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. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. The patient is also instructed to keep the words around the lines clear to control accommodation. Divergence insufficiency associated with high myopia | OPTH Convergence Insufficiency (CI): Symptoms, Diagnosis - Cleveland Clinic Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. 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. Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre, If you can remember the old newspaper comics that had a green image with a red image overlying it, that would turn into a 3-D image if you put on red/blue 3-D glasses, In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees, Different cards with different images will require different amount. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. Prescribing for some patients with intermittent strabismus can be done by using Sheards or Percivals criteria or determining the associated phoria as with heterophoric patients. 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. A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. Extraordinary symptoms equivalent to diplopia 2.3.1. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. 5. From there, basic vergence exercises will be added in. Reproduction in whole or in part without permission is prohibited. Abstract. 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. 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. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. What is the cause of convergence spasm? 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. 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). 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). Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. 2023 American Medical Association. RMDiagnosis and management of divergence paresis. It involves a specialty optical system and a uniquely created image book. 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. This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. All Rights Reserved. Krohel Convergence Insufficiency. Jampolsky DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. ISOphthalmoplegia in cranial arteritis. A Vectogram is a tool which utilizes specialized imaging along with the fusional vergence system to create a 3-D object. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. If no movement is seen on the unilateral cover test, the patient has normal correspondence. Pencil pushups may be effective in some cases. J AAPOS. 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. NRNewman PDF Divergence Insufficiency - Jama Strabismus. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. 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. Certain factors are associated with exotropia, including genetics and health conditions. 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. Concussion: Understanding Vision Problems Post-Injury - bocatc.org MBSavitsky The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). The information below is from Neuro-ophthalmology Illustrated-2nd Edition. Between the polarizing glasses and the patients fusional vergence system, he or she will be asked to either converge or diverge to fuse the two partial images into one 3-D image. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. Chaudhuri Z, Demer JL. These exercises were discussed in detail in Part 6 of this series. 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. 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. Surgical effect was assessed immediately by sitting the patient up and repeating the measurements at near and distance. Reproduction in whole or in part without permission is prohibited. Roper-Hall Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. JJSavino 2009;86(2):153-6. What are the symptoms of Convergence Insufficiency? 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. Kerala J Ophthalmol. 2023 Stanford School of Medicine | Terms of Use | To prevent double vision, the individual exerts extra effort to make the eyes turn back in. 4. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. Vision suppression stops you from seeing double, but it doesn't fix the problem. Terms of Use| Bender AIs divergence active? Divergence insufficiency associated with high myopia They use head thrusts to shift fixation. 134. None of these patients developed signs of an underlying neurologic disorder during follow-up. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. More respect for connective tissues. Convergence and Divergence - Vivid Vision From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. Goldberg Committee on Aging. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. Customize your JAMA Network experience by selecting one or more topics from the list below. SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As Effectiveness of base in prism for presbyopes with convergence insufficiency. To increase convergence, the two cards will be pushed inward, making the image smaller (Small In for the SI in SILO). ACSanders RLMagnetic resonance images in a case of "divergence paralysis.". Chang MY, Pineles SL, Velez FG. Stern The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. 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). 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. Therefore, it forces the patient to use both eyes properly to see the image. 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. divergence excess eyewiki MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). Caloroso E, Rouse MW. What is convergence insufficiency? People notice symptoms while reading or doing other near work. GBurde 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. doi:10.1001/archopht.118.9.1237. Diplopia at Distance in Older Patients: Is It Sagging Eye Syndrome? an electromyographic study. The remainder of the neurological examination should be normal, without any cranial neuropathies. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. It is most often related to raised intracranial pressure or Chiari malformation. For example, many investigators propose criteria to differentiate divergence insufficiency from divergence paralysis or paresis.1-3 However these arbitrarily defined criteria more likely describe varying severity of symptoms and ocular motor signs along a continuum of the same condition. [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. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. Nonparetic Diplopia - EyeWiki Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. To begin therapy, many therapists will focus first on normalizing the accommodative system. 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. Other associated symptoms can include asthenopia of panoramic type. Tamhankar MA, Ying GS, Volpe NJ. Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. 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. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. The main treatment for convergence insufficiency is vision therapy. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. Lewis [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. 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 LR-SR band vertically supports the LR pulley against the downward force of the inferior oblique muscle to maintain the LR pulleys vertical position. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. Biousse V and Newman NJ. Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. Strabismus. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults.
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