The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. 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. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. 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). MGallaway Diagnosing convergence insufficiency J Pediatr Ophthalmol Strabismus. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. Tranaglyphs are similar to vectograms, however instead of there being two different transparent image cards that need to be fused into one, there is one image card with a stereo image already pre-made onto the card. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. While viewing the card, the patient reports what color line the black arrow is aligned with. MEBarrows 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 . 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. Sensory Anomalies. RDInternuclear ophthalmoplegia in giant cell arteritis. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. 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. [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. This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. 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. JLSaccadic velocity analysis in patients with divergence paralysis. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. Lets continue the conversation over on your social network of choice. Clin Exp Optom. Graefes Arch Clin Exp Ophthalmol. Chaudhuri Z, Demer JL. 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. 2012;95(2):192-7. 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. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. What is the cause of convergence spasm? Otherwise, neuroimaging can be deferred in patients with neurologically isolated divergence insufficiency, although careful follow-up is indicated to identify developing suspicious neurologic symptoms or signs. 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. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. What is congenital ocular motor apraxia? 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. if you would like to learn more about convergence and divergence insufficiency. 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. Long-term follow-up and clinical features of the 2 groups were compared. Drs. All Rights Reserved. She had been previously diagnosed with esotropia and amblyopia but was not currently wearing any correction. Antireflective coating is also beneficial for patients wearing prism lenses. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. Six patients underwent CT and 10 underwent MRI. 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. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. This ocular misalignment has two main types: esotropia and exotropia. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. 1. Chaudhuri Z, Demer JL. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. 2005;9:711. ARKline What causes divergence insufficiency? It can also decrease distance judgement, coordination, and sports performance. Cunningham FDDutton [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). 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. Convergence Insufficiency. HS 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. 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. Retrospective survey of patients with divergence insufficiency. Visual loss in pseudotumor cerebri: follow-up of 57 patients from five to 41 years and a profile of 14 patients with permanent severe visual loss. 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]. None of the patients initially classified as having primary divergence insufficiency developed additional neurologic dysfunction during the period of follow-up. LMDivergence paralysis with increased intracranial pressure: further observations. 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. HMDivergence paralysis following head trauma. What are the symptoms of Convergence Insufficiency? It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, 2000;118(9):1237-1241. doi:10.1001/archopht.118.9.1237. 126. Lyle 1993, Oxford, UK: Butterworth Heinemann Books. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. highest quality optometry services and eye exams in Wilmington, Delaware and its surrounding areas. In that study, strabismus surgery was performed in 50% of all SES cases. With exercises that adapt to each patient and their specific needs, it is an ideal solution for problems such as lazy eye, strabismus, convergence insufficiency, double vision, or other binocular problems. 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. Her research interests include strabismus and binocular vision disorders. Prism prescriptions often greatly improve the quality of life of your patients by reducing asthenopia and diplopia. 2009;86(2):153-6. Individuals with convergence insufficiency often have a low AC/A ratio and a low near point of convergence. How is convergence insufficiency treated? 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. I reviewed the medical records of patients with divergence insufficiency that I had evaluated from July 1987 through April 1999 in my neuro-ophthalmology practice at a single institution. Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. They use head thrusts to shift fixation. p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 10.0px Sabon} p.p2 {margin: 0.0px 0.0px 0.0px 0.0px; text-indent: 10.0px; line-height: 12.0px; font: 10.0px Sabon} p.p3 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #867245; min-height: 12.0px} p.p4 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #b87c4c} p.p5 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #b37749} span.s1 {letter-spacing: -0.2px}. Adnexal signs such as: retraction of the upper eyelid into the superior orbit (superior sulcus deepening), aponeurotic blepharoptosis, floppy lower lids, and high upper eyelid crease. 2012;49(4):222-8. [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. RLMagnetic resonance images in a case of "divergence paralysis.". 2023 American Medical Association. Duane During the total period of follow-up, none of the patients developed an alternative neurologic disorder. 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. A Maddox rod was also used to determine the near point of orthophoria in most patients. 2008;12(1):56. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. 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. 130. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. 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. All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). 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. 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. 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). The patient places two transparent cards into the vectogram system. Krohel Connective tissues reflect different mechanisms of strabismus over the life span. 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. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. EHBilateral sixth-nerve paresis simulating divergence paralysis. 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. Br J Ophthalmol. Patients will be able to work on fusing the images of one. Demer JL. Divergence excess is an over-divergence when attempting to look at distant objects. 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. All Rights Reserved. is fixed. In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment.
