divergence insufficiency double vision

2009;86(2):153-6. Chaudhuri Z, Demer JL. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. As a . 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. An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. 2000;118(9):12371241. 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. 2023 American Medical Association. 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. MThe child with divergence paresis. Divergence excess is an over-divergence when attempting to look at distant objects. Strabismus. Prism in reading glasses or strabismus surgery may be required. Per some observations, its is more common in Caucasian females. 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. 2011;31(3):206-9. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. 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. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. DIdiopathic intracranial hypertension: a prospective study of 50 patients. While viewing the card, the patient reports what color line the black arrow is aligned with. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. None of these patients underwent strabismus surgery. Parkinson disease 4. 2012;130:12801284. Accepted for publication February 11, 2000. 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. [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. . In many of these cases, the initial management strategy is prescribing vertical prism.1 Often, if the vertical deviation is decreased or eliminated, the patient may be able to comfortably fuse the horizontal deviation. 2016 May; 100(5): 648651. 2008;126(10):1336-49. [12]Later Chaudhuri and Demer reported 24 patients and compared the results of those undergoing lateral rectus resection (n = 8) to those undergoing medial rectus recession (n = 16). Although each method has its advantages and disadvantages, they all suffer from being subjective. However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. 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. Common symptoms include: headaches; blurred vision ; double vision In that study, strabismus surgery was performed in 50% of all SES cases. The tool itself can be calibrated to work on increasing divergence or convergence, depending on, Our eye doctors at Wilmington Family Eye Care in Wilmington, DE excel in prescription of glasses, contact lenses and the diagnosis of a variety of eye diseases. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. RDDivergence paralysis. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. What is divergence insufficiency? In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. 1. Scheiman M, Wick B. RMTomsak One of the most important aspects of successfully prescribing prism is choosing patients who will benefit the most from it. Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. 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. Many affected patients experience spontaneous resolution of double vision within several months. LMDivergence paralysis with increased intracranial pressure: further observations. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. Clinical management of strabismus. [1]SES should be differentiated from heavy eye syndrome (HES) which is an association of axial high myopia, esotropia, and hypotropia. Prism can be a powerful treatment for many conditions and for many patients, specifically for those who suffer from asthenopia or diplopia. Customize your JAMA Network experience by selecting one or more topics from the list below. Chamlin ARKline . What is convergence spasm? Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. 2008;12(1):56. 130. 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. AParalysis of divergence. Scheiman THBird Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. Eye - Diplopia following cataract surgery . 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. 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. American Journal of Ophthalmology, Volume 209, January 2020, Pages 55-61. 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. [1][5][8] The patients may also present with bilateral ptosis. What are causes of convergence insufficiency? How is convergence insufficiency treated? Sagging Eye Syndrome. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. ACSanders 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. Patel SH, Cunnane ME, Juliano AF, Vangel MG, Kazlas MA, Moonis G. Imaging appearance of the lateral rectus-superior rectus band in 100 consecutive patients without strabismus. 2016. Kirkham 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. The diverse conditions and sites of associated lesions of the patients with secondary divergence insufficiency in this series imply that secondary divergence insufficiency is not particularly localizing, nor is it necessarily specific for intracranial hypertension. 2005;9:711. 132. Antireflective coating is also beneficial for patients wearing prism lenses. The Apt Lecture. The patient is also instructed to keep the words around the lines clear to control accommodation. All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. Divergence insufficiency can also result in headaches, motion sickness and sensitivity to bright lights. Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. 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. A near card is brought toward the patients nose until the patient sees double. Pencil pushups may be effective in some cases. 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). 128. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. 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. 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. 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. The two prevalent hypotheses put forth so far include altered cerebrospinal fluid flow in the posterior cranial fossa, and involvement of the abducens nucleus or infranuclear portion. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. Rutkowski After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. Neena R, Giridhar A. 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. Demer JL et al. Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. [unreliable source?] All rights reserved. Blurred vision. 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. Br J Ophthalmol. 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. Esotropia resolved within days of initiating corticosteroid treatment in both patients. The main treatment for convergence insufficiency is vision therapy. In many individuals with, Normalizing accommodation is important because. Bothun ED, Archer SM. Most pertinent from a clinical point of view is the controversy surrounding whether divergence insufficiency is a distinct entity, or is a sign of subtle abducens nerve palsy. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. You can schedule your next appointment with us online! Audio blog post. 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. The orbital layer, inserts on the pulley, not on the globe. None of these patients developed signs of an underlying neurologic disorder during follow-up. Progressive supranuclear palsy. et al. DBGlaser The difficulty of training vertical vergence ranges along with the success in treating vertical deviations with prism make prism the most appropriate initial management tool in these patients. Retrospective survey of patients with divergence insufficiency. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. RLMagnetic resonance images in a case of "divergence paralysis.". Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. 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. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. JLSharpe What causes divergence insufficiency? 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. It is most often related to raised intracranial pressure or Chiari malformation. Other training exercises include base-out prisms for near viewing and convergence exercises. All rights reserved. It is a disorder involving binocular vision vision using both eyes. divergence excess eyewikibc kutaisi vs energy invest rustavi. Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. 