Arch Ophthalmol. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. What is divergence insufficiency? 132. With a trial frame, she was not able to appreciate RDS stereoacuity in-office. Head trauma 3. This page has been accessed 63,795 times. divergence insufficiency synonyms, divergence insufficiency pronunciation, divergence insufficiency translation, English dictionary definition of divergence insufficiency. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. MGallaway The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. JAInman During the total period of follow-up, none of the patients developed an alternative neurologic disorder. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. Long-term follow-up and clinical features of the 2 groups were compared. JLSaccadic velocity analysis in patients with divergence paralysis. Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. 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. You can also use Random Dot Stereo (RDS) testing to determine fusion prism. RMDiagnosis and management of divergence paresis. As a . What is the cause of convergence spasm? Differentiating sagging eye syndrome (SES) from other causes of strabismus is not always a straight forward task given that patients with SES may have risk factors for strokes or tumors. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Lewis J AAPOS. [5], There has been an increased awareness and diagnosis of these degenerative strabismic disorders after 2000. Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. 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. The cyclotorsion component of SES was present in 65% of patients. Sometimes it is exacerbated by fatigue and improves with rest. Lepore 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). After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. [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). 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). While the size of divergence fusion amplitude was significantly larger in the group of patients with secondary disorders than in the primary group, the magnitude of this difference was small and the range of values between the 2 groups demonstrated considerable overlap (Table 1). Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. A Maddox rod was the tool used to assess ocular comitancy in this study, but other methods exist, including prism-cover techniques, the Hess chart, and the Lancaster red-green test. DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. 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. Instead, the initial history and physical examination proved to be powerful tools to distinguish those patients with a primary disorder from those with an underlying neurologic or systemic (ie, secondary) cause of divergence insufficiency. Parkinson disease 4. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. 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. Primary divergence insufficiency is generally a benign condition. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. https://www.aao.org/interview/heavy-eye-vs-sagging-eye-syndrome, https://www.aao.org/audio/sagging-eye-syndrome, https://doi.org/10.1016/j.ajo.2019.09.006, https://eyewiki.org/w/index.php?title=Sagging_Eye_Syndrome&oldid=89033, Results from bilateral inferior shift of the LR pulleys, Characterized by esotropia at distance fixation, orthotropia or esophoria at near fixation, Normal horizontal duction range and normal horizontal saccadic velocities, Results from asymmetrical inferior shift of the LR pulley, Characteristically by hypotropia and excyclotortion of the lower eye, ARDE only: incomitant esotropia worse in distance and in side gaze with no strabismus or small phoria for near and, ARDE and CVS: incomitant esotropia with a small hypotropia in one side, CVS only: hypotropia with no horizontal deviation, Normal horizontal duction range, and normal horizontal saccadic velocities, Cranial nerve palsy (Third, Fourth or Sixth nerves). The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. Divergence insufficiency is the opposite problem of convergence insufficiency. 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. Prism in reading glasses or strabismus surgery may be required. Reproduction in whole or in part without permission is prohibited. Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. 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). When patients are spectacle independent and want to remain independent, surgical approach could be offered. JWStockbridge 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. The distance at which diplopia occurs is noted (near point of convergence). NParalysis of divergence. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. Vertical deviations often cause patients to experience significant symptoms even when the deviation is small. The main treatment for convergence insufficiency is vision therapy. In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. 126. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. 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. Posted by . Other training exercises include base-out prisms for near viewing and convergence exercises. 2016 May; 100(5): 648651. When looking at the image on the card, patients will be required to use their fusional vergence system to fuse the red and green images into one 3-D image. 129. Long-term Surgical Outcomes in the Sagging Eye Syndrome. PCBurian Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. Typically, patients note that they do not have any diplopia at near. Results American Journal of Ophthalmology, Volume 209, January 2020, Pages 55-61. Near point convergence is the distance you can use both eyes without seeing double. This page was last edited on January 26, 2023, at 08:42. With the exception of the size of vertical fusion amplitude, ocular motor signs associated with divergence insufficiency did not distinguish patients with idiopathic from those with secondary disorders. MBSavitsky What is divergence insufficiency? One patient was followed up for only 1 month, but her esotropia resolved during that time. JAAcquired esotropia due to Arnold-Chiari I malformation. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. No clear sex predilection has been identified for the primary form of the condition. Corbett What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? You can schedule your next appointment with us online! SDiagnosis and management of divergence weakness in adults. 131. LDivergence insufficiency. 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. She had been previously diagnosed with esotropia and amblyopia but was not currently wearing any correction. It is usually benign. Since most of the patients have good fusional capacities they do not experience double vision for near with that said these patient can likely manage without the need for intervention. Scheiman M, Wick B. I prescribed glasses (+3.00 sph OD, +2.25 sph OS) for the patient, and she returned for follow-up care, eventually patching and undergoing vision therapy for her amblyopia. . 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]. 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. J AAPOS. Customize your JAMA Network experience by selecting one or more topics from the list below. CI affects children and adults. Actually it's not synonymous with divergence paralysis, but it is a separate clinical entity None of these patients developed signs of an underlying neurologic disorder during follow-up. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. Sagging Eye Syndrome. With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. 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. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. MCiner ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. 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. Introduction. What is convergence insufficiency? Near point of convergence test: This test will . People notice symptoms while reading or doing other near work. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. Initial tenotomy 30% of tendon width was performed to avoid intraoperative overcorrection. 2013;97(11):1415-9. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. Reproduction in whole or in part without permission is prohibited. 2005;89(10):1318-23. Accessibility Statement, Our website uses cookies to enhance your experience. Diagnosing convergence insufficiency 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. 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. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. To begin therapy, many therapists will focus first on normalizing the accommodative system. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. Tamler 133. SHarbison Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. Caloroso E, Rouse MW. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. 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. Prism is a powerful tool that can be used to successfully treat a variety of binocular vision conditions. 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 . Methods The patient places two transparent cards into the vectogram system. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). Most trial lens sets come with prism lenses, but for larger angles of strabismus, it may be helpful to use a Fresnel prism trial set. "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. How is convergence insufficiency treated? PMDivergence paralysis. Histories reveal the possibility of a number of etiologic factors. Chaudhuri Z, Demer JL. None of these patients underwent strabismus surgery. Clinical management of strabismus. 13.119). Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. Prism prescriptions often greatly improve the quality of life of your patients by reducing asthenopia and diplopia. Weird vision divergence upon waking at night User Name: Remember Me: Password . 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. 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. Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. American Academy of Ophthalmology. Many affected patients experience spontaneous resolution of double vision within several months. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. 2012;95(2):192-7. A Maddox rod was also used to determine the near point of orthophoria in most patients. Lateral rectus resections in divergence palsy: Results of long-term follow-up. The Apt Lecture. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. 632. Keep moving to the next dot along the card, gradually getting closer to the nose. What are causes of convergence insufficiency? DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Wall Biousse V and Newman NJ. Neena R, Giridhar A. Cunningham 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. 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. 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. Hold focus on this dot for 10 seconds. 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. All Rights Reserved. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. 2018 Jan 3:1-5. doi: 10.1080/09273972.2017.1421676. [unreliable source?] 127. ACSanders Their symptom was controlled using prisms. NADivergence paralysis. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. Another method used for prescribing for patients with intermittent strabismus, particularly for those who have difficulty with fusion in free space, is Calorosos Residual Vergence Demand (RVD).7 RVD criteria look at the direction and size of the deviation and determine how much residual vergence demand the patient should have after prescribing relieving prism. 9. All rights reserved. Moore DBGlaser Eye - Diplopia following cataract surgery . Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. 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.

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