After these patients are evaluated for any underlying systemic or neurological disease, which must always be ruled out in any case of new-onset strabismus, they are often good candidates for a prism prescription. It is most often related to raised intracranial pressure or Chiari malformation. 12. What is convergence insufficiency? This page was last edited on January 26, 2023, at 08:42. By continuing to use our site, or clicking "Continue," you are agreeing to our, Clinical Features of Patients With Primary and Secondary Divergence Insufficiency, Disorders Associated With Secondary Divergence Insufficiency. 2008;12(1):56. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. Although ophthalmoplegia associated with temporal arteritis has been rarely attributed to brainstem23 or ocular motor nerve injury,24 most cases are thought to result from extraocular muscle ischemia.25,26 The association of divergence insufficiency and temporal arteritis in these 2 cases emphasizes that the diagnostic signs of this ocular motor disturbance are not localizing and could occur in other disorders associated with local injury of extraocular muscles, such as myasthenia gravis, as was identified in 1 of the patients of Lepore.15, Divergence insufficiency was observed in 4 patients with pseudotumor cerebri. Smith People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. [5], There has been an increased awareness and diagnosis of these degenerative strabismic disorders after 2000. CHNuclear and infranuclear ocular motility disorders. We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. In support of that hypothesis, some investigators have reported clinical-radiographic and clinical-pathologic correlations of patients with divergence insufficiency associated with focal lesions, usually of the pons and midbrain,7-10 but also in other locations, such as the craniovertebral junction.8,11 On the other hand, patients with divergence insufficiency and a variety of diffuse brain injuries have also been described.8,12-15 The site of this elusive region, if in fact such a region exists, remains undefined. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. 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. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. Home Vision Therapy Convergence Insufficiency Testing. Patients will be able to work on fusing the images of one. Tamler Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. Scheiman M, Cotter S, Rouse M, et al. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. Lateral rectus resections in divergence palsy: Results of long-term follow-up. What is divergence insufficiency? What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). Clin Exp Optom. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. Each card contains a partial view of the complete image. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. Drs. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. NParalysis of divergence. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. 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. Heavy eye syndrome versus sagging eye syndrome in high myopia. LDivergence insufficiency. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? Again it seems unlikely, since CTs performed in 2 patients and an MRI performed in 1 were normal, and signs of divergence insufficiency were improving in 2 of these patients at the time of their last evaluation. 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. They are low in cost and can be easily applied to a pair of spectacle lenses in-office to try out on a patient for several days or weeks, and refining the prism prescription is inexpensive and simple. 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. 2012;130:12801284. 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. Moore Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. 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. MGallaway ARKline It is idiopathic most often in children or young adults 2. 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. 2005;9:711. Success of prisms in the management of diplopia due to fourth nerve palsy. THBird As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. In spectacle-dependent patients, a temporary Fresnel prism or permanent ground in prism are usually helpful in managing the double vision for distance without inducing diplopia for near given their strong near fusional capacities as mentioned before. Questions with answers: 125. doi:10.1136/bjophthalmol-2015-306783. 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. 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. 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. Tamhankar MA, Ying GS, Volpe NJ. I still have mild double vision and . In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. Primary divergence insufficiency is generally a benign condition. 2018 Jan 3:1-5. doi: 10.1080/09273972.2017.1421676. What is congenital ocular motor apraxia? 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. EHBilateral sixth-nerve paresis simulating divergence paralysis. 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. Objectives 13.119). In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or. The EOM angles in these patients ranged from 100 to . Strabismus. The patient places two transparent cards into the vectogram system. characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. 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 . It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. These patients often present with horizontal and vertical deviations. While the size of divergence fusion amplitude was significantly larger in the group of patients with secondary disorders than in the primary group, the magnitude of this difference was small and the range of values between the 2 groups demonstrated considerable overlap (Table 1). 131. 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. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. Convergence Insufficiency Testing. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. In addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. J AAPOS. Lepore 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. How is convergence insufficiency treated? Trans Am Ophthalmol Soc. 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. With CI, the eyes do not point together inward as one looks at objects close-up. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. Long-term follow-up and clinical features of the 2 groups were compared. 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. In that study, strabismus surgery was performed in 50% of all SES cases. unable to diverge appropriately to a given target. 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. More advanced exercises for vergence insufficiencies include. Stern FEDivergence paresis: a nonlocalizing cause of diplopia. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. RMDiagnosis and management of divergence paresis. Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. 2014;18(4):309-15. divergence excess eyewikibc kutaisi vs energy invest rustavi. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. 132. 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). 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]. The main treatment for convergence insufficiency is vision therapy. Moller Many patients were first evaluated within 1 month of the onset of symptoms, far sooner than the expected time course for the spread of comitance to convert a sixth cranial nerve palsy to a comitant esotropia. Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. This is the brain's answer to coping with double vision and the stress of eyes not working as a . Scheiman M, Wick B. The use of topical anaesthesia does not abolish this surgical risk. Reproduction in whole or in part without permission is prohibited. Prism can be a powerful treatment for many conditions and for many patients, specifically for those who suffer from asthenopia or diplopia. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. NRNewman HS 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. Double vision. Bruce Individuals with convergence insufficiency often have a low AC/A ratio and a low near point of convergence. Rutar T, Demer JL. ISOphthalmoplegia in cranial arteritis. along with the fusional vergence system to create a 3-D object. A Vectogram is a tool which utilizes specialized imaging along with the fusional vergence system to create a 3-D object. Scheiman the accommodative and vergence systems are tightly correlated. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. Chaudhuri Z, Demer JL. Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. Patients presenting with a greater eso deviation at distance than at near, a concomitant deviation, and diplopia pose a challenging and critical diagnostic and therapeutic puzzle for . The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. . 2000;118(9):12371241. CI affects children and adults. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. In some circumstances, individuals with convergence insufficiency will also suffer from high exophoria or exotropia, meaning the eyes like to sit in an outward position. The aspect of divergence paralysis or divergence insufficiency is stated as esotropia or high esophoria at a distance with much lower esophoria or near to normal fixation. Chang MY, Pineles SL, Velez FG. Br J Ophthalmol. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. It is very a common condition where there is a comitant exotropia greater at near than at distance by at least 10 prism diopters. Patients may also present with ductional deficits depending on the grade of muscle displacement. Fresnel prism, however, degrades visual acuity and contrast sensitivity, and some patients may not find it cosmetically appealing.12 A significant decrease in visual acuity through the Fresnel lens can be seen at larger prism powers, particularly at those greater than 12 PDs.13 When trialing Fresnel prism, it is advisable to only place the Fresnel over one eye so that the patient retains good binocular visual acuity with the prism in place. Graefes Arch Clin Exp Ophthalmol. In normal cases, the ocular axis length was 23.5 1.0 mm. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. EDivergence insufficiency: characteristics, diagnosis, and treatment. This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. 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. 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. Chaudhuri Z, Demer JL. 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. MBSavitsky None of these patients underwent strabismus surgery. People notice symptoms while reading or doing other near work. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. Retrospective survey of patients with divergence insufficiency. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. J Neuroophthalmol. 128. This ocular misalignment has two main types: esotropia and exotropia. In the meantime, temporary paste-on and, if stable for several weeks, permanent ground-in prisms, were effective and conservative means of relieving symptoms in these patients. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. On initial presentation, her best-corrected visual acuities were 20/40 OD and 20/25 OS. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. RDDivergence paralysis. She had been previously diagnosed with esotropia and amblyopia but was not currently wearing any correction. Connective tissues reflect different mechanisms of strabismus over the life span. Barricks However, the cause of convergence insufficiency is often unknown. MCiner 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. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event.

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