American Academy of Ophthalmology. Divergence insufficiency revisited: natural history of idiopathic cases and neurologic associations. 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. 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. SDiagnosis and management of divergence weakness in adults. Sometimes it is exacerbated by fatigue and improves with rest. 13. In 2005 Thacker NM et al. [4]A dense band iss present from the medial rectus to the inferior pulleys (MRIR band) and from the medial rectus to the superior rectus pulleys (MRSR band). 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. 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. Pang Y, Teitelbaum B, Krall J. Connective tissues reflect different mechanisms of strabismus over the life span. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . Roper-Hall In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or. 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. Scheiman M, Wick B. 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. Chaudhuri Z, Demer JL. MCiner 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. 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. Effectiveness of base in prism for presbyopes with convergence insufficiency. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. While viewing the card, the patient reports what color line the black arrow is aligned with. Chamlin 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. 6. 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. Ductions and versions are full. 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. Bothun ED, Archer SM. 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. unable to diverge appropriately to a given target. A 5-year-old female initially presented for a strabismus and amblyopia evaluation. PMDivergence paralysis. [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. Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. Although younger patients may not be able to give good, subjective feedback, older children and adult patients should wear the trial prism set while engaging in an activity that normally causes them to experience diplopia or asthenopia (reading or distance viewing) to see if it eliminates diplopia and improves comfort. EJampolsky Scheiman Results from this study also supported previously published evidence of normal age-related connective tissue degeneration as there was a positive age effect in correlation to supero-temporal bowing of the LR-SR band.[9]. Progressive supranuclear palsy. Recent trauma 133. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. 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. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. Theme. This page has been accessed 63,795 times. 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 . Clin Exp Optom. Schanzer Primary divergence insufficiency is generally a benign condition. Br J Ophthalmol. 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. The normal amount of fusional divergence ability at distance is lower than that of fusional convergence ability, making it challenging to sufficiently increase ranges to compensate for esophoria or esotropia at distance. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. 2012. A common a daily, home rehabilitation technique is to have the patient do push-up exercises (looking at an object intermittently moved in and out from the bridge of the nose) to decrease the near point of convergence. Chang MY, Pineles SL, Velez FG. JAInman 2011;31(3):206-9. Classically convergence spasm is nonorganic. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. Moore The signs and symptoms with this condition are similar to convergence excess. Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. is variable. Ductions should be tested with the fellow eye covered. 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] What is the cause of convergence spasm? 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). GBurde REBaumgartner It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. Antireflective coating is also beneficial for patients wearing prism lenses. RMTomsak The association with refractive errors (and high myopia in particular) has been a point of contention for some time. Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre, If you can remember the old newspaper comics that had a green image with a red image overlying it, that would turn into a 3-D image if you put on red/blue 3-D glasses, In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees, Different cards with different images will require different amount. Home Vision Therapy Convergence Insufficiency Testing. 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. 132. 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. The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. It is very a common condition where there is a comitant exotropia greater at near than at distance by at least 10 prism diopters. Kerala J Ophthalmol. This is the brain's answer to coping with double vision and the stress of eyes not working as a . NJeds, Leigh The cyclotorsion component of SES was present in 65% of patients. 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Wednesday, March 15, 2023 | All Eyes On Evaporation, Thursday, April 13, 2023 | All Eyes On Evaporation, Tuesday, April 18, 2023 | All Eyes On Evaporation. Divergence excess is an over-divergence when attempting to look at distant objects. The use of topical anaesthesia does not abolish this surgical risk. Parkinson disease 4. JLSaccadic velocity analysis in patients with divergence paralysis. Conclusions Some patients report double pictures, but when checked with the torch, only one light is seen. The patient will wear a pair of polarizing glasses (similar to what is worn in modern 3-D movies) to create depth within the image (stereopsis). 2016 May; 100(5): 648651. Other associated symptoms can include asthenopia of panoramic type. NADivergence paralysis. RDDivergence paralysis. 5. Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. What are causes of convergence insufficiency? ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. Thomson What is convergence insufficiency? Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. 12. Define divergence insufficiency. How is convergence insufficiency treated? 2. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. Divergence Insufficiency. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Basic Esophoria and Exophoria. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. 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. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. 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. 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. 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. MGallaway 2023 American Medical Association. if you would like to learn more about convergence and divergence insufficiency. 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. More advanced exercises for vergence insufficiencies include. 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. 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. Each card contains a partial view of the complete image. Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. When patients are spectacle independent and want to remain independent, surgical approach could be offered. Typically, patients note that they do not have any diplopia at near. GMOcular divergence: its physiology and pathology. Arch Ophthalmol. However, it seems unlikely, since divergence insufficiency resolved in all 4 patients and no other neurologic problems developed during the time of each patient's follow-up of 1 month, 5.5 months, 34 months, and 44 months, respectively. PCBurian Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. Supported by All but 1 patient were older than 50 years. 130. 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. Ghanchi Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. 1. R. London. Vision suppression stops you from seeing double, but it doesn't fix the problem. In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. Accepted for publication February 11, 2000. There are many different ways to do this, but the best method to use depends on the type of binocular vision disorder for which you are prescribing. Strabismus. 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. 127. I still have mild double vision and . Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. It involves a specialty optical system and a uniquely created image book. 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. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. Retrospective case reviews of patients with an acquired hyper deviation secondary to a superior oblique palsy found that 76% to 92% of participants were successfully treated with prism alone.5,6. Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. 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. make average daily distance tasks more manageable with less frequent symptoms. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. 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. When you try to focus on something close to your eyes, you may have: Tired eyes. Tamhankar MA, Ying GS, Volpe NJ. With CI, the eyes do not point together inward as one looks at objects close-up. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Caloroso E, Rouse MW. Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. Again it seems unlikely, since CTs performed in 2 patients and an MRI performed in 1 were normal, and signs of divergence insufficiency were improving in 2 of these patients at the time of their last evaluation. HMDivergence paralysis following head trauma. Chaudhuri Z, Demer JL. Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. 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. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). Eye - Diplopia following cataract surgery . It is a disorder involving binocular vision vision using both eyes. 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. Initial tenotomy 30% of tendon width was performed to avoid intraoperative overcorrection. an electromyographic study. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. "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. Barricks Another historically reported feature of DI is significantly decreased negative fusional vergence (fusional divergence), along with the deficits direct relationship to distance of gaze. Abstract. Reproduction in whole or in part without permission is prohibited. This recommendation is based on the small size of the study population, the problems inherent in a retrospective investigation, and the grave consequences of failing to identify other neurologic signs. From a practical point of view, it seems reasonable to defer further investigation, including neuroimaging, in an affected patient who has no other neurologic or systemic symptoms or signs.

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