Head trauma 3. Only 2 patients were followed up for less than 6 months. if you would like to learn more about convergence and divergence insufficiency. Different cards with different images will require different amounts of negative and positive fusional vergence. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. 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. Stern In a recent study by Goseki et.al. 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. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. 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. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. Convergence insufficiency (CI) is a vision disorder. Sometimes it is exacerbated by fatigue and improves with rest. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. A 5-year-old female initially presented for a strabismus and amblyopia evaluation. Lets continue the conversation over on your social network of choice. No clear sex predilection has been identified for the primary form of the condition. Diplopia at Distance in Older Patients: Is It Sagging Eye Syndrome? SDiagnosis and management of divergence weakness in adults. Audio blog post. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. Home Vision Therapy Convergence Insufficiency Testing. If the patient is only using one eyethe image will not be formed correctly. 7. 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. Customize your JAMA Network experience by selecting one or more topics from the list below. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. Also found significant displacement of all four rectus pulleys away from the orbital center, lateral displacement of the inferior rectus pulley and obliquely angulated lateral rectus pulley. This patient continued with vision therapy to help improve her sensory and motor fusion with the hope of eventually titrating down the amount of prism she wears. 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. 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 main treatment for convergence insufficiency is vision therapy. Questions with answers: 125. As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. Prism is a powerful tool that can be used to successfully treat a variety of binocular vision conditions. However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. [unreliable source?] 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 misalignment almost 100%. Vision therapy uses various exercises to train the connection between the eyes and the brain as more than 50% of the brain is dedicated to visual function. 2000;118(9):1237-41. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. The remainder of the neurological examination should be normal, without any cranial neuropathies. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. Similarly, the theories on mechanism of divergence itself have varied. The first hurdle is ensuring your patient is comfortable with wearing spectacles. et al. 129. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. DIdiopathic intracranial hypertension: a prospective study of 50 patients. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." Wall Accessibility Statement, Our website uses cookies to enhance your experience. Effectiveness of prisms in relieving diplopia in superior oblique palsies. From a practical point of view, it seems reasonable to defer further investigation, including neuroimaging, in an affected patient who has no other neurologic or systemic symptoms or signs. Smith PCBurian of negative and positive fusional vergence. 2023 American Medical Association. 2013;97(11):1415-9. Strabismus. The cyclotorsion component of SES was present in 65% of patients. Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. 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. 128. NADivergence paralysis. 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. The exercises for divergence and convergence insufficiencies are very similar in structure, but fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. 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. This page has been accessed 63,795 times. 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. THBird 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. 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. 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. Typically, patients note that they do not have any diplopia at near. RTOcular muscle paresis and cranial arteritisan unusual case. No such signs were identified in any of the patients in this series. 4 Binocular Vision Problems that Cause Eyestrain Convergence Insufficiency Testing. Convergence and Divergence - Vivid Vision 13.120). During the total period of follow-up, none of the patients developed an alternative neurologic disorder. 4. CI affects children and adults. Arch Ophthalmol. He usually volunteers the infor mation that he has no trouble in reading or close use of his eyes. It is a disorder involving binocular vision vision using both eyes. Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. Bender 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. Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. Barricks ARKline In many of these cases, the initial management strategy is prescribing vertical prism.1 Often, if the vertical deviation is decreased or eliminated, the patient may be able to comfortably fuse the horizontal deviation. 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. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. Convergence Insufficiency. J Pediatr Ophthalmol Strabismus. What is congenital ocular motor apraxia? 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. Bruce The patient places two transparent cards into the vectogram system. 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. 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. Optom Vis Sci. 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. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging.2, Vision therapy aims to decrease symptoms of vergence anomalies by increasing the compensating fusional vergence range (base-in for esophoria and base-out for exophoria). Chaudhuri Z, Demer JL. Goldberg Tamhankar MA, Ying GS, Volpe NJ. 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) In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. Convergence Insufficiency/Vision Therapy - Eye Docs For Kids Diagnosing convergence insufficiency Committee on Aging. The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. The distance at which diplopia occurs is noted (near point of convergence). Neena R, Giridhar A. AIs divergence active? The Apt Lecture. The mirror stereoscope is one of the most commonly used types. 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. Reference: 1. Some patients report double pictures, but when checked with the torch, only one light is seen. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. One study successfully treated 87 patients with divergence insufficiency between two and 18 prism diopters (PDs) with prism with none of the patients in the study requiring additional treatment or surgery.3 Another study found that 100% of patients with divergence insufficiency (30 patients) had success with prism.4. A secondary vertical deviation, on the other hand, presents when the patients eyes are strabismic but disappears when the patient aligns their eyes to the ortho position.7 Secondary vertical deviations are common in strabismic patients, particularly in those with intermittent exotropia. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). 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. 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. J AAPOS. 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. Basic Esophoria and Exophoria. Privacy Policy| Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. Trans Am Ophthalmol Soc. Prism in reading glasses or strabismus surgery may be required. 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 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. Lyle [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. Corbett This problem is most commonly found in children. Wednesday, March 15, 2023 | All Eyes On Evaporation, Thursday, April 13, 2023 | All Eyes On Evaporation, Tuesday, April 18, 2023 | All Eyes On Evaporation. MCiner With exercises that adapt to each patient and their specific needs, it is an ideal solution for problems such as lazy eye, strabismus, convergence insufficiency, double vision, or other binocular problems. A near card is brought toward the patients nose until the patient sees double. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. GMOcular divergence: its physiology and pathology. These questions are archived at https://neuro-ophthalmology.stanford.eduFollow https://twitter.com/NeuroOphthQandA to be notified of new neuro-ophthalmology questions of the week.Please send feedback, questions, and corrections to tcooper@stanford.edu. Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. 2009;86(2):153-6. 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. While viewing the card, the patient reports what color line the black arrow is aligned with. Other training exercises include base-out prisms for near viewing and convergence exercises. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. Terms of Use| 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. Schanzer The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. GTDJohnston Vision suppression stops you from seeing double, but it doesn't fix the problem. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. . Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. . The mechanical properties of pulleys are critical for the support and rotational properties of the eye. 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. 2014;35(9):1830-5. Clinical management of 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. Connective tissues reflect different mechanisms of strabismus over the life span. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. Simultaneous injury of the medial longitudinal fasciculus has been postulated as another reason sixth cranial nerve palsy may appear comitant.4 However, none of the patients classified as primary had clinical signs of internuclear ophthalmoplegia. Objectives doi:10.1136/bjophthalmol-2015-306783. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. BBordaberry This decreases the motor fusion demand, allowing the patient to fuse more comfortably. 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. 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. JAAcquired esotropia due to Arnold-Chiari I malformation. MGallaway 2. Hold focus on this dot for 10 seconds. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. AOcular divergence mechanisms. An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. In that study, strabismus surgery was performed in 50% of all SES cases. For example, the right eye might see a lion while the left eye sees a cage. Certain factors are associated with exotropia, including genetics and health conditions. J AAPOS. With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. NRNewman American Academy of Ophthalmology. Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. People notice symptoms while reading or doing other near work. Br J Ophthalmol. In 2005 Thacker NM et al. Histories reveal the possibility of a number of etiologic factors. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. J AAPOS 2014;18:370-373. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . Most trial lens sets come with prism lenses, but for larger angles of strabismus, it may be helpful to use a Fresnel prism trial set. Vertical Heterophoria. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. Since divergence is an active process, not a passive one associated with relaxation of the medial rectus muscles,5 some investigators hypothesize that a "divergence center" must exist. 11. 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. At the follow-up examination, she reported no diplopia in her glasses, and, eventually, she was able to see 250 seconds of arc RDS stereoacuity. The orbital layer, inserts on the pulley, not on the globe. Sagging Eye Syndrome. Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. . 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. 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. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. AParalysis of divergence. R. London. AJNR Am J Neuroradiol. 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. Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. Accordingly, I would recommend deferring consideration of strabismus surgery in this population for a sufficiently prolonged period of time to determine whether the esotropia might resolve spontaneously. Patients will be able to work on fusing the images of one. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. 2005;9:711. 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. We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Divergence Insufficiency. Divergence insufficiency is the opposite problem of convergence insufficiency. Ductions and versions are full. 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. From there, basic vergence exercises will be added in. If a patient does not have good potential for sensory fusion, then the assistance that prism gives to the motor system wont allow for normal fusion, and it doesnt make sense to prescribe it. 1993, Oxford, UK: Butterworth Heinemann Books. DIVERGENCE INSUFFICIENCY - Optography as their fusional vergence ranges expand. The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging.