12. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. 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. With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. SHarbison Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. Neuro-ophthalmology Illustrated Chapter 13 Diplopia 10 - Convergence If the dot becomes doubled, go back to the previous dot and try again. No clear sex predilection has been identified for the primary form of the condition. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. What is congenital ocular motor apraxia? [1][5][8] The patients may also present with bilateral ptosis. The author has no commercial or proprietary interest in any product or company mentioned in this manuscript, and has no financial interest nor receives payment as a consultant, reviewer, or evaluator. 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. _________________________________________________________________. Arch Ophthalmol. Patients with non-strabismic binocular vision disorderssuch as divergence insufficiency, basic esophoria and vertical heterophoriacan often benefit from treatment with prism, particularly relieving prism, while othersincluding those with convergence excess, convergence insufficiency, divergence excess or basic exophoriaare better managed with other treatment modalities, such as vision therapy or lenses.1 An option for prism patients is prescribing prism to relieve diplopia and asthenopia and concurrently having the patient do vision therapy to attempt to decrease or eliminate the amount of prism needed. Conclusions Tamhankar MA, Ying GS, Volpe NJ. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. Long-term follow-up and clinical features of the 2 groups were compared. Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. Jacobson DM. 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. Similarly, the theories on mechanism of divergence itself have varied. Chaudhuri Z, Demer JL. They are low in cost and can be easily applied to a pair of spectacle lenses in-office to try out on a patient for several days or weeks, and refining the prism prescription is inexpensive and simple. 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. Divergence insufficiency associated with high myopia - PubMed 2014;18(4):309-15. The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. J Neuroophthalmol. Convergence Insufficiency Testing. [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). Fresnel membrane prisms can be very useful for many aspects of prescribing prism. 9. 1978;76:610-53. DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. 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] [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. Convergence Insufficiency (CI): Symptoms, Diagnosis - Cleveland Clinic Convergence Insufficiency - American Academy of Ophthalmology Accessibility Statement, Our website uses cookies to enhance your experience. In those patients with secondary divergence insufficiency, the underlying disorder was either already established or strongly suspected based on the additional neurologic symptoms and signs at their initial evaluation. 2. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. Eye - Diplopia following cataract surgery . JAAcquired esotropia due to Arnold-Chiari I malformation. 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. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. The remainder of the neurological examination should be normal, without any cranial neuropathies. 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}. Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. Connective tissues reflect different mechanisms of strabismus over the life span. Theme. THBird People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. Diplopia Developed in Later Life, An Ophthalmologic Approach is fixed. 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. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. Heavy Eye vs. Questions: 125. Keep moving to the next dot along the card, gradually getting closer to the nose. Cotter SA. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. Strabismus. RMTomsak I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. Other training exercises include base-out prisms for near viewing and convergence exercises. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. PJThompson created image book. Parkinson disease 4. Divergence insufficiency associated with high myopia | OPTH Common symptoms include: headaches; blurred vision ; double vision All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. 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. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. MGallaway 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. 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. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. 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. Convergence Insufficiency Testing. It is possible that with longer follow-up, the number of patients with resolution of diplopia might increase. divergence excess eyewiki The orbital layer, inserts on the pulley, not on the globe. 132. Terms of Use| Strabismus. Objectives Exercises for double vision: 4 things to try - Medical News Today DIVERGENCE INSUFFICIENCY - Optography Blurred vision. 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. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. The first hurdle is ensuring your patient is comfortable with wearing spectacles. 2008;12(1):56. 2005;9:36. The association with refractive errors (and high myopia in particular) has been a point of contention for some time. If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. What causes divergence insufficiency? Divergence Insufficiency. Br J Ophthalmol. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. and asking the patient to converge or diverge will work on the focusing system and expand the eyes abilities to converge or divergehence helping with an insufficiency problem. The patient places two transparent cards into the vectogram system. Bender It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. ALDemer Graefes Arch Clin Exp Ophthalmol. 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. The patient is also instructed to keep the words around the lines clear to control accommodation. Other associated symptoms can include asthenopia of panoramic type. American Academy of Ophthalmology. None of these patients developed signs of an underlying neurologic disorder during follow-up. Goldberg Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. [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. 