133. 126. This page was last edited on January 26, 2023, at 08:42. PMDivergence paralysis. Interestingly, they found that the relative proportion of SES was just 4.7% in patients younger than 50 years but it increased to 60.9% in patients older than 90. Divergence fusion amplitudes were significantly larger in patients with secondary divergence insufficiency compared with those with primary divergence insufficiency, although there was considerable overlap of values between the 2 groups. Clin Exp Optom. 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 . This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. The patient places two transparent cards into the vectogram system. MThe child with divergence paresis. It is very a common condition where there is a comitant exotropia greater at near than at distance by at least 10 prism diopters. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. Divergence fusion amplitudes were significantly larger in patients with secondary divergence insufficiency compared with those with primary divergence insufficiency, although there was considerable overlap of values between the 2 groups. BBordaberry 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. Rutar T, Demer JL. 132. Committee on Aging. 132. Krohel RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. 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. What causes divergence insufficiency? Sagging Eye Syndrome. Rutkowski Chaudhuri Z, Demer JL. If the patient is only using one eyethe image will not be formed correctly. Theme, Congenital Ocular Motor Apraxia It affects young children. Defective or absence of voluntary horizontal saccades to visual stimuli: they cannot move their eyes horizontally to look at a target. Her research interests include strabismus and binocular vision disorders. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. Eight (40%) of the 20 patients recalled such an event, including a viral pro-drome in 3 patients, minor head trauma in 2 patients, and hospitalization for an unrelated illness in 3 pa-tients. REBaumgartner Biousse V and Newman NJ. If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. 2. 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. One patient was followed up for only 1 month, but her esotropia resolved during that time. The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. Individuals with convergence insufficiency often have a low AC/A ratio and a low near point of convergence. 2016 May; 100(5): 648651. Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. J AAPOS. Ductions and versions are full. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. 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. Distance esotropia in the elderly. Divergence insufficiency can vary in severity, from minor deficits to complete divergence paralysis. The first hurdle is ensuring your patient is comfortable with wearing spectacles. use an approach called the SILO affect to work on increasing divergence or convergence ranges. None of these patients developed signs of an underlying neurologic disorder during follow-up. Scheiman Convergence insufficiency is an anomaly that causes the eye to under-converge at near. 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. Effectiveness of prisms in relieving diplopia in superior oblique palsies. Sensory Anomalies. Other associated symptoms can include asthenopia of panoramic type. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. A 5-year-old female initially presented for a strabismus and amblyopia evaluation. Demer JL. 2023 American Medical Association. Strabismus. The EOM angles in these patients ranged from 100 to . What is convergence spasm? is fixed. Call our optometrists at 302-299-1286 or. . 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. Patients will be able to work on fusing the images of one. What is convergence insufficiency? Miller 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. How is convergence insufficiency treated? Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. CI affects children and adults. [3], from 945 patients complaining of double vision, majority of patients between 60 and 80 years, approx 31% had SES and were older, ~71 years old, with ~60% female predominance. It is most often related to raised intracranial pressure or Chiari malformation. 13.119). [5], There has been an increased awareness and diagnosis of these degenerative strabismic disorders after 2000. RDInternuclear ophthalmoplegia in giant cell arteritis. 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. Many affected patients experience spontaneous resolution of double vision within several months. 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. We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. How is convergence insufficiency treated? 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. Initial tenotomy 30% of tendon width was performed to avoid intraoperative overcorrection. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. Strabismus. Accessibility Statement, Our website uses cookies to enhance your experience. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. They had experienced double vision for 5 weeks, 5 months, and 6 months, respectively, up to the time of their last evaluation, but did not return for further follow-up. In the 17 patients with primary divergence insufficiency who had adequate information to ascertain long-term follow-up, double vision persisted in 9 individuals. LBSharpe Barricks 130. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. [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. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. [2] 2005;89(10):1318-23. 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. 20-20-20 Still Not Enough to Alleviate Eye Strain, Binocular Vision and Sports Concussions: A Bad Combo, Vision Impairment Increases Risk of Cardiovascular Disease, Monocular Eye Closure Common with Epiretinal Membrane. 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. Arch Ophthalmol. None of these patients developed signs of an underlying neurologic disorder during follow-up. ARKline 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. Br J Ophthalmol. 1993, Oxford, UK: Butterworth Heinemann Books. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations | Neurology | JAMA Ophthalmology | JAMA Network ObjectivesTo determine the natural history of primary divergence insufficiency and to identify clinical features that distinguish patients with this neurologica [Skip to Navigation] The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. 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. Sagging Eye Syndrome. highest quality optometry services and eye exams in Wilmington, Delaware and its surrounding areas. When patients are spectacle independent and want to remain independent, surgical approach could be offered. All patients with double vision routinely were assessed for the speed of saccades and for the presence of nystagmus to identify signs of abducens nerve palsy or internuclear ophthalmoplegia. Long-term Surgical Outcomes in the Sagging Eye Syndrome. It can also decrease distance judgement, coordination, and sports performance. 13.120). SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. LMDivergence paralysis with increased intracranial pressure: further observations. 