These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. DOI: Demer JL. 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. 2005;89(10):1318-23. The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. 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. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. 2012;130:12801284. DRHartnett A Vectogram is a tool which utilizes specialized imaging along with the fusional vergence system to create a 3-D object. Stager DR, Sr, Black T, Felius J. ARKline 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. JJSavino Committee on Aging. Graefes Arch Clin Exp Ophthalmol. MEBarrows 13. Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. 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. 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). [unreliable source?] DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. 2016 May; 100(5): 648651. Reproduction in whole or in part without permission is prohibited. Goldberg Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. EHBilateral sixth-nerve paresis simulating divergence paralysis. Strabismus. This is the brain's answer to coping with double vision and the stress of eyes not working as a . Pang Y, Teitelbaum B, Krall J. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. THBird The aspect of divergence paralysis or divergence insufficiency is stated as esotropia or high esophoria at a distance with much lower esophoria or near to normal fixation. Her research interests include strabismus and binocular vision disorders. RJZee How is convergence insufficiency treated? Corresponding author: Daniel M. Jacobson, MD, Neuro-ophthalmology (4F-2), Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (email: jacobsod@mfldclin.edu). RLMagnetic resonance images in a case of "divergence paralysis.". 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. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. 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. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. Kerala J Ophthalmol. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. unable to diverge appropriately to a given target. With CI, the eyes do not point together inward as one looks at objects close-up. Thomson Many affected patients experience spontaneous resolution of double vision within several months. Convergence Insufficiency. FDDutton After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. To prevent double vision, the individual exerts extra effort to make the eyes turn back in. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. The tool itself can be calibrated to work on increasing divergence or convergence, depending on, Our eye doctors at Wilmington Family Eye Care in Wilmington, DE excel in prescription of glasses, contact lenses and the diagnosis of a variety of eye diseases. Keep moving to the next dot along the card, gradually getting closer to the nose. Reproduction in whole or in part without permission is prohibited. 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. The EOM angles in these patients ranged from 100 to . Abstract. Chaudhuri Z, Demer JL. Scheiman M, Cotter S, Rouse M, et al. ISOphthalmoplegia in cranial arteritis. SDiagnosis and management of divergence weakness in adults. 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. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. 12. 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. Optom Vis Sci. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. 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. 134. 5. Divergence insufficiency is the opposite problem of convergence insufficiency. Convergence Insufficiency Testing. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. the accommodative and vergence systems are tightly correlated. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. CHNuclear and infranuclear ocular motility disorders. ALDemer Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. While viewing the card, the patient reports what color line the black arrow is aligned with. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. One patient was followed up for only 1 month, but her esotropia resolved during that time. Double vision. Effectiveness of base in prism for presbyopes with convergence insufficiency. The main treatment for convergence insufficiency is vision therapy. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. 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. 2000;118(9):1237-41. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. 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. Tamler Divergence excess is an over-divergence when attempting to look at distant objects. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. Divergence Insufficiency. 3rd ed. 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). It is most often related to raised intracranial pressure or Chiari malformation. 126. 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. 2012;49(4):222-8. . 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). Chaudhuri Z, Demer JL. 2023 American Medical Association. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. On initial presentation, her best-corrected visual acuities were 20/40 OD and 20/25 OS. 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. It is spasm of the near triad: 1. 130. Most pertinent from a clinical point of view is the controversy surrounding whether divergence insufficiency is a distinct entity, or is a sign of subtle abducens nerve palsy. 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. 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. Head trauma 3. . if you would like to learn more about convergence and divergence insufficiency. What Are the Symptoms of Convergence Insufficiency? it is highly advisable that you check them out first as they cover basics not explained here. 126. A new prescription for prism lenses was dispensed to the patient at the follow-up examination. 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. It is a disorder involving binocular vision vision using both eyes. Customize your JAMA Network experience by selecting one or more topics from the list below. Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. In that study, strabismus surgery was performed in 50% of all SES cases. Between the polarizing glasses and the patients fusional vergence system, he or she will be asked to either converge or diverge to fuse the two partial images into one 3-D image. CI affects children and adults. FEDivergence paresis: a nonlocalizing cause of diplopia. 