EJampolsky The distance at which diplopia occurs is noted (near point of convergence). NRNewman 2016 May; 100(5): 648651. After these patients are evaluated for any underlying systemic or neurological disease, which must always be ruled out in any case of new-onset strabismus, they are often good candidates for a prism prescription. 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). 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. When nonisolated, divergence insufficiency is most often reported in patients with intracranial hypertension, a neurologic condition often associated with sixth cranial nerve palsy.8,12-14,16 Some investigators have recorded slow abducting saccades in patients with signs consistent with divergence insufficiency, suggesting that abducens palsy was the cause of esotropia in these individuals.14 However, this finding has not been reproduced.11,17. characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . More advanced exercises for vergence insufficiencies include. 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. Only 2 patients were followed up for less than 6 months. To begin therapy, many therapists will focus first on normalizing the accommodative system. Motion sickness or dizziness ( vertigo) Headache . When prescribing ground-in prism, high index lenses, plastic frames and frames that are smaller in size help improve the weight and cosmesis of the lenses. 127. 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. The author has no commercial or proprietary interest in any product or company mentioned in this manuscript, and has no financial interest nor receives payment as a consultant, reviewer, or evaluator. Godts D, Mathysen DG. A Maddox rod was also used to determine the near point of orthophoria in most patients. 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. REBaumgartner This decreases the motor fusion demand, allowing the patient to fuse more comfortably. Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation 13. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. 133. Customize your JAMA Network experience by selecting one or more topics from the list below. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. the accommodative and vergence systems are tightly correlated. Otherwise, neuroimaging can be deferred in patients with neurologically isolated divergence insufficiency, although careful follow-up is indicated to identify developing suspicious neurologic symptoms or signs. 2016;28(1):38-42. The mechanical properties of pulleys are critical for the support and rotational properties of the eye. MThe child with divergence paresis. 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. Divergence insufficiency can also result in headaches, motion sickness and sensitivity to bright lights. 127. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. Committee on Aging. J AAPOS. J AAPOS. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . None of these patients underwent strabismus surgery. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. It was found that the mean distance-esotropia deviation in Prism was 6.9 0.7 and it resolved to 0.3 0.3 after surgery, while mean vertical deviation went from 3.0 0.3 to 0.7 0.2. 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. While none of the patients had other symptoms to suggest giant cell arteritis or myasthenia gravis, erythrocyte sedimentation rate (performed in 7 patients) and acetylcholine receptor antibody assay (performed in 6 patients) were tested, and the results were normal in all. Parkinson disease 4. Reproduction in whole or in part without permission is prohibited. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. HMDivergence paralysis following head trauma. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. Visual loss in pseudotumor cerebri: follow-up of 57 patients from five to 41 years and a profile of 14 patients with permanent severe visual loss. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. Near point of convergence (NPC) is measured by bringing an object to the nose and observing when the patient sees double, or one eye deviates . How is convergence insufficiency treated? will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. AJNR Am J Neuroradiol. It involves a specialty optical system and a uniquely created image book. Biousse V and Newman NJ. What is congenital ocular motor apraxia? In many of these cases, the initial management strategy is prescribing vertical prism.1 Often, if the vertical deviation is decreased or eliminated, the patient may be able to comfortably fuse the horizontal deviation. The mirror stereoscope is one of the most commonly used types. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. JLSaccadic velocity analysis in patients with divergence paralysis. NADivergence paralysis. Graefes Arch Clin Exp Ophthalmol. Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency. Reproduction in whole or in part without permission is prohibited. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. RJZee 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. Vision therapy uses various exercises to train the connection between the eyes and the brain as more than 50% of the brain is dedicated to visual function. Krohel RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . 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. 128. 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. One patient was followed up for only 1 month, but her esotropia resolved during that time. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. In spectacle-dependent patients, a temporary Fresnel prism or permanent ground in prism are usually helpful in managing the double vision for distance without inducing diplopia for near given their strong near fusional capacities as mentioned before. Stager DR, Sr, Black T, Felius J. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. She had been previously diagnosed with esotropia and amblyopia but was not currently wearing any correction. GBTobin The differential includes: It can be difficult to adjudicate small angle deviations such as HES and SES from mild myasthenia gravis, incompletely resolved sixth nerve palsy, thyroid eye disease, and decompensated prior phorias. 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. