Primary divergence insufficiency is generally a benign condition. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. A new prescription for prism lenses was dispensed to the patient at the follow-up examination. 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. 13.119). Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. 3. In this example, the patient will be asked to either relax his or her eyes to put the lion in the cage (diverge) or stimulate his or her eyes to put the lion in the cage (converge). 2005;89(10):1318-23. Conclusions 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. Pencil pushups may be effective in some cases. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? This decreases the motor fusion demand, allowing the patient to fuse more comfortably. I still have mild double vision and . To begin therapy, many therapists will focus first on normalizing the accommodative system. Smith Head trauma 3. 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. 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. What is convergence spasm? 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. [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. An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. Of note among this cohort of patients without strabismus, noncontinuous LR-SR bands were found in 5% of cases, and superotemporal bowing in 24% of cases. Archives of Neurology & Psychiatry (1919-1959), Subscribe to the JAMA Ophthalmology journal, JAMA Surgery Guide to Statistics and Methods, Antiretroviral Drugs for HIV Treatment and Prevention in Adults - 2022 IAS-USA Recommendations, CONSERVE 2021 Guidelines for Reporting Trials Modified for the COVID-19 Pandemic, Global Burden of Skin Diseases, 1990-2017, Guidelines for Reporting Outcomes in Trial Protocols: The SPIRIT-Outcomes 2022 Extension, Mass Violence and the Complex Spectrum of Mental Illness and Mental Functioning, Organization and Performance of US Health Systems, Spirituality in Serious Illness and Health, The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity, Screening for Prediabetes and Type 2 Diabetes, Statins for Primary Prevention of Cardiovascular Disease, Vitamin and Mineral Supplements for Primary Prevention of of Cardiovascular Disease and Cancer, Statement on Potentially Offensive Content, Register for email alerts with links to free full-text articles. 2012;49(4):222-8. 127. LMDivergence paralysis with increased intracranial pressure: further observations. Chaudhuri Z, Demer JL. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. MGeorge Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. The association with refractive errors (and high myopia in particular) has been a point of contention for some time. Double vision is a troublesome complication of otherwise successful cataract surgery. Neena R, Giridhar A. 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. 3rd ed. MThe child with divergence paresis. Divergence Insufficiency. 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. 10. Initial tenotomy 30% of tendon width was performed to avoid intraoperative overcorrection. Lepore Her research interests include strabismus and binocular vision disorders. 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. Miller Many affected patients experience spontaneous resolution of double vision within several months. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. One of the most important aspects of successfully prescribing prism is choosing patients who will benefit the most from it. 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. One patient was followed up for only 1 month, but her esotropia resolved during that time. Tamhankar MA, Ying GS, Volpe NJ. Clinical management of strabismus. Exotropia (Eyes Turning Outward): Types, Signs & Treatment Other training exercises include base-out prisms for near viewing and convergence exercises. 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. 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. Retrospective case reviews of patients with an acquired hyper deviation secondary to a superior oblique palsy found that 76% to 92% of participants were successfully treated with prism alone.5,6. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. Convergence insufficiency | AOA In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. Many affected patients experience spontaneous resolution of double vision within several months. The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. Some patients report double pictures, but when checked with the torch, only one light is seen. Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. Chamlin If the eyes do drift out, the person is likely to have double vision. 129. if you would like to learn more about convergence and divergence insufficiency. Thomson Strabismus. DIVERGENCE INSUFFICIENCY - Optography 4. Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. 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. Divergence insufficiency can also result in headaches, motion sickness and sensitivity to bright lights. RDInternuclear ophthalmoplegia in giant cell arteritis. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. What is congenital ocular motor apraxia? reported a series of 57 patients underwent unilateral lateral rectus resection for distance esotropia deviations of 530 with 96.5% did not require further surgery.[11]. Blurred vision. [2] R. London. This page was last edited on January 26, 2023, at 08:42. . Roper-Hall This problem is most commonly found in children. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. A Maddox rod was also used to determine the near point of orthophoria in most patients. 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. Reference: 1. The use of topical anaesthesia does not abolish this surgical risk. Other associated symptoms can include asthenopia of panoramic type. AJNR Am J Neuroradiol. 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. Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. unable to diverge appropriately to a given target. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. 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). 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. 2023 Stanford School of Medicine | Terms of Use | In 2015 Chaudhuri and Demer published a retrospective observational study about utilizing Graded Vertical Rectus Tenotomy (GVRT) for treating incomitant vertical misalignment. A secondary vertical deviation, on the other hand, presents when the patients eyes are strabismic but disappears when the patient aligns their eyes to the ortho position.7 Secondary vertical deviations are common in strabismic patients, particularly in those with intermittent exotropia. PDF CLINICAL SCIENCES Divergence Insufficiency Revisited - JAMA 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. 132. Per some observations, its is more common in Caucasian females. J AAPOS. . The orbital layer, inserts on the pulley, not on the globe. 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. 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. Chang MY et al. CI affects children and adults. 1995, St. Louis, Missouri: Mosby. 13. It is most often related to raised intracranial pressure or Chiari malformation. 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. Graefes Arch Clin Exp Ophthalmol. IRT. 2014;18(4):309-15. 1978;76:610-53. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Heavy eye syndrome versus sagging eye syndrome in high myopia. Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. Clinical uses of prism: a spectrum of applications. Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. Although small amounts of vertical prism can be prescribed in contact lenses, patients who need prism usually have to wear it on a spectacle lens. 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. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. Divergence Insufficiency: An Ongoing Challenge - Review of Ophthalmology No such signs were identified in any of the patients in this series. Primary divergence insufficiency is generally a benign condition. AOcular divergence mechanisms. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. 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%. 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. 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. 6. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. The mechanical properties of pulleys are critical for the support and rotational properties of the eye. 8. 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. 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. 2008;126(10):1336-49. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. [4]The pulleys inflect rectus and inferior oblique paths by the exact same way that the trochlea inflects the path of the superior oblique (SO) tendon. Patients presenting with a greater eso deviation at distance than at near, a concomitant deviation, and diplopia pose a challenging and critical diagnostic and therapeutic puzzle for . 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. To increase convergence, the two cards will be pushed inward, making the image smaller (Small In for the SI in SILO). 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. A 5-year-old female initially presented for a strabismus and amblyopia evaluation. ISOphthalmoplegia in cranial arteritis. 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. Vision suppression stops you from seeing double, but it doesn't fix the problem. People notice symptoms while reading or doing other near work. 130. 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. [1][5][8] The patients may also present with bilateral ptosis. If no movement is seen on the unilateral cover test, the patient has normal correspondence. Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. Barricks 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. Heavy Eye vs. What is convergence insufficiency? 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. 12. Increasing or decreasing the distance between the two cards and asking the patient to converge or diverge will work on the focusing system and expand the eyes abilities to converge or divergehence helping with an insufficiency problem.