[1][5][8] The patients may also present with bilateral ptosis. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. On initial presentation, her best-corrected visual acuities were 20/40 OD and 20/25 OS. NRNewman Primary divergence insufficiency is generally a benign condition. 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. Heavy eye syndrome versus sagging eye syndrome in high myopia. 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. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. 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. 2000;118(9):12371241. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. 2023 American Medical Association. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. 2013;97(11):1415-9. MGeorge At the follow-up examination after nine weeks of patching and vision therapy for amblyopia, her visual acuities were equal in both eyes, and all testing showed normal correspondence. On the other hand, it remains possible that these events were casual and not pathogenetically important. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. 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. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. 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]. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. While the size of divergence fusion amplitude was significantly larger in the group of patients with secondary disorders than in the primary group, the magnitude of this difference was small and the range of values between the 2 groups demonstrated considerable overlap (Table 1). Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. How is convergence insufficiency treated? et al. 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. JAInman Primary divergence insufficiency is generally a benign condition. Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. American Academy of Ophthalmology. The use of topical anaesthesia does not abolish this surgical risk. 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. ACSanders MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. It is idiopathic most often in children or young adults 2. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging.2, Vision therapy aims to decrease symptoms of vergence anomalies by increasing the compensating fusional vergence range (base-in for esophoria and base-out for exophoria). LBSharpe Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. Lim 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. Peripheral double pictures Usually double vision arises from a squint deviation of the eyes and is checked with a torch and a red glass before one eye to separate the pictures. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." Heavy Eye vs. 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. Br J Ophthalmol. What Are the Symptoms of Convergence Insufficiency? The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. Prism can be a powerful treatment for many conditions and for many patients, specifically for those who suffer from asthenopia or diplopia. A 5-year-old female initially presented for a strabismus and amblyopia evaluation. Another method used for prescribing for patients with intermittent strabismus, particularly for those who have difficulty with fusion in free space, is Calorosos Residual Vergence Demand (RVD).7 RVD criteria look at the direction and size of the deviation and determine how much residual vergence demand the patient should have after prescribing relieving prism. Long-term follow-up and clinical features of the 2 groups were compared. 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. Near point of convergence (NPC) is measured by bringing an object to the nose and observing when the patient sees double, or one eye deviates . Electronic charts are now routinely used in practice, and many of them have an available distance target for determining fixation disparity and the associated phoria. DBGlaser Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. In the 2 patients with temporal arteritis, the rapid resolution of esotropia coincident with initiation of corticosteroid treatment, along with the development of posterior ischemic optic neuropathy in 1 case, point to ischemic injury of extraocular muscles as the cause of ophthalmoplegia. [5], There has been an increased awareness and diagnosis of these degenerative strabismic disorders after 2000. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. All patients with double vision routinely were assessed for the speed of saccades and for the presence of nystagmus to identify signs of abducens nerve palsy or internuclear ophthalmoplegia. Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. [10] In 2013, Stager et al. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. 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). Conclusions 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. Hold focus on this dot for 10 seconds. [2] 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. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. 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 . Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency. 129. 5. Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. Reference: 1. New York, NY Oxford University Press1999;405-610. GBurde 1995, St. Louis, Missouri: Mosby. 2009;86(2):153-6. Strabismus. is variable. Terms of Use| In 2015 Chaudhuri and Demer published a retrospective observational study about utilizing Graded Vertical Rectus Tenotomy (GVRT) for treating incomitant vertical misalignment. Corresponding author: Daniel M. Jacobson, MD, Neuro-ophthalmology (4F-2), Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (email: jacobsod@mfldclin.edu). What lesion location is likely in the presence of horizontal conjugate deviation of the eyes to one side? If the dot becomes doubled, go back to the previous dot and try again. Keep moving to the next dot along the card, gradually getting closer to the nose. In fact, when the vergence system is struggling, the accommodative system often picks up the slack and becomes overworked, which can also play a role in some of the symptoms of eye strain, fatigue, and headaches. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. 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. 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 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. Before settling on a final prism prescription, it is often helpful to trial frame the amount of prism you are about to prescribe to ensure that it will help you achieve your goals. You can also use Random Dot Stereo (RDS) testing to determine fusion prism. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. 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. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . 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. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. . 3. Bruce What is convergence spasm? Convergence Insufficiency Testing. You can schedule your next appointment with us online! Most trial lens sets come with prism lenses, but for larger angles of strabismus, it may be helpful to use a Fresnel prism trial set. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. It is most often related to raised intracranial pressure or Chiari malformation. Wiggins My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. Patients and methods. Neuro-ophthalmology Illustrated-2nd Edition. 