In the 17 patients with primary divergence insufficiency who had adequate information to ascertain long-term follow-up, double vision persisted in 9 individuals. It is most often related to raised intracranial pressure or Chiari malformation. Another historically reported feature of DI is significantly decreased negative fusional vergence (fusional divergence), along with the deficits direct relationship to distance of gaze. Results: In high-myopia patients with divergence insufficiency, ocular axis measurements ranged from 24.8 to 31.0 (mean SD: 27.6 1.6) mm. By continuing to use our site, or clicking "Continue," you are agreeing to our, Clinical Features of Patients With Primary and Secondary Divergence Insufficiency, Disorders Associated With Secondary Divergence Insufficiency. If your patient is still experiencing diplopia, additional prism may be needed to help them achieve fusion. In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. Divergence insufficiency is the opposite problem, accommodation will be worked on first to ensure it is equal between the two eyes, basic vergence exercises will be added in. This decreases the motor fusion demand, allowing the patient to fuse more comfortably. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. More advanced exercises for vergence insufficiencies include. All Rights Reserved. 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. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. MCiner NRNewman Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. Questions with answers: 125. It is possible that with longer follow-up, the number of patients with resolution of diplopia might increase. Objectives Convergence insufficiency is a common problem with the eyes, and is the main culprit behind eyestrain, blurred vision, and headaches. Between the polarizing glasses and the patients fusional vergence system, he or she will be asked to either converge or diverge to fuse the two partial images into one 3-D image. Patients will be able to work on fusing the images of one. make average daily distance tasks more manageable with less frequent symptoms. Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. 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). Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. 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). LRosenbaum EHBilateral sixth-nerve paresis simulating divergence paralysis. [3], from 945 patients complaining of double vision, majority of patients between 60 and 80 years, approx 31% had SES and were older, ~71 years old, with ~60% female predominance. What Are the Symptoms of Convergence Insufficiency? Certain factors are associated with exotropia, including genetics and health conditions. 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. Bedrossian The distance at which diplopia occurs is noted (near point of convergence). 13.119). 2023 American Medical Association. Antireflective coating is also beneficial for patients wearing prism lenses. Esodeviation is comitant in all fields of . 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. 13. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. 2016;28(1):38-42. The other patient with focal brainstem injury, a stroke with double vision, vertigo, and left arm numbness, did not have the responsible lesion identified by the CT. 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. It involves a specialty optical system and a uniquely created image book. Primary divergence insufficiency is generally a benign condition. Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. Patients who wear contact lenses the majority of the time or who have undergone refractive, cataract or strabismus surgery may not be happy with the idea of moving or going back to spectacle wear even if it relieves asthenopia or diplopia. Bothun ED, Archer SM. 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. All rights reserved. Divergence insufficiency revisited: natural history of idiopathic cases and neurologic associations. NADivergence paralysis. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. AParalysis of divergence. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. Caloroso E, Rouse MW. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. Histories reveal the possibility of a number of etiologic factors. Reproduction in whole or in part without permission is prohibited. Thomson Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Prism in reading glasses or strabismus surgery may be required. 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. J Pediatr Ophthalmol Strabismus. CHNuclear and infranuclear ocular motility disorders. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. 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. 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. LMDivergence paralysis with increased intracranial pressure: further observations. JAAcquired esotropia due to Arnold-Chiari I malformation. Different cards with different images will require different amounts of negative and positive fusional vergence. 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. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Accepted for publication February 11, 2000. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. 2000;118(9):1237-41. 2005;9:711. 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. Retrospective survey of patients with divergence insufficiency. FDDutton What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Extraordinary symptoms equivalent to diplopia 2.3.1. Patients will be able to work on fusing the images of one card and move on to a more difficult card as their fusional vergence ranges expand. 2012;95(2):192-7. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . Divergence insufficiency can vary in severity, from minor deficits to complete divergence paralysis. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Since divergence is an active process, not a passive one associated with relaxation of the medial rectus muscles,5 some investigators hypothesize that a "divergence center" must exist. American Academy of Ophthalmology. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. Each card contains a partial view of the complete image. Sagging Eye Syndrome. In spectacle-dependent patients, a temporary Fresnel prism or permanent ground in prism are usually helpful in managing the double vision for distance without inducing diplopia for near given their strong near fusional capacities as mentioned before. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. What is divergence insufficiency? This ocular misalignment has two main types: esotropia and exotropia. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Only 2 patients were followed up for less than 6 months. 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. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. 2012;49(4):222-8. The signs and symptoms with this condition are similar to convergence excess. PMDivergence paralysis. Smith along with the fusional vergence system to create a 3-D object. unable to diverge appropriately to a given target. Lateral rectus resections in divergence palsy: Results of long-term follow-up. It is spasm of the near triad: 1. use an approach called the SILO affect to work on increasing divergence or convergence ranges. 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. Ductions and versions are full. JSLevy When patients are spectacle independent and want to remain independent, surgical approach could be offered. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. 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. 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. Also found significant displacement of all four rectus pulleys away from the orbital center, lateral displacement of the inferior rectus pulley and obliquely angulated lateral rectus pulley. DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. 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. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. . 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. 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. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or esotropia, meaning the eyes like to sit in an inward position. Long-term follow-up and clinical features of the 2 groups were compared. 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. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. [10] In 2013, Stager et al. [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. A secondary vertical deviation, on the other hand, presents when the patients eyes are strabismic but disappears when the patient aligns their eyes to the ortho position.7 Secondary vertical deviations are common in strabismic patients, particularly in those with intermittent exotropia. Progressive supranuclear palsy. Many affected patients experience spontaneous resolution of double vision within several months. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As 13.121). A common a daily, home rehabilitation technique is to have the patient do push-up exercises (looking at an object intermittently moved in and out from the bridge of the nose) to decrease the near point of convergence. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre, If you can remember the old newspaper comics that had a green image with a red image overlying it, that would turn into a 3-D image if you put on red/blue 3-D glasses, In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees, Different cards with different images will require different amount. the accommodative and vergence systems are tightly correlated. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. [4]A dense band iss present from the medial rectus to the inferior pulleys (MRIR band) and from the medial rectus to the superior rectus pulleys (MRSR band). Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations | Neurology | JAMA Ophthalmology | JAMA Network ObjectivesTo determine the natural history of primary divergence insufficiency and to identify clinical features that distinguish patients with this neurologica [Skip to Navigation] RJZee Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. 133. Many patients were first evaluated within 1 month of the onset of symptoms, far sooner than the expected time course for the spread of comitance to convert a sixth cranial nerve palsy to a comitant esotropia. 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). Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Chang MY et al. A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. The cyclotorsion component of SES was present in 65% of patients. 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. In many individuals with, Normalizing accommodation is important because. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . J AAPOS. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. Neena R, Giridhar A. 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. 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. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. Optom Vis Sci. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. Stager DR, Sr, Black T, Felius J. This is the brain's answer to coping with double vision and the stress of eyes not working as a . Other training exercises include base-out prisms for near viewing and convergence exercises. Convergence Insufficiency Symptoms. The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. if you would like to learn more about convergence and divergence insufficiency. Although each method has its advantages and disadvantages, they all suffer from being subjective.
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