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. Customize your JAMA Network experience by selecting one or more topics from the list below. Another area of controversy concerns whether divergence insufficiency is a localizing sign referable to injury of a "divergence center," or is a nonlocalizing sign associated with a variety of focal and diffuse brain insults. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. The mechanical properties of pulleys are critical for the support and rotational properties of the eye. Vertical deviations often cause patients to experience significant symptoms even when the deviation is small. FEDivergence paresis: a nonlocalizing cause of diplopia. RMTomsak
Long-term Surgical Outcomes in the Sagging Eye Syndrome. You can also use Random Dot Stereo (RDS) testing to determine fusion prism. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. 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. DIdiopathic intracranial hypertension: a prospective study of 50 patients. The mirror stereoscope is one of the most commonly used types. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. 6. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. 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. Pang Y, Teitelbaum B, Krall J. This means the eyes do not like to move inward toward the nose and is problematic when trying to look at a near target. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. More respect for connective tissues. 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. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. Chaudhuri Z, Demer JL. Of the 15 patients with secondary divergence insufficiency, there were 11 women and 4 men, ranging in age from 8 to 86 years, with a median (mean) age of 56 (51) years. divergence insufficiency synonyms, divergence insufficiency pronunciation, divergence insufficiency translation, English dictionary definition of divergence insufficiency. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. 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). RDDivergence paralysis. What causes divergence insufficiency? Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. What is convergence spasm? Depending on the clinical circumstances, the imaging, and the course, clinicians should consider evaluating for other etiologies prior to making the diagnosis of HES or SES. Moore
[5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. How is convergence insufficiency treated? Arch Ophthalmol. Hold focus on this dot for 10 seconds. Jacobson DM. Teitelbaum B, Pang Y, Krall J. To be enrolled in the study, patients had to meet the following 5 criteria: 1) relatively sudden onset of double vision at far vision, 2) no double vision at near vision, 3) high myopia >6.0 diopters (D) in both eyes, 4) no other neurological symptoms, and 5) a normal . The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). Sagging Eye Syndrome. [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. RDInternuclear ophthalmoplegia in giant cell arteritis. 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. Supported by Vertical Heterophoria. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. [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. All Rights Reserved. Reference: 1. 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. Clinical management of strabismus. Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. From there, basic vergence exercises will be added in. JAInman
[Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. It is a disorder involving binocular vision vision using both eyes. 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. When nonisolated, divergence insufficiency is most often reported in patients with intracranial hypertension, a neurologic condition often associated with sixth cranial nerve palsy.8,12-14,16 Some investigators have recorded slow abducting saccades in patients with signs consistent with divergence insufficiency, suggesting that abducens palsy was the cause of esotropia in these individuals.14 However, this finding has not been reproduced.11,17. 12. Lewis
While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. They use head thrusts to shift fixation. Results from this study also supported previously published evidence of normal age-related connective tissue degeneration as there was a positive age effect in correlation to supero-temporal bowing of the LR-SR band.[9]. Bedrossian
Wiggins
MThe child with divergence paresis. 1993, Oxford, UK: Butterworth Heinemann Books. NParalysis of divergence. Jacobson DM. Clin Exp Optom. Although each method has its advantages and disadvantages, they all suffer from being subjective. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. 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}. 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 the meantime, temporary paste-on and, if stable for several weeks, permanent ground-in prisms, were effective and conservative means of relieving symptoms in these patients. None of these patients developed signs of an underlying neurologic disorder during follow-up. What is congenital ocular motor apraxia? THBird
Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. Divergence insufficiency is the opposite problem of convergence insufficiency. What are the symptoms of Convergence Insufficiency? . 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. ACSanders
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. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. it is highly advisable that you check them out first as they cover basics not explained here. With CI, the eyes do not point together inward as one looks at objects close-up. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. The normal amount of fusional divergence ability at distance is lower than that of fusional convergence ability, making it challenging to sufficiently increase ranges to compensate for esophoria or esotropia at distance. After these patients are evaluated for any underlying systemic or neurological disease, which must always be ruled out in any case of new-onset strabismus, they are often good candidates for a prism prescription. Home Vision Therapy Convergence Insufficiency Testing. 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. Adnexal signs such as: retraction of the upper eyelid into the superior orbit (superior sulcus deepening), aponeurotic blepharoptosis, floppy lower lids, and high upper eyelid crease. Of note among this cohort of patients without strabismus, noncontinuous LR-SR bands were found in 5% of cases, and superotemporal bowing in 24% of cases. 2016. 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) In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. 2023 American Medical Association. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. 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. 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 most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. One patient was followed up for only 1 month, but her esotropia resolved during that time. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? AmblyoPlay is a vision therapy solution that is performed through playing therapeutic games and exercises on your tablet or computer for 30 minutes per day. 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. Lyle
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. 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. No clear sex predilection has been identified for the primary form of the condition. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. [12]Later Chaudhuri and Demer reported 24 patients and compared the results of those undergoing lateral rectus resection (n = 8) to those undergoing medial rectus recession (n = 16). [10] In 2013, Stager et al. 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. It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. Committee on Aging. 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. Lepore
Smith
The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. Demer JL et al. It is spasm of the near triad: 1. 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. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. doi:10.1136/bjophthalmol-2015-306783. Scheiman M, Cotter S, Rouse M, et al. 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 information below is from Neuro-ophthalmology Illustrated-2nd Edition. Convergence Insufficiency. Krohel
The most successful prism cases are often patients who have intermittent strabismus and good potential for normal fusion or patients with strabismus who have not developed any sensory anomalies. 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. To begin therapy, many therapists will focus first on normalizing the accommodative system. if you would like to learn more about convergence and divergence insufficiency. DRHartnett
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. Accessibility Statement, Our website uses cookies to enhance your experience. When patients are spectacle independent and want to remain independent, surgical approach could be offered. All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. J AAPOS. Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. Reproduction in whole or in part without permission is prohibited. Demer JL. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. NJeds, Leigh
GBTobin
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. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. NRNewman
The EOM angles in these patients ranged from 100 to . 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. 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. 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. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and help make average daily distance tasks more manageable with less frequent symptoms. Progressive supranuclear palsy. Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. New York, NY Oxford University Press1999;405-610. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. 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. an electromyographic study. Basic Esophoria and Exophoria. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. Convergence Insufficiency. MCiner
[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. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. 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). 2023 Stanford School of Medicine | Terms of Use | Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. Divergence excess is an over-divergence when attempting to look at distant objects. Accepted for publication February 11, 2000. J Neuroophthalmol. Divergence insufficiency revisited: natural history of idiopathic cases and neurologic associations. JAAcquired esotropia due to Arnold-Chiari I malformation. 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. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Arch Ophthalmol. Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. Chang MY et al. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. 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.