Caloroso E, Rouse MW. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, 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. 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. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Lim Br J Ophthalmol. 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. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. Br J Ophthalmol. These patients often present with horizontal and vertical deviations. What Are the Symptoms of Convergence Insufficiency? All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. GTDJohnston American Academy of Ophthalmology. Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. 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. Stager DR, Sr, Black T, Felius J. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. Godts D, Mathysen DG. The aspect of divergence paralysis or divergence insufficiency is stated as esotropia or high esophoria at a distance with much lower esophoria or near to normal fixation. J Pediatr Ophthalmol Strabismus. 2005;9:711. 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. What is the cause of convergence spasm? AParalysis of divergence. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. Primary divergence insufficiency is generally a benign condition. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. 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. 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). During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. Ductions should be tested with the fellow eye covered. 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. 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) Her research interests include strabismus and binocular vision disorders. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. 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. I prescribed glasses (+3.00 sph OD, +2.25 sph OS) for the patient, and she returned for follow-up care, eventually patching and undergoing vision therapy for her amblyopia. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. is fixed. The remainder of the neurological examination should be normal, without any cranial neuropathies. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. LMDivergence paralysis with increased intracranial pressure: further observations. 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. 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. Drs. Double vision is a troublesome complication of otherwise successful cataract surgery. Esodeviation is comitant in all fields of . Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. 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. Since true paralysis of divergence generally cannot be documented in most affected patients,4 I prefer the term divergence insufficiency to describe this disorder, regardless of the severity of associated symptoms and signs. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." Long-term follow-up and clinical features of the 2 groups were compared. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. Privacy Policy| 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. . Clinical management of strabismus. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. Scheiman M, Wick B. 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. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. 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. GNCurrent concepts in giant cell (temporal) arteritis. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. Terms of Use| Trans Am Ophthalmol Soc. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Therapists can make this activity more advanced by increasing the amount the, changing the target) or by using multiple, and making the patient look from one to another, , however instead of there being two different transparent image, that need to be fused into one, there is one image. It is idiopathic most often in children or young adults 2. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. The first hurdle is ensuring your patient is comfortable with wearing spectacles. Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. 132. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. 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). While viewing the card, the patient reports what color line the black arrow is aligned with. 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. Neena R, Giridhar A. Moore 2023 American Medical Association. 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. Chaudhuri Z, Demer JL. 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). In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. EDivergence insufficiency: characteristics, diagnosis, and treatment. 632. J AAPOS. If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. MBSavitsky MThe child with divergence paresis. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. 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. Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. What is divergence insufficiency? Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. 2000;118(9):12371241. 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. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. PCBurian Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. Audio blog post. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. NParalysis of divergence. Similarly, the theories on mechanism of divergence itself have varied. What are the symptoms of Convergence Insufficiency? Bender PJThompson Patients with constant strabismus may need corrective prism, or an amount of prism that completely neutralizes their strabismus, in order to obtain good levels of fusion. ACSanders Many affected patients experience spontaneous resolution of double vision within several months. We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. 1993, Oxford, UK: Butterworth Heinemann Books. Customize your JAMA Network experience by selecting one or more topics from the list below. 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. Committee on Aging. In the remaining 17 patients who were still alive, the total duration of follow-up extended from 1 month to 16 years (median, 35 months). [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. The signs and symptoms with this condition are similar to convergence excess. Motion sickness or dizziness ( vertigo) Headache . 1994, Philadelphia, PA: Lippincott Williams & Wilkins. Krohel Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. Call our optometrists at 302-299-1286 or. 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. 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]. 1. Bothun ED, Archer SM. MGeorge If a patient does not have good potential for sensory fusion, then the assistance that prism gives to the motor system wont allow for normal fusion, and it doesnt make sense to prescribe it. unable to diverge appropriately to a given target. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. If a patient sees four dots in free space or gives a diplopia response but is able to fuse with prism, perform a unilateral cover test. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. 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. MDavidoff A Maddox rod was the tool used to assess ocular comitancy in this study, but other methods exist, including prism-cover techniques, the Hess chart, and the Lancaster red-green test. Per some observations, its is more common in Caucasian females. LBSharpe For example, the right eye might see a lion while the left eye sees a cage. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Visual loss in pseudotumor cerebri: follow-up of 57 patients from five to 41 years and a profile of 14 patients with permanent severe visual loss. 2023 Stanford School of Medicine | Terms of Use | It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. Cunningham When patients are spectacle independent and want to remain independent, surgical approach could be offered. Sometimes it is exacerbated by fatigue and improves with rest. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Diagnosing convergence insufficiency From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. 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. 2012. Methods Introduction. 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. 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. Corresponding author: Daniel M. Jacobson, MD, Neuro-ophthalmology (4F-2), Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (email: jacobsod@mfldclin.edu). This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." 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. In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. The EOM angles in these patients ranged from 100 to . Bothun and Archer reported a series of 8 patients who underwent bilateral medial rectus recessions for distance esotropias of 1235; 5 patients had satisfactory results with collapse of the distance-near deviation from 15 pre-operatively to 5 postoperatively. 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. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. JLSaccadic velocity analysis in patients with divergence paralysis. LRosenbaum The LR-SR band vertically supports the LR pulley against the downward force of the inferior oblique muscle to maintain the LR pulleys vertical position. It is an unusual form of strabismus with esotropia and diplopia only at distance and single binocular vision at near. Wall When you try to focus on something close to your eyes, you may have: Tired eyes. 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. Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. One study successfully treated 87 patients with divergence insufficiency between two and 18 prism diopters (PDs) with prism with none of the patients in the study requiring additional treatment or surgery.3 Another study found that 100% of patients with divergence insufficiency (30 patients) had success with prism.4. None of the patients initially classified as having primary divergence insufficiency developed additional neurologic dysfunction during the period of follow-up. 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. 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. 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. 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. 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. It is most often related to raised intracranial pressure or Chiari malformation. If the patient is still symptomatic, combining prism and vision therapy may help improve convergence and divergence ranges. Parkinson disease 4. All but 1 patient were older than 50 years. This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. [1]SES should be differentiated from heavy eye syndrome (HES) which is an association of axial high myopia, esotropia, and hypotropia. In some circumstances, individuals with convergence insufficiency will also suffer from high exophoria or, In many cases, individuals with convergence insufficiency will notice that their symptoms worsen as they get tired or after attempting to do near tasks for a prolonged. Long-term follow-up and clinical features of the 2 groups were compared. The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. If your patient is still experiencing diplopia, additional prism may be needed to help them achieve fusion. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. 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. She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. EHBilateral sixth-nerve paresis simulating divergence paralysis. The Apt Lecture. Tamhankar MA, Ying GS, Volpe NJ. Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. 130. 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. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Certain factors are associated with exotropia, including genetics and health conditions. Fresnel membrane prisms can be very useful for many aspects of prescribing prism. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. Keep moving to the next dot along the card, gradually getting closer to the nose. DRHartnett Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. Roper-Hall These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. 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. Tamhankar MA, Ying GS, Volpe NJ. highest quality optometry services and eye exams in Wilmington, Delaware and its surrounding areas. SHarbison 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. With CI, the eyes do not point together inward as one looks at objects close-up. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. 2009;86(2):153-6. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Divergence insufficiency is a benign phenomenon causing horizontal diplopia at distance viewing . Bruce [4]The pulleys inflect rectus and inferior oblique paths by the exact same way that the trochlea inflects the path of the superior oblique (SO) tendon. 1. Biousse V and Newman NJ. 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. MCiner
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