Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. Diagnosing convergence insufficiency The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. EDivergence insufficiency: characteristics, diagnosis, and treatment. Convergence Insufficiency Symptoms. While none of the patients had other symptoms to suggest giant cell arteritis or myasthenia gravis, erythrocyte sedimentation rate (performed in 7 patients) and acetylcholine receptor antibody assay (performed in 6 patients) were tested, and the results were normal in all. REBaumgartner
Arch Ophthalmol. Patients will be able to work on fusing the images of one. What is divergence insufficiency? In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or. It is spasm of the near triad: 1. All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). Jacobson DM. Graefes Arch Clin Exp Ophthalmol. Divergence excess is an over-divergence when attempting to look at distant objects. Sagging Eye Syndrome. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. These arguments do not preclude the possibility that some patients with comitant esotropia at distance and full-appearing ocular ductions might be suffering from sixth cranial nerve palsy, not divergence insufficiency. 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. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. If no movement is seen on the unilateral cover test, the patient has normal correspondence. DBGlaser
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. Ductions should be tested with the fellow eye covered. 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. Convergence Insufficiency Testing. 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. 129. Tamhankar MA, Ying GS, Volpe NJ. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. 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). Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. DIdiopathic intracranial hypertension: a prospective study of 50 patients. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. doi:10.1001/archopht.118.9.1237. 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. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. Thomson
Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. 2009;86(2):153-6. Posted by . Convergence describes the way our eyes move together and point inward when we look at near objects. 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. Cotter SA. Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task 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. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. doi:10.1136/bjophthalmol-2015-306783. 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. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. Pencil pushups may be effective in some cases. I still have mild double vision and . LBSharpe
We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. Blurred vision. Patients will be able to work on fusing the images of one card and move on to a more difficult card as their fusional vergence ranges expand. Certain factors are associated with exotropia, including genetics and health conditions. 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. New York, NY Oxford University Press1999;405-610. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. Tamler
More respect for connective tissues. 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. 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. These patients often present with horizontal and vertical deviations. 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] Clinical uses of prism: a spectrum of applications. et al. MGeorge
Effectiveness of prisms in relieving diplopia in superior oblique palsies. Kerala J Ophthalmol. If you have not read the previous portions of the vision therapy series it is highly advisable that you check them out first as they cover basics not explained here. characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . is fixed. Chang MY et al. Head trauma 3. Divergence excess is an over-divergence when attempting to look at distant objects. . 134. 10. GNCurrent concepts in giant cell (temporal) arteritis. Stager DR, Sr, Black T, Felius J. Retrospective survey of patients with divergence insufficiency. SHarbison
One study successfully treated 87 patients with divergence insufficiency between two and 18 prism diopters (PDs) with prism with none of the patients in the study requiring additional treatment or surgery.3 Another study found that 100% of patients with divergence insufficiency (30 patients) had success with prism.4. Lim
Privacy Policy| The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. What is convergence spasm? Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. with a stereo image already pre-made onto the card. Scheiman M, Cotter S, Rouse M, et al. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. 13.119). Simultaneous injury of the medial longitudinal fasciculus has been postulated as another reason sixth cranial nerve palsy may appear comitant.4 However, none of the patients classified as primary had clinical signs of internuclear ophthalmoplegia. 2023 Stanford School of Medicine | Terms of Use | The EOM angles in these patients ranged from 100 to . SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As 1. 128. It is usually benign. It is very a common condition where there is a comitant exotropia greater at near than at distance by at least 10 prism diopters. 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. 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. 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. These questions are archived at https://neuro-ophthalmology.stanford.eduFollow https://twitter.com/NeuroOphthQandA to be notified of new neuro-ophthalmology questions of the week.Please send feedback, questions, and corrections to tcooper@stanford.edu. No clear sex predilection has been identified for the primary form of the condition. 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. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. highest quality optometry services and eye exams in Wilmington, Delaware and its surrounding areas. THBird
What is the cause of convergence spasm? Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. She had been previously diagnosed with esotropia and amblyopia but was not currently wearing any correction. Methods
Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Ductions and versions are full. 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. If a patient sees four dots in free space or gives a diplopia response but is able to fuse with prism, perform a unilateral cover test. This decreases the motor fusion demand, allowing the patient to fuse more comfortably. 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. Success of prisms in the management of diplopia due to fourth nerve palsy. 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. an electromyographic study. Only 2 patients were followed up for less than 6 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. RTOcular muscle paresis and cranial arteritisan unusual case. 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 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. What are causes of convergence insufficiency? 2000;118(9):12371241. J Neuroophthalmol. 133. It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. 3rd ed. If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. However, the cause of convergence insufficiency is often unknown. 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. EJampolsky
Therefore, it forces the patient to use both eyes properly to see the image. 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 . Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. American Academy of Ophthalmology. 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. J AAPOS. Her research interests include strabismus and binocular vision disorders. Results
A Maddox rod was also used to determine the near point of orthophoria in most patients. 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. Per some observations, its is more common in Caucasian females. 2016. 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. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. 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. NRNewman
13.121). 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. This problem is most commonly found in children. Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. If the patient is only using one eyethe image will not be formed correctly. Of the 15 patients with secondary divergence insufficiency, there were 11 women and 4 men, ranging in age from 8 to 86 years, with a median (mean) age of 56 (51) years. To increase convergence, the two cards will be pushed inward, making the image smaller (Small In for the SI in SILO). JAAcquired esotropia due to Arnold-Chiari I malformation. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. The opposite of divergence insufficiency is divergence excess. More advanced exercises for vergence insufficiencies include. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. Reproduction in whole or in part without permission is prohibited. FEDivergence paresis: a nonlocalizing cause of diplopia. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . Drs. 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. The mirror stereoscope is one of the most commonly used types. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Patients and methods. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Their symptom was controlled using prisms. [unreliable source?] It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading.