1993, Oxford, UK: Butterworth Heinemann Books. Long-term follow-up and clinical features of the 2 groups were compared. 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. 3rd ed. Divergence insufficiency associated with high myopia - PubMed Double vision is a troublesome complication of otherwise successful cataract surgery. 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. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. 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. ALDemer Although each method has its advantages and disadvantages, they all suffer from being subjective. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. Before settling on a final prism prescription, it is often helpful to trial frame the amount of prism you are about to prescribe to ensure that it will help you achieve your goals. Divergence excess is an over-divergence when attempting to look at distant objects. NRNewman In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. A Maddox rod was also used to determine the near point of orthophoria in most patients. 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]. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Reproduction in whole or in part without permission is prohibited. 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. The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). 130. Arch Ophthalmol. If no movement is seen on the unilateral cover test, the patient has normal correspondence. Fusion prism is the minimum amount of prism needed to see a change from diplopia or suppression to normal binocular vision.12 To determine prism using this method, use the Worth Dot test to find a preliminary prism amount. If the dot becomes doubled, go back to the previous dot and try again. Accepted for publication February 11, 2000. PCBurian 130. 2023 American Medical Association. Ghanchi The signs and symptoms with this condition are similar to convergence excess. 133. Chang MY, Pineles SL, Velez FG. Demer JL et al. 2009;86(2):153-6. Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. 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}. JWStockbridge 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. 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. Patients with non-strabismic binocular vision disorderssuch as divergence insufficiency, basic esophoria and vertical heterophoriacan often benefit from treatment with prism, particularly relieving prism, while othersincluding those with convergence excess, convergence insufficiency, divergence excess or basic exophoriaare better managed with other treatment modalities, such as vision therapy or lenses.1 An option for prism patients is prescribing prism to relieve diplopia and asthenopia and concurrently having the patient do vision therapy to attempt to decrease or eliminate the amount of prism needed. 10. 8. [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. DIdiopathic intracranial hypertension: a prospective study of 50 patients. 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. 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. 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. Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. Lets continue the conversation over on your social network of choice. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. 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. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. Barricks Using the Mann-Whitney test, there was no significant difference in the size of esotropia in forward gaze at distance or near point of fusion between the groups of patients with primary and secondary divergence insufficiency (Table 1). DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. Customize your JAMA Network experience by selecting one or more topics from the list below. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . 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. A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. 12. Results: In high-myopia patients with divergence insufficiency, ocular axis measurements ranged from 24.8 to 31.0 (mean SD: 27.6 1.6) mm. 2012. 2012;49(4):222-8. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. Neuro-ophthalmology Illustrated Chapter 13 Diplopia 10 - Convergence Convergence describes the way our eyes move together and point inward when we look at near objects. Lewis Many affected patients experience spontaneous resolution of double vision within several months. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. 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. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. 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. Convergence Insufficiency Testing. The EOM angles in these patients ranged from 100 to . 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. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. 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. I still have mild double vision and . https://www.aao.org/interview/heavy-eye-vs-sagging-eye-syndrome, https://www.aao.org/audio/sagging-eye-syndrome, https://doi.org/10.1016/j.ajo.2019.09.006, https://eyewiki.org/w/index.php?title=Sagging_Eye_Syndrome&oldid=89033, Results from bilateral inferior shift of the LR pulleys, Characterized by esotropia at distance fixation, orthotropia or esophoria at near fixation, Normal horizontal duction range and normal horizontal saccadic velocities, Results from asymmetrical inferior shift of the LR pulley, Characteristically by hypotropia and excyclotortion of the lower eye, ARDE only: incomitant esotropia worse in distance and in side gaze with no strabismus or small phoria for near and, ARDE and CVS: incomitant esotropia with a small hypotropia in one side, CVS only: hypotropia with no horizontal deviation, Normal horizontal duction range, and normal horizontal saccadic velocities, Cranial nerve palsy (Third, Fourth or Sixth nerves). How is convergence insufficiency treated? et al. 2014;35(9):1830-5. As a . The patient places two transparent cards into the vectogram system. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. Objectives Goldberg With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. AJNR Am J Neuroradiol. 133. Convergence and Divergence - Vivid Vision What is divergence insufficiency? Convergence Insufficiency. Moller Rutar T, Demer JL. Lim Exercises for double vision: 4 things to try - Medical News Today 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. 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. J AAPOS. [5], In recent imaging studies, Patel et al. 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. unable to diverge appropriately to a given target. doi:10.1136/bjophthalmol-2015-306783. 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. 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. Convergence Insufficiency/Vision Therapy - Eye Docs For Kids Scheiman M, Wick B. SDiagnosis and management of divergence weakness in adults. Diplopia Developed in Later Life, An Ophthalmologic Approach Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. 