divergence insufficiency double vision

Prism is a powerful tool that can be used to successfully treat a variety of binocular vision conditions. 2000;118(9):1237-41. JWStockbridge The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. In this example, the patient will be asked to either relax his or her eyes to put the lion in the cage (diverge) or stimulate his or her eyes to put the lion in the cage (converge). If no movement is seen on the unilateral cover test, the patient has normal correspondence. Demer JL et al. 4. Vertical Heterophoria. 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. JLSharpe GBurde This means that in a vectogram the amount of convergence or divergence needed to fuse the image depends solely upon how far apart the two cards are held, i.e. 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 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. This ocular misalignment has two main types: esotropia and exotropia. J Pediatr Ophthalmol Strabismus. Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. Although successfully prescribing it can sometimes seem like a time-consuming and daunting task, the following tips can help you smoothly incorporate the use of prism for binocular vision conditions into your practice for the best outcomes. The preferred method for prescribing prism for vertical heterophoria is determining the vertical associated phoria.12 This can be done at near using the Wesson card or at distance. [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. FDDutton Long-term follow-up and clinical features of the 2 groups were compared. 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. 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. 2023 Stanford School of Medicine | Terms of Use | LMDivergence paralysis with increased intracranial pressure: further observations. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. _________________________________________________________________. is variable. 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. R. London. make average daily distance tasks more manageable with less frequent symptoms. 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. Strabismus. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. Graefes Arch Clin Exp Ophthalmol. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. What is congenital ocular motor apraxia? Bothun and Archer reported a series of 8 patients who underwent bilateral medial rectus recessions for distance esotropias of 1235; 5 patients had satisfactory results with collapse of the distance-near deviation from 15 pre-operatively to 5 postoperatively. 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. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. LDivergence insufficiency. 2008;12(1):56. Trans Am Ophthalmol Soc. Godts D, Mathysen DG. None of these patients developed signs of an underlying neurologic disorder during follow-up. JSLevy Tamhankar MA, Ying GS, Volpe NJ. What Are the Symptoms of Convergence Insufficiency? 2013;251:16411644. All but 1 patient were older than 50 years. A near card is brought toward the patients nose until the patient sees double. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. Customize your JAMA Network experience by selecting one or more topics from the list below. The patient is also instructed to keep the words around the lines clear to control accommodation. All rights reserved. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. Goldberg JAInman If the patient is still symptomatic, combining prism and vision therapy may help improve convergence and divergence ranges. 6. J AAPOS. 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. If the dot becomes doubled, go back to the previous dot and try again. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. Posted by . On the other hand, it remains possible that these events were casual and not pathogenetically important. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. 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 revisited: natural history of idiopathic cases and neurologic associations. 2012. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or. 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] Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Head trauma 3. I still have mild double vision and . 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. Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. 5. This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. Per some observations, its is more common in Caucasian females. Barricks [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). Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. 10. Biousse V and Newman NJ. with a stereo image already pre-made onto the card. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. Divergence insufficiency is a benign phenomenon causing horizontal diplopia at distance viewing . Patients in the study population shared the following symptoms: double vision when viewing distant objects, full-appearing ocular ductions, and esotropia identified during cover testing while fixing a distant target. 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. Parkinson disease 4. Six patients underwent CT and 10 underwent MRI. Interestingly, they found that the relative proportion of SES was just 4.7% in patients younger than 50 years but it increased to 60.9% in patients older than 90. If an intermittent horizontal strabismus patient has a primary vertical deviation, vertical prism may help improve their ability to fuse the horizontal deviation. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. Our eye doctors. IRT. While the size of divergence fusion amplitude was significantly larger in the group of patients with secondary disorders than in the primary group, the magnitude of this difference was small and the range of values between the 2 groups demonstrated considerable overlap (Table 1). In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. From there, basic vergence exercises will be added in. Results 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. In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. What is divergence insufficiency? Committee on Aging. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. LBSharpe Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. 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. [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. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. Although each method has its advantages and disadvantages, they all suffer from being subjective. Diagnosing convergence insufficiency Certain factors are associated with exotropia, including genetics and health conditions. 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. 131. Divergence excess is an over-divergence when attempting to look at distant objects. SHarbison Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and help make average daily distance tasks more manageable with less frequent symptoms. 2016. ARKline 127. This period included the duration of diplopia prior to the first evaluation in addition to the duration of diplopia until either resolution of it or until the last follow-up evaluation. It is usually benign. A Maddox rod was also used to determine the near point of orthophoria in most patients. No clear sex predilection has been identified for the primary form of the condition. 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. Supported by Typically, patients note that they do not have any diplopia at near. In that study, strabismus surgery was performed in 50% of all SES cases. 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 . This page has been accessed 63,795 times. Patel SH, Cunnane ME, Juliano AF, Vangel MG, Kazlas MA, Moonis G. Imaging appearance of the lateral rectus-superior rectus band in 100 consecutive patients without strabismus. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Sensory Anomalies. Patients will be able to work on fusing the images of one. Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. In 2015 Chaudhuri and Demer published a retrospective observational study about utilizing Graded Vertical Rectus Tenotomy (GVRT) for treating incomitant vertical misalignment. 