To determine the natural history of primary divergence insufficiency and to identify clinical features that distinguish patients with this neurologically isolated form of divergence insufficiency from those harboring neurologic disorders. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. How is convergence insufficiency treated? 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. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. What lesion location is likely in the presence of horizontal conjugate deviation of the eyes to one side? Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. 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. These exercises were discussed in detail in Part 6 of this series. Fusion prism is the minimum amount of prism needed to see a change from diplopia or suppression to normal binocular vision.12 To determine prism using this method, use the Worth Dot test to find a preliminary prism amount. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. Convergence Insufficiency Symptoms. Customize your JAMA Network experience by selecting one or more topics from the list below. The author has no commercial or proprietary interest in any product or company mentioned in this manuscript, and has no financial interest nor receives payment as a consultant, reviewer, or evaluator. FDDutton
Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). How to test convergence eyes | Math Index 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. 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. In 2005 Thacker NM et al. By continuing to use our site, or clicking "Continue," you are agreeing to our, Clinical Features of Patients With Primary and Secondary Divergence Insufficiency, Disorders Associated With Secondary Divergence Insufficiency. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. 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]. 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 misalignment almost 100%. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. RDDivergence paralysis. 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. If the patient gives a fusion response with or without prism but movement on the unilateral cover test is seen, then anomalous correspondence is suspected and relieving or corrective prism is not an appropriate management option. Although prescribing it can seem intimidating at first, with practice and a bit of trial and error, you can perfect your ability to prescribe prism for your patients in no time. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. 7. 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. 2016. The cyclotorsion component of SES was present in 65% of patients. Exercises for double vision: 4 things to try - Medical News Today Another area of controversy concerns whether divergence insufficiency is a localizing sign referable to injury of a "divergence center," or is a nonlocalizing sign associated with a variety of focal and diffuse brain insults. 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. BBordaberry
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. One of the most important aspects of successfully prescribing prism is choosing patients who will benefit the most from it. 129. Arch Ophthalmol. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. 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. 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. SHarbison
However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. MGallaway
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. 1995, St. Louis, Missouri: Mosby. Eye - Diplopia following cataract surgery . 2014;18(4):309-15. 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. Kirkham
Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. Accessibility Statement, Our website uses cookies to enhance your experience. They use head thrusts to shift fixation. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. J Neuroophthalmol. Conclusions
What is divergence insufficiency? Br J Ophthalmol. What is congenital ocular motor apraxia? Sometimes it is exacerbated by fatigue and improves with rest. Drs. 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. Wall
Some patients report double pictures, but when checked with the torch, only one light is seen. 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. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Stager DR, Sr, Black T, Felius J. In many of these cases, the initial management strategy is prescribing vertical prism.1 Often, if the vertical deviation is decreased or eliminated, the patient may be able to comfortably fuse the horizontal deviation. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. The distance at which diplopia occurs is noted (near point of convergence). use an approach called the SILO affect to work on increasing divergence or convergence ranges. Patients who wear contact lenses the majority of the time or who have undergone refractive, cataract or strabismus surgery may not be happy with the idea of moving or going back to spectacle wear even if it relieves asthenopia or diplopia. A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. 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. The preferred method for prescribing prism for vertical heterophoria is determining the vertical associated phoria.12 This can be done at near using the Wesson card or at distance. Connective tissues reflect different mechanisms of strabismus over the life span. Godts D, Mathysen DG. METraviesa
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. 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. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. It is most often related to raised intracranial pressure or Chiari malformation. GTDJohnston
13.120). Results
A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. Treatment options include correction with base-out prisms for distance, Tomasz A. Wiraszka, MD, and Praveena Gupta, OD, PhD, FAAO, Galveston, Texas, April 2015 Wills Eye Resident Case Series, Wills Eye Resident Case Series - Diagnosis and Discussion, November 2014 Wills Eye Resident Case Series, February 2016 Wills Eye Resident Case Series - Diagnosis & Discussion. Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. Moller
Teitelbaum B, Pang Y, Krall J. Archives of Neurology & Psychiatry (1919-1959), Subscribe to the JAMA Ophthalmology journal, JAMA Surgery Guide to Statistics and Methods, Antiretroviral Drugs for HIV Treatment and Prevention in Adults - 2022 IAS-USA Recommendations, CONSERVE 2021 Guidelines for Reporting Trials Modified for the COVID-19 Pandemic, Global Burden of Skin Diseases, 1990-2017, Guidelines for Reporting Outcomes in Trial Protocols: The SPIRIT-Outcomes 2022 Extension, Mass Violence and the Complex Spectrum of Mental Illness and Mental Functioning, Organization and Performance of US Health Systems, Spirituality in Serious Illness and Health, The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity, Screening for Prediabetes and Type 2 Diabetes, Statins for Primary Prevention of Cardiovascular Disease, Vitamin and Mineral Supplements for Primary Prevention of of Cardiovascular Disease and Cancer, Statement on Potentially Offensive Content, Register for email alerts with links to free full-text articles. Graefes Arch Clin Exp Ophthalmol. Divergence insufficiency can vary in severity, from minor deficits to complete divergence paralysis. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. The opposite of divergence insufficiency is divergence excess. . Methods: We investigated 20 cases of high myopia (>-6 D) with divergence insufficiency, 20 cases of high myopia without double vision, and 10 normal cases as controls. Strabismus. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. Esotropia resolved within days of initiating corticosteroid treatment in both patients. 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. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. RLMagnetic resonance images in a case of "divergence paralysis.". Divergence insufficiency was also observed in 2 patients, each with idiopathic cerebellar degeneration and progressive supranuclear palsy, an association that is generally not recognized in either condition.30 This did not cause clinical confusion, however, since divergence insufficiency was overshadowed in each patient by the cardinal signs that characterized their underlying neurologic conditions. Scheiman M, Cotter S, Rouse M, et al. 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. 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. 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. Call our optometrists at 302-299-1286 or. Progressive supranuclear palsy. Primary divergence insufficiency is generally a benign condition. it is highly advisable that you check them out first as they cover basics not explained here. 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. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. Corbett
2005;9:711. In many individuals with, Normalizing accommodation is important because. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. DBGlaser
What is divergence insufficiency? Tamler
. 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. Divergence insufficiency is a benign phenomenon causing horizontal diplopia at distance viewing . Home Vision Therapy Convergence Insufficiency Testing. If an intermittent horizontal strabismus patient has a primary vertical deviation, vertical prism may help improve their ability to fuse the horizontal deviation. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. Ghanchi
Convergence Insufficiency Testing. . People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. 5. PDF CLINICAL SCIENCES Divergence Insufficiency Revisited - JAMA Chaudhuri Z, Demer JL. Questions: 125. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. Effectiveness of prisms in relieving diplopia in superior oblique palsies. The main treatment for convergence insufficiency is vision therapy. ARKline
Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. Diplopia at Distance in Older Patients: Is It Sagging Eye Syndrome? 133. Blurred vision. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. Clinical management of strabismus. Antireflective coating is also beneficial for patients wearing prism lenses. Common symptoms include: headaches; blurred vision ; double vision This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. However, the cause of convergence insufficiency is often unknown. I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. You can schedule your next appointment with us online! A Vectogram is a tool which utilizes specialized imaging along with the fusional vergence system to create a 3-D object. Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. 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. 3 Advanced Exercises for Convergence and Divergence Insufficiency Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. 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. Divergence Insufficiency Revisited: Natural History of - JAMA They are low in cost and can be easily applied to a pair of spectacle lenses in-office to try out on a patient for several days or weeks, and refining the prism prescription is inexpensive and simple. The patient is also instructed to keep the words around the lines clear to control accommodation. J AAPOS 2014;18:370-373. JAInman
Br J Ophthalmol. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. 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 . Sensory Anomalies. The remainder of the neurological examination should be normal, without any cranial neuropathies. 2023 American Medical Association. What is the cause of convergence spasm? To begin therapy, many therapists will focus first on normalizing the accommodative system. Instead they turn their head briskly (head thrust) to shift fixation. Smooth pursuit and vertical eye movements are usually preserved. Eye movements are usually bilateral and symmetric in the horizontal plane. It is often idiopathic, but it has also been associated with several cerebral malformations and genetic disorders.Acquired Ocular Motor Apraxia Occurs in older children Associated with mostly metabolic disorders (Gaucher disease, ataxia-telangiectasia, spinocerebellar ataxias, NiemannPick disease) Convergence SpasmAlso called spasm of the near triad (Fig. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. 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. It is most often related to raised intracranial pressure or Chiari malformation. GMOcular divergence: its physiology and pathology. Accepted for publication February 11, 2000. IRT. 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. Neena R, Giridhar A. Chang MY, Pineles SL, Velez FG. Convergence and Divergence - Vivid Vision 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. Demer JL et al. The patient places two transparent cards into the vectogram system. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying 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. If the patient is only using one eyethe image will not be formed correctly. . Patients will be able to work on fusing the images of one. Divergence insufficiency is the opposite problem of convergence insufficiency. Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. 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. DIdiopathic intracranial hypertension: a prospective study of 50 patients. 2012. 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. Many affected patients experience spontaneous resolution of double vision within several months. J AAPOS. Theme. If no movement is seen on the unilateral cover test, the patient has normal correspondence. In addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. [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). Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. 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. Arch Ophthalmol. In that study, strabismus surgery was performed in 50% of all SES cases. Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. et al. 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. This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. RMTomsak
Patients may also present with ductional deficits depending on the grade of muscle displacement. make average daily distance tasks more manageable with less frequent symptoms. Prism can be a powerful treatment for many conditions and for many patients, specifically for those who suffer from asthenopia or diplopia. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. DIVERGENCE INSUFFICIENCY - Optography Surgical effect was assessed immediately by sitting the patient up and repeating the measurements at near and distance. 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. 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. Prism in reading glasses or strabismus surgery may be required. [5], In recent imaging studies, Patel et al. A new prescription for prism lenses was dispensed to the patient at the follow-up examination. 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 tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. Divergence insufficiency revisited: natural history of idiopathic cases and neurologic associations. With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. 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.