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. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. Convergence Insufficiency Testing. A Vectogram is a tool which utilizes specialized imaging along with the fusional vergence system to create a 3-D object. 2005;89(10):1318-23. 127. When you try to focus on something close to your eyes, you may have: Tired eyes. Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. 2016. Tamhankar MA, Ying GS, Volpe NJ. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. It is a disorder involving binocular vision vision using both eyes. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. 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. 134. If the patient is only using one eyethe image will not be formed correctly. 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. What is the cause of convergence spasm? This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. This recommendation is based on the small size of the study population, the problems inherent in a retrospective investigation, and the grave consequences of failing to identify other neurologic signs. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. The patient is also instructed to keep the words around the lines clear to control accommodation. AmblyoPlay is a vision therapy solution that is performed through playing therapeutic games and exercises on your tablet or computer for 30 minutes per day. Recent trauma The Apt Lecture. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. 13.120). A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. 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. Divergence insufficiency: characteristics, diagnosis, and treatment Of the 20 patients with primary divergence insufficiency, there were 10 women and 10 men, ranging in age from 24 to 90 years, with a median (mean) age of 74 (70) years. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. 126. In normal cases, the ocular axis length was 23.5 1.0 mm. Connective tissues reflect different mechanisms of strabismus over the life span. is variable. Bender In that study, strabismus surgery was performed in 50% of all SES cases. 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. 11. Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. To begin therapy, many therapists will focus first on normalizing the accommodative system. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. With the exception of the size of vertical fusion amplitude, ocular motor signs associated with divergence insufficiency did not distinguish patients with idiopathic from those with secondary disorders. This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. 134. If the patient is still symptomatic, combining prism and vision therapy may help improve convergence and divergence ranges. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Wiggins All rights reserved. IRT. 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. Per some observations, its is more common in Caucasian females. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. 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. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Divergence Insufficiency. CI affects children and adults. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. . ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. In the 17 patients with primary divergence insufficiency who had adequate information to ascertain long-term follow-up, double vision persisted in 9 individuals. Although cosmesis can be an issue with prism glasses, educating your patients on proper frame and lens selection will help them choose a frame and lens combination for the best cosmetic outcome. _________________________________________________________________. 2000;118(9):1237-41. They use head thrusts to shift fixation. Mosbys Optometric Problem Solving Series, ed. A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. 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The orbital layer, inserts on the pulley, not on the globe. Supported by Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. Biousse V and Newman NJ. RLMagnetic resonance images in a case of "divergence paralysis.". Prism in reading glasses or strabismus surgery may be required. 3 Advanced Exercises for Convergence and Divergence Insufficiency 1. make average daily distance tasks more manageable with less frequent symptoms. Prism can be a powerful treatment for many conditions and for many patients, specifically for those who suffer from asthenopia or diplopia. Br J Ophthalmol. [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. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. . The mirror stereoscope is one of the most commonly used types. It is usually benign. Head trauma 3. 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. Neuro-ophthalmology Illustrated-2nd Edition. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. 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. 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. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. What is the cause of convergence spasm? Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. All but 1 patient were older than 50 years. Exotropia (Eyes Turning Outward): Types, Signs & Treatment You can also use Random Dot Stereo (RDS) testing to determine fusion prism. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. Parkinson disease 4. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. 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. 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. 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. Chaudhuri Z, Demer JL. Six patients underwent CT and 10 underwent MRI. Chaudhuri Z, Demer JL. 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. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. 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. Weird vision divergence upon waking at night User Name: Remember Me: Password . Scheiman M, Cotter S, Rouse M, et al. Sagging Eye Syndrome - EyeWiki To increase convergence, the two cards will be pushed inward, making the image smaller (Small In for the SI in SILO). 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. 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. 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. divergence insufficiency synonyms, divergence insufficiency pronunciation, divergence insufficiency translation, English dictionary definition of divergence insufficiency. As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. 129. Only 2 patients were followed up for less than 6 months. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. 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. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." It involves a specialty optical system and a uniquely created image book.
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