None of the patients initially classified as having primary divergence insufficiency developed additional neurologic dysfunction during the period of follow-up. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. The patient places two transparent cards into the vectogram system. Head trauma 3. RMTomsak Convergence insufficiency is an anomaly that causes the eye to under-converge at near. Trans Am Ophthalmol Soc. No signs of orbital ischemia were present in the second patient. Divergence Insufficiency/Excess | Vision Therapy Paducah Kentucky Divergence Insufficiency and Divergence Excess Symptom Checklist Vision Therapy: Alex's Success Story | Wow Vision Therapy Share Watch on Share this: Twitter Facebook Like this: Loading. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. Godts D, Mathysen DG. 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. It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. Roper-Hall 632. Symptoms of vergence disorders occur only under binocular viewing conditions and may include eyestrain, double vision and headaches.4,7,9,10,15 Interventions: Vision Training Many TBI patients respond well to efforts to improve vision, cope with impairment, or both. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. Convergence Insufficiency (CI): Symptoms, Diagnosis - Cleveland Clinic Terms of Use| Near point convergence is the distance you can use both eyes without seeing double. It involves a specialty optical system and a uniquely created image book. Vergence - Wikipedia 2016 May; 100(5): 648651. More advanced exercises for vergence insufficiencies include. 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. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. It is most often related to raised intracranial pressure or Chiari malformation. 3. Demer JL. Near point of convergence (NPC) is measured by bringing an object to the nose and observing when the patient sees double, or one eye deviates . Br J Ophthalmol. 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. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. It is idiopathic most often in children or young adults 2. 8. an electromyographic study. If the patient is only using one eyethe image will not be formed correctly. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, 2000;118(9):1237-1241. doi:10.1001/archopht.118.9.1237. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. None of these patients underwent strabismus surgery. The opposite of divergence insufficiency is divergence excess. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. Goldberg DBGlaser of negative and positive fusional vergence. With CI, the eyes do not point together inward as one looks at objects close-up. It is spasm of the near triad: 1. JAAcquired esotropia due to Arnold-Chiari I malformation. 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. No clear sex predilection has been identified for the primary form of the condition. Mosbys Optometric Problem Solving Series, ed. 2005;9:711. 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. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. 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 . 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. JWStockbridge 1. While viewing the card, the patient reports what color line the black arrow is aligned with. None of these patients developed signs of an underlying neurologic disorder during follow-up. 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. Intermittent convergence Always with accommodation and pupillary constrictionClassic causes of convergence spasm include the following: Most often nonorganic Excessive accommodation from uncorrected refractive error Lesions at the diencephalicmesencephalic junction (very rare)Convergence InsufficiencyConvergence insufficiency is a very common condition, characterized by the following: Exotropia greater at near than at distance (at least 10 prism diopters difference) Causes symptoms of asthenopia (fatigue with reading, diplopia at near, intermittent blurred vision when reading) Usually benign; may improve with orthoptic exercises Sometimes requires prisms in reading glasses or strabismus surgeryClassic causes of convergence insufficiency include the following: Idiopathic most often (in children or young adults) Head trauma Parkinson disease Progressive supranuclear palsyThe ability to converge can be measured (Fig. Divergence insufficiency: characteristics, diagnosis, and treatment American Academy of Ophthalmology. Ghanchi 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. Sagging Eye Syndrome. The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. Patients who wear contact lenses the majority of the time or who have undergone refractive, cataract or strabismus surgery may not be happy with the idea of moving or going back to spectacle wear even if it relieves asthenopia or diplopia. The procedure is performed under topical anesthesia in the presence of an anesthesiologist. 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. Their symptom was controlled using prisms. 2008;12(1):56. 3 Advanced Exercises for Convergence and Divergence Insufficiency 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. 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. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Bruce FDDutton JLSaccadic velocity analysis in patients with divergence paralysis. doi:10.1001/archopht.118.9.1237. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. One patient was followed up for only 1 month, but her esotropia resolved during that time. Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. 2023 American Medical Association. 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. With a trial frame, she was not able to appreciate RDS stereoacuity in-office. 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. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. Parkinson disease 4. The cyclotorsion component of SES was present in 65% of patients. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. This patient continued with vision therapy to help improve her sensory and motor fusion with the hope of eventually titrating down the amount of prism she wears. is variable. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. ALDemer IRT. The first hurdle is ensuring your patient is comfortable with wearing spectacles. Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. None of these patients developed signs of an underlying neurologic disorder during follow-up. 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. 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. Methods: We investigated 20 cases of high myopia (>-6 D) with divergence insufficiency, 20 cases of high myopia without double vision, and 10 normal cases as controls. Convergence Insufficiency - American Academy of Ophthalmology Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." Wednesday, March 15, 2023 | All Eyes On Evaporation, Thursday, April 13, 2023 | All Eyes On Evaporation, Tuesday, April 18, 2023 | All Eyes On Evaporation. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. In many cases, individuals with convergence insufficiency will notice that their symptoms worsen as they get tired or after attempting to do near tasks for a prolonged period of time. 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. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. 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}. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. Strabismus. Moore What Is Convergence Insufficiency? Symptoms, Causes, and Treatments - WebMD