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. 134. 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. 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. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. 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. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. FEDivergence paresis: a nonlocalizing cause of diplopia. Arch Ophthalmol. Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. 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. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Trans Am Ophthalmol Soc. Long-term follow-up and clinical features of the 2 groups were compared. AOcular divergence mechanisms. JWStockbridge Surgical effect was assessed immediately by sitting the patient up and repeating the measurements at near and distance. Esodeviation is comitant in all fields of . 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). This page has been accessed 63,795 times. 134. 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. The two prevalent hypotheses put forth so far include altered cerebrospinal fluid flow in the posterior cranial fossa, and involvement of the abducens nucleus or infranuclear portion. REBaumgartner 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. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. When looking at the image on the card, patients will be required to use their fusional vergence system to fuse the red and green images into one 3-D image. Magnetic resonance imaging resolution showed superotemporal bowing of the LR-SR band in milder cases and abrupt termination of an attenuated band remnant in the superolateral orbit in more severe cases. Keep moving to the next dot along the card, gradually getting closer to the nose. Rutkowski Wall I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. 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. 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. Br J Ophthalmol. The first hurdle is ensuring your patient is comfortable with wearing spectacles. Extraordinary symptoms equivalent to diplopia 2.3.1. American Academy of Ophthalmology. Questions with answers: 125. This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. Retrospective survey of patients with divergence insufficiency. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. Convergence describes the way our eyes move together and point inward when we look at near objects. Heavy Eye vs. Ductions should be tested with the fellow eye covered. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. The cyclotorsion component of SES was present in 65% of patients. THBird it is highly advisable that you check them out first as they cover basics not explained here. 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. 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. . Although cosmesis can be an issue with prism glasses, educating your patients on proper frame and lens selection will help them choose a frame and lens combination for the best cosmetic outcome. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. It is most often related to raised intracranial pressure or Chiari malformation. What causes divergence insufficiency? 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). With the exception of the size of vertical fusion amplitude, ocular motor signs associated with divergence insufficiency did not distinguish patients with idiopathic from those with secondary disorders. MGeorge At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. Some patients report double pictures, but when checked with the torch, only one light is seen. 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. Other associated symptoms can include asthenopia of panoramic type. Pencil pushups may be effective in some cases. Chang MY, Pineles SL, Velez FG. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. 129. [3], from 945 patients complaining of double vision, majority of patients between 60 and 80 years, approx 31% had SES and were older, ~71 years old, with ~60% female predominance. Accordingly, I would recommend deferring consideration of strabismus surgery in this population for a sufficiently prolonged period of time to determine whether the esotropia might resolve spontaneously. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. 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. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. RLMagnetic resonance images in a case of "divergence paralysis.". Many affected patients experience spontaneous resolution of double vision within several months. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. More respect for connective tissues. If no movement is seen on the unilateral cover test, the patient has normal correspondence. with a stereo image already pre-made onto the card. 2018 Jan 3:1-5. doi: 10.1080/09273972.2017.1421676. 1. None of these patients underwent strabismus surgery. 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]. [10] In 2013, Stager et al. 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. an electromyographic study. 130. It is spasm of the near triad: 1. How is convergence insufficiency treated? 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. None of these patients developed signs of an underlying neurologic disorder during follow-up. Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. RJZee will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. All rights reserved. is fixed. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. J Neuroophthalmol. All rights reserved. Since divergence is an active process, not a passive one associated with relaxation of the medial rectus muscles,5 some investigators hypothesize that a "divergence center" must exist. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. LBSharpe 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. Heavy eye syndrome versus sagging eye syndrome in high myopia. 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. Weird vision divergence upon waking at night User Name: Remember Me: Password . LMDivergence paralysis with increased intracranial pressure: further observations. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. 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. 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. 8. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. 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. Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. 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. This ocular misalignment has two main types: esotropia and exotropia. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. To prevent double vision, the individual exerts extra effort to make the eyes turn back in. ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. Roper-Hall 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. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. Differentiating sagging eye syndrome (SES) from other causes of strabismus is not always a straight forward task given that patients with SES may have risk factors for strokes or tumors. RMTomsak BBordaberry It involves a specialty optical system and a uniquely created image book. 2000;118(9):12371241. 1978;76:610-53. 128. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. This patient continued with vision therapy to help improve her sensory and motor fusion with the hope of eventually titrating down the amount of prism she wears. 3. It is idiopathic most often in children or young adults 2. Although no unsuspected neurologic disorder surfaced during the period of follow-up in these patients, I strongly recommend that a patient with isolated divergence insufficiency be followed closely to detect, for example, signs of developing intracranial hypertension or abducens nerve palsy. Bruce 1995, St. Louis, Missouri: Mosby. 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. The preferred method for prescribing prism for vertical heterophoria is determining the vertical associated phoria.12 This can be done at near using the Wesson card or at distance. Committee on Aging. RDDivergence paralysis. Patients with non-strabismic binocular vision disorderssuch as divergence insufficiency, basic esophoria and vertical heterophoriacan often benefit from treatment with prism, particularly relieving prism, while othersincluding those with convergence excess, convergence insufficiency, divergence excess or basic exophoriaare better managed with other treatment modalities, such as vision therapy or lenses.1 An option for prism patients is prescribing prism to relieve diplopia and asthenopia and concurrently having the patient do vision therapy to attempt to decrease or eliminate the amount of prism needed. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. 20-20-20 Still Not Enough to Alleviate Eye Strain, Binocular Vision and Sports Concussions: A Bad Combo, Vision Impairment Increases Risk of Cardiovascular Disease, Monocular Eye Closure Common with Epiretinal Membrane. Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. For example, many investigators propose criteria to differentiate divergence insufficiency from divergence paralysis or paresis.1-3 However these arbitrarily defined criteria more likely describe varying severity of symptoms and ocular motor signs along a continuum of the same condition.
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