divergence insufficiency double vision

I still have mild double vision and . All rights reserved. Questions with answers: 125. 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 patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. GTDJohnston A near card is brought toward the patients nose until the patient sees double. 2016;28(1):38-42. 128. 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. 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. Arch Ophthalmol. Graefes Arch Clin Exp Ophthalmol. Tamhankar MA, Ying GS, Volpe NJ. Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. 13.121). Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. Godts D, Mathysen DG. Cunningham Results from this study also supported previously published evidence of normal age-related connective tissue degeneration as there was a positive age effect in correlation to supero-temporal bowing of the LR-SR band.[9]. 12. Objectives Convergence insufficiency | AOA 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. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or. 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. There are many different ways to do this, but the best method to use depends on the type of binocular vision disorder for which you are prescribing. Recognizing TBI-related Vision Disorders - Review of Optometry Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. Prism in reading glasses or strabismus surgery may be required. Only 2 patients were followed up for less than 6 months. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. 2016. GMOcular divergence: its physiology and pathology. 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. DIVERGENCE INSUFFICIENCY - Optography Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. If the eyes do drift out, the person is likely to have double vision. While patients with strabismus often benefit from prism wear, it is important to first determine whether a strabismic patient is fit for treatment with prism by evaluating their potential for sensory fusion and whether the addition of prism will improve their sensory fusion status. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. 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). Long-term follow-up and clinical features of the 2 groups were compared. From there, basic vergence exercises will be added in. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. AOcular divergence mechanisms. 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. American Academy of Ophthalmology. Divergence insufficiency associated with high myopia Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. EDivergence insufficiency: characteristics, diagnosis, and treatment. Success of prisms in the management of diplopia due to fourth nerve palsy. After a preliminary prescription of fusion prism is determined, it is recommended that you trial frame the patient and have them look around to see if they experience any diplopia when viewing objects in the room. Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. What is congenital ocular motor apraxia? Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations | Neurology | JAMA Ophthalmology | JAMA Network ObjectivesTo determine the natural history of primary divergence insufficiency and to identify clinical features that distinguish patients with this neurologica [Skip to Navigation] My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. 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. Nonparetic Diplopia - EyeWiki 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. If you have not read the previous portions of the vision therapy series it is highly advisable that you check them out first as they cover basics not explained here. Committee on Aging. Many affected patients experience spontaneous resolution of double vision within several months. Supported by In the meantime, temporary paste-on and, if stable for several weeks, permanent ground-in prisms, were effective and conservative means of relieving symptoms in these patients. Br J Ophthalmol. 3. Define divergence insufficiency. CI affects children and adults. The first hurdle is ensuring your patient is comfortable with wearing spectacles. 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. Divergence Insufficiency/Excess | Vision Therapy Paducah Kentucky How is convergence insufficiency treated? These studies were unrevealing in all 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. RDInternuclear ophthalmoplegia in giant cell arteritis. 1. This page has been accessed 63,795 times. Esodeviation is comitant in all fields of . Bruce 134. J Pediatr Ophthalmol Strabismus. 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. Neuro-ophthalmology Illustrated Chapter 13 Diplopia 10 - Convergence 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. 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. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. [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). What is convergence insufficiency? 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. One patient was followed up for only 1 month, but her esotropia resolved during that time. What is convergence spasm? 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. What is convergence insufficiency? Patients with constant strabismus may need corrective prism, or an amount of prism that completely neutralizes their strabismus, in order to obtain good levels of fusion. J AAPOS. Smith GBTobin 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. Divergence excess is an over-divergence when attempting to look at distant objects. Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. 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. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. 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. 13.119). Wall RLMagnetic resonance images in a case of "divergence paralysis.". 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. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. MCiner A recent review in January 2020 supported the evidence that when the symptoms of diplopia are burdensome to the patient, surgery is the only treatment that can eliminate the . Moore What is the cause of convergence spasm? A new prescription for prism lenses was dispensed to the patient at the follow-up examination. Br J Ophthalmol. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? 3 Advanced Exercises for Convergence and Divergence Insufficiency What is divergence insufficiency? Optom Vis Sci. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. Her research interests include strabismus and binocular vision disorders. When you try to focus on something close to your eyes, you may have: Tired eyes. PMDivergence paralysis. Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. 7. What Is Convergence Insufficiency? Symptoms, Causes, and Treatments - WebMD JSLevy Eight (40%) of the 20 patients recalled such an event, including a viral prodrome in 3 patients, minor head trauma in 2 patients, and hospitalization for an unrelated illness in 3 patients. 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. . RMTomsak Primary divergence insufficiency is generally a benign condition. To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. 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. MGallaway The remainder of the neurological examination should be normal, without any cranial neuropathies. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. 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. If no movement is seen on the unilateral cover test, the patient has normal correspondence. Lepore Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. DOI: Demer JL. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. Their symptom was controlled using prisms. 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. Eye - Diplopia following cataract surgery . 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. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. Schanzer Many affected patients experience spontaneous resolution of double vision within several months. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. Another area of controversy concerns whether divergence insufficiency is a localizing sign referable to injury of a "divergence center," or is a nonlocalizing sign associated with a variety of focal and diffuse brain insults. 4 Binocular Vision Problems that Cause Eyestrain 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. Stern It is a disorder involving binocular vision vision using both eyes. Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. 4. This decreases the motor fusion demand, allowing the patient to fuse more comfortably. 2000;118(9):12371241. Effectiveness of prisms in relieving diplopia in superior oblique palsies. The most successful prism cases are often patients who have intermittent strabismus and good potential for normal fusion or patients with strabismus who have not developed any sensory anomalies. Bender Kirkham Retrospective survey of patients with divergence insufficiency. None of these patients developed signs of an underlying neurologic disorder during follow-up. Similarly, the theories on mechanism of divergence itself have varied. [13]In their case series patients with lateral incomitance, the adjustable suture was generally placed on the MR opposite the horizontal direction of the greatest ET. Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. 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. Divergence insufficiency esotropia (DIE), originally described by Duane in 1896, is an acquired condition characterized by an esodeviation that measures at least 10 prism diopters (PD) greater at distant rather than near fixation [].Patients with DIE complain about double vision at distance. Pencil pushups may be effective in some cases. A Maddox rod was the tool used to assess ocular comitancy in this study, but other methods exist, including prism-cover techniques, the Hess chart, and the Lancaster red-green test. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Scheiman Diplopia following cataract surgery: a review of 150 patients Posted by . [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. 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. is variable. 2023 American Medical Association. Divergence insufficiency - definition of divergence insufficiency by 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. Results Another method used for prescribing for patients with intermittent strabismus, particularly for those who have difficulty with fusion in free space, is Calorosos Residual Vergence Demand (RVD).7 RVD criteria look at the direction and size of the deviation and determine how much residual vergence demand the patient should have after prescribing relieving prism. an electromyographic study. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. Some patients report double pictures, but when checked with the torch, only one light is seen. 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. Ghanchi During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. Chamlin This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. The two prevalent hypotheses put forth so far include altered cerebrospinal fluid flow in the posterior cranial fossa, and involvement of the abducens nucleus or infranuclear portion. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). Divergence insufficiency associated with high myopia - PubMed 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. No signs of orbital ischemia were present in the second patient. FDDutton [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. A similar technique is used for rehabilitation: the patient is instructed to do push-up exercises (looking at an object intermittently moved in and out from the bridge of the nose) daily at home to decrease the near point of convergence.Divergence InsufficiencyDivergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Ductions and versions are full. It is most often related to raised intracranial pressure or Chiari malformation.Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation Head trauma Intracranial hypotension (low CSF pressure syndrome) Cerebellar lesions Midbrain massAbnormal Horizontal Conjugate DeviationsGaze deviations are relatively common in large cerebral and pontine lesions (Fig. Divergence Paralysis - Optography 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 seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. Six patients underwent CT and 10 underwent MRI. [10] In 2013, Stager et al. Comparison of surgical dose response between divergence insufficiency [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).