Intermittent convergence Always with accommodation and pupillary constrictionClassic causes of convergence spasm include the following: Most often nonorganic Excessive accommodation from uncorrected refractive error Lesions at the diencephalicmesencephalic junction (very rare)Convergence InsufficiencyConvergence insufficiency is a very common condition, characterized by the following: Exotropia greater at near than at distance (at least 10 prism diopters difference) Causes symptoms of asthenopia (fatigue with reading, diplopia at near, intermittent blurred vision when reading) Usually benign; may improve with orthoptic exercises Sometimes requires prisms in reading glasses or strabismus surgeryClassic causes of convergence insufficiency include the following: Idiopathic most often (in children or young adults) Head trauma Parkinson disease Progressive supranuclear palsyThe ability to converge can be measured (Fig. Chaudhuri Z, Demer JL. 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. doi:10.1136/bjophthalmol-2015-306783. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. Our eye doctors. DJDivergence insufficiency. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. In addition, all patients underwent examination of ocular motility using a Maddox rod to demonstrate that the angle of uncrossed deviation increased as the viewing distance increased, remained the same or decreased in right and left gazes at distance, and decreased as the viewing distance decreased. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. 2012;95(2):192-7. [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). 10. 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. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Retrospective survey of patients with divergence insufficiency. 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. Schanzer Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. 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. 3. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. Different cards with different images will require different amounts of negative and positive fusional vergence. 1978;76:610-53. This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. The association with refractive errors (and high myopia in particular) has been a point of contention for some time. 5. Mosbys Optometric Problem Solving Series, ed. GBTobin The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. NJeds, Leigh 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. 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. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. Similarly, the theories on mechanism of divergence itself have varied. 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. 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. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Moore 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. 2012. Prism is a powerful tool that can be used to successfully treat a variety of binocular vision conditions. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. In that study, strabismus surgery was performed in 50% of all SES cases. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. 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). JAInman Fresnel membrane prisms can be very useful for many aspects of prescribing prism. A near card is brought toward the patients nose until the patient sees double. 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. 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). 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 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. 129. These studies were unrevealing in all patients. 2012;49(4):222-8. Convergence insufficiency (CI) is a vision disorder. an electromyographic study. Although each method has its advantages and disadvantages, they all suffer from being subjective. Initial tenotomy 30% of tendon width was performed to avoid intraoperative overcorrection. All rights reserved. Jampolsky Lepore What is convergence insufficiency? Using the Mann-Whitney test, there was no significant difference in the size of esotropia in forward gaze at distance or near point of fusion between the groups of patients with primary and secondary divergence insufficiency (Table 1). If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. It is a disorder involving binocular vision vision using both eyes. . Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. Hold focus on this dot for 10 seconds. This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. 133. Jacobson DM. MEBarrows DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. 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. Bedrossian THBird EJampolsky reported a case series of 9 patients with vertical strabismus incomitant in horizontal gaze positions and cyclotorsion who underwent Adjustable small-incision selective tenotomy and plication. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. The remainder of the neurological examination should be normal, without any cranial neuropathies. 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. Motion sickness or dizziness ( vertigo) Headache . [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). Although prescribing it can seem intimidating at first, with practice and a bit of trial and error, you can perfect your ability to prescribe prism for your patients in no time. 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 . 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. Convergence Insufficiency. Ductions and versions are full. With CI, the eyes do not point together inward as one looks at objects close-up. This conclusion was recently confirmed by Wiggins and Baumgartner,22 who characterized a benign long-term prognosis in their cohort of patients with neurologically isolated divergence insufficiency. 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. The following information was abstracted from the medical records: current medical history, past medical history, details of the ocular motor and general neurologic examinations, results of radiographic and laboratory tests, and long-term follow-up of those cases that were classified as idiopathic. Thomson Basic Esophoria and Exophoria. 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. The EOM angles in these patients ranged from 100 to . 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). It is idiopathic most often in children or young adults 2. Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. The patient is also instructed to keep the words around the lines clear to control accommodation. To prevent double vision, the individual exerts extra effort to make the eyes turn back in. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. If a patient sees four dots in free space or gives a diplopia response but is able to fuse with prism, perform a unilateral cover test. ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As Neena R, Giridhar A. 2023 American Medical Association. Heavy eye syndrome versus sagging eye syndrome in high myopia. The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. Bothun ED, Archer SM. Near point convergence is the distance you can use both eyes without seeing double. 2009;86(2):153-6. Six patients underwent CT and 10 underwent MRI. Keep moving to the next dot along the card, gradually getting closer to the nose. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. 2023 Stanford School of Medicine | Terms of Use | However, it seems unlikely, since divergence insufficiency resolved in all 4 patients and no other neurologic problems developed during the time of each patient's follow-up of 1 month, 5.5 months, 34 months, and 44 months, respectively. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. GBurde 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. 132. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. . 2016;28(1):38-42. Of the 20 patients with primary divergence insufficiency, there were 10 women and 10 men, ranging in age from 24 to 90 years, with a median (mean) age of 74 (70) years. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. More respect for connective tissues. Patients will be able to work on fusing the images of one. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? DOI: Demer JL. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Methods 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. Posted by . Call our optometrists at 302-299-1286 or. Chang MY et al. 7. Instead, the initial history and physical examination proved to be powerful tools to distinguish those patients with a primary disorder from those with an underlying neurologic or systemic (ie, secondary) cause of divergence insufficiency. 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. The exercises for divergence and convergence insufficiencies are very similar in structure, but fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. Her research interests include strabismus and binocular vision disorders. 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. AParalysis of divergence. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. 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. Jacobson DM. Actually it's not synonymous with divergence paralysis, but it is a separate clinical entity A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. 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. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. 2008;12(1):56. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. Their symptom was controlled using prisms. J Neuroophthalmol. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. Typically, patients note that they do not have any diplopia at near. 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. Connective tissues reflect different mechanisms of strabismus over the life span. Wiggins 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. Lets continue the conversation over on your social network of choice. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. Another historically reported feature of DI is significantly decreased negative fusional vergence (fusional divergence), along with the deficits direct relationship to distance of gaze. MThe child with divergence paresis. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. Privacy Policy| ISOphthalmoplegia in cranial arteritis. Other associated symptoms can include asthenopia of panoramic type. 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. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. You can schedule your next appointment with us online! PCBurian J AAPOS. This page was last edited on January 26, 2023, at 08:42. In those patients without an established disorder, additional clinical clues indicated the need for neuroimaging or additional diagnostic studies, independent of the signs of divergence insufficiency. Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. Divergence Insufficiency/Excess | Vision Therapy Paducah Kentucky Divergence Insufficiency and Divergence Excess Symptom Checklist Vision Therapy: Alex's Success Story | Wow Vision Therapy Share Watch on Share this: Twitter Facebook Like this: Loading. 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. 2013;251:16411644. Br J Ophthalmol. 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. Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. 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}. Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. 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. The main treatment for convergence insufficiency is vision therapy. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. A Maddox rod was also used to determine the near point of orthophoria in most patients. DBGlaser 11. 2012. What is convergence spasm? FDDutton Many affected patients experience spontaneous resolution of double vision within several months. One patient was followed up for only 1 month, but her esotropia resolved during that time. It is most often related to raised intracranial pressure or Chiari malformation. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). 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. Instead they turn their head briskly (head thrust) to shift fixation. Smooth pursuit and vertical eye movements are usually preserved. Eye movements are usually bilateral and symmetric in the horizontal plane. It is often idiopathic, but it has also been associated with several cerebral malformations and genetic disorders.Acquired Ocular Motor Apraxia Occurs in older children Associated with mostly metabolic disorders (Gaucher disease, ataxia-telangiectasia, spinocerebellar ataxias, NiemannPick disease) Convergence SpasmAlso called spasm of the near triad (Fig. To begin therapy, many therapists will focus first on normalizing the accommodative system. 13.121). Introduction. divergence excess eyewikibc kutaisi vs energy invest rustavi. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. [2] Convergence describes the way our eyes move together and point inward when we look at near objects. 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. All but 1 patient were older than 50 years. Long-term follow-up and clinical features of the 2 groups were compared. When prescribing ground-in prism, high index lenses, plastic frames and frames that are smaller in size help improve the weight and cosmesis of the lenses. 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. Blurred vision. The procedure is performed under topical anesthesia in the presence of an anesthesiologist. It involves a specialty optical system and a uniquely created image book. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. 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Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. 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. Although no unsuspected neurologic disorder surfaced during the period of follow-up in these patients, I strongly recommend that a patient with isolated divergence insufficiency be followed closely to detect, for example, signs of developing intracranial hypertension or abducens nerve palsy. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. MGallaway 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. Since true paralysis of divergence generally cannot be documented in most affected patients,4 I prefer the term divergence insufficiency to describe this disorder, regardless of the severity of associated symptoms and signs. Prism can be a powerful treatment for many conditions and for many patients, specifically for those who suffer from asthenopia or diplopia. highest quality optometry services and eye exams in Wilmington, Delaware and its surrounding areas. 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. 2005;9:36. 134. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. Rutar T, Demer JL. 2013;97(11):1415-9. Histories reveal the possibility of a number of etiologic factors. Unfortunately, since the ocular ductions appear full in a patient with suspected divergence insufficiency, objective means to assess the state of ocular comitancy do not exist for office determination. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. 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. What is divergence insufficiency? After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. 2008;126(10):1336-49. 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. Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency. Divergence insufficiency revisited: natural history of idiopathic cases and neurologic associations. Divergence insufficiency can vary in severity, from minor deficits to complete divergence paralysis. 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. 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.
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