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. Wall Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. In addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. What lesion location is likely in the presence of horizontal conjugate deviation of the eyes to one side? EJampolsky 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. Adnexal signs such as: retraction of the upper eyelid into the superior orbit (superior sulcus deepening), aponeurotic blepharoptosis, floppy lower lids, and high upper eyelid crease. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. Reproduction in whole or in part without permission is prohibited. MGallaway changing the target) or by using multiple vectograms and making the patient look from one to another and quickly adapting the vergence system appropriately to each target (this is called jumping vectograms). 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. J AAPOS. Clin Exp Optom. Keep moving to the next dot along the card, gradually getting closer to the nose. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. 127. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . Most pertinent from a clinical point of view is the controversy surrounding whether divergence insufficiency is a distinct entity, or is a sign of subtle abducens nerve palsy. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. What are causes of convergence insufficiency? [5], There has been an increased awareness and diagnosis of these degenerative strabismic disorders after 2000. EDivergence insufficiency: characteristics, diagnosis, and treatment. The main treatment for convergence insufficiency is vision therapy. 1978;76:610-53. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. The Apt Lecture. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. Theme. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. Many patients were first evaluated within 1 month of the onset of symptoms, far sooner than the expected time course for the spread of comitance to convert a sixth cranial nerve palsy to a comitant esotropia. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. MCiner Divergence insufficiency is the opposite problem, accommodation will be worked on first to ensure it is equal between the two eyes, basic vergence exercises will be added in. 131. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. The normal amount of fusional divergence ability at distance is lower than that of fusional convergence ability, making it challenging to sufficiently increase ranges to compensate for esophoria or esotropia at distance. 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. Then, a horizontal prism bar was used to place increasing strengths of base-in prism over the other eye until fusion could no longer be maintained, as assessed subjectively using a distant target for fixation. . All rights reserved. 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. This problem is most commonly found in children. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. AIs divergence active? DIdiopathic intracranial hypertension: a prospective study of 50 patients. 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. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. 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. Heavy eye syndrome versus sagging eye syndrome in high myopia. 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. 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. Accessibility Statement, Our website uses cookies to enhance your experience. 2012;95(2):192-7. While viewing the card, the patient reports what color line the black arrow is aligned with. Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. divergence insufficiency synonyms, divergence insufficiency pronunciation, divergence insufficiency translation, English dictionary definition of divergence insufficiency. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. What is convergence spasm? fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. The LR-SR band vertically supports the LR pulley against the downward force of the inferior oblique muscle to maintain the LR pulleys vertical position. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. Unfortunately, since the ocular ductions appear full in a patient with suspected divergence insufficiency, objective means to assess the state of ocular comitancy do not exist for office determination. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. Terms of Use| Questions with answers: 125. Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. 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. Lets continue the conversation over on your social network of choice. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. Divergence excess is an over-divergence when attempting to look at distant objects. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. Smith Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. With CI, the eyes do not point together inward as one looks at objects close-up. [unreliable source?] HMDivergence paralysis following head trauma. Clinical management of strabismus. 2023 American Medical Association. Moller Call our optometrists at 302-299-1286 or. Long-term Surgical Outcomes in the Sagging Eye Syndrome. Convergence insufficiency (CI) is a vision disorder. Although small amounts of vertical prism can be prescribed in contact lenses, patients who need prism usually have to wear it on a spectacle lens. Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. ALDemer Reference: 1. . 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. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. 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. Thomson characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . Rutar T, Demer JL. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . Many affected patients experience spontaneous resolution of double vision within several months. 129. It is a disorder involving binocular vision vision using both eyes. Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. MEBarrows Demer JL. The use of topical anaesthesia does not abolish this surgical risk. SDiagnosis and management of divergence weakness in adults. 7. Define divergence insufficiency. None of these patients developed signs of an underlying neurologic disorder during follow-up. GMOcular divergence: its physiology and pathology. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. Only 2 patients were followed up for less than 6 months. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. Wiggins 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. Ghanchi CI affects children and adults. In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. Histories reveal the possibility of a number of etiologic factors. Strabismus. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. Their symptom was controlled using prisms. RDDivergence paralysis. Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. In the remaining 17 patients who were still alive, the total duration of follow-up extended from 1 month to 16 years (median, 35 months). [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). Different cards with different images will require different amounts of negative and positive fusional vergence. 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 duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). Abstract. Sometimes it is exacerbated by fatigue and improves with rest. More advanced exercises for vergence insufficiencies include. Chaudhuri Z, Demer JL. 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. RDInternuclear ophthalmoplegia in giant cell arteritis. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. Effectiveness of prisms in relieving diplopia in superior oblique palsies. 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. 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. The patients with primary divergence insufficiency in this retrospective survey were most often middle-aged or elderly persons with neurologically isolated double vision for distance who, not uncommonly, developed symptoms following a nonspecific illness or minor head trauma. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions.