divergence insufficiency double vision

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. 1995, St. Louis, Missouri: Mosby. with a stereo image already pre-made onto the card. JAAcquired esotropia due to Arnold-Chiari I malformation. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. Reference: 1. What is the cause of convergence spasm? Teitelbaum B, Pang Y, Krall J. When patients are spectacle independent and want to remain independent, surgical approach could be offered. FDDutton Pencil pushups may be effective in some cases. 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. AParalysis of divergence. use an approach called the SILO affect to work on increasing divergence or convergence ranges. "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. In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. . HMDivergence paralysis following head trauma. Other associated symptoms can include asthenopia of panoramic type. 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]. Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. 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. Demer JL. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . Smith In that study, strabismus surgery was performed in 50% of all SES cases. Stern Extraordinary symptoms equivalent to diplopia 2.3.1. Convergence insufficiency | AOA Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. Convergence Insufficiency Symptoms. Audio blog post. 2008;126(10):1336-49. More advanced exercises for vergence insufficiencies include. Basic Esophoria and Exophoria. 2023 American Medical Association. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. 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. [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). 4. 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. [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. Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. Once this can be repeated multiple times, the amount of required divergence or convergence can be increased, thus expanding the vergence range and strengthening the problem area. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. 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. 133. DIdiopathic intracranial hypertension: a prospective study of 50 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. Vertical deviations often cause patients to experience significant symptoms even when the deviation is small. Divergence insufficiency is the opposite problem of convergence insufficiency. 129. The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). Clinical uses of prism: a spectrum of applications. Jacobson DM. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. She had been previously diagnosed with esotropia and amblyopia but was not currently wearing any correction. Double vision. If the eyes do drift out, the person is likely to have double vision. A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. Near point of convergence test: This test will . [unreliable source?] 131. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. [5], There has been an increased awareness and diagnosis of these degenerative strabismic disorders after 2000. 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. None of these patients underwent strabismus surgery. NParalysis of divergence. In addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. 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. 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. 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. Other training exercises include base-out prisms for near viewing and convergence exercises. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. Reproduction in whole or in part without permission is prohibited. More respect for connective tissues. 4 Binocular Vision Problems that Cause Eyestrain Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. If your patient is still experiencing diplopia, additional prism may be needed to help them achieve fusion. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. 8. EJampolsky Chamlin PDF CLINICAL SCIENCES Divergence Insufficiency Revisited - JAMA Biousse V and Newman NJ. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. DOI: Demer JL. Convergence and Divergence - Vivid Vision DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. He usually volunteers the infor mation that he has no trouble in reading or close use of his eyes. 2013;251:16411644. 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). Strabismus. 632. American Academy of Ophthalmology. ACSanders 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. 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. It involves a specialty optical system and a uniquely created image book. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. Retrospective survey of patients with divergence insufficiency. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. Convergence Insufficiency | National Eye Institute MThe child with divergence paresis. These exercises were discussed in detail in Part 6 of this series. Retrospective case reviews of patients with an acquired hyper deviation secondary to a superior oblique palsy found that 76% to 92% of participants were successfully treated with prism alone.5,6. Stager DR, Sr, Black T, Felius J. Rutkowski Bruce Certain factors are associated with exotropia, including genetics and health conditions. Then, a horizontal prism bar was used to place increasing strengths of base-in prism over the other eye until fusion could no longer be maintained, as assessed subjectively using a distant target for fixation. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. Heavy Eye vs. Scheiman M, Wick B. Chaudhuri Z, Demer JL. Reproduction in whole or in part without permission is prohibited. Primary divergence insufficiency is generally a benign condition. of negative and positive fusional vergence. LDivergence insufficiency. Thomson Therefore, it forces the patient to use both eyes properly to see the image. People notice symptoms while reading or doing other near work. Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. 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. Optom Vis Sci. 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. 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. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. J AAPOS. Ghanchi The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. Bender Convergence Insufficiency. 2008;12(1):56. NADivergence paralysis. 5. 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. RMTomsak The distance at which diplopia occurs is noted (near point of convergence). This decreases the motor fusion demand, allowing the patient to fuse more comfortably. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. 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. 2023 American Medical Association. Histologic studies showed that each rectus pulley consists of an encircling ring of collagen located near the globe equator in tenon fascia, coupled to the orbital wall, adjacent EOMs, and equatorial Tenon fascia by bands containing densely woven collagen, elastin, and smooth muscle. Corresponding author: Daniel M. Jacobson, MD, Neuro-ophthalmology (4F-2), Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (email: jacobsod@mfldclin.edu). AJNR Am J Neuroradiol. 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. Results from this study also supported previously published evidence of normal age-related connective tissue degeneration as there was a positive age effect in correlation to supero-temporal bowing of the LR-SR band.[9]. 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. [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. 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. American Journal of Ophthalmology, Volume 209, January 2020, Pages 55-61. Initial tenotomy 30% of tendon width was performed to avoid intraoperative overcorrection. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." Due to the degenerative etiology of this syndrome, the connective tissue involution may progress after surgery, up to 20% of patients[15], therefore is important to inform the patient of this possibility prior to surgery. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. 1. Retrospective survey of patients with divergence insufficiency. Schanzer characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . Moore It is usually benign. What is convergence insufficiency? 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. unable to diverge appropriately to a given target. 126. RTOcular muscle paresis and cranial arteritisan unusual case. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. Lewis 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. Vision Therapy with AmblyoPlay - Learn about your path to better vision! 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. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? PJThompson J AAPOS. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. an electromyographic study. 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. 2005;9:711. Godts D, Mathysen DG. BBordaberry LBSharpe 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. Miller 11. 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. Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. Wednesday, March 15, 2023 | All Eyes On Evaporation, Thursday, April 13, 2023 | All Eyes On Evaporation, Tuesday, April 18, 2023 | All Eyes On Evaporation. Hold focus on this dot for 10 seconds. 128. A 5-year-old female initially presented for a strabismus and amblyopia evaluation. ALDemer This ocular misalignment has two main types: esotropia and exotropia. MGallaway All Rights Reserved. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. 2. What is convergence spasm? Patients with 20 to 30 PDs of exotropia should be left with 10 to 15 PDs of residual vergence demand, and patients with a vertical strabismus of 3 to 10 PDs should be left with 2 to 4 PDs of residual vergence demand.7 RVD is best used in patients who have vergence ranges that have been maximally trained through vision therapy but still need prism to maintain binocular vision in free space.12. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. Lyle 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. CHNuclear and infranuclear ocular motility disorders. A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. Fresnel membrane prisms can be very useful for many aspects of prescribing prism. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. Demer JL et al. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre, 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 glasses, In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees, Different cards with different images will require different amount. 13.120). Accepted for publication February 11, 2000. Instead, the initial history and physical examination proved to be powerful tools to distinguish those patients with a primary disorder from those with an underlying neurologic or systemic (ie, secondary) cause of divergence insufficiency. divergence excess eyewiki My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. A Vectogram is a tool which utilizes specialized imaging along with the fusional vergence system to create a 3-D object. Of note among this cohort of patients without strabismus, noncontinuous LR-SR bands were found in 5% of cases, and superotemporal bowing in 24% of cases. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. These patients often present with horizontal and vertical deviations. Convergence insufficiency is a common problem with the eyes, and is the main culprit behind eyestrain, blurred vision, and headaches. In normal cases, the ocular axis length was 23.5 1.0 mm. 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. 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. To begin therapy, many therapists will focus first on normalizing the accommodative system. 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. 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. JSLevy Patients may also present with ductional deficits depending on the grade of muscle displacement. Heavy eye syndrome versus sagging eye syndrome in high myopia. 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. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. GNCurrent concepts in giant cell (temporal) arteritis. 2012;130:12801284. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. Keep moving to the next dot along the card, gradually getting closer to the nose. 134. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. New York, NY Oxford University Press1999;405-610. This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. In a recent study by Goseki et.al. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. Bothun ED, Archer SM. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. Perfecting Prism - Review of Optometry 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. Recognizing TBI-related Vision Disorders - Review of Optometry Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. Vision suppression stops you from seeing double, but it doesn't fix the problem. Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. 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). Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. 13. Divergence insufficiency is a benign phenomenon causing horizontal diplopia at distance viewing . The cyclotorsion component of SES was present in 65% of patients. Trans Am Ophthalmol Soc. 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. Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. 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. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. Kirkham Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency. Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. JLSharpe Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. Between the polarizing glasses and the patients fusional vergence system, he or she will be asked to either converge or diverge to fuse the two partial images into one 3-D image. The association with refractive errors (and high myopia in particular) has been a point of contention for some time. 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. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. Objectives Prism in reading glasses or strabismus surgery may be required. Patients with constant strabismus may need corrective prism, or an amount of prism that completely neutralizes their strabismus, in order to obtain good levels of fusion.

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