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. reported a series of 57 patients underwent unilateral lateral rectus resection for distance esotropia deviations of 530 with 96.5% did not require further surgery.[11]. 2012. This means that in a vectogram the amount of convergence or divergence needed to fuse the image depends solely upon how far apart the two cards are held, i.e. 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. . I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. 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 . Vision suppression stops you from seeing double, but it doesn't fix the problem. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. J Neuroophthalmol. 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. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. This problem is most commonly found in children. [1]SES should be differentiated from heavy eye syndrome (HES) which is an association of axial high myopia, esotropia, and hypotropia. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. RMDiagnosis and management of divergence paresis. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. Antireflective coating is also beneficial for patients wearing prism lenses. Chamlin [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. Extraordinary symptoms equivalent to diplopia 2.3.1. She had been previously diagnosed with esotropia and amblyopia but was not currently wearing any correction. 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. If an intermittent horizontal strabismus patient has a primary vertical deviation, vertical prism may help improve their ability to fuse the horizontal deviation. Another historically reported feature of DI is significantly decreased negative fusional vergence (fusional divergence), along with the deficits direct relationship to distance of gaze. 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. Many affected patients experience spontaneous resolution of double vision within several months. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. 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 high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. To prevent double vision, the individual exerts extra effort to make the eyes turn back in. JSLevy The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying [5], In recent imaging studies, Patel et al. Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. None of the patients initially classified as having primary divergence insufficiency developed additional neurologic dysfunction during the period of follow-up. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. Ghanchi 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. Therapists can make this activity more advanced by increasing the amount the, changing the target) or by using multiple, and making the patient look from one to another, , however instead of there being two different transparent image, that need to be fused into one, there is one image. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. 131. 2012. Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. with a stereo image already pre-made onto the card. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. Although each method has its advantages and disadvantages, they all suffer from being subjective. It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. 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. Tamhankar MA, Ying GS, Volpe NJ. However, the cause of convergence insufficiency is often unknown. Convergence Insufficiency. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging.2, Vision therapy aims to decrease symptoms of vergence anomalies by increasing the compensating fusional vergence range (base-in for esophoria and base-out for exophoria). Long-term follow-up and clinical features of the 2 groups were compared. Lim A Maddox rod was also used to determine the near point of orthophoria in most patients. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. Arch Ophthalmol. Vertical Heterophoria. This means the eyes do not like to move inward toward the nose and is problematic when trying to look at a near target. 9. divergence insufficiency synonyms, divergence insufficiency pronunciation, divergence insufficiency translation, English dictionary definition of divergence insufficiency. FDDutton If the dot becomes doubled, go back to the previous dot and try again. The two prevalent hypotheses put forth so far include altered cerebrospinal fluid flow in the posterior cranial fossa, and involvement of the abducens nucleus or infranuclear portion. In that study, strabismus surgery was performed in 50% of all SES cases. Tamhankar MA, Ying GS, Volpe NJ. 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. 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. 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. Retrospective survey of patients with divergence insufficiency. 12. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). JLSaccadic velocity analysis in patients with divergence paralysis. The diverse conditions and sites of associated lesions of the patients with secondary divergence insufficiency in this series imply that secondary divergence insufficiency is not particularly localizing, nor is it necessarily specific for intracranial hypertension. 129. Goldberg 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. Actually it's not synonymous with divergence paralysis, but it is a separate clinical entity Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. Wiggins 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. 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. Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. 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. 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. Divergence excess is an over-divergence when attempting to look at distant objects. MBSavitsky 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. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. 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. The difficulty of training vertical vergence ranges along with the success in treating vertical deviations with prism make prism the most appropriate initial management tool in these patients. 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. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). What is the cause of convergence spasm? To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. Diagnosing convergence insufficiency What are the symptoms of Convergence Insufficiency? MEBarrows 5. 4. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. MCiner NRNewman . enlisted 100 patients without strabismus, and readers graded the LR-SR band visible in 95% of orbits on non-fat-suppressed coronal T1-weighted sequences, 68% on coronal STIR sequences. Fresnel membrane prisms can be very useful for many aspects of prescribing prism. 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. A secondary vertical deviation, on the other hand, presents when the patients eyes are strabismic but disappears when the patient aligns their eyes to the ortho position.7 Secondary vertical deviations are common in strabismic patients, particularly in those with intermittent exotropia. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients.