When nonisolated, divergence insufficiency is most often reported in patients with intracranial hypertension, a neurologic condition often associated with sixth cranial nerve palsy.8,12-14,16 Some investigators have recorded slow abducting saccades in patients with signs consistent with divergence insufficiency, suggesting that abducens palsy was the cause of esotropia in these individuals.14 However, this finding has not been reproduced.11,17. Weird vision divergence upon waking at night User Name: Remember Me: Password . Br J Ophthalmol. 10. Primary divergence insufficiency is generally a benign condition. Interestingly, they found that the relative proportion of SES was just 4.7% in patients younger than 50 years but it increased to 60.9% in patients older than 90. Extraordinary symptoms equivalent to diplopia 2.3.1. 126. Accepted for publication February 11, 2000. It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. 130. 1978;76:610-53. 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. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. Divergence Insufficiency Revisited: Natural History of - JAMA Lewis
Long-term follow-up and clinical features of the 2 groups were compared. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. It is an unusual form of strabismus with esotropia and diplopia only at distance and single binocular vision at near. Abstract. Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. To prevent double vision, the individual exerts extra effort to make the eyes turn back in. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. 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. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. 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. 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. Smith
Different cards with different images will require different amounts of negative and positive fusional vergence. 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. doi:10.1136/bjophthalmol-2015-306783. Committee on Aging. Divergence insufficiency: characteristics, diagnosis, and treatment 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. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. This page was last edited on January 26, 2023, at 08:42. divergence insufficiency synonyms, divergence insufficiency pronunciation, divergence insufficiency translation, English dictionary definition of divergence insufficiency. [5], In recent imaging studies, Patel et al. of negative and positive fusional vergence. The Apt Lecture. 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. If the patient is only using one eyethe image will not be formed correctly. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. At the follow-up examination after nine weeks of patching and vision therapy for amblyopia, her visual acuities were equal in both eyes, and all testing showed normal correspondence. AParalysis of divergence. published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. unable to diverge appropriately to a given target. It is usually benign. Convergence Insufficiency. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. Methods
Neuro-ophthalmology Illustrated-2nd Edition. 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. 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. Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task At the follow-up examination, she reported no diplopia in her glasses, and, eventually, she was able to see 250 seconds of arc RDS stereoacuity. Sagging Eye Syndrome - EyeWiki Divergence insufficiency can also result in headaches, motion sickness and sensitivity to bright lights. Long-term follow-up and clinical features of the 2 groups were compared. Effectiveness of prisms in relieving diplopia in superior oblique palsies. [1]SES should be differentiated from heavy eye syndrome (HES) which is an association of axial high myopia, esotropia, and hypotropia. 133. Goldberg
Chaudhuri Z, Demer JL. 127. 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. AJNR Am J Neuroradiol. 2005;9:711. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. How is convergence insufficiency treated? Classically convergence spasm is nonorganic. Stern
Common symptoms include: headaches; blurred vision ; double vision LMDivergence paralysis with increased intracranial pressure: further observations. Ductions and versions are full. 2012. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. 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. 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. J Pediatr Ophthalmol Strabismus. Vertical deviations often cause patients to experience significant symptoms even when the deviation is small. In normal cases, the ocular axis length was 23.5 1.0 mm. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. This association has been reported before, and has contributed to the controversy of whether divergence insufficiency represents a separate disorder or subtle sixth nerve palsy.14 Although the double vision reported in patients with pseudotumor cerebri is generally attributed to sixth cranial nerve palsy,27,28 I suspect that many symptomatic patients have divergence insufficiency, as suggested by Smith.29. Kirkham
Exercises for double vision: 4 things to try - Medical News Today 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. Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. 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. 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. Lyle
More advanced exercises for vergence insufficiencies include. 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] 3 Advanced Exercises for Convergence and Divergence Insufficiency Success of prisms in the management of diplopia due to fourth nerve palsy. Distance esotropia in the elderly. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. 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. 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. NADivergence paralysis. PMDivergence paralysis. None of these patients developed signs of an underlying neurologic disorder during follow-up. Although each method has its advantages and disadvantages, they all suffer from being subjective. Recognizing TBI-related Vision Disorders - Review of Optometry Heavy eye syndrome versus sagging eye syndrome in high myopia. 2013;251:16411644. A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. A Maddox rod was the tool used to assess ocular comitancy in this study, but other methods exist, including prism-cover techniques, the Hess chart, and the Lancaster red-green test. Arch Ophthalmol. Convergence Insufficiency. MCiner
