People notice symptoms while reading or doing other near work. Posted by . It involves a specialty optical system and a uniquely created image book. Similarly, the theories on mechanism of divergence itself have varied. Scheiman M, Cotter S, Rouse M, et al. Godts D, Mathysen DG. 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. Tamhankar MA, Ying GS, Volpe NJ. A near card is brought toward the patients nose until the patient sees double. The main treatment for convergence insufficiency is vision therapy. is fixed. et al. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. Common symptoms include: headaches; blurred vision ; double vision Schanzer Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. 1993, Oxford, UK: Butterworth Heinemann Books. Classically convergence spasm is nonorganic. If the patient is only using one eyethe image will not be formed correctly. ARKline 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. Parkinson disease 4. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. 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. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. 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. 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Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. 132. 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. The EOM angles in these patients ranged from 100 to . In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. Patients in the study population shared the following symptoms: double vision when viewing distant objects, full-appearing ocular ductions, and esotropia identified during cover testing while fixing a distant target. Privacy Policy| 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. Long-term Surgical Outcomes in the Sagging Eye Syndrome. Divergence insufficiency is the opposite problem of convergence insufficiency. LBSharpe She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. 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 misalignment almost 100%. Many affected patients experience spontaneous resolution of double vision within several months. The first hurdle is ensuring your patient is comfortable with wearing spectacles. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. 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. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. 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}. 3rd ed. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. If the eyes do drift out, the person is likely to have double vision. FEDivergence paresis: a nonlocalizing cause of diplopia. 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. JAInman A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. Vertical deviations often cause patients to experience significant symptoms even when the deviation is small. 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. The additional literature on the subject of divergence insufficiency largely consists of small series of patients mainly reported in the precomputed tomography (CT) era and patients with neurologically isolated divergence insufficiency mixed with those who additionally had other signs of intracranial hypertension or a structural brain lesion.15,18-21 The purpose of my study was to describe a large series of patients with divergence insufficiency evaluated in the post-CT era to determine the natural history of neurologically isolated cases, to determine the spectrum of neurologic associations, and to identify clinical features that might be helpful in distinguishing those patients with an isolated disorder from those harboring neurologic disorders. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. On initial presentation, her best-corrected visual acuities were 20/40 OD and 20/25 OS. Duane 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. 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. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. 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. Wednesday, March 15, 2023 | All Eyes On Evaporation, Thursday, April 13, 2023 | All Eyes On Evaporation, Tuesday, April 18, 2023 | All Eyes On Evaporation. 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. . Accepted for publication February 11, 2000. Moller The patient places two transparent cards into the vectogram system. While viewing the card, the patient reports what color line the black arrow is aligned with. Methods There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. Another historically reported feature of DI is significantly decreased negative fusional vergence (fusional divergence), along with the deficits direct relationship to distance of gaze. Br J Ophthalmol. Before settling on a final prism prescription, it is often helpful to trial frame the amount of prism you are about to prescribe to ensure that it will help you achieve your goals. 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). HS Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. 130. When you try to focus on something close to your eyes, you may have: Tired eyes. as their fusional vergence ranges expand. Prescribing relieving prism for horizontal, non-strabismic, binocular vision disorders can be done by calculating Sheards or Percivals criteria by using clinical data or analyzing fixation disparity and determining the associated phoria.1 At near, fixation disparity and the associated phoria can be found with a Wesson card. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. Therapists can make this activity more advanced by increasing the amount the, changing the target) or by using multiple, and making the patient look from one to another, , however instead of there being two different transparent image, that need to be fused into one, there is one image. A Vectogram is a tool which utilizes specialized imaging along with the fusional vergence system to create a 3-D object. When patients are spectacle independent and want to remain independent, surgical approach could be offered. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. R. London. 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. PJThompson Sagging Eye Syndrome. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. 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. Recent trauma Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. 1. 2014;35(9):1830-5. 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. 129. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. 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 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. AOcular divergence mechanisms. GTDJohnston The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. In addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." 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 . Questions with answers: 125. One patient was followed up for only 1 month, but her esotropia resolved during that time. NParalysis of divergence. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. Ghanchi Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. The mechanical properties of pulleys are critical for the support and rotational properties of the eye. Distance esotropia in the elderly. 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. Patients and methods. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . [5], MRI measurements of horizontal EOM lengths in SES were approximately 40%, or 14 mm, longer than the EOMs of nonstrabismic younger and older controls. Lets continue the conversation over on your social network of choice. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Wiggins We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. 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. Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. 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. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. 129. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Terms of Use| J AAPOS. Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency. Lewis EHBilateral sixth-nerve paresis simulating divergence paralysis. 132. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. [5], There has been an increased awareness and diagnosis of these degenerative strabismic disorders after 2000. In 2015 Chaudhuri and Demer published a retrospective observational study about utilizing Graded Vertical Rectus Tenotomy (GVRT) for treating incomitant vertical misalignment. All rights reserved. 13.119). 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. with a stereo image already pre-made onto the card. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. Lim The cyclotorsion component of SES was present in 65% of patients. 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. If no movement is seen on the unilateral cover test, the patient has normal correspondence. Primary divergence insufficiency is generally a benign condition. 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. 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. Kerala J Ophthalmol. Cotter SA. Divergence insufficiency revisited: natural history of idiopathic cases and neurologic associations. The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . RJZee In 2005 Thacker NM et al. 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 [email protected]. Stager DR, Sr, Black T, Felius J. Rather, treatment for a secondary vertical deviation should aim to improve horizontal sensory and motor fusion through vision therapy so the patient is not in the strabismic position as often, thus eliminating the vertical deviation. unable to diverge appropriately to a given target. To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. 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. Divergence insufficiency can also result in headaches, motion sickness and sensitivity to bright lights. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. Prism prescriptions often greatly improve the quality of life of your patients by reducing asthenopia and diplopia. 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. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. AJNR Am J Neuroradiol. Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. 12. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. 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. doi:10.1001/archopht.118.9.1237. 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. It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. Near point convergence is the distance you can use both eyes without seeing double. Blurred vision. Over a period of several months, the diplopia becomes more constant and is noticed while driving, watching television, and in other long-distance vision situations. Krohel Lateral rectus resections in divergence palsy: Results of long-term follow-up. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. None of these patients underwent strabismus surgery. 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. 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 describes the way our eyes move together and point inward when we look at near objects. Caloroso E, Rouse MW. The most effective treatment for this condition is office-based vision therapy, but prism can be considered in patients who are unable to undergo this treatment modality.1,8 A study did not find a significant difference in the signs or symptoms of children with convergence insufficiency who wore base-in prism compared with children who wore placebo lenses.9 Although prism has not been shown to be beneficial in children with this condition, adult presbyopic patients with convergence insufficiency may benefit from prism treatment.10,11. RTOcular muscle paresis and cranial arteritisan unusual case. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. 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. The procedure is performed under topical anesthesia in the presence of an anesthesiologist. If the patient is still symptomatic, combining prism and vision therapy may help improve convergence and divergence ranges. What is convergence spasm? A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. Bothun ED, Archer SM. 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. 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. 1. LDivergence insufficiency. In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. [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]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).
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