, Pang Y, Krall J. Home Vision Therapy Convergence Insufficiency Testing. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. Near point convergence is the distance you can use both eyes without seeing double. 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. Chaudhuri Z, Demer JL. Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. Biousse V and Newman NJ. It is most often related to raised intracranial pressure or Chiari malformation. I doubt that assessment of the size of vertical fusion amplitude would be a helpful discriminating tool, however, since the size of it was small in most patients in both groups, it was measured using a subjective end point, and there was considerable overlap of values. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). 127. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. DOI: Demer JL. Demer JL et al. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. [12]Later Chaudhuri and Demer reported 24 patients and compared the results of those undergoing lateral rectus resection (n = 8) to those undergoing medial rectus recession (n = 16). Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. Patients and methods. If the dot becomes doubled, go back to the previous dot and try again. SHarbison Chaudhuri Z, Demer JL. Chaudhuri Z, Demer JL. REBaumgartner Mosbys Optometric Problem Solving Series, ed. 2023 American Medical Association. Actually it's not synonymous with divergence paralysis, but it is a separate clinical entity 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. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. Our eye doctors. We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. The EOM angles in these patients ranged from 100 to . Heavy Eye vs. 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. Intravenous edrophonium chloride testing was performed in 2 patients because of the referring physician's concern about the possibility of myasthenia gravis despite the absence of other symptoms or signs of this condition, but the test did not resolve double vision or reduce the amount of esotropia. Scheiman M, Wick B. It can also decrease distance judgement, coordination, and sports performance. RDInternuclear ophthalmoplegia in giant cell arteritis. Some patients report double pictures, but when checked with the torch, only one light is seen. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. . Questions: 125. reported a case series of 9 patients with vertical strabismus incomitant in horizontal gaze positions and cyclotorsion who underwent Adjustable small-incision selective tenotomy and plication. CHNuclear and infranuclear ocular motility disorders. Common symptoms include: headaches; blurred vision ; double vision 6. Patients with primary divergence insufficiency were those who had no other neurologic symptoms or signs, and patients with secondary divergence insufficiency were those who had additional symptoms or signs of neurologic dysfunction. Parkinson disease 4. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. None of the patients initially classified as having primary divergence insufficiency developed additional neurologic dysfunction during the period of follow-up. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. AmblyoPlay is a vision therapy solution that is performed through playing therapeutic games and exercises on your tablet or computer for 30 minutes per day. doi:10.1136/bjophthalmol-2015-306783. EJampolsky Eye - Diplopia following cataract surgery . Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. 128. Of the 15 patients with secondary divergence insufficiency, there were 11 women and 4 men, ranging in age from 8 to 86 years, with a median (mean) age of 56 (51) years. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." If the patient is still symptomatic, combining prism and vision therapy may help improve convergence and divergence ranges. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. Pang Y, Teitelbaum B, Krall J. 134. 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. Arch Ophthalmol. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. Information obtained from direct telephone interviews with the patients and review of office records of referring physicians who continued to follow up some patients were included in the determination of follow-up. Although each method has its advantages and disadvantages, they all suffer from being subjective. Initial tenotomy 30% of tendon width was performed to avoid intraoperative overcorrection. 130. MBSavitsky How is convergence insufficiency treated? Magnetic resonance imaging resolution showed superotemporal bowing of the LR-SR band in milder cases and abrupt termination of an attenuated band remnant in the superolateral orbit in more severe cases. What is convergence insufficiency? Using the Mann-Whitney test, there was no significant difference in the size of esotropia in forward gaze at distance or near point of fusion between the groups of patients with primary and secondary divergence insufficiency (Table 1). It involves a specialty optical system and a uniquely created image book. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. ISOphthalmoplegia in cranial arteritis. RMTomsak The results of CT or magnetic resonance imaging (MRI), available at the time of initial evaluation, were not initially considered since one of the aims of this study was to identify clinical features that might be helpful in predicting which patient was harboring a neurologic disorder. Bender Rutar T, Demer JL. It is an unusual form of strabismus with esotropia and diplopia only at distance and single binocular vision at near. These arguments do not preclude the possibility that some patients with comitant esotropia at distance and full-appearing ocular ductions might be suffering from sixth cranial nerve palsy, not divergence insufficiency. In the remaining 17 patients who were still alive, the total duration of follow-up extended from 1 month to 16 years (median, 35 months). 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. Convergence describes the way our eyes move together and point inward when we look at near objects. Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. Double vision is a troublesome complication of otherwise successful cataract surgery. Certain factors are associated with exotropia, including genetics and health conditions. 13.120). 