Arch Ophthalmol. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. Divergence insufficiency revisited: natural history of idiopathic cases and neurologic associations. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. As a . To begin therapy, many therapists will focus first on normalizing the accommodative system. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Recent trauma They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. Primary divergence insufficiency is generally a benign condition. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Sensory Anomalies. JLSaccadic velocity analysis in patients with divergence paralysis. 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. Prism is a powerful tool that can be used to successfully treat a variety of binocular vision conditions. When considering whether it is appropriate to prescribe vertical prism for a patient with combined horizontal and vertical deviations, particularly for a patient with intermittent strabismus, first identify whether the vertical deviation is primary or secondary. 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. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. The patients with primary divergence insufficiency in this retrospective survey were most often middle-aged or elderly persons with neurologically isolated double vision for distance who, not uncommonly, developed symptoms following a nonspecific illness or minor head trauma. In that study, strabismus surgery was performed in 50% of all SES cases. 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. Jampolsky Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. PJThompson This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. These exercises were discussed in detail in Part 6 of this series. The distance at which diplopia occurs is noted (near point of convergence). Esotropia resolved within days of initiating corticosteroid treatment in both patients. REBaumgartner AParalysis of divergence. Effectiveness of base in prism for presbyopes with convergence insufficiency. In a recent study by Goseki et.al. et al. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. 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. The association with refractive errors (and high myopia in particular) has been a point of contention for some time. 7. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. 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. CHNuclear and infranuclear ocular motility disorders. Privacy Policy| 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. What is convergence insufficiency? 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. 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). Moller Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. FDDutton What Are the Symptoms of Convergence Insufficiency? SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As 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. Extraordinary symptoms equivalent to diplopia 2.3.1. What are causes of convergence insufficiency? If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. Success of prisms in the management of diplopia due to fourth nerve palsy. Convergence describes the way our eyes move together and point inward when we look at near objects. 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. 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. Br J Ophthalmol. 133. Basic Esophoria and Exophoria. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. Cunningham Chang MY, Pineles SL, Velez FG. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. If the patient is only using one eyethe image will not be formed correctly. Divergence insufficiency can vary in severity, from minor deficits to complete divergence paralysis. 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. 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. . PMDivergence paralysis. 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. To determine the natural history of primary divergence insufficiency and to identify clinical features that distinguish patients with this neurologically isolated form of divergence insufficiency from those harboring neurologic disorders. Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. RMTomsak 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. Weird vision divergence upon waking at night User Name: Remember Me: Password . 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. None of these patients underwent strabismus surgery. It is possible that with longer follow-up, the number of patients with resolution of diplopia might increase. as their fusional vergence ranges expand. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. Divergence excess is an over-divergence when attempting to look at distant objects. 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. 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. RJZee SHarbison [5], In recent imaging studies, Patel et al. Pang Y, Teitelbaum B, Krall J. IRT. Caloroso E, Rouse MW. Clinical management of strabismus. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. The signs and symptoms with this condition are similar to convergence excess. MThe child with divergence paresis. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][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. More advanced exercises for vergence insufficiencies include. Pencil pushups may be effective in some cases. Roper-Hall Dr. Jenewein is an assistant professor at Salus University, Salus Universitys Principal Site Investigator for the Pediatric Eye Disease Investigator Group, a Fellow of the American Academy of Optometry and a Diplomate of the Binocular Vision, Perception and Pediatric Optometry Section of the Academy. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. 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. With CI, the eyes do not point together inward as one looks at objects close-up. Motion sickness or dizziness ( vertigo) Headache . Divergence insufficiency is the opposite problem of convergence insufficiency. GTDJohnston 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. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. 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. 133. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. 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. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? 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. Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. Patients presenting with a greater eso deviation at distance than at near, a concomitant deviation, and diplopia pose a challenging and critical diagnostic and therapeutic puzzle for . Wiggins Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. This page was last edited on January 26, 2023, at 08:42. Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. Reproduction in whole or in part without permission is prohibited. In 2005 Thacker NM et al. None of the patients initially classified as having primary divergence insufficiency developed additional neurologic dysfunction during the period of follow-up. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. Scheiman M, Cotter S, Rouse M, et al. If the dot becomes doubled, go back to the previous dot and try again. Chaudhuri Z, Demer JL. 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. Due to the degenerative etiology of this syndrome, the connective tissue involution may progress after surgery, up to 20% of patients[15], therefore is important to inform the patient of this possibility prior to surgery. METraviesa What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? J Pediatr Ophthalmol Strabismus. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. BBordaberry Convergence Insufficiency Testing. New York, NY Oxford University Press1999;405-610. 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}. 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. Most trial lens sets come with prism lenses, but for larger angles of strabismus, it may be helpful to use a Fresnel prism trial set. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. https://www.aao.org/interview/heavy-eye-vs-sagging-eye-syndrome, https://www.aao.org/audio/sagging-eye-syndrome, https://doi.org/10.1016/j.ajo.2019.09.006, https://eyewiki.org/w/index.php?title=Sagging_Eye_Syndrome&oldid=89033, Results from bilateral inferior shift of the LR pulleys, Characterized by esotropia at distance fixation, orthotropia or esophoria at near fixation, Normal horizontal duction range and normal horizontal saccadic velocities, Results from asymmetrical inferior shift of the LR pulley, Characteristically by hypotropia and excyclotortion of the lower eye, ARDE only: incomitant esotropia worse in distance and in side gaze with no strabismus or small phoria for near and, ARDE and CVS: incomitant esotropia with a small hypotropia in one side, CVS only: hypotropia with no horizontal deviation, Normal horizontal duction range, and normal horizontal saccadic velocities, Cranial nerve palsy (Third, Fourth or Sixth nerves). However, the cause of convergence insufficiency is often unknown. 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. 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. Lepore What causes divergence insufficiency? The orbital layer, inserts on the pulley, not on the globe. She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . Lets continue the conversation over on your social network of choice. Another historically reported feature of DI is significantly decreased negative fusional vergence (fusional divergence), along with the deficits direct relationship to distance of gaze. 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. Teitelbaum B, Pang Y, Krall J. Home Vision Therapy 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. Thomson DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. 2013;97(11):1415-9. Long-term follow-up and clinical features of the 2 groups were compared. From there, basic vergence exercises will be added in. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. All rights reserved. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Chaudhuri Z, Demer JL. 2005;9:36. 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.
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