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. No clear sex predilection has been identified for the primary form of the condition. Individuals with convergence insufficiency often have a low AC/A ratio and a low near point of convergence. Chaudhuri Z, Demer JL. [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. 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%. J AAPOS. In the meantime, temporary paste-on and, if stable for several weeks, permanent ground-in prisms, were effective and conservative means of relieving symptoms in these patients. 2000;118(9):12371241. Many affected patients experience spontaneous resolution of double vision within several months. Sagging Eye Syndrome. . In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. Scheiman M, Cotter S, Rouse M, et al. NParalysis of divergence. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. Godts D, Mathysen DG. The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. The main treatment for convergence insufficiency is vision therapy. CHNuclear and infranuclear ocular motility disorders. What is the cause of convergence spasm? What causes divergence insufficiency? Divergence Paralysis - Optography SDiagnosis and management of divergence weakness in adults. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. 2008;126(10):1336-49. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. 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. Privacy Policy| Accordingly, I would recommend deferring consideration of strabismus surgery in this population for a sufficiently prolonged period of time to determine whether the esotropia might resolve spontaneously. Convergence insufficiency is a common problem with the eyes, and is the main culprit behind eyestrain, blurred vision, and headaches. This decreases the motor fusion demand, allowing the patient to fuse more comfortably. 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. Their symptom was controlled using prisms. 3rd ed. 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. DRHartnett
What is divergence insufficiency? Patients will be able to work on fusing the images of one. American Academy of Ophthalmology. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. To begin therapy, many therapists will focus first on normalizing the accommodative system. 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. They include: double vision (diplopia) headaches blurry vision while reading squinting or closing one eye while reading words appearing to move around or float on the page while reading eyestrain or fatigue (asthenopia) 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. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. While patients with strabismus often benefit from prism wear, it is important to first determine whether a strabismic patient is fit for treatment with prism by evaluating their potential for sensory fusion and whether the addition of prism will improve their sensory fusion status. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). Wiggins
Posted by . We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. Moller
ACSanders
The distance at which diplopia occurs is noted (near point of convergence). Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. Vergence - Wikipedia 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. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. Although no unsuspected neurologic disorder surfaced during the period of follow-up in these patients, I strongly recommend that a patient with isolated divergence insufficiency be followed closely to detect, for example, signs of developing intracranial hypertension or abducens nerve palsy. As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. What is congenital ocular motor apraxia? LBSharpe
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. There are many different ways to do this, but the best method to use depends on the type of binocular vision disorder for which you are prescribing. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. 13.121). Scheiman M, Wick B. R. London. Bruce
Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. 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. Divergence insufficiency associated with high myopia RMTomsak
What is convergence insufficiency? JLSaccadic velocity analysis in patients with divergence paralysis. Motion sickness or dizziness ( vertigo) Headache . This is the brain's answer to coping with double vision and the stress of eyes not working as a . Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. 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. It was found that the mean distance-esotropia deviation in Prism was 6.9 0.7 and it resolved to 0.3 0.3 after surgery, while mean vertical deviation went from 3.0 0.3 to 0.7 0.2. 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. 132. Convergence insufficiency | AOA A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. 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. Supported by Convergence insufficiency is an anomaly that causes the eye to under-converge at near. 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. They had experienced double vision for 5 weeks, 5 months, and 6 months, respectively, up to the time of their last evaluation, but did not return for further follow-up. Antireflective coating is also beneficial for patients wearing prism lenses. 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. Double vision is a troublesome complication of otherwise successful cataract surgery. The patient places two transparent cards into the vectogram system. For example, the right eye might see a lion while the left eye sees a cage. HS
Her research interests include strabismus and binocular vision disorders. When you try to focus on something close to your eyes, you may have: Tired eyes. Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. 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. 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. A new prescription for prism lenses was dispensed to the patient at the follow-up examination. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. Divergence insufficiency is the opposite problem, accommodation will be worked on first to ensure it is equal between the two eyes, basic vergence exercises will be added in. 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. 2011;31(3):206-9. Some patients report double pictures, but when checked with the torch, only one light is seen. 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). NRNewman
divergence excess eyewiki Convergence and Divergence - Vivid Vision Cotter SA. No such signs were identified in any of the patients in this series. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. No signs of orbital ischemia were present in the second patient. use an approach called the SILO affect to work on increasing divergence or convergence ranges. 2008;12(1):56. This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. American Academy of Ophthalmology. Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. 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. However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. 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. Eye - Diplopia following cataract surgery . Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency.