Chaudhuri Z, Demer JL. The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation Sensory Anomalies. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? Weird vision divergence upon waking at night User Name: Remember Me: Password . LRosenbaum 13.119). The distance at which diplopia occurs is noted (near point of convergence). Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. JWStockbridge ALDemer DJDivergence insufficiency. 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. 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. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). For example, the right eye might see a lion while the left eye sees a cage. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. 2000;118(9):1237-41. Similarly, the theories on mechanism of divergence itself have varied. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. 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. In addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. 2013;97(11):1415-9. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. 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. To begin therapy, many therapists will focus first on normalizing the accommodative system. 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. Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. [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). Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. 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 had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. The following information was abstracted from the medical records: current medical history, past medical history, details of the ocular motor and general neurologic examinations, results of radiographic and laboratory tests, and long-term follow-up of those cases that were classified as idiopathic. 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. DRHartnett Effectiveness of base in prism for presbyopes with convergence insufficiency. 2016;28(1):38-42. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. as their fusional vergence ranges expand. J AAPOS. 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. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. How is convergence insufficiency treated? Primary divergence insufficiency is generally a benign condition. 2005;9:36. The other patient with focal brainstem injury, a stroke with double vision, vertigo, and left arm numbness, did not have the responsible lesion identified by the CT. DOI: Demer JL. None of the patients initially classified as having primary divergence insufficiency developed additional neurologic dysfunction during the period of follow-up. GTDJohnston Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. 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. 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. GMOcular divergence: its physiology and pathology. Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. Arch Ophthalmol. "The term divergence insufficiency implies a problem at the level of the brainstem, suggesting that there is decreased neural output to the extraocular muscles," said Prem S. Subramanian, MD, PhD, at the University of Colorado in Aurora. ARKline Smith Clinical management of strabismus. Intravenous edrophonium chloride testing was performed in 2 patients because of the referring physician's concern about the possibility of myasthenia gravis despite the absence of other symptoms or signs of this condition, but the test did not resolve double vision or reduce the amount of esotropia. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). Bruce It can also decrease distance judgement, coordination, and sports performance. Br J Ophthalmol. 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. [10] In 2013, Stager et al. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. Different cards with different images will require different amounts of negative and positive fusional vergence. 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. Schanzer JLSaccadic velocity analysis in patients with divergence paralysis. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. 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 convergence spasm? Although prescribing it can seem intimidating at first, with practice and a bit of trial and error, you can perfect your ability to prescribe prism for your patients in no time. Treatment options include correction with base-out prisms for distance, Tomasz A. Wiraszka, MD, and Praveena Gupta, OD, PhD, FAAO, Galveston, Texas, April 2015 Wills Eye Resident Case Series, Wills Eye Resident Case Series - Diagnosis and Discussion, November 2014 Wills Eye Resident Case Series, February 2016 Wills Eye Resident Case Series - Diagnosis & Discussion. [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. Arch Ophthalmol. Graefes Arch Clin Exp Ophthalmol. In 2005 Thacker NM et al. SDiagnosis and management of divergence weakness in adults. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . 127. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. It is very a common condition where there is a comitant exotropia greater at near than at distance by at least 10 prism diopters. Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). When their medical records were reviewed at the time this study was being designed, I learned that they had since died of unrelated illnesses, so the course of their disorder could not be completely ascertained. Ghanchi 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. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. 134. Esodeviation is comitant in all fields of . CI affects children and adults. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. Convergence Insufficiency Symptoms. 127. [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. 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. 2016 May; 100(5): 648651. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. 2018 Jan 3:1-5. doi: 10.1080/09273972.2017.1421676. [unreliable source?] Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency. FEDivergence paresis: a nonlocalizing cause of diplopia. 2008;12(1):56. Bender Divergence insufficiency is a benign phenomenon causing horizontal diplopia at distance viewing . Wall Retrospective survey of patients with divergence insufficiency. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. 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. Committee on Aging. it is highly advisable that you check them out first as they cover basics not explained here. Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. Demer JL. Tamhankar MA, Ying GS, Volpe NJ. Lets continue the conversation over on your social network of choice. AOcular divergence mechanisms. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. Kirkham 2012. 126. 2009;86(2):153-6. J AAPOS. 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. Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. 11. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. 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. Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. Using magnetic resonance imaging (MRI), a coronal image 6 mm anterior to the eyeball-optic nerve junction was measured and used to examine the extraocular muscle (EOM) path shift . Duane 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. 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. Divergence excess is an over-divergence when attempting to look at distant objects. MBSavitsky Prism is a powerful tool that can be used to successfully treat a variety of binocular vision conditions. Peripheral double pictures Usually double vision arises from a squint deviation of the eyes and is checked with a torch and a red glass before one eye to separate the pictures. Methods To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. RJZee 12. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. Bedrossian Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. The EOM angles in these patients ranged from 100 to . 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. You can schedule your next appointment with us online! 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 . 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. The preferred method for prescribing prism for vertical heterophoria is determining the vertical associated phoria.12 This can be done at near using the Wesson card or at distance. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. What is congenital ocular motor apraxia? METraviesa Chaudhuri Z, Demer JL. highest quality optometry services and eye exams in Wilmington, Delaware and its surrounding areas. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. Since true paralysis of divergence generally cannot be documented in most affected patients,4 I prefer the term divergence insufficiency to describe this disorder, regardless of the severity of associated symptoms and signs. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. 134. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. 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. 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. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. Some patients report double pictures, but when checked with the torch, only one light is seen. 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. Pang Y, Teitelbaum B, Krall J. While none of the patients had other symptoms to suggest giant cell arteritis or myasthenia gravis, erythrocyte sedimentation rate (performed in 7 patients) and acetylcholine receptor antibody assay (performed in 6 patients) were tested, and the results were normal in all. JLSharpe RMTomsak Audio blog post. 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). 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. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. What are causes of convergence insufficiency? A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. What causes divergence insufficiency? The cyclotorsion component of SES was present in 65% of patients. 130. 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). What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Rather, treatment for a secondary vertical deviation should aim to improve horizontal sensory and motor fusion through vision therapy so the patient is not in the strabismic position as often, thus eliminating the vertical deviation. American Academy of Ophthalmology. 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. Terms of Use| It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. 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. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. 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. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. 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. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. ISOphthalmoplegia in cranial arteritis. 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. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. Typically, patients note that they do not have any diplopia at near. The characteristics of the patients in this series who have an idiopathic disorder suggest that if certain rules of diagnosis are obeyed, divergence insufficiency can be distinguished from sixth cranial nerve palsy in most cases using clinical techniques. Goldberg Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). GBurde Patients with primary divergence insufficiency were those who had no other neurologic symptoms or signs, and patients with secondary divergence insufficiency were those who had additional symptoms or signs of neurologic dysfunction. What are the symptoms of Convergence Insufficiency? 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. 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. Lateral rectus resections in divergence palsy: Results of long-term follow-up. If the eyes do drift out, the person is likely to have double vision. Convergence Insufficiency Testing. Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. Primary divergence insufficiency is generally a benign condition. 6. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying Reference: 1. However, the cause of convergence insufficiency is often unknown. Esotropia resolved within days of initiating corticosteroid treatment in both patients. the accommodative and vergence systems are tightly correlated. The orbital layer, inserts on the pulley, not on the globe. Br J Ophthalmol. After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or. 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. 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. When you try to focus on something close to your eyes, you may have: Tired eyes. enlisted 100 patients without strabismus, and readers graded the LR-SR band visible in 95% of orbits on non-fat-suppressed coronal T1-weighted sequences, 68% on coronal STIR sequences.
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