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Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. Questions with answers: 125. What is divergence insufficiency? 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. 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 . 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. [5], There has been an increased awareness and diagnosis of these degenerative strabismic disorders after 2000. 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}. 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. of negative and positive fusional vergence. Bothun ED, Archer SM. 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 tool itself can be calibrated to work on increasing divergence or convergence, depending on, Our eye doctors at Wilmington Family Eye Care in Wilmington, DE excel in prescription of glasses, contact lenses and the diagnosis of a variety of eye diseases. 5. divergence excess eyewikibc kutaisi vs energy invest rustavi. 2013;251:16411644. 10. To be enrolled in the study, patients had to meet the following 5 criteria: 1) relatively sudden onset of double vision at far vision, 2) no double vision at near vision, 3) high myopia >6.0 diopters (D) in both eyes, 4) no other neurological symptoms, and 5) a normal . On initial presentation, her best-corrected visual acuities were 20/40 OD and 20/25 OS. Prism prescriptions often greatly improve the quality of life of your patients by reducing asthenopia and diplopia. 2013;97(11):1415-9. 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. ACSanders During the total period of follow-up, none of the patients developed an alternative neurologic disorder. 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. Goldberg A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. Sagging Eye Syndrome. HMDivergence paralysis following head trauma. The Apt Lecture. More respect for connective tissues. Br J Ophthalmol. 2014;18(4):309-15. This ocular misalignment has two main types: esotropia and exotropia. 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. MGallaway The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. highest quality optometry services and eye exams in Wilmington, Delaware and its surrounding areas. Rather, treatment for a secondary vertical deviation should aim to improve horizontal sensory and motor fusion through vision therapy so the patient is not in the strabismic position as often, thus eliminating the vertical deviation. Diplopia Developed in Later Life, An Ophthalmologic Approach Diagnosing convergence insufficiency All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). J Pediatr Ophthalmol Strabismus. No clear sex predilection has been identified for the primary form of the condition. 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. What is the cause of convergence spasm? Although each method has its advantages and disadvantages, they all suffer from being subjective. Diplopia following cataract surgery: a review of 150 patients Surgical effect was assessed immediately by sitting the patient up and repeating the measurements at near and distance. CI affects children and adults. The patient will wear a pair of polarizing glasses (similar to what is worn in modern 3-D movies) to create depth within the image (stereopsis). In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. Questions: 125. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. Moore Convergence Insufficiency Testing. J AAPOS 2014;18:370-373. 129. MEBarrows A Vectogram is a tool which utilizes specialized imaging along with the fusional vergence system to create a 3-D object. These exercises were discussed in detail in Part 6 of this series. All patients with double vision routinely were assessed for the speed of saccades and for the presence of nystagmus to identify signs of abducens nerve palsy or internuclear ophthalmoplegia. AJNR Am J Neuroradiol. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. along with the fusional vergence system to create a 3-D object. American Academy of Ophthalmology. 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. Chamlin 3 Advanced Exercises for Convergence and Divergence Insufficiency 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. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. Primary divergence insufficiency is generally a benign condition. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. 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 glassestranaglyphs are made similarly. with a stereo image already pre-made onto the card. it is highly advisable that you check them out first as they cover basics not explained here. J AAPOS. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. _________________________________________________________________. 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. 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. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or. Pencil pushups may be effective in some cases. 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. What is convergence insufficiency? To begin therapy, many therapists will focus first on normalizing the accommodative system. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. NRNewman 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. Sensory Anomalies. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). 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. How is convergence insufficiency treated? Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. This decreases the motor fusion demand, allowing the patient to fuse more comfortably. Esotropia resolved within days of initiating corticosteroid treatment in both patients. Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. Divergence insufficiency was also observed in 2 patients, each with idiopathic cerebellar degeneration and progressive supranuclear palsy, an association that is generally not recognized in either condition.30 This did not cause clinical confusion, however, since divergence insufficiency was overshadowed in each patient by the cardinal signs that characterized their underlying neurologic conditions. In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. Their symptom was controlled using prisms. NADivergence paralysis. an electromyographic study. If the patient is only using one eyethe image will not be formed correctly. 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. This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. [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. Convergence Insufficiency - American Academy of Ophthalmology 128. 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. Call our optometrists at 302-299-1286 or. Convergence Insufficiency Symptoms. 133. Define divergence insufficiency. GMOcular divergence: its physiology and pathology. The cyclotorsion component of SES was present in 65% of patients. 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. Objectives Wednesday, March 15, 2023 | All Eyes On Evaporation, Thursday, April 13, 2023 | All Eyes On Evaporation, Tuesday, April 18, 2023 | All Eyes On Evaporation. 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. [10] In 2013, Stager et al. The mechanical properties of pulleys are critical for the support and rotational properties of the eye. Primary divergence insufficiency is generally a benign condition. Scheiman M, Cotter S, Rouse M, et al. 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). 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. characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . Moller The distance at which diplopia occurs is noted (near point of convergence). Convergence insufficiency (CI) is a vision disorder. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. BBordaberry Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. Vergence - Wikipedia Biousse V and Newman NJ. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Concussion: Understanding Vision Problems Post-Injury - bocatc.org Smith Bender Divergence Insufficiency Revisited: Natural History of - JAMA 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) It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. Convergence Insufficiency | National Eye Institute How is convergence insufficiency treated? 12. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. [3], from 945 patients complaining of double vision, majority of patients between 60 and 80 years, approx 31% had SES and were older, ~71 years old, with ~60% female predominance. 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. When considering whether it is appropriate to prescribe vertical prism for a patient with combined horizontal and vertical deviations, particularly for a patient with intermittent strabismus, first identify whether the vertical deviation is primary or secondary. 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. doi:10.1136/bjophthalmol-2015-306783. . In many individuals with, Normalizing accommodation is important because. 2005;89(10):1318-23. 3. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . A 5-year-old female initially presented for a strabismus and amblyopia evaluation. 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. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. 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. LBSharpe 2000;118(9):12371241. This recommendation is based on the small size of the study population, the problems inherent in a retrospective investigation, and the grave consequences of failing to identify other neurologic signs. Br J Ophthalmol. The use of topical anaesthesia does not abolish this surgical risk. SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As Recognizing TBI-related Vision Disorders - Review of Optometry EHBilateral sixth-nerve paresis simulating divergence paralysis. The results of CT or magnetic resonance imaging (MRI), available at the time of initial evaluation, were not initially considered since one of the aims of this study was to identify clinical features that might be helpful in predicting which patient was harboring a neurologic disorder. This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. Demer JL. Committee on Aging. Rutar T, Demer JL. 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. I still have mild double vision and . Other associated symptoms can include asthenopia of panoramic type. et al. 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. "The term divergence insufficiency implies a problem at the level of the brainstem, suggesting that there is decreased neural output to the extraocular muscles," said Prem S. Subramanian, MD, PhD, at the University of Colorado in Aurora. Primary divergence insufficiency is generally a benign condition. Sagging eye syndrome (SES) was first described by Rutar and Demer in 2009, as a potential leading cause of strabismus in older adult population as a combination of horizontal and vertical strabismus in addition to bilateral blepharoptosis (ptosis with high lid creases) and deepening of the sulcus. 127. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying 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. Divergence excess is an over-divergence when attempting to look at distant objects. 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. Abstract. Long-term follow-up and clinical features of the 2 groups were compared. 2. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. A new prescription for prism lenses was dispensed to the patient at the follow-up examination. Optom Vis Sci. Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. Electronic charts are now routinely used in practice, and many of them have an available distance target for determining fixation disparity and the associated phoria. Common symptoms include: headaches; blurred vision ; double vision Convergence insufficiency is an anomaly that causes the eye to under-converge at near. 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. 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. Lewis Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. However, the cause of convergence insufficiency is often unknown. Divergence insufficiency can also result in headaches, motion sickness and sensitivity to bright lights. 2016. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. New York, NY Oxford University Press1999;405-610. 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. 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. This means the eyes do not like to move inward toward the nose and is problematic when trying to look at a near target. Neena R, Giridhar A. 132. Privacy Policy| 13.119). 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. 2016 May; 100(5): 648651. Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. They use head thrusts to shift fixation. Customize your JAMA Network experience by selecting one or more topics from the list below. Wall unable to diverge appropriately to a given target. 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 period of time. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. 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In the 17 patients with primary divergence insufficiency who had adequate information to ascertain long-term follow-up, double vision persisted in 9 individuals. The signs and symptoms with this condition are similar to convergence excess. Six patients underwent CT and 10 underwent MRI. The patient with a metastatic lesion of the midbrain additionally had skew deviation, an afferent pupillary defect without visual loss, and other signs of brainstem injury, but no symptoms or signs of intracranial hypertension. Divergence Paralysis - Optography J AAPOS. 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. 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. Corresponding author: Daniel M. Jacobson, MD, Neuro-ophthalmology (4F-2), Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (email: jacobsod@mfldclin.edu). Br J Ophthalmol. [5], In recent imaging studies, Patel et al. What Are the Symptoms of Convergence Insufficiency? Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. 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 tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. Stager DR, Sr, Black T, Felius J. Demer JL et al. 130. The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). What is the cause of convergence spasm? It is spasm of the near triad: 1. Perfecting Prism - Review of Optometry 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 is the opposite problem of convergence insufficiency. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. Schedule Appointment Our Doctors Contact UsAccepted Providers, Comprehensive Eye Exams Glasses Contact Lens Exams Dry Eye Emergency Care, 801 East Newport Pike, Wilmington, DE 19804 | (302) 999-1286, If you have not read the previous portions of the vision therapy.