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. Privacy Policy| In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. J AAPOS 2014;18:370-373. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. To increase convergence, the two cards will be pushed inward, making the image smaller (Small In for the SI in SILO). Convergence Insufficiency. Eight (40%) of the 20 patients recalled such an event, including a viral pro-drome in 3 patients, minor head trauma in 2 patients, and hospitalization for an unrelated illness in 3 pa-tients. If the patient is only using one eyethe image will not be formed correctly. Krohel J Pediatr Ophthalmol Strabismus. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. If no movement is seen on the unilateral cover test, the patient has normal correspondence. Questions with answers: 125. Dr. Jenewein is an assistant professor at Salus University, Salus Universitys Principal Site Investigator for the Pediatric Eye Disease Investigator Group, a Fellow of the American Academy of Optometry and a Diplomate of the Binocular Vision, Perception and Pediatric Optometry Section of the Academy. To be enrolled in the study, patients had to meet the following 5 criteria: 1) relatively sudden onset of double vision at far vision, 2) no double vision at near vision, 3) high myopia >6.0 diopters (D) in both eyes, 4) no other neurological symptoms, and 5) a normal . Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. 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). Conclusions Convergence and Divergence The only way to diagnose CI is with an eye exam 1. EJampolsky A new prescription for prism lenses was dispensed to the patient at the follow-up examination. In the 2 patients with temporal arteritis, the rapid resolution of esotropia coincident with initiation of corticosteroid treatment, along with the development of posterior ischemic optic neuropathy in 1 case, point to ischemic injury of extraocular muscles as the cause of ophthalmoplegia. Chang MY et al. It is also possible that the 3 patients who died and did not undergo long-term follow-up had some unsuspected neurologic disorder at the time they were evaluated. Arch Ophthalmol. In those patients with secondary divergence insufficiency, the underlying disorder was either already established or strongly suspected based on the additional neurologic symptoms and signs at their initial evaluation. MCiner Reference: 1. 5. When looking at the image on the card, patients will be required to use their fusional vergence system to fuse the red and green images into one 3-D image. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. 2. In normal cases, the ocular axis length was 23.5 1.0 mm. GBTobin 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. Ductions and versions are full. Convergence Insufficiency Symptoms. Demer JL. Near point of convergence (NPC) is measured by bringing an object to the nose and observing when the patient sees double, or one eye deviates . Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. Therefore, it forces the patient to use both eyes properly to see the image. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. 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 . Stern Histories reveal the possibility of a number of etiologic factors. Different cards with different images will require different amounts of negative and positive fusional vergence. 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. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? After these patients are evaluated for any underlying systemic or neurological disease, which must always be ruled out in any case of new-onset strabismus, they are often good candidates for a prism prescription. Objectives In the remaining 17 patients who were still alive, the total duration of follow-up extended from 1 month to 16 years (median, 35 months). 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 you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. What is congenital ocular motor apraxia? 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. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. This problem is most commonly found in children. 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. Their symptom was controlled using prisms. Near point of convergence test: This test will . At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. JSLevy Mosbys Optometric Problem Solving Series, ed. FEDivergence paresis: a nonlocalizing cause of diplopia. Arch Ophthalmol. LRosenbaum if you would like to learn more about convergence and divergence insufficiency. [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. 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. 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. Theme, Congenital Ocular Motor Apraxia It affects young children. Defective or absence of voluntary horizontal saccades to visual stimuli: they cannot move their eyes horizontally to look at a target. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. In the 17 patients with primary divergence insufficiency who had adequate information to ascertain long-term follow-up, double vision persisted in 9 individuals. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Chang MY, Pineles SL, Velez FG. Moller Near point convergence is the distance you can use both eyes without seeing double. [2] Sagging Eye Syndrome. 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. I prescribed glasses (+3.00 sph OD, +2.25 sph OS) for the patient, and she returned for follow-up care, eventually patching and undergoing vision therapy for her amblyopia. This page has been accessed 63,795 times. GTDJohnston More respect for connective tissues. If the patient is still symptomatic, combining prism and vision therapy may help improve convergence and divergence ranges. 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]. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. People notice symptoms while reading or doing other near work. The procedure is performed under topical anesthesia in the presence of an anesthesiologist. Individuals with convergence insufficiency often have a low AC/A ratio and a low near point of convergence. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. 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. LDivergence insufficiency. Lim Sometimes it is exacerbated by fatigue and improves with rest. None of these patients developed signs of an underlying neurologic disorder during follow-up. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. RDInternuclear ophthalmoplegia in giant cell arteritis. 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) One patient was followed up for only 1 month, but her esotropia resolved during that time. 2014;18(4):309-15. They use head thrusts to shift fixation. 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. The distance at which diplopia occurs is noted (near point of convergence). Lepore Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. In support of that hypothesis, some investigators have reported clinical-radiographic and clinical-pathologic correlations of patients with divergence insufficiency associated with focal lesions, usually of the pons and midbrain,7-10 but also in other locations, such as the craniovertebral junction.8,11 On the other hand, patients with divergence insufficiency and a variety of diffuse brain injuries have also been described.8,12-15 The site of this elusive region, if in fact such a region exists, remains undefined. The patient places two transparent cards into the vectogram system. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. 2023 Stanford School of Medicine | Terms of Use | Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. Bedrossian The patients with primary divergence insufficiency in this retrospective survey were most often middle-aged or elderly persons with neurologically isolated double vision for distance who, not uncommonly, developed symptoms following a nonspecific illness or minor head trauma. 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. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. 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. 3rd ed. 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.