Divergence insufficiency revisited: natural history of idiopathic cases and neurologic associations. They concluded that medial rectus recession is as effective as lateral rectus resection and suggested that double the distance angle of esotropia should be used as the surgical target. Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. It is possible that with longer follow-up, the number of patients with resolution of diplopia might increase.
What is Convergence Insufficiency? Symptoms, Treatments - Healthline Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. 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. What is the cause of convergence spasm? MCiner
Common symptoms include: headaches; blurred vision ; double vision Fresnel prism, however, degrades visual acuity and contrast sensitivity, and some patients may not find it cosmetically appealing.12 A significant decrease in visual acuity through the Fresnel lens can be seen at larger prism powers, particularly at those greater than 12 PDs.13 When trialing Fresnel prism, it is advisable to only place the Fresnel over one eye so that the patient retains good binocular visual acuity with the prism in place. 13.121). 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. Actually it's not synonymous with divergence paralysis, but it is a separate clinical entity METraviesa
Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. This conclusion was recently confirmed by Wiggins and Baumgartner,22 who characterized a benign long-term prognosis in their cohort of patients with neurologically isolated divergence insufficiency. 2000;118(9):1237-41. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. The opposite of divergence insufficiency is divergence excess. 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. 126. 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. MThe child with divergence paresis. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. American Academy of Ophthalmology. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. Tamhankar MA, Ying GS, Volpe NJ. 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. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . 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. 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.
Comparison of surgical dose response between divergence insufficiency JLSharpe
Once this can be repeated multiple times, the amount of required divergence or convergence can be increased, thus expanding the vergence range and strengthening the problem area. J Pediatr Ophthalmol Strabismus. Corresponding author: Daniel M. Jacobson, MD, Neuro-ophthalmology (4F-2), Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (email: jacobsod@mfldclin.edu). 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. With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. MGallaway
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. More advanced exercises for vergence insufficiencies include. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. Tamhankar MA, Ying GS, Volpe NJ. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. Although cosmesis can be an issue with prism glasses, educating your patients on proper frame and lens selection will help them choose a frame and lens combination for the best cosmetic outcome. Godts D, Mathysen DG. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. 632. 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. 131. Krohel
will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. 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. AParalysis of divergence. Bedrossian
People notice symptoms while reading or doing other near work. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). 2011;31(3):206-9. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. Information obtained from direct telephone interviews with the patients and review of office records of referring physicians who continued to follow up some patients were included in the determination of follow-up. In 2005 Thacker NM et al. an electromyographic study. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. Of note among this cohort of patients without strabismus, noncontinuous LR-SR bands were found in 5% of cases, and superotemporal bowing in 24% of cases. RDInternuclear ophthalmoplegia in giant cell arteritis. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." 5. . [2] 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. Patients with non-strabismic binocular vision disorderssuch as divergence insufficiency, basic esophoria and vertical heterophoriacan often benefit from treatment with prism, particularly relieving prism, while othersincluding those with convergence excess, convergence insufficiency, divergence excess or basic exophoriaare better managed with other treatment modalities, such as vision therapy or lenses.1 An option for prism patients is prescribing prism to relieve diplopia and asthenopia and concurrently having the patient do vision therapy to attempt to decrease or eliminate the amount of prism needed. With a trial frame, she was not able to appreciate RDS stereoacuity in-office. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively.
Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. doi:10.1136/bjophthalmol-2015-306783. Lepore
The patients with primary divergence insufficiency in this retrospective survey were most often middle-aged or elderly persons with neurologically isolated double vision for distance who, not uncommonly, developed symptoms following a nonspecific illness or minor head trauma. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. Miller
Her research interests include strabismus and binocular vision disorders. It is spasm of the near triad: 1. Clin Exp Optom. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. 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. .
Vergence - Wikipedia Divergence insufficiency - definition of divergence insufficiency by make average daily distance tasks more manageable with less frequent symptoms. 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. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. 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. 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. LDivergence insufficiency. Chaudhuri Z, Demer JL.