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. Divergence excess is an over-divergence when attempting to look at distant objects. For example, the right eye might see a lion while the left eye sees a cage. An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. Lewis Keep moving to the next dot along the card, gradually getting closer to the nose. Although small amounts of vertical prism can be prescribed in contact lenses, patients who need prism usually have to wear it on a spectacle lens. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. Wiggins 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. They concluded that medial rectus recession is as effective as lateral rectus resection and suggested that double the distance angle of esotropia should be used as the surgical target. Prism in reading glasses or strabismus surgery may be required. These patients often present with horizontal and vertical deviations. 2012;95(2):192-7. No signs of orbital ischemia were present in the second patient. Symptoms of vergence disorders occur only under binocular viewing conditions and may include eyestrain, double vision and headaches.4,7,9,10,15 Interventions: Vision Training Many TBI patients respond well to efforts to improve vision, cope with impairment, or both. With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. 2000;118(9):12371241. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. However, it seems unlikely, since divergence insufficiency resolved in all 4 patients and no other neurologic problems developed during the time of each patient's follow-up of 1 month, 5.5 months, 34 months, and 44 months, respectively. as their fusional vergence ranges expand. Divergence insufficiency was also observed in 2 patients, each with idiopathic cerebellar degeneration and progressive supranuclear palsy, an association that is generally not recognized in either condition.30 This did not cause clinical confusion, however, since divergence insufficiency was overshadowed in each patient by the cardinal signs that characterized their underlying neurologic conditions. Demer JL. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. These studies were unrevealing in all patients. [10] In 2013, Stager et al. 2023 Stanford School of Medicine | Terms of Use | This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. Tamhankar MA, Ying GS, Volpe NJ. [2] ARKline Also found significant displacement of all four rectus pulleys away from the orbital center, lateral displacement of the inferior rectus pulley and obliquely angulated lateral rectus pulley. This problem is most commonly found in children. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. To determine the natural history of primary divergence insufficiency and to identify clinical features that distinguish patients with this neurologically isolated form of divergence insufficiency from those harboring neurologic disorders. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. Different cards with different images will require different amounts of negative and positive fusional vergence. Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. Progressive supranuclear palsy. 1993, Oxford, UK: Butterworth Heinemann Books. Many affected patients experience spontaneous resolution of double vision within several months. To begin therapy, many therapists will focus first on normalizing the accommodative system. 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) Neena R, Giridhar A. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. The patient with a metastatic lesion of the midbrain additionally had skew deviation, an afferent pupillary defect without visual loss, and other signs of brainstem injury, but no symptoms or signs of intracranial hypertension. A similar technique is used for rehabilitation: the patient is instructed to do push-up exercises (looking at an object intermittently moved in and out from the bridge of the nose) daily at home to decrease the near point of convergence.Divergence InsufficiencyDivergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Ductions and versions are full. It is most often related to raised intracranial pressure or Chiari malformation.Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation Head trauma Intracranial hypotension (low CSF pressure syndrome) Cerebellar lesions Midbrain massAbnormal Horizontal Conjugate DeviationsGaze deviations are relatively common in large cerebral and pontine lesions (Fig. Bothun ED, Archer SM. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. 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. Treatment options include correction with base-out prisms for distance, Tomasz A. Wiraszka, MD, and Praveena Gupta, OD, PhD, FAAO, Galveston, Texas, April 2015 Wills Eye Resident Case Series, Wills Eye Resident Case Series - Diagnosis and Discussion, November 2014 Wills Eye Resident Case Series, February 2016 Wills Eye Resident Case Series - Diagnosis & Discussion. The patient will wear a pair of polarizing glasses (similar to what is worn in modern 3-D movies) to create depth within the image (stereopsis). Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. While viewing the card, the patient reports what color line the black arrow is aligned with. Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. LRosenbaum Objectives The additional literature on the subject of divergence insufficiency largely consists of small series of patients mainly reported in the precomputed tomography (CT) era and patients with neurologically isolated divergence insufficiency mixed with those who additionally had other signs of intracranial hypertension or a structural brain lesion.15,18-21 The purpose of my study was to describe a large series of patients with divergence insufficiency evaluated in the post-CT era to determine the natural history of neurologically isolated cases, to determine the spectrum of neurologic associations, and to identify clinical features that might be helpful in distinguishing those patients with an isolated disorder from those harboring neurologic disorders. Although no unsuspected neurologic disorder surfaced during the period of follow-up in these patients, I strongly recommend that a patient with isolated divergence insufficiency be followed closely to detect, for example, signs of developing intracranial hypertension or abducens nerve palsy.
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