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. 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. 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. Long-term Surgical Outcomes in the Sagging Eye Syndrome. Arch Ophthalmol. 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. More advanced exercises for vergence insufficiencies include. Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. Success of prisms in the management of diplopia due to fourth nerve palsy. The first hurdle is ensuring your patient is comfortable with wearing spectacles. Each card contains a partial view of the complete image. Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. Individuals with convergence insufficiency often have a low AC/A ratio and a low near point of convergence. Chang MY et al. . 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. Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. Wiggins 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. JLSaccadic velocity analysis in patients with divergence paralysis. One study successfully treated 87 patients with divergence insufficiency between two and 18 prism diopters (PDs) with prism with none of the patients in the study requiring additional treatment or surgery.3 Another study found that 100% of patients with divergence insufficiency (30 patients) had success with prism.4. 2000;118(9):12371241. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. [1][5][8] The patients may also present with bilateral ptosis. Convergence Insufficiency Testing. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. Fusion prism is the minimum amount of prism needed to see a change from diplopia or suppression to normal binocular vision.12 To determine prism using this method, use the Worth Dot test to find a preliminary prism amount. Arch Ophthalmol. The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. Biousse V and Newman NJ. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. It is most often related to raised intracranial pressure or Chiari malformation. Define divergence insufficiency. SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). Sagging Eye Syndrome. 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. Primary divergence insufficiency is generally a benign condition. All Rights Reserved. Clin Exp Optom. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. 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. I still have mild double vision and . 132. 8. Arch Ophthalmol. The other patient with focal brainstem injury, a stroke with double vision, vertigo, and left arm numbness, did not have the responsible lesion identified by the CT. 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. 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 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. 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. Krohel NJeds, Leigh 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. Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. Prism is a powerful tool that can be used to successfully treat a variety of binocular vision conditions. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. Jacobson DM. Accordingly, I would recommend deferring consideration of strabismus surgery in this population for a sufficiently prolonged period of time to determine whether the esotropia might resolve spontaneously. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. Different cards with different images will require different amounts of negative and positive fusional vergence. Questions with answers: 125. The patient is also instructed to keep the words around the lines clear to control accommodation. Terms of Use| In the 2 patients with temporal arteritis, the rapid resolution of esotropia coincident with initiation of corticosteroid treatment, along with the development of posterior ischemic optic neuropathy in 1 case, point to ischemic injury of extraocular muscles as the cause of ophthalmoplegia. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. Br J Ophthalmol. Roper-Hall Clinical management of strabismus. 133. 2005;9:36. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. Increasing or decreasing the distance between the two cards 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. doi:10.1001/archopht.118.9.1237. [4]The pulleys inflect rectus and inferior oblique paths by the exact same way that the trochlea inflects the path of the superior oblique (SO) tendon. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . This page was last edited on January 26, 2023, at 08:42. 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. Other associated symptoms can include asthenopia of panoramic type. 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. Bothun ED, Archer SM. None of these patients developed signs of an underlying neurologic disorder during follow-up. In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. is variable. This association has been reported before, and has contributed to the controversy of whether divergence insufficiency represents a separate disorder or subtle sixth nerve palsy.14 Although the double vision reported in patients with pseudotumor cerebri is generally attributed to sixth cranial nerve palsy,27,28 I suspect that many symptomatic patients have divergence insufficiency, as suggested by Smith.29. This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence 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. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. 127. 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. Mosbys Optometric Problem Solving Series, ed. New York, NY Oxford University Press1999;405-610. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. American Journal of Ophthalmology, Volume 209, January 2020, Pages 55-61. Over a period of several months, the diplopia becomes more constant and is noticed while driving, watching television, and in other long-distance vision situations. These patients often present with horizontal and vertical deviations. 130. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. 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. This ocular misalignment has two main types: esotropia and exotropia. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. From there, basic vergence exercises will be added in. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass.
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