Neuro-ophthalmology Illustrated Chapter 13 Diplopia 10 - Convergence Objectives
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. Divergence insufficiency is a benign phenomenon causing horizontal diplopia at distance viewing . Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. The orbital layer, inserts on the pulley, not on the globe. 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. JLSaccadic velocity analysis in patients with divergence paralysis. [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. J Neuroophthalmol. Eye - Diplopia following cataract surgery . Prism prescriptions often greatly improve the quality of life of your patients by reducing asthenopia and diplopia. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. 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. 131. Convergence Insufficiency. If your patient is still experiencing diplopia, additional prism may be needed to help them achieve fusion. Demer JL et al. No such signs were identified in any of the patients in this series. DOI: Demer JL. This page has been accessed 63,795 times. In those patients without an established disorder, additional clinical clues indicated the need for neuroimaging or additional diagnostic studies, independent of the signs of divergence insufficiency. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. You can schedule your next appointment with us online! [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). Home Vision Therapy Convergence Insufficiency Testing. [5], In recent imaging studies, Patel et al. 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No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. What is convergence insufficiency? Each card contains a partial view of the complete image. 12. Convergence Insufficiency Symptoms. In support of that hypothesis, some investigators have reported clinical-radiographic and clinical-pathologic correlations of patients with divergence insufficiency associated with focal lesions, usually of the pons and midbrain,7-10 but also in other locations, such as the craniovertebral junction.8,11 On the other hand, patients with divergence insufficiency and a variety of diffuse brain injuries have also been described.8,12-15 The site of this elusive region, if in fact such a region exists, remains undefined. 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 a disorder involving binocular vision vision using both eyes. Divergence excess is an over-divergence when attempting to look at distant objects. Long-term Surgical Outcomes in the Sagging Eye Syndrome. Introduction. Hold focus on this dot for 10 seconds. In a recent study by Goseki et.al. Scheiman M, Cotter S, Rouse M, et al. if you would like to learn more about convergence and divergence insufficiency. 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. 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). Chaudhuri Z, Demer JL. When prescribing ground-in prism, high index lenses, plastic frames and frames that are smaller in size help improve the weight and cosmesis of the lenses. 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. Duane
4 Binocular Vision Problems that Cause Eyestrain Committee on Aging. 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. 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). Stager DR, Sr, Black T, Felius J. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. Bothun ED, Archer SM. Chang MY et al. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. 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. Rutar T, Demer JL. Convergence Insufficiency Testing. Sensory Anomalies. MBSavitsky
Using magnetic resonance imaging (MRI), a coronal image 6 mm anterior to the eyeball-optic nerve junction was measured and used to examine the extraocular muscle (EOM) path shift . I reviewed the medical records of patients with divergence insufficiency that I had evaluated from July 1987 through April 1999 in my neuro-ophthalmology practice at a single institution. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. This patient continued with vision therapy to help improve her sensory and motor fusion with the hope of eventually titrating down the amount of prism she wears. Other training exercises include base-out prisms for near viewing and convergence exercises. 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. 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. If the patient is only using one eyethe image will not be formed correctly. Retrospective survey of patients with divergence insufficiency. Roper-Hall
Wall
Educating patients on the benefits of prism wear is key in helping get them on board in these cases.
Convergence and Divergence - Vivid Vision Divergence Insufficiency/Excess | Vision Therapy Paducah Kentucky Divergence Insufficiency and Divergence Excess Symptom Checklist Vision Therapy: Alex's Success Story | Wow Vision Therapy Share Watch on Share this: Twitter Facebook Like this: Loading. For example, the right eye might see a lion while the left eye sees a cage. Vertical deviations often cause patients to experience significant symptoms even when the deviation is small. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. These patients often present with horizontal and vertical deviations. 2005;9:711. In 2015 Chaudhuri and Demer published a retrospective observational study about utilizing Graded Vertical Rectus Tenotomy (GVRT) for treating incomitant vertical misalignment. Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. Schanzer
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. Parkinson disease 4. Abstract. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. [5], MRI measurements of horizontal EOM lengths in SES were approximately 40%, or 14 mm, longer than the EOMs of nonstrabismic younger and older controls. 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.
Divergence Insufficiency Revisited: Natural History of - JAMA RMDiagnosis and management of divergence paresis. The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. Sagging eye syndrome (SES) was first described by Rutar and Demer in 2009, as a potential leading cause of strabismus in older adult population as a combination of horizontal and vertical strabismus in addition to bilateral blepharoptosis (ptosis with high lid creases) and deepening of the sulcus. [unreliable source?] FDDutton
The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). How is convergence insufficiency treated? Arch Ophthalmol. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading.
PDF CLINICAL SCIENCES Divergence Insufficiency Revisited - JAMA The mirror stereoscope is one of the most commonly used types. . et al. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. Although no unsuspected neurologic disorder surfaced during the period of follow-up in these patients, I strongly recommend that a patient with isolated divergence insufficiency be followed closely to detect, for example, signs of developing intracranial hypertension or abducens nerve palsy. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. Recent trauma Prescribing for some patients with intermittent strabismus can be done by using Sheards or Percivals criteria or determining the associated phoria as with heterophoric patients. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. Cotter SA. Primary divergence insufficiency is generally a benign condition. Conclusions
These exercises were discussed in detail in Part 6 of this series. Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia.