Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. Although cosmesis can be an issue with prism glasses, educating your patients on proper frame and lens selection will help them choose a frame and lens combination for the best cosmetic outcome. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. 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 glassestranaglyphs are made similarly. 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. Trans Am Ophthalmol Soc. 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). Convergence and Divergence - Vivid Vision 2009;86(2):153-6. Biousse V and Newman NJ. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. To prevent double vision, the individual exerts extra effort to make the eyes turn back in. To begin therapy, many therapists will focus first on normalizing the accommodative system. JJSavino Long-term Surgical Outcomes in the Sagging Eye Syndrome. 130. 2000;118(9):1237-41. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. New York, NY Oxford University Press1999;405-610. 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 . [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). Depending on the clinical circumstances, the imaging, and the course, clinicians should consider evaluating for other etiologies prior to making the diagnosis of HES or SES. Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. American Academy of Ophthalmology. Once this can be repeated multiple times, the amount of required divergence or convergence can be increased, thus expanding the vergence range and strengthening the problem area. JWStockbridge if you would like to learn more about convergence and divergence insufficiency. In addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. In some circumstances, individuals with convergence insufficiency will also suffer from high exophoria or exotropia, meaning the eyes like to sit in an outward position. it is highly advisable that you check them out first as they cover basics not explained here. 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. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. It can also decrease distance judgement, coordination, and sports performance. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. 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. 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. What Are the Symptoms of Convergence Insufficiency? What is the cause of convergence spasm? What is divergence insufficiency? PCBurian These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. 1978;76:610-53. 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. Using the Mann-Whitney test, there was no significant difference in the size of esotropia in forward gaze at distance or near point of fusion between the groups of patients with primary and secondary divergence insufficiency (Table 1). "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. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. Convergence Insufficiency. reported a case series of 9 patients with vertical strabismus incomitant in horizontal gaze positions and cyclotorsion who underwent Adjustable small-incision selective tenotomy and plication. GMOcular divergence: its physiology and pathology. Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. After a preliminary prescription of fusion prism is determined, it is recommended that you trial frame the patient and have them look around to see if they experience any diplopia when viewing objects in the room. In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. These questions are archived at https://neuro-ophthalmology.stanford.eduFollow https://twitter.com/NeuroOphthQandA to be notified of new neuro-ophthalmology questions of the week.Please send feedback, questions, and corrections to tcooper@stanford.edu. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. EDivergence insufficiency: characteristics, diagnosis, and treatment. None of these patients developed signs of an underlying neurologic disorder during follow-up. 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. Lateral rectus resections in divergence palsy: Results of long-term follow-up. Accepted for publication February 11, 2000. 2023 American Medical Association. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. Weird vision divergence upon waking at night - Retirement -Social Krohel In that study, strabismus surgery was performed in 50% of all SES cases. [1][5][8] The patients may also present with bilateral ptosis. JLSaccadic velocity analysis in patients with divergence paralysis. GBTobin NRNewman 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. 3 Advanced Exercises for Convergence and Divergence Insufficiency 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. Duane 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. 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. However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. Lim Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. This ocular misalignment has two main types: esotropia and exotropia. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. 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. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. Neuro-ophthalmology Illustrated-2nd Edition. 6. Heavy Eye vs. Near point convergence is the distance you can use both eyes without seeing double. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. Divergence insufficiency associated with high myopia | OPTH Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. Scheiman 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. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. Schedule Appointment Our Doctors Contact UsAccepted Providers, Comprehensive Eye Exams Glasses Contact Lens Exams Dry Eye Emergency Care, 801 East Newport Pike, Wilmington, DE 19804 | (302) 999-1286, If you have not read the previous portions of the vision therapy. This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. DRHartnett What is convergence spasm? 130. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. [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. 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. No clear sex predilection has been identified for the primary form of the condition. Patients in the study population shared the following symptoms: double vision when viewing distant objects, full-appearing ocular ductions, and esotropia identified during cover testing while fixing a distant target. 