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. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. 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. Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. As a . 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. Roper-Hall Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. Convergence Insufficiency Testing. 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. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. Lyle 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. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. 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. JAAcquired esotropia due to Arnold-Chiari I malformation. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. Chaudhuri Z, Demer JL. 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R. London. Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. JLSaccadic velocity analysis in patients with divergence paralysis. Keep moving to the next dot along the card, gradually getting closer to the nose. [1][5][8] The patients may also present with bilateral ptosis. 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. [13]In their case series patients with lateral incomitance, the adjustable suture was generally placed on the MR opposite the horizontal direction of the greatest ET. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. J Neuroophthalmol. 4. Scheiman 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. A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. Questions: 125. These studies were unrevealing in all patients. Jacobson DM. 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%. Many affected patients experience spontaneous resolution of double vision within several months. They concluded that medial rectus recession is as effective as lateral rectus resection and suggested that double the distance angle of esotropia should be used as the surgical target. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. 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. 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. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. 2005;89(10):1318-23. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. 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. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. MGeorge the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . ISOphthalmoplegia in cranial arteritis. 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. 3rd ed. Heavy eye syndrome versus sagging eye syndrome in high myopia. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Blurred vision. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. Reference: 1. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. 2005;9:711. Success of prisms in the management of diplopia due to fourth nerve palsy. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. 2023 American Medical Association. Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. 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. 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. Lets continue the conversation over on your social network of choice. Our eye doctors. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. RTOcular muscle paresis and cranial arteritisan unusual case. 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. For example, the right eye might see a lion while the left eye sees a cage. 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. 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. 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. Convergence Insufficiency Testing. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. Prescribing relieving prism for horizontal, non-strabismic, binocular vision disorders can be done by calculating Sheards or Percivals criteria by using clinical data or analyzing fixation disparity and determining the associated phoria.1 At near, fixation disparity and the associated phoria can be found with a Wesson card. 128. 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. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. 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. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. The remainder of the neurological examination should be normal, without any cranial neuropathies. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. More respect for connective tissues. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. Thomson The distance at which diplopia occurs is noted (near point of convergence). Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. AIs divergence active? Eight (40%) of the 20 patients recalled such an event, including a viral pro-drome in 3 patients, minor head trauma in 2 patients, and hospitalization for an unrelated illness in 3 pa-tients. 2016. 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. 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. Diagnosing convergence insufficiency 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. 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. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. Theme, Congenital Ocular Motor Apraxia It affects young children. Defective or absence of voluntary horizontal saccades to visual stimuli: they cannot move their eyes horizontally to look at a target. Primary divergence insufficiency is generally a benign condition. 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. 7. RLMagnetic resonance images in a case of "divergence paralysis.". METraviesa 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. 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. To increase convergence, the two cards will be pushed inward, making the image smaller (Small In for the SI in SILO). It is usually benign. FEDivergence paresis: a nonlocalizing cause of diplopia. Lewis Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. What causes divergence insufficiency? 2008;12(1):56. Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . This period included the duration of diplopia prior to the first evaluation in addition to the duration of diplopia until either resolution of it or until the last follow-up evaluation. p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 10.0px Sabon} p.p2 {margin: 0.0px 0.0px 0.0px 0.0px; text-indent: 10.0px; line-height: 12.0px; font: 10.0px Sabon} p.p3 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #867245; min-height: 12.0px} p.p4 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #b87c4c} p.p5 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #b37749} span.s1 {letter-spacing: -0.2px}. 2005;9:36. They use head thrusts to shift fixation. GTDJohnston To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). Kerala J Ophthalmol. This page has been accessed 63,795 times. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). What is divergence insufficiency? 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. Abstract. Duane 2013;251:16411644. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. 5. What Are the Symptoms of Convergence Insufficiency? These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. 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. The opposite of divergence insufficiency is divergence excess. [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. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. Committee on Aging. JSLevy Biousse V and Newman NJ. unable to diverge appropriately to a given target. Chaudhuri Z, Demer JL. American Journal of Ophthalmology, Volume 209, January 2020, Pages 55-61. Jacobson DM. 130. along with the fusional vergence system to create a 3-D object. 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). To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. Arch Ophthalmol. Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. Divergence insufficiency esotropia (DIE), originally described by Duane in 1896, is an acquired condition characterized by an esodeviation that measures at least 10 prism diopters (PD) greater at distant rather than near fixation [].Patients with DIE complain about double vision at distance. The patient is also instructed to keep the words around the lines clear to control accommodation. Histories reveal the possibility of a number of etiologic factors. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." 127. 2014;35(9):1830-5. highest quality optometry services and eye exams in Wilmington, Delaware and its surrounding areas. Lepore Accessibility Statement, Our website uses cookies to enhance your experience. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. Sagging eye syndrome (SES) was first described by Rutar and Demer in 2009, as a potential leading cause of strabismus in older adult population as a combination of horizontal and vertical strabismus in addition to bilateral blepharoptosis (ptosis with high lid creases) and deepening of the sulcus. Patients may also present with ductional deficits depending on the grade of muscle displacement. 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. The characteristics of the patients in this series who have an idiopathic disorder suggest that if certain rules of diagnosis are obeyed, divergence insufficiency can be distinguished from sixth cranial nerve palsy in most cases using clinical techniques. The orbital layer, inserts on the pulley, not on the globe. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. 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. Convergence Insufficiency. The differential includes: It can be difficult to adjudicate small angle deviations such as HES and SES from mild myasthenia gravis, incompletely resolved sixth nerve palsy, thyroid eye disease, and decompensated prior phorias. 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 of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. 131. This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. Simultaneous injury of the medial longitudinal fasciculus has been postulated as another reason sixth cranial nerve palsy may appear comitant.4 However, none of the patients classified as primary had clinical signs of internuclear ophthalmoplegia. . However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. To prevent double vision, the individual exerts extra effort to make the eyes turn back in. 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. it is highly advisable that you check them out first as they cover basics not explained here. I still have mild double vision and . Introduction. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. Mosbys Optometric Problem Solving Series, ed. Drs. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. What is congenital ocular motor apraxia? Instead, the initial history and physical examination proved to be powerful tools to distinguish those patients with a primary disorder from those with an underlying neurologic or systemic (ie, secondary) cause of divergence insufficiency. 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. . 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 many individuals with, Normalizing accommodation is important because. Conclusions PMDivergence paralysis. HMDivergence paralysis following head trauma. EDivergence insufficiency: characteristics, diagnosis, and treatment. THBird Again it seems unlikely, since CTs performed in 2 patients and an MRI performed in 1 were normal, and signs of divergence insufficiency were improving in 2 of these patients at the time of their last evaluation. Trans Am Ophthalmol Soc. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. Reproduction in whole or in part without permission is prohibited. Corbett Patients will be able to work on fusing the images of one. When prescribing ground-in prism, high index lenses, plastic frames and frames that are smaller in size help improve the weight and cosmesis of the lenses. 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. Connective tissues reflect different mechanisms of strabismus over the life span. Audio blog post. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. Krohel 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. 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. 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. CHNuclear and infranuclear ocular motility disorders. 2016;28(1):38-42. This is the brain's answer to coping with double vision and the stress of eyes not working as a . Wednesday, March 15, 2023 | All Eyes On Evaporation, Thursday, April 13, 2023 | All Eyes On Evaporation, Tuesday, April 18, 2023 | All Eyes On Evaporation. Goldberg 1995, St. Louis, Missouri: Mosby. 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. Eye - Diplopia following cataract surgery . An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. 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. [5], There has been an increased awareness and diagnosis of these degenerative strabismic disorders after 2000. Corresponding author: Daniel M. Jacobson, MD, Neuro-ophthalmology (4F-2), Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (email: jacobsod@mfldclin.edu). Strabismus. These exercises were discussed in detail in Part 6 of this series. Near point convergence is the distance you can use both eyes without seeing double. The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). American Academy of Ophthalmology. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. What is divergence insufficiency? 2012;95(2):192-7. We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. All Rights Reserved. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. Therefore, it forces the patient to use both eyes properly to see the image. Similarly, the theories on mechanism of divergence itself have varied. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. Objectives 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. 1. Divergence excess is an over-divergence when attempting to look at distant objects. 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.