Reference: 1. How is convergence insufficiency treated? Chaudhuri Z, Demer JL. Again it seems unlikely, since CTs performed in 2 patients and an MRI performed in 1 were normal, and signs of divergence insufficiency were improving in 2 of these patients at the time of their last evaluation. . Biousse V and Newman NJ. 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. 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. Jacobson DM. 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. 2008;126(10):1336-49. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Strabismus. Patients and methods. 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. 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. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). 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. The most effective treatment for this condition is office-based vision therapy, but prism can be considered in patients who are unable to undergo this treatment modality.1,8 A study did not find a significant difference in the signs or symptoms of children with convergence insufficiency who wore base-in prism compared with children who wore placebo lenses.9 Although prism has not been shown to be beneficial in children with this condition, adult presbyopic patients with convergence insufficiency may benefit from prism treatment.10,11. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. 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. Tamhankar MA, Ying GS, Volpe NJ. How is convergence insufficiency treated? 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. Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. 12. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. et al. 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. For example, many investigators propose criteria to differentiate divergence insufficiency from divergence paralysis or paresis.1-3 However these arbitrarily defined criteria more likely describe varying severity of symptoms and ocular motor signs along a continuum of the same condition. I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. Ghanchi From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. With CI, the eyes do not point together inward as one looks at objects close-up. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. changing the target) or by using multiple vectograms and making the patient look from one to another and quickly adapting the vergence system appropriately to each target (this is called jumping vectograms). A Maddox rod was also used to determine the near point of orthophoria in most patients. PCBurian 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. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Divergence excess is an over-divergence when attempting to look at distant objects. Divergence insufficiency is a benign phenomenon causing horizontal diplopia at distance viewing . Roughly half of the patients experienced spontaneous resolution of diplopia after several months. Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. 130. Clinical uses of prism: a spectrum of applications. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. The procedure is performed under topical anesthesia in the presence of an anesthesiologist. The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. 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. created image book. Prism can be a powerful treatment for many conditions and for many patients, specifically for those who suffer from asthenopia or diplopia. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. THBird 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. GBurde JJSavino 1978;76:610-53. 131. JWStockbridge LMDivergence paralysis with increased intracranial pressure: further observations. What is the cause of convergence spasm? 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. Classically convergence spasm is nonorganic. All but 1 patient were older than 50 years. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. What is the cause of convergence spasm? Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. Success of prisms in the management of diplopia due to fourth nerve palsy. Caloroso E, Rouse MW. Lateral rectus resections in divergence palsy: Results of long-term follow-up. American Journal of Ophthalmology, Volume 209, January 2020, Pages 55-61. [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). 2012;130:12801284. Long-term follow-up and clinical features of the 2 groups were compared. Long-term Surgical Outcomes in the Sagging Eye Syndrome. 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. Lim HS 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. Connective tissues reflect different mechanisms of strabismus over the life span. Privacy Policy| It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. Primary divergence insufficiency is generally a benign condition. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. Conclusions Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. While patients with strabismus often benefit from prism wear, it is important to first determine whether a strabismic patient is fit for treatment with prism by evaluating their potential for sensory fusion and whether the addition of prism will improve their sensory fusion status. 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. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. Cotter SA. it is highly advisable that you check them out first as they cover basics not explained here. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. Their symptom was controlled using prisms. On initial presentation, her best-corrected visual acuities were 20/40 OD and 20/25 OS. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. It is usually benign. Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task is variable. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. LDivergence insufficiency. She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. This problem is most commonly found in children. In many individuals with, Normalizing accommodation is important because. 133. NJeds, Leigh 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. Divergence excess is an over-divergence when attempting to look at distant objects. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. 1. Prism in reading glasses or strabismus surgery may be required. No such signs were identified in any of the patients in this series. Esodeviation is comitant in all fields of . It is very a common condition where there is a comitant exotropia greater at near than at distance by at least 10 prism diopters. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. Divergence insufficiency is the opposite problem of convergence insufficiency. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. It involves a specialty optical system and a uniquely created image book. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. Motion sickness or dizziness ( vertigo) Headache . Bender [10] In 2013, Stager et al. This ocular misalignment has two main types: esotropia and exotropia. What is convergence insufficiency? Theme. MThe child with divergence paresis. J AAPOS. Retrospective survey of patients with divergence insufficiency. 1. A new prescription for prism lenses was dispensed to the patient at the follow-up examination. Six patients underwent CT and 10 underwent MRI. The distance at which diplopia occurs is noted (near point of convergence). 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. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. Esotropia resolved within days of initiating corticosteroid treatment in both patients. It is a disorder involving binocular vision vision using both eyes. 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 this example, the patient will be asked to either relax his or her eyes to put the lion in the cage (diverge) or stimulate his or her eyes to put the lion in the cage (converge). 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. You can schedule your next appointment with us online! Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. RJZee Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. By continuing to use our site, or clicking "Continue," you are agreeing to our, Clinical Features of Patients With Primary and Secondary Divergence Insufficiency, Disorders Associated With Secondary Divergence Insufficiency. Unfortunately, since the ocular ductions appear full in a patient with suspected divergence insufficiency, objective means to assess the state of ocular comitancy do not exist for office determination. 632. 2012;49(4):222-8. GMOcular divergence: its physiology and pathology. All rights reserved. the accommodative and vergence systems are tightly correlated. 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. Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. 2016 May; 100(5): 648651. When you try to focus on something close to your eyes, you may have: Tired eyes. The Apt Lecture. Strabismus. On the other hand, it remains possible that these events were casual and not pathogenetically important. 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. Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency. 9. 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 each method has its advantages and disadvantages, they all suffer from being subjective. 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. The patient places two transparent cards into the vectogram system. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. J AAPOS. Primary divergence insufficiency is generally a benign condition. Adnexal signs such as: retraction of the upper eyelid into the superior orbit (superior sulcus deepening), aponeurotic blepharoptosis, floppy lower lids, and high upper eyelid crease. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. 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. None of these patients developed signs of an underlying neurologic disorder during follow-up. 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. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. Recent trauma Biousse V and Newman NJ. JLSaccadic velocity analysis in patients with divergence paralysis. Schanzer While viewing the card, the patient reports what color line the black arrow is aligned with. Bedrossian Duane A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. Supported by The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Eight (40%) of the 20 patients recalled such an event, including a viral prodrome in 3 patients, minor head trauma in 2 patients, and hospitalization for an unrelated illness in 3 patients. A recent review in January 2020 supported the evidence that when the symptoms of diplopia are burdensome to the patient, surgery is the only treatment that can eliminate the misalignment almost 100%. Wednesday, March 15, 2023 | All Eyes On Evaporation, Thursday, April 13, 2023 | All Eyes On Evaporation, Tuesday, April 18, 2023 | All Eyes On Evaporation. 2018 Jan 3:1-5. doi: 10.1080/09273972.2017.1421676. 2012. MDavidoff Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. Neuro-ophthalmology Illustrated-2nd Edition. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. 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. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. Arch Ophthalmol. Reproduction in whole or in part without permission is prohibited. . I still have mild double vision and . Krohel Committee on Aging. Bothun and Archer reported a series of 8 patients who underwent bilateral medial rectus recessions for distance esotropias of 1235; 5 patients had satisfactory results with collapse of the distance-near deviation from 15 pre-operatively to 5 postoperatively.