2012. HS Only 2 patients were followed up for less than 6 months. In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . 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. LRosenbaum All but 1 patient were older than 50 years. Wall A 5-year-old female initially presented for a strabismus and amblyopia evaluation. This association has been reported before, and has contributed to the controversy of whether divergence insufficiency represents a separate disorder or subtle sixth nerve palsy.14 Although the double vision reported in patients with pseudotumor cerebri is generally attributed to sixth cranial nerve palsy,27,28 I suspect that many symptomatic patients have divergence insufficiency, as suggested by Smith.29. The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. 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). 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. In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. This page was last edited on January 26, 2023, at 08:42. 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. 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. 2014;35(9):1830-5. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). 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. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. 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. This means the eyes do not like to move inward toward the nose and is problematic when trying to look at a near target. PDF CLINICAL SCIENCES Divergence Insufficiency Revisited - JAMA Chaudhuri Z, Demer JL. 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. 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. What is Convergence Insufficiency? Symptoms, Treatments - Healthline Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. Arch Ophthalmol. FDDutton The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. 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. PDF Divergence Insufficiency - Jama Lateral rectus resections in divergence palsy: Results of long-term follow-up. CI affects children and adults. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . Prescribing for some patients with intermittent strabismus can be done by using Sheards or Percivals criteria or determining the associated phoria as with heterophoric patients. The most effective treatment for this condition is office-based vision therapy, but prism can be considered in patients who are unable to undergo this treatment modality.1,8 A study did not find a significant difference in the signs or symptoms of children with convergence insufficiency who wore base-in prism compared with children who wore placebo lenses.9 Although prism has not been shown to be beneficial in children with this condition, adult presbyopic patients with convergence insufficiency may benefit from prism treatment.10,11. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. PCBurian The main treatment for convergence insufficiency is vision therapy. Using magnetic resonance imaging (MRI), a coronal image 6 mm anterior to the eyeball-optic nerve junction was measured and used to examine the extraocular muscle (EOM) path shift . Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. One of the most important aspects of successfully prescribing prism is choosing patients who will benefit the most from it. 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. The use of topical anaesthesia does not abolish this surgical risk. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. 3. Bruce It was found that the mean distance-esotropia deviation in Prism was 6.9 0.7 and it resolved to 0.3 0.3 after surgery, while mean vertical deviation went from 3.0 0.3 to 0.7 0.2. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. LBSharpe Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. 4 Binocular Vision Problems that Cause Eyestrain Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. What is divergence insufficiency? Divergence Insufficiency: An Ongoing Challenge - Review of Ophthalmology Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. Six patients underwent CT and 10 underwent MRI. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. RDInternuclear ophthalmoplegia in giant cell arteritis. Home Vision Therapy Convergence Insufficiency Testing. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. PMDivergence paralysis. Define divergence insufficiency. . As a . Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. 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. It can also decrease distance judgement, coordination, and sports performance. 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. Concussion: Understanding Vision Problems Post-Injury - bocatc.org All Rights Reserved. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. Hold focus on this dot for 10 seconds. Convergence and Divergence - Vivid Vision 129. DIdiopathic intracranial hypertension: a prospective study of 50 patients. The additional literature on the subject of divergence insufficiency largely consists of small series of patients mainly reported in the precomputed tomography (CT) era and patients with neurologically isolated divergence insufficiency mixed with those who additionally had other signs of intracranial hypertension or a structural brain lesion.15,18-21 The purpose of my study was to describe a large series of patients with divergence insufficiency evaluated in the post-CT era to determine the natural history of neurologically isolated cases, to determine the spectrum of neurologic associations, and to identify clinical features that might be helpful in distinguishing those patients with an isolated disorder from those harboring neurologic disorders. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Divergence Insufficiency/Excess | Vision Therapy Paducah Kentucky Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. In 2015 Chaudhuri and Demer published a retrospective observational study about utilizing Graded Vertical Rectus Tenotomy (GVRT) for treating incomitant vertical misalignment. 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. . 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. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. 2005;9:711. These studies were unrevealing in all patients. 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Convergence and Divergence - Vivid Vision Reproduction in whole or in part without permission is prohibited. Pencil pushups may be effective in some cases. What is the cause of convergence spasm? 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.
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