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. A similar technique is used for rehabilitation: the patient is instructed to do push-up exercises (looking at an object intermittently moved in and out from the bridge of the nose) daily at home to decrease the near point of convergence.Divergence InsufficiencyDivergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Ductions and versions are full. It is most often related to raised intracranial pressure or Chiari malformation.Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation Head trauma Intracranial hypotension (low CSF pressure syndrome) Cerebellar lesions Midbrain massAbnormal Horizontal Conjugate DeviationsGaze deviations are relatively common in large cerebral and pontine lesions (Fig. Retrospective survey of patients with divergence insufficiency. 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. Information obtained from direct telephone interviews with the patients and review of office records of referring physicians who continued to follow up some patients were included in the determination of follow-up. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. None of these patients developed signs of an underlying neurologic disorder during follow-up. 13.121). Chaudhuri Z, Demer JL. Lewis 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. Abstract. Surgical effect was assessed immediately by sitting the patient up and repeating the measurements at near and distance. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. 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. 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. Convergence Insufficiency/Vision Therapy - Eye Docs For Kids GBurde DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. 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. ALDemer In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. It is possible that with longer follow-up, the number of patients with resolution of diplopia might increase. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, 2000;118(9):1237-1241. doi:10.1001/archopht.118.9.1237. Ductions and versions are full. published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. American Academy of Ophthalmology. Unfortunately, since the ocular ductions appear full in a patient with suspected divergence insufficiency, objective means to assess the state of ocular comitancy do not exist for office determination. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. RMTomsak If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. As a . 2012;49(4):222-8. 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. 132. Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. If the patient is only using one eyethe image will not be formed correctly. The two prevalent hypotheses put forth so far include altered cerebrospinal fluid flow in the posterior cranial fossa, and involvement of the abducens nucleus or infranuclear portion. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. When patients are spectacle independent and want to remain independent, surgical approach could be offered. The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. All Rights Reserved. along with the fusional vergence system to create a 3-D object. 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. The first hurdle is ensuring your patient is comfortable with wearing spectacles. This conclusion was recently confirmed by Wiggins and Baumgartner,22 who characterized a benign long-term prognosis in their cohort of patients with neurologically isolated divergence insufficiency. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. THBird The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. SDiagnosis and management of divergence weakness in adults. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? 9. Divergence excess is an over-divergence when attempting to look at distant objects. Long-term follow-up and clinical features of the 2 groups were compared. Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. These exercises were discussed in detail in Part 6 of this series. This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. LBSharpe 126. Miller J AAPOS. It is also possible that the 3 patients who died and did not undergo long-term follow-up had some unsuspected neurologic disorder at the time they were evaluated. 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. 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. Vision Therapy with AmblyoPlay - Learn about your path to better vision! Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. You can also use Random Dot Stereo (RDS) testing to determine fusion prism. 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. Chaudhuri Z, Demer JL. Arch Ophthalmol. 2. Wiggins 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. Clinical management of strabismus. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. Success of prisms in the management of diplopia due to fourth nerve palsy. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. Although no unsuspected neurologic disorder surfaced during the period of follow-up in these patients, I strongly recommend that a patient with isolated divergence insufficiency be followed closely to detect, for example, signs of developing intracranial hypertension or abducens nerve palsy. ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. It is most often related to raised intracranial pressure or Chiari malformation. Chamlin 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. Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. Then, a horizontal prism bar was used to place increasing strengths of base-in prism over the other eye until fusion could no longer be maintained, as assessed subjectively using a distant target for fixation. 13.119). What causes divergence insufficiency? Divergence insufficiency associated with high myopia - PubMed With a trial frame, she was not able to appreciate RDS stereoacuity in-office. Bender For example, many investigators propose criteria to differentiate divergence insufficiency from divergence paralysis or paresis.1-3 However these arbitrarily defined criteria more likely describe varying severity of symptoms and ocular motor signs along a continuum of the same condition. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. 128. 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.
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