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. After these patients are evaluated for any underlying systemic or neurological disease, which must always be ruled out in any case of new-onset strabismus, they are often good candidates for a prism prescription. METraviesa
Neuro-ophthalmology Illustrated-2nd Edition. In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. Convergence and Divergence - Vivid Vision 126. 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. J AAPOS. Corresponding author: Daniel M. Jacobson, MD, Neuro-ophthalmology (4F-2), Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (email: jacobsod@mfldclin.edu). Godts D, Mathysen DG. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. [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). 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. I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. Arch Ophthalmol. [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. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. RMDiagnosis and management of divergence paresis. Near point convergence is the distance you can use both eyes without seeing double. 2023 American Medical Association. Dr. Jenewein is an assistant professor at Salus University, Salus Universitys Principal Site Investigator for the Pediatric Eye Disease Investigator Group, a Fellow of the American Academy of Optometry and a Diplomate of the Binocular Vision, Perception and Pediatric Optometry Section of the Academy. Differentiating sagging eye syndrome (SES) from other causes of strabismus is not always a straight forward task given that patients with SES may have risk factors for strokes or tumors. The EOM angles in these patients ranged from 100 to . Miller
The association with refractive errors (and high myopia in particular) has been a point of contention for some time. As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. Chang MY, Pineles SL, Velez FG. 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. However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. What is convergence spasm? 2011;31(3):206-9. it is highly advisable that you check them out first as they cover basics not explained here. NJeds, Leigh
Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. LMDivergence paralysis with increased intracranial pressure: further observations. created image book. No clear sex predilection has been identified for the primary form of the condition. RTOcular muscle paresis and cranial arteritisan unusual case. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. 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. Neena R, Giridhar A. . NRNewman
Eye - Diplopia following cataract surgery . None of these patients underwent strabismus surgery. 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. Tamhankar MA, Ying GS, Volpe NJ. FDDutton
What is divergence insufficiency? No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. 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. Tamler
Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Thomson
Weird vision divergence upon waking at night User Name: Remember Me: Password . Actually it's not synonymous with divergence paralysis, but it is a separate clinical entity Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. RDInternuclear ophthalmoplegia in giant cell arteritis. Supported by Lepore
Prism prescriptions often greatly improve the quality of life of your patients by reducing asthenopia and diplopia. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. DJDivergence insufficiency. All rights reserved. Double vision. Distance esotropia in the elderly. 7. 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. What are the symptoms of Convergence Insufficiency? 128. These exercises were discussed in detail in Part 6 of this series. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. 2005;89(10):1318-23. 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. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. 13. 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. Mosbys Optometric Problem Solving Series, ed. Divergence insufficiency is a benign phenomenon causing horizontal diplopia at distance viewing . 1994, Philadelphia, PA: Lippincott Williams & Wilkins. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. JJSavino
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] She had been previously diagnosed with esotropia and amblyopia but was not currently wearing any correction. DBGlaser
Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. EHBilateral sixth-nerve paresis simulating divergence paralysis. Jampolsky
A new prescription for prism lenses was dispensed to the patient at the follow-up examination. Recent trauma Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. ACSanders
[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. 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. Schedule Appointment Our Doctors Contact UsAccepted Providers, Comprehensive Eye Exams Glasses Contact Lens Exams Dry Eye Emergency Care, 801 East Newport Pike, Wilmington, DE 19804 | (302) 999-1286, If you have not read the previous portions of the vision therapy. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. 130. What are causes of convergence insufficiency? It is spasm of the near triad: 1. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? 130. 8. Goldberg
Cotter SA. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. 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. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. What is divergence insufficiency? How to test convergence eyes | Math Index New York, NY Oxford University Press1999;405-610. 128. If the dot becomes doubled, go back to the previous dot and try again. Exercises for double vision: 4 things to try - Medical News Today Histologic studies showed that each rectus pulley consists of an encircling ring of collagen located near the globe equator in tenon fascia, coupled to the orbital wall, adjacent EOMs, and equatorial Tenon fascia by bands containing densely woven collagen, elastin, and smooth muscle. When considering whether it is appropriate to prescribe vertical prism for a patient with combined horizontal and vertical deviations, particularly for a patient with intermittent strabismus, first identify whether the vertical deviation is primary or secondary. Smith
Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. This page has been accessed 63,795 times. Divergence insufficiency can also result in headaches, motion sickness and sensitivity to bright lights. 1978;76:610-53. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. 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. 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. 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. However, the cause of convergence insufficiency is often unknown. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. 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. What are causes of convergence insufficiency? Sometimes it is exacerbated by fatigue and improves with rest. doi:10.1001/archopht.118.9.1237. Ductions and versions are full. Many affected patients experience spontaneous resolution of double vision within several months. 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). This is the brain's answer to coping with double vision and the stress of eyes not working as a . Increasing or decreasing the distance between the two cards and asking the patient to converge or diverge will work on the focusing system and expand the eyes abilities to converge or divergehence helping with an insufficiency problem. 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. I doubt that assessment of the size of vertical fusion amplitude would be a helpful discriminating tool, however, since the size of it was small in most patients in both groups, it was measured using a subjective end point, and there was considerable overlap of values. The mirror stereoscope is one of the most commonly used types. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. Per some observations, its is more common in Caucasian females. Customize your JAMA Network experience by selecting one or more topics from the list below. Other training exercises include base-out prisms for near viewing and convergence exercises. 131. CHNuclear and infranuclear ocular motility disorders. If no movement is seen on the unilateral cover test, the patient has normal correspondence. 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. 2012. 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. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. 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. Duane
He usually volunteers the infor mation that he has no trouble in reading or close use of his eyes. This conclusion was recently confirmed by Wiggins and Baumgartner,22 who characterized a benign long-term prognosis in their cohort of patients with neurologically isolated divergence insufficiency. 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). 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. Progressive supranuclear palsy. Theme, Congenital Ocular Motor Apraxia It affects young children. Defective or absence of voluntary horizontal saccades to visual stimuli: they cannot move their eyes horizontally to look at a target. Each card contains a partial view of the complete image. JAAcquired esotropia due to Arnold-Chiari I malformation. American Academy of Ophthalmology. 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. All Rights Reserved. Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. Common symptoms include: headaches; blurred vision ; double vision 2023 Stanford School of Medicine | Terms of Use | 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. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or. JLSharpe
In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. Scheiman
Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. All patients with double vision routinely were assessed for the speed of saccades and for the presence of nystagmus to identify signs of abducens nerve palsy or internuclear ophthalmoplegia. 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. Chang MY et al. EDivergence insufficiency: characteristics, diagnosis, and treatment. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. IRT. These arguments do not preclude the possibility that some patients with comitant esotropia at distance and full-appearing ocular ductions might be suffering from sixth cranial nerve palsy, not divergence insufficiency. Convergence Insufficiency/Vision Therapy - Eye Docs For Kids 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.