The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. 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 is convergence insufficiency? Divergence insufficiency is a benign phenomenon causing horizontal diplopia at distance viewing . 1993, Oxford, UK: Butterworth Heinemann Books. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Patel SH, Cunnane ME, Juliano AF, Vangel MG, Kazlas MA, Moonis G. Imaging appearance of the lateral rectus-superior rectus band in 100 consecutive patients without strabismus. JLSaccadic velocity analysis in patients with divergence paralysis. 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. 130. 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. 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. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. FDDutton Audio blog post. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. RMDiagnosis and management of divergence paresis. In that study, strabismus surgery was performed in 50% of all SES cases. Chang MY, Pineles SL, Velez FG. What is convergence insufficiency? Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. 3rd ed. How is convergence insufficiency treated? Chaudhuri Z, Demer JL. Drs. This problem is most commonly found in children. [5], MRI measurements of horizontal EOM lengths in SES were approximately 40%, or 14 mm, longer than the EOMs of nonstrabismic younger and older controls. 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. 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. 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. 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. People notice symptoms while reading or doing other near work. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. As a . Objectives Prism prescriptions often greatly improve the quality of life of your patients by reducing asthenopia and diplopia. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. What is congenital ocular motor apraxia? Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. 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. AOcular divergence mechanisms. A Vectogram is a tool which utilizes specialized imaging along with the fusional vergence system to create a 3-D object. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. Biousse V and Newman NJ. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying 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}. Convergence 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. Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. doi:10.1001/archopht.118.9.1237. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). Histories reveal the possibility of a number of etiologic factors. Chang MY et al. Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation LMDivergence paralysis with increased intracranial pressure: further observations. None of these patients developed signs of an underlying neurologic disorder during follow-up. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? PCBurian These patients often present with horizontal and vertical deviations. GNCurrent concepts in giant cell (temporal) arteritis. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? Effectiveness of prisms in relieving diplopia in superior oblique palsies. All Rights Reserved. ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. Sagging Eye Syndrome. JAAcquired esotropia due to Arnold-Chiari I malformation. 8. 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. Committee on Aging. Treatment options include correction with base-out prisms for distance, Tomasz A. Wiraszka, MD, and Praveena Gupta, OD, PhD, FAAO, Galveston, Texas, April 2015 Wills Eye Resident Case Series, Wills Eye Resident Case Series - Diagnosis and Discussion, November 2014 Wills Eye Resident Case Series, February 2016 Wills Eye Resident Case Series - Diagnosis & Discussion. 12. J AAPOS. The EOM angles in these patients ranged from 100 to . Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. Privacy Policy| unable to diverge appropriately to a given target. Jacobson DM. Therefore, it forces the patient to use both eyes properly to see the image. 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. Ductions should be tested with the fellow eye covered. The main treatment for convergence insufficiency is vision therapy. 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. For example, the right eye might see a lion while the left eye sees a cage. Extraordinary symptoms equivalent to diplopia 2.3.1. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. 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. Corbett changing the target) or by using multiple vectograms and making the patient look from one to another and quickly adapting the vergence system appropriately to each target (this is called jumping vectograms). If the patient is only using one eyethe image will not be formed correctly. Abstract. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). 126. 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 . 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 addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. Godts D, Mathysen DG. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. [1]SES should be differentiated from heavy eye syndrome (HES) which is an association of axial high myopia, esotropia, and hypotropia. No signs of orbital ischemia were present in the second patient. 5. 13. is variable. 13.119). What is congenital ocular motor apraxia? These arguments do not preclude the possibility that some patients with comitant esotropia at distance and full-appearing ocular ductions might be suffering from sixth cranial nerve palsy, not divergence insufficiency. 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. 132. Clin Exp Optom. You can also use Random Dot Stereo (RDS) testing to determine fusion prism. MCiner Terms of Use| Double vision. Scheiman M, Wick B. 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. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. 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. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. RLMagnetic resonance images in a case of "divergence paralysis.". This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. 1978;76:610-53. 7. 1. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. 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. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. 2013;97(11):1415-9. 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. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. Heavy eye syndrome versus sagging eye syndrome in high myopia. [2] 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. Lim Roper-Hall A near card is brought toward the patients nose until the patient sees double. 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. 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. 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. Arch Ophthalmol. JWStockbridge 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. Customize your JAMA Network experience by selecting one or more topics from the list below. FEDivergence paresis: a nonlocalizing cause of diplopia. 126. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. JAInman Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. 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). The association with refractive errors (and high myopia in particular) has been a point of contention for some time. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. Convergence Insufficiency Symptoms. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. When patients are spectacle independent and want to remain independent, surgical approach could be offered. Per some observations, its is more common in Caucasian females. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. Kerala J Ophthalmol. Patients and methods. 130. 133. After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. 2008;126(10):1336-49. Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. In many of these cases, the initial management strategy is prescribing vertical prism.1 Often, if the vertical deviation is decreased or eliminated, the patient may be able to comfortably fuse the horizontal deviation. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. New York, NY Oxford University Press1999;405-610. Thomson Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. 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. Another historically reported feature of DI is significantly decreased negative fusional vergence (fusional divergence), along with the deficits direct relationship to distance of gaze. It is idiopathic most often in children or young adults 2. I still have mild double vision and . 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. 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). Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. 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 . Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. None of these patients developed signs of an underlying neurologic disorder during follow-up. 133. American Academy of Ophthalmology. 2. 2014;35(9):1830-5. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. It can also decrease distance judgement, coordination, and sports performance. 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. A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. Patients may also present with ductional deficits depending on the grade of muscle displacement. Rather, treatment for a secondary vertical deviation should aim to improve horizontal sensory and motor fusion through vision therapy so the patient is not in the strabismic position as often, thus eliminating the vertical deviation. 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. Their symptom was controlled using prisms. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. . Br J Ophthalmol. 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. [unreliable source?] If your patient is still experiencing diplopia, additional prism may be needed to help them achieve fusion. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. Posted by . They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. Retrospective survey of patients with divergence insufficiency. Biousse V and Newman NJ. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. 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.
