He usually volunteers the infor mation that he has no trouble in reading or close use of his eyes. 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) Accepted for publication February 11, 2000. published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. Clin Exp Optom. 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. Graefes Arch Clin Exp Ophthalmol. Certain factors are associated with exotropia, including genetics and health conditions. 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. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. . 12. Accessibility Statement, Our website uses cookies to enhance your experience. When patients are spectacle independent and want to remain independent, surgical approach could be offered. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. AOcular divergence mechanisms. EHBilateral sixth-nerve paresis simulating divergence paralysis. R. London. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging.2, Vision therapy aims to decrease symptoms of vergence anomalies by increasing the compensating fusional vergence range (base-in for esophoria and base-out for exophoria). In many cases, individuals with convergence insufficiency will notice that their symptoms worsen as they get tired or after attempting to do near tasks for a prolonged period of time. the accommodative and vergence systems are tightly correlated. Lim How is convergence insufficiency treated? Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. REBaumgartner [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 were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). These patients often present with horizontal and vertical deviations. AJNR Am J Neuroradiol. 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. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. In those patients without an established disorder, additional clinical clues indicated the need for neuroimaging or additional diagnostic studies, independent of the signs of divergence insufficiency. 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. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. What is divergence insufficiency? Convergence Insufficiency Testing. 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. ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. 13.120). Chang MY, Pineles SL, Velez FG. Surgical effect was assessed immediately by sitting the patient up and repeating the measurements at near and distance. . SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As This decreases the motor fusion demand, allowing the patient to fuse more comfortably. Stager DR, Sr, Black T, Felius J. One patient was followed up for only 1 month, but her esotropia resolved during that time. Double vision is a troublesome complication of otherwise successful cataract surgery. In some circumstances, individuals with convergence insufficiency will also suffer from high exophoria or, In many cases, individuals with convergence insufficiency will notice that their symptoms worsen as they get tired or after attempting to do near tasks for a prolonged. 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. This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. These studies were unrevealing in all patients. NParalysis of divergence. Barricks It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. MEBarrows Double vision. The remainder of the neurological examination should be normal, without any cranial neuropathies. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. [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). 2009;86(2):153-6. Terms of Use| Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Near point of convergence test: This test will . The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. 13.121). Convergence Insufficiency Symptoms. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. What are causes of convergence insufficiency? 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. of negative and positive fusional vergence. "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. 13.119). Abstract. Chaudhuri Z, Demer JL. Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. A new prescription for prism lenses was dispensed to the patient at the follow-up examination. 2016;28(1):38-42. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. 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 . Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. Retrospective survey of patients with divergence insufficiency. as their fusional vergence ranges expand. LBSharpe [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. EJampolsky Moore Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. Only 2 patients were followed up for less than 6 months. 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. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. The patient with a metastatic lesion of the midbrain additionally had skew deviation, an afferent pupillary defect without visual loss, and other signs of brainstem injury, but no symptoms or signs of intracranial hypertension. Their symptom was controlled using prisms. MCiner Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. Committee on Aging. Tamler 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). Stern Convergence insufficiency is a common problem with the eyes, and is the main culprit behind eyestrain, blurred vision, and headaches. RJZee What causes divergence insufficiency? These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. Of the 20 patients with primary divergence insufficiency, there were 10 women and 10 men, ranging in age from 24 to 90 years, with a median (mean) age of 74 (70) years. From there, basic vergence exercises will be added in. [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. is variable. 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. Effectiveness of prisms in relieving diplopia in superior oblique palsies. Mosbys Optometric Problem Solving Series, ed. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. 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. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. 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. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. In a recent study by Goseki et.al. How is convergence insufficiency treated? Wednesday, March 15, 2023 | All Eyes On Evaporation, Thursday, April 13, 2023 | All Eyes On Evaporation, Tuesday, April 18, 2023 | All Eyes On Evaporation. The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. RTOcular muscle paresis and cranial arteritisan unusual case. 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. 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. Divergence insufficiency revisited: natural history of idiopathic cases and neurologic associations. All rights reserved. JWStockbridge What is the cause of convergence spasm? 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. ISOphthalmoplegia in cranial arteritis. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. 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. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . Eye - Diplopia following cataract surgery . 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. 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. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. Goldberg MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. This page was last edited on January 26, 2023, at 08:42. J AAPOS 2014;18:370-373. 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. Bruce Br J Ophthalmol. Head trauma 3. Retrospective survey of patients with divergence insufficiency. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. The first hurdle is ensuring your patient is comfortable with wearing spectacles. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. SDiagnosis and management of divergence weakness in adults. Scheiman Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. Long-term follow-up and clinical features of the 2 groups were compared.
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