The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. Demer JL et al. The use of topical anaesthesia does not abolish this surgical risk. You can schedule your next appointment with us online! 10. The mechanical properties of pulleys are critical for the support and rotational properties of the eye. One patient was followed up for only 1 month, but her esotropia resolved during that time. Of the 15 patients with secondary divergence insufficiency, an underlying neurologic or systemic disorder was either known or initially suspected in all based on the initial history and physical examination. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Questions with answers: 125. Eight (40%) of the 20 patients recalled such an event, including a viral prodrome in 3 patients, minor head trauma in 2 patients, and hospitalization for an unrelated illness in 3 patients. doi:10.1001/archopht.118.9.1237. Intravenous edrophonium chloride testing was performed in 2 patients because of the referring physician's concern about the possibility of myasthenia gravis despite the absence of other symptoms or signs of this condition, but the test did not resolve double vision or reduce the amount of esotropia. Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. Posted by . RMTomsak It is an unusual form of strabismus with esotropia and diplopia only at distance and single binocular vision at near. Ghanchi 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. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. AParalysis of divergence. 127. Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. 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. Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. Basic Esophoria and Exophoria. Introduction. J AAPOS. 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. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. J Neuroophthalmol. Patients may also present with ductional deficits depending on the grade of muscle displacement. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. LDivergence insufficiency. This is the brain's answer to coping with double vision and the stress of eyes not working as a . [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. 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. Divergence Insufficiency. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. 2012. Results: In high-myopia patients with divergence insufficiency, ocular axis measurements ranged from 24.8 to 31.0 (mean SD: 27.6 1.6) mm. NJeds, Leigh "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. 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. Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. JSLevy In many individuals with, Normalizing accommodation is important because. Godts D, Mathysen DG. Clin Exp Optom. Surgical effect was assessed immediately by sitting the patient up and repeating the measurements at near and distance. 1. DIdiopathic intracranial hypertension: a prospective study of 50 patients. From there, basic vergence exercises will be added in. What are the symptoms of Convergence Insufficiency? Effectiveness of prisms in relieving diplopia in superior oblique palsies. 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 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. Heavy eye syndrome versus sagging eye syndrome in high myopia. . Extraordinary symptoms equivalent to diplopia 2.3.1. In the 17 patients with primary divergence insufficiency who had adequate information to ascertain long-term follow-up, double vision persisted in 9 individuals. unable to diverge appropriately to a given target. If the dot becomes doubled, go back to the previous dot and try again. Although successfully prescribing it can sometimes seem like a time-consuming and daunting task, the following tips can help you smoothly incorporate the use of prism for binocular vision conditions into your practice for the best outcomes. it is highly advisable that you check them out first as they cover basics not explained here. Different cards with different images will require different amounts of negative and positive fusional vergence. Dr. Jenewein is an assistant professor at Salus University, Salus Universitys Principal Site Investigator for the Pediatric Eye Disease Investigator Group, a Fellow of the American Academy of Optometry and a Diplomate of the Binocular Vision, Perception and Pediatric Optometry Section of the Academy. Vertical deviations often cause patients to experience significant symptoms even when the deviation is small. Six patients underwent CT and 10 underwent MRI. Many affected patients experience spontaneous resolution of double vision within several months. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and help make average daily distance tasks more manageable with less frequent symptoms. JAInman PCBurian AOcular divergence mechanisms. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. SDiagnosis and management of divergence weakness in adults. What causes divergence insufficiency? 129. Success of prisms in the management of diplopia due to fourth nerve palsy. Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. Goldberg The mirror stereoscope is one of the most commonly used types. Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. The results of CT or magnetic resonance imaging (MRI), available at the time of initial evaluation, were not initially considered since one of the aims of this study was to identify clinical features that might be helpful in predicting which patient was harboring a neurologic disorder. 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. highest quality optometry services and eye exams in Wilmington, Delaware and its surrounding areas. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. It is most often related to raised intracranial pressure or Chiari malformation. The signs and symptoms with this condition are similar to convergence excess. Their symptom was controlled using prisms. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. After these patients are evaluated for any underlying systemic or neurological disease, which must always be ruled out in any case of new-onset strabismus, they are often good candidates for a prism prescription. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. 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. Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. Although each method has its advantages and disadvantages, they all suffer from being subjective. DRHartnett It is idiopathic most often in children or young adults 2. DBGlaser [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. EDivergence insufficiency: characteristics, diagnosis, and treatment. 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. All but 1 patient were older than 50 years. 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. Histologic studies showed that each rectus pulley consists of an encircling ring of collagen located near the globe equator in tenon fascia, coupled to the orbital wall, adjacent EOMs, and equatorial Tenon fascia by bands containing densely woven collagen, elastin, and smooth muscle. None of these patients developed signs of an underlying neurologic disorder during follow-up. 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. This page has been accessed 63,795 times. Motion sickness or dizziness ( vertigo) Headache . Progressive supranuclear palsy. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. Miller Vision suppression stops you from seeing double, but it doesn't fix the problem. Biousse V and Newman NJ. In normal cases, the ocular axis length was 23.5 1.0 mm. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. with a stereo image already pre-made onto the card. Convergence Insufficiency. The differential includes: It can be difficult to adjudicate small angle deviations such as HES and SES from mild myasthenia gravis, incompletely resolved sixth nerve palsy, thyroid eye disease, and decompensated prior phorias. 2005;89(10):1318-23. Pencil pushups may be effective in some cases. A near card is brought toward the patients nose until the patient sees double. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. All Rights Reserved. All Rights Reserved. Scheiman M, Cotter S, Rouse M, et al. 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). Long-term Surgical Outcomes in the Sagging Eye Syndrome. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. Magnetic resonance imaging resolution showed superotemporal bowing of the LR-SR band in milder cases and abrupt termination of an attenuated band remnant in the superolateral orbit in more severe cases. 2023 American Medical Association. Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. In those patients with secondary divergence insufficiency, the underlying disorder was either already established or strongly suspected based on the additional neurologic symptoms and signs at their initial evaluation. The patient is also instructed to keep the words around the lines clear to control accommodation. 8. 13.121). When you try to focus on something close to your eyes, you may have: Tired eyes. Br J Ophthalmol. After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. 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. 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. PMDivergence paralysis. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Neena R, Giridhar A. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. Many patients were first evaluated within 1 month of the onset of symptoms, far sooner than the expected time course for the spread of comitance to convert a sixth cranial nerve palsy to a comitant esotropia. Jacobson DM. [1]SES should be differentiated from heavy eye syndrome (HES) which is an association of axial high myopia, esotropia, and hypotropia. GTDJohnston Our eye doctors. Esodeviation is comitant in all fields of . ARKline LMDivergence paralysis with increased intracranial pressure: further observations. 2005;9:36. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. 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. What is the cause of convergence spasm? Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. If no movement is seen on the unilateral cover test, the patient has normal correspondence. The orbital layer, inserts on the pulley, not on the globe. Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. A new prescription for prism lenses was dispensed to the patient at the follow-up examination. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. 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. THBird 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. characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . Roughly half of the patients experienced spontaneous resolution of diplopia after several months. 2016. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. Long-term follow-up and clinical features of the 2 groups were compared. Another historically reported feature of DI is significantly decreased negative fusional vergence (fusional divergence), along with the deficits direct relationship to distance of gaze. Therefore, it forces the patient to use both eyes properly to see the image. Other associated symptoms can include asthenopia of panoramic type. 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. 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). Strabismus. 2. Abstract. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. 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. MDavidoff On the other hand, it remains possible that these events were casual and not pathogenetically important. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. With exercises that adapt to each patient and their specific needs, it is an ideal solution for problems such as lazy eye, strabismus, convergence insufficiency, double vision, or other binocular problems. The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. MThe child with divergence paresis. 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. Distance esotropia in the elderly. 134. Committee on Aging. Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation More respect for connective tissues. These arguments do not preclude the possibility that some patients with comitant esotropia at distance and full-appearing ocular ductions might be suffering from sixth cranial nerve palsy, not divergence insufficiency. 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]. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. While patients with strabismus often benefit from prism wear, it is important to first determine whether a strabismic patient is fit for treatment with prism by evaluating their potential for sensory fusion and whether the addition of prism will improve their sensory fusion status. Primary divergence insufficiency is generally a benign condition. 6. Convergence Insufficiency Testing. [2] Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. To be enrolled in the study, patients had to meet the following 5 criteria: 1) relatively sudden onset of double vision at far vision, 2) no double vision at near vision, 3) high myopia >6.0 diopters (D) in both eyes, 4) no other neurological symptoms, and 5) a normal . FEDivergence paresis: a nonlocalizing cause of diplopia. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. Common symptoms include: headaches; blurred vision ; double vision Convergence insufficiency is a common problem with the eyes, and is the main culprit behind eyestrain, blurred vision, and headaches. No clear sex predilection has been identified for the primary form of the condition.

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