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Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Differentiating sagging eye syndrome (SES) from other causes of strabismus is not always a straight forward task given that patients with SES may have risk factors for strokes or tumors. Results: In high-myopia patients with divergence insufficiency, ocular axis measurements ranged from 24.8 to 31.0 (mean SD: 27.6 1.6) mm. 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. Tranaglyphs are similar to vectograms, however instead of there being two different transparent image cards that need to be fused into one, there is one image card with a stereo image already pre-made onto the card. Schanzer Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. If an intermittent horizontal strabismus patient has a primary vertical deviation, vertical prism may help improve their ability to fuse the horizontal deviation. It is possible that with longer follow-up, the number of patients with resolution of diplopia might increase. 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. 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. Methods: We investigated 20 cases of high myopia (>-6 D) with divergence insufficiency, 20 cases of high myopia without double vision, and 10 normal cases as controls. Customize your JAMA Network experience by selecting one or more topics from the list below. 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. No clear sex predilection has been identified for the primary form of the condition. Extraordinary symptoms equivalent to diplopia 2.3.1. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. In the 17 patients with primary divergence insufficiency who had adequate information to ascertain long-term follow-up, double vision persisted in 9 individuals. Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. 1. Each card contains a partial view of the complete image. In that study, strabismus surgery was performed in 50% of all SES cases. 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. Retrospective survey of patients with divergence insufficiency. MEBarrows Exercises for double vision: 4 things to try - Medical News Today 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. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. DRHartnett Near point of convergence test: This test will . As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. The orbital layer, inserts on the pulley, not on the globe. 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. How is convergence insufficiency treated? 131. DIdiopathic intracranial hypertension: a prospective study of 50 patients. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. American Academy of Ophthalmology. More respect for connective tissues. Nonparetic Diplopia - EyeWiki Roughly half of the patients experienced spontaneous resolution of diplopia after several months. Divergence Insufficiency. Goldberg Heavy Eye vs. Divergence insufficiency is a benign phenomenon causing horizontal diplopia at distance viewing . Fresnel prism, however, degrades visual acuity and contrast sensitivity, and some patients may not find it cosmetically appealing.12 A significant decrease in visual acuity through the Fresnel lens can be seen at larger prism powers, particularly at those greater than 12 PDs.13 When trialing Fresnel prism, it is advisable to only place the Fresnel over one eye so that the patient retains good binocular visual acuity with the prism in place. Stager DR, Sr, Black T, Felius J. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. 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. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. [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. She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. Divergence Insufficiency Revisited: Natural History of - JAMA Patients with 20 to 30 PDs of exotropia should be left with 10 to 15 PDs of residual vergence demand, and patients with a vertical strabismus of 3 to 10 PDs should be left with 2 to 4 PDs of residual vergence demand.7 RVD is best used in patients who have vergence ranges that have been maximally trained through vision therapy but still need prism to maintain binocular vision in free space.12. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. 2013;97(11):1415-9. [2] FDDutton If no movement is seen on the unilateral cover test, the patient has normal correspondence. JJSavino What is the cause of convergence spasm? More advanced exercises for vergence insufficiencies include. FEDivergence paresis: a nonlocalizing cause of diplopia. Weird vision divergence upon waking at night - Retirement -Social 2023 Stanford School of Medicine | Terms of Use | 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. 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. Lateral rectus resections in divergence palsy: Results of long-term follow-up. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. 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. All rights reserved. RLMagnetic resonance images in a case of "divergence paralysis.". BBordaberry Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. Six patients underwent CT and 10 underwent MRI. 130. 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. with a stereo image already pre-made onto the card. The difficulty of training vertical vergence ranges along with the success in treating vertical deviations with prism make prism the most appropriate initial management tool in these patients. [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. When their medical records were reviewed at the time this study was being designed, I learned that they had since died of unrelated illnesses, so the course of their disorder could not be completely ascertained. The EOM angles in these patients ranged from 100 to . The Apt Lecture. Although each method has its advantages and disadvantages, they all suffer from being subjective. Divergence insufficiency associated with high myopia Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. 13. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Retrospective survey of patients with divergence insufficiency. 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 differential includes: It can be difficult to adjudicate small angle deviations such as HES and SES from mild myasthenia gravis, incompletely resolved sixth nerve palsy, thyroid eye disease, and decompensated prior phorias. . The aspect of divergence paralysis or divergence insufficiency is stated as esotropia or high esophoria at a distance with much lower esophoria or near to normal fixation. How is convergence insufficiency treated? Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. . Long-term follow-up and clinical features of the 2 groups were compared. Only 2 patients were followed up for less than 6 months. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. Scheiman M, Wick B. of negative and positive fusional vergence. Krohel 126. JLSharpe characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. Accessibility Statement, Our website uses cookies to enhance your experience. 2005;89(10):1318-23. 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. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. PJThompson Graefes Arch Clin Exp Ophthalmol. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. None of the patients initially classified as having primary divergence insufficiency developed additional neurologic dysfunction during the period of follow-up. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. 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. Wiggins Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. R. London. Jacobson DM. Surgical effect was assessed immediately by sitting the patient up and repeating the measurements at near and distance. Reference: 1. 13.119). Patients will be able to work on fusing the images of one. Esotropia resolved within days of initiating corticosteroid treatment in both patients. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. Tamhankar MA, Ying GS, Volpe NJ. CI affects children and adults. A Maddox rod was also used to determine the near point of orthophoria in most patients. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. Convergence Insufficiency (CI): Symptoms, Diagnosis - Cleveland Clinic Parkinson disease 4. EDivergence insufficiency: characteristics, diagnosis, and treatment. RMDiagnosis and management of divergence paresis. All Rights Reserved. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. Convergence Insufficiency/Vision Therapy - Eye Docs For Kids 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. LDivergence insufficiency. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Optom Vis Sci. Retrospective case reviews of patients with an acquired hyper deviation secondary to a superior oblique palsy found that 76% to 92% of participants were successfully treated with prism alone.5,6. 128. Patients may also present with ductional deficits depending on the grade of muscle displacement. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. it is highly advisable that you check them out first as they cover basics not explained here. 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. Privacy Policy| 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. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. 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. Some patients report double pictures, but when checked with the torch, only one light is seen. Keep moving to the next dot along the card, gradually getting closer to the nose. 6. Lepore MThe child with divergence paresis. 2000;118(9):12371241. Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. 127. Caloroso E, Rouse MW. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. At the follow-up examination after nine weeks of patching and vision therapy for amblyopia, her visual acuities were equal in both eyes, and all testing showed normal correspondence. Duane J AAPOS. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. 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. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). Biousse V and Newman NJ. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. 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 use of topical anaesthesia does not abolish this surgical risk. Convergence insufficiency is a common problem with the eyes, and is the main culprit behind eyestrain, blurred vision, and headaches. In some circumstances, individuals with convergence insufficiency will also suffer from high exophoria or exotropia, meaning the eyes like to sit in an outward position. In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. Smith 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. Home Vision Therapy Convergence Insufficiency Testing. Kirkham Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. If the dot becomes doubled, go back to the previous dot and try again. 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. Vision suppression stops you from seeing double, but it doesn't fix the problem. Trans Am Ophthalmol Soc. 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 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. Sensory Anomalies. Tamhankar MA, Ying GS, Volpe NJ. 2016 May; 100(5): 648651. SDiagnosis and management of divergence weakness in adults. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. 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. Divergence insufficiency: characteristics, diagnosis, and treatment 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. 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) Reproduction in whole or in part without permission is prohibited. Other training exercises include base-out prisms for near viewing and convergence exercises. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. One patient was followed up for only 1 month, but her esotropia resolved during that time. 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. J Pediatr Ophthalmol Strabismus. 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. 132. Clinical management of strabismus. Jacobson DM. HMDivergence paralysis following head trauma. Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. HS This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. Chaudhuri Z, Demer JL. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? All rights reserved. ALDemer Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. 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. 2014;18(4):309-15. et al. 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 mechanical properties of pulleys are critical for the support and rotational properties of the eye. Actually it's not synonymous with divergence paralysis, but it is a separate clinical entity Stern 2000;118(9):1237-41. The signs and symptoms with this condition are similar to convergence excess. Strabismus. Cotter SA. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. Rutkowski If the eyes do drift out, the person is likely to have double vision. The first hurdle is ensuring your patient is comfortable with wearing spectacles. What is convergence insufficiency? My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. 2008;126(10):1336-49. Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. These patients often present with horizontal and vertical deviations. 132. 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. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof."