However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. 8. They had experienced double vision for 5 weeks, 5 months, and 6 months, respectively, up to the time of their last evaluation, but did not return for further follow-up. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. This page has been accessed 63,795 times. 126. 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. 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. 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. 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. Lateral rectus resections in divergence palsy: Results of long-term follow-up. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. JLSharpe
NJeds, Leigh
Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. 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. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. Long-term Surgical Outcomes in the Sagging Eye Syndrome. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. 131. DIVERGENCE INSUFFICIENCY - Optography Double vision. Weird vision divergence upon waking at night - Retirement -Social Primary divergence insufficiency is generally a benign condition. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. No clear sex predilection has been identified for the primary form of the condition. American Academy of Ophthalmology. GTDJohnston
11. PDF Divergence Insufficiency - Jama Posted by . Privacy Policy| Vertical deviations often cause patients to experience significant symptoms even when the deviation is small. In 2005 Thacker NM et al. The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. 2012. Scheiman M, Wick B. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. Actually it's not synonymous with divergence paralysis, but it is a separate clinical entity This page was last edited on January 26, 2023, at 08:42. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. All Rights Reserved. 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. 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. DIdiopathic intracranial hypertension: a prospective study of 50 patients. Goldberg
Clin Exp Optom. Chang MY et al. None of these patients developed signs of an underlying neurologic disorder during follow-up. 7. 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. It is most often related to raised intracranial pressure or Chiari malformation. Questions with answers: 125. 1. [10] In 2013, Stager et al. Convergence and Divergence - Vivid Vision Mosbys Optometric Problem Solving Series, ed. If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. What is convergence insufficiency? 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. Patients will be able to work on fusing the images of one. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). In normal cases, the ocular axis length was 23.5 1.0 mm. Jacobson DM. 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. Recent trauma Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. 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). Otherwise, neuroimaging can be deferred in patients with neurologically isolated divergence insufficiency, although careful follow-up is indicated to identify developing suspicious neurologic symptoms or signs. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. Lepore
Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. [5], In recent imaging studies, Patel et al. Convergence Insufficiency/Vision Therapy - Eye Docs For Kids Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. Different cards with different images will require different amounts of negative and positive fusional vergence. In that study, strabismus surgery was performed in 50% of all SES cases. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. PDF CLINICAL SCIENCES Divergence Insufficiency Revisited - JAMA Histologic studies showed that each rectus pulley consists of an encircling ring of collagen located near the globe equator in tenon fascia, coupled to the orbital wall, adjacent EOMs, and equatorial Tenon fascia by bands containing densely woven collagen, elastin, and smooth muscle. I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. 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. It is possible that with longer follow-up, the number of patients with resolution of diplopia might increase. _________________________________________________________________. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. Distance esotropia in the elderly. Progressive supranuclear palsy. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. No signs of orbital ischemia were present in the second patient. Patients and methods. The mirror stereoscope is one of the most commonly used types. 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. Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. . THBird
Information obtained from direct telephone interviews with the patients and review of office records of referring physicians who continued to follow up some patients were included in the determination of follow-up. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Strabismus. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. 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). New York, NY Oxford University Press1999;405-610. 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. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." Eye - Diplopia following cataract surgery . Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. What is divergence insufficiency? If no movement is seen on the unilateral cover test, the patient has normal correspondence. Wall
To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying 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. This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. 13.119). MBSavitsky
Success of prisms in the management of diplopia due to fourth nerve palsy. EHBilateral sixth-nerve paresis simulating divergence paralysis. 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. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. et al. 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. 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. It is usually benign. Divergence insufficiency associated with high myopia - PubMed 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 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. The mechanical properties of pulleys are critical for the support and rotational properties of the eye. Connective tissues reflect different mechanisms of strabismus over the life span. LBSharpe
20-20-20 Still Not Enough to Alleviate Eye Strain, Binocular Vision and Sports Concussions: A Bad Combo, Vision Impairment Increases Risk of Cardiovascular Disease, Monocular Eye Closure Common with Epiretinal Membrane. What is the cause of convergence spasm? Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. Divergence insufficiency - definition of divergence insufficiency by Effectiveness of prisms in relieving diplopia in superior oblique palsies. 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. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. Sagging Eye Syndrome - EyeWiki It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. Chaudhuri Z, Demer JL. RLMagnetic resonance images in a case of "divergence paralysis.". 10. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. [2] 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. Drs. 2023 Stanford School of Medicine | Terms of Use | 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. It can also decrease distance judgement, coordination, and sports performance. 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. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. Ghanchi
Common symptoms include: headaches; blurred vision ; double vision RJZee
Strabismus. In addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. Moller
What is Convergence Insufficiency? Symptoms, Treatments - Healthline Although successfully prescribing it can sometimes seem like a time-consuming and daunting task, the following tips can help you smoothly incorporate the use of prism for binocular vision conditions into your practice for the best outcomes. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. Committee on Aging. 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. The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). 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. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. 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. as their fusional vergence ranges expand. Prism in reading glasses or strabismus surgery may be required. Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. 2016;28(1):38-42. Abstract. Jampolsky
LDivergence insufficiency. RMTomsak
For example, the right eye might see a lion while the left eye sees a cage. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. Chang MY, Pineles SL, Velez FG. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. 2012;95(2):192-7. One of the most important aspects of successfully prescribing prism is choosing patients who will benefit the most from it. What is congenital ocular motor apraxia? J AAPOS. Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. However, the cause of convergence insufficiency is often unknown. 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. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. 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. 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. Schanzer
What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? 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.