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. Demer JL. Vertical deviations often cause patients to experience significant symptoms even when the deviation is small. Chang MY, Pineles SL, Velez FG. For example, the right eye might see a lion while the left eye sees a cage. Due to the degenerative etiology of this syndrome, the connective tissue involution may progress after surgery, up to 20% of patients[15], therefore is important to inform the patient of this possibility prior to surgery. Call our optometrists at 302-299-1286 or. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. 2005;9:711. HS 2018 Jan 3:1-5. doi: 10.1080/09273972.2017.1421676. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. These patients often present with horizontal and vertical deviations. Since divergence is an active process, not a passive one associated with relaxation of the medial rectus muscles,5 some investigators hypothesize that a "divergence center" must exist. Drs. What is divergence insufficiency? 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. This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. Patients will be able to work on fusing the images of one card and move on to a more difficult card as their fusional vergence ranges expand. Sagging Eye Syndrome. 2012. an electromyographic study. 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. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. As a . Progressive supranuclear palsy. Success of prisms in the management of diplopia due to fourth nerve palsy. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. MEBarrows 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. Moore What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? LRosenbaum Objectives No clear sex predilection has been identified for the primary form of the condition. These exercises were discussed in detail in Part 6 of this series. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. 126. JSLevy RDDivergence paralysis. Wall 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. Lepore Schedule Appointment Our Doctors Contact UsAccepted Providers, Comprehensive Eye Exams Glasses Contact Lens Exams Dry Eye Emergency Care, 801 East Newport Pike, Wilmington, DE 19804 | (302) 999-1286, If you have not read the previous portions of the vision therapy. Esotropia resolved within days of initiating corticosteroid treatment in both patients. Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. 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. 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. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." The normal amount of fusional divergence ability at distance is lower than that of fusional convergence ability, making it challenging to sufficiently increase ranges to compensate for esophoria or esotropia at distance. Surgical effect was assessed immediately by sitting the patient up and repeating the measurements at near and distance. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. 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. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. Questions: 125. With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. Simultaneous injury of the medial longitudinal fasciculus has been postulated as another reason sixth cranial nerve palsy may appear comitant.4 However, none of the patients classified as primary had clinical signs of internuclear ophthalmoplegia. With a trial frame, she was not able to appreciate RDS stereoacuity in-office. Arch Ophthalmol. If no movement is seen on the unilateral cover test, the patient has normal correspondence. Patients with 20 to 30 PDs of exotropia should be left with 10 to 15 PDs of residual vergence demand, and patients with a vertical strabismus of 3 to 10 PDs should be left with 2 to 4 PDs of residual vergence demand.7 RVD is best used in patients who have vergence ranges that have been maximally trained through vision therapy but still need prism to maintain binocular vision in free space.12. p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 10.0px Sabon} p.p2 {margin: 0.0px 0.0px 0.0px 0.0px; text-indent: 10.0px; line-height: 12.0px; font: 10.0px Sabon} p.p3 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #867245; min-height: 12.0px} p.p4 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #b87c4c} p.p5 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #b37749} span.s1 {letter-spacing: -0.2px}. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. What are causes of convergence insufficiency? Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. 131. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. . In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. Bender 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. 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 period of time. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. In those patients with secondary divergence insufficiency, the underlying disorder was either already established or strongly suspected based on the additional neurologic symptoms and signs at their initial evaluation. More respect for connective tissues. 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 . it is highly advisable that you check them out first as they cover basics not explained here. All Rights Reserved. Methods: We investigated 20 cases of high myopia (>-6 D) with divergence insufficiency, 20 cases of high myopia without double vision, and 10 normal cases as controls. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, 2000;118(9):1237-1241. doi:10.1001/archopht.118.9.1237. Different cards with different images will require different amounts of negative and positive fusional vergence. Neena R, Giridhar A. Jampolsky Biousse V and Newman NJ. To increase convergence, the two cards will be pushed inward, making the image smaller (Small In for the SI in SILO). Lyle Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. Divergence excess is an over-divergence when attempting to look at distant objects. 2008;12(1):56. 632. LDivergence insufficiency. The exercises for divergence and convergence insufficiencies are very similar in structure, but fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. Other associated symptoms can include asthenopia of panoramic type. and asking the patient to converge or diverge will work on the focusing system and expand the eyes abilities to converge or divergehence helping with an insufficiency problem. Tranaglyphs are similar to vectograms, however instead of there being two different transparent image cards that need to be fused into one, there is one image card with a stereo image already pre-made onto the card.
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