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Kerala J Ophthalmol. 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 . The first hurdle is ensuring your patient is comfortable with wearing spectacles. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. PMDivergence paralysis. The author has no commercial or proprietary interest in any product or company mentioned in this manuscript, and has no financial interest nor receives payment as a consultant, reviewer, or evaluator. 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. 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. 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. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. 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. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. 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). 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. 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. Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. Demer JL et al. In spectacle-dependent patients, a temporary Fresnel prism or permanent ground in prism are usually helpful in managing the double vision for distance without inducing diplopia for near given their strong near fusional capacities as mentioned before. SDiagnosis and management of divergence weakness in adults. Clin Exp Optom. 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. MGallaway 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%. People notice symptoms while reading or doing other near work. Diagnosing convergence insufficiency Mosbys Optometric Problem Solving Series, ed. p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 10.0px Sabon} p.p2 {margin: 0.0px 0.0px 0.0px 0.0px; text-indent: 10.0px; line-height: 12.0px; font: 10.0px Sabon} p.p3 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #867245; min-height: 12.0px} p.p4 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #b87c4c} p.p5 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #b37749} span.s1 {letter-spacing: -0.2px}. 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. PJThompson Goldberg 128. 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. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. 132. [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). 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. 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]. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. 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. Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. 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. 2009;86(2):153-6. MThe child with divergence paresis. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. MEBarrows 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. Krohel FEDivergence paresis: a nonlocalizing cause of diplopia. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. All Rights Reserved. Jacobson DM. Hold focus on this dot for 10 seconds. The main treatment for convergence insufficiency is vision therapy. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Convergence insufficiency (CI) is a vision disorder. 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. 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. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Chaudhuri Z, Demer JL. 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. This is the brain's answer to coping with double vision and the stress of eyes not working as a . Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. Initial tenotomy 30% of tendon width was performed to avoid intraoperative overcorrection. The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. Our eye doctors. To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. Barricks To be enrolled in the study, patients had to meet the following 5 criteria: 1) relatively sudden onset of double vision at far vision, 2) no double vision at near vision, 3) high myopia >6.0 diopters (D) in both eyes, 4) no other neurological symptoms, and 5) a normal . By continuing to use our site, or clicking "Continue," you are agreeing to our, Clinical Features of Patients With Primary and Secondary Divergence Insufficiency, Disorders Associated With Secondary Divergence Insufficiency. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. Neena R, Giridhar A. Corresponding author: Daniel M. Jacobson, MD, Neuro-ophthalmology (4F-2), Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (email: jacobsod@mfldclin.edu). 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. 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. J AAPOS. Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. Similarly, the theories on mechanism of divergence itself have varied. 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. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. In 2005 Thacker NM et al. Patients and methods. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task R. London. 131. J Pediatr Ophthalmol Strabismus. JAAcquired esotropia due to Arnold-Chiari I malformation. He usually volunteers the infor mation that he has no trouble in reading or close use of his eyes. 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. When patients are spectacle independent and want to remain independent, surgical approach could be offered. ARKline MDavidoff More respect for connective tissues. The cyclotorsion component of SES was present in 65% of patients. 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). No such signs were identified in any of the patients in this series. While viewing the card, the patient reports what color line the black arrow is aligned with. Esotropia resolved within days of initiating corticosteroid treatment in both patients. All Rights Reserved. . In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. Lateral rectus resections in divergence palsy: Results of long-term follow-up. 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. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or esotropia, meaning the eyes like to sit in an inward position. LBSharpe 2023 American Medical Association. 2000;118(9):1237-41. CI affects children and adults. Only 2 patients were followed up for less than 6 months. ALDemer The tool itself can be calibrated to work on increasing divergence or convergence, depending on, Our eye doctors at Wilmington Family Eye Care in Wilmington, DE excel in prescription of glasses, contact lenses and the diagnosis of a variety of eye diseases. Terms of Use| Godts D, Mathysen DG. In many individuals with, Normalizing accommodation is important because. Chaudhuri Z, Demer JL. 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. Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. 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). AOcular divergence mechanisms. Over a period of several months, the diplopia becomes more constant and is noticed while driving, watching television, and in other long-distance vision situations. The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. 12. PCBurian Lewis Optom Vis Sci. Objectives Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. 2012;49(4):222-8. The opposite of divergence insufficiency is divergence excess. 3rd ed. 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 still have mild double vision and . 2008;126(10):1336-49. 2013;97(11):1415-9. It involves a specialty optical system and a uniquely created image book. 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. Antireflective coating is also beneficial for patients wearing prism lenses. with a stereo image already pre-made onto the card. Committee on Aging. Parkinson disease 4. It is usually benign. [1][5][8] The patients may also present with bilateral ptosis. Prescribing relieving prism for horizontal, non-strabismic, binocular vision disorders can be done by calculating Sheards or Percivals criteria by using clinical data or analyzing fixation disparity and determining the associated phoria.1 At near, fixation disparity and the associated phoria can be found with a Wesson card. 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] Keep moving to the next dot along the card, gradually getting closer to the nose. Chamlin 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. Demer JL. As a . It is most often related to raised intracranial pressure or Chiari malformation. If no movement is seen on the unilateral cover test, the patient has normal correspondence. Tamhankar MA, Ying GS, Volpe NJ. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. JWStockbridge Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. Certain factors are associated with exotropia, including genetics and health conditions. The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. _________________________________________________________________. 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. 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. 13.119). No clear sex predilection has been identified for the primary form of the condition. 126. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. 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. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. Ductions and versions are full. What is convergence spasm? Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Their symptom was controlled using prisms. J AAPOS. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. Divergence insufficiency is the opposite problem of convergence insufficiency. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. 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. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. All but 1 patient were older than 50 years. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. Patients may also present with ductional deficits depending on the grade of muscle displacement. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. Cunningham Teitelbaum B, Pang Y, Krall J. All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). Neuro-ophthalmology Illustrated-2nd Edition. et al. 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Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. Pencil pushups may be effective in some cases. Methods 6. RDInternuclear ophthalmoplegia in giant cell arteritis. 9. 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. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. Accepted for publication February 11, 2000. Patients with divergence insufficiency 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. A Maddox rod was also used to determine the near point of orthophoria in most patients. Success of prisms in the management of diplopia due to fourth nerve palsy. GMOcular divergence: its physiology and pathology. it is highly advisable that you check them out first as they cover basics not explained here. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. What is congenital ocular motor apraxia? Strabismus. 129. 2012;95(2):192-7. 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. Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. Committee on Aging. 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. None of these patients developed signs of an underlying neurologic disorder during follow-up. DJDivergence insufficiency. American Academy of Ophthalmology. Pang Y, Teitelbaum B, Krall J. One patient was followed up for only 1 month, but her esotropia resolved during that time. Audio blog post. 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. created image book. RTOcular muscle paresis and cranial arteritisan unusual case. Abstract. Patients with divergence insufficiency 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. . The results of CT or magnetic resonance imaging (MRI), available at the time of initial evaluation, were not initially considered since one of the aims of this study was to identify clinical features that might be helpful in predicting which patient was harboring a neurologic disorder. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. [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. . Otherwise, neuroimaging can be deferred in patients with neurologically isolated divergence insufficiency, although careful follow-up is indicated to identify developing suspicious neurologic symptoms or signs. Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. This means the eyes do not like to move inward toward the nose and is problematic when trying to look at a near target. 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. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. Effectiveness of prisms in relieving diplopia in superior oblique palsies. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. 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. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). 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. Thomson Long-term follow-up and clinical features of the 2 groups were compared. Introduction. 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. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. In those patients with secondary divergence insufficiency, the underlying disorder was either already established or strongly suspected based on the additional neurologic symptoms and signs at their initial evaluation. ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. 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). Eye - Diplopia following cataract surgery . To begin therapy, many therapists will focus first on normalizing the accommodative system. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. 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. 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. Clinical uses of prism: a spectrum of applications. 2016;28(1):38-42. These studies were unrevealing in all patients. Long-term Surgical Outcomes in the Sagging Eye Syndrome. Arch Ophthalmol. Arch Ophthalmol. BBordaberry Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. 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. What is convergence spasm? Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. 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. Divergence insufficiency can vary in severity, from minor deficits to complete divergence paralysis. 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. Scheiman M, Wick B. In addition, all patients underwent examination of ocular motility using a Maddox rod to demonstrate that the angle of uncrossed deviation increased as the viewing distance increased, remained the same or decreased in right and left gazes at distance, and decreased as the viewing distance decreased.