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 . Convergence and Divergence The only way to diagnose CI is with an eye exam 1. With a trial frame, she was not able to appreciate RDS stereoacuity in-office. 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. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. 2012;95(2):192-7. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. NADivergence paralysis. Primary divergence insufficiency is generally a benign condition. if you would like to learn more about convergence and divergence insufficiency. What are causes of convergence insufficiency? JJSavino METraviesa 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. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. 2016;28(1):38-42. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. 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. Typically, patients note that they do not have any diplopia at near. 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. Prism in reading glasses or strabismus surgery may be required. The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). One of the most important aspects of successfully prescribing prism is choosing patients who will benefit the most from it. This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. Duane Educating patients on the benefits of prism wear is key in helping get them on board in these cases. Eye - Diplopia following cataract surgery . Scheiman M, Wick B. RTOcular muscle paresis and cranial arteritisan unusual case. AParalysis of divergence. HMDivergence paralysis following head trauma. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. 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. Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). Convergence Insufficiency Symptoms. 1. 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. They include: double vision (diplopia) headaches blurry vision while reading squinting or closing one eye while reading words appearing to move around or float on the page while reading eyestrain or fatigue (asthenopia) No clear sex predilection has been identified for the primary form of the condition. Patients may also present with ductional deficits depending on the grade of muscle displacement. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." The association with refractive errors (and high myopia in particular) has been a point of contention for some time. 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. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. 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. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. 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. GNCurrent concepts in giant cell (temporal) arteritis. Antireflective coating is also beneficial for patients wearing prism lenses. [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. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. 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. It is most often related to raised intracranial pressure or Chiari malformation. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. Many affected patients experience spontaneous resolution of double vision within several months. DIdiopathic intracranial hypertension: a prospective study of 50 patients. DJDivergence insufficiency. [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. 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. Surgical effect was assessed immediately by sitting the patient up and repeating the measurements at near and distance. 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. 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. Divergence insufficiency can vary in severity, from minor deficits to complete divergence paralysis. 130. 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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. 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. 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 . 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. Neena R, Giridhar A. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. Parkinson disease 4. Effectiveness of base in prism for presbyopes with convergence insufficiency. Divergence insufficiency is the opposite problem, accommodation will be worked on first to ensure it is equal between the two eyes, basic vergence exercises will be added in. It is very a common condition where there is a comitant exotropia greater at near than at distance by at least 10 prism diopters. 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. This decreases the motor fusion demand, allowing the patient to fuse more comfortably. Certain factors are associated with exotropia, including genetics and health conditions. FEDivergence paresis: a nonlocalizing cause of diplopia. 2016. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. Arch Ophthalmol. GMOcular divergence: its physiology and pathology. Abstract. PMDivergence paralysis. Accessibility Statement, Our website uses cookies to enhance your experience. Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. GBTobin J AAPOS. 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. SDiagnosis and management of divergence weakness in adults. REBaumgartner 127. RJZee Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. 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. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. Histories reveal the possibility of a number of etiologic factors. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. When their medical records were reviewed at the time this study was being designed, I learned that they had since died of unrelated illnesses, so the course of their disorder could not be completely ascertained. 4. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. 6. Divergence insufficiency is a benign phenomenon causing horizontal diplopia at distance viewing . All but 1 patient were older than 50 years. Trans Am Ophthalmol Soc. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. AJNR Am J Neuroradiol. 2012;130:12801284. 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. ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. What is the cause of convergence spasm? 2012. Basic Esophoria and Exophoria. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. 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 . I still have mild double vision and . Chaudhuri Z, Demer JL. 13.121). While none of the patients had other symptoms to suggest giant cell arteritis or myasthenia gravis, erythrocyte sedimentation rate (performed in 7 patients) and acetylcholine receptor antibody assay (performed in 6 patients) were tested, and the results were normal in all. as their fusional vergence ranges expand. 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. Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. 133. Long-term follow-up and clinical features of the 2 groups were compared. 11. He usually volunteers the infor mation that he has no trouble in reading or close use of his eyes. Corbett If the eyes do drift out, the person is likely to have double vision. The patient is also instructed to keep the words around the lines clear to control accommodation.
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