Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Antireflective coating is also beneficial for patients wearing prism lenses. Biousse V and Newman NJ. 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. I prescribed glasses (+3.00 sph OD, +2.25 sph OS) for the patient, and she returned for follow-up care, eventually patching and undergoing vision therapy for her amblyopia. Bothun ED, Archer SM. Kerala J Ophthalmol. Tamler Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. 13.120). Actually it's not synonymous with divergence paralysis, but it is a separate clinical entity 126. Divergence Paralysis - Optography Many affected patients experience spontaneous resolution of double vision within several months. RLMagnetic resonance images in a case of "divergence paralysis.". Pang Y, Teitelbaum B, Krall J. [5], In recent imaging studies, Patel et al. _________________________________________________________________. JSLevy Divergence insufficiency can vary in severity, from minor deficits to complete divergence paralysis. Committee on Aging. Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. 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. Demer JL et al. 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. 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. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. CHNuclear and infranuclear ocular motility disorders. Neuro-ophthalmology Illustrated-2nd Edition. Using magnetic resonance imaging (MRI), a coronal image 6 mm anterior to the eyeball-optic nerve junction was measured and used to examine the extraocular muscle (EOM) path shift . divergence excess eyewikibc kutaisi vs energy invest rustavi. An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. What is convergence spasm? When prescribing ground-in prism, high index lenses, plastic frames and frames that are smaller in size help improve the weight and cosmesis of the lenses. 2012;130:12801284. 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. 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. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. What are the symptoms of Convergence Insufficiency? Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. 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. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. 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]. This decreases the motor fusion demand, allowing the patient to fuse more comfortably. JAInman SDiagnosis and management of divergence weakness in adults. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. MBSavitsky None of these patients developed signs of an underlying neurologic disorder during follow-up. Home Vision Therapy Convergence Insufficiency Testing. DIVERGENCE INSUFFICIENCY - Optography Convergence Insufficiency Testing. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. NADivergence paralysis. 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. PDF Divergence Insufficiency - Jama Br J Ophthalmol. A similar technique is used for rehabilitation: the patient is instructed to do push-up exercises (looking at an object intermittently moved in and out from the bridge of the nose) daily at home to decrease the near point of convergence.Divergence InsufficiencyDivergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Ductions and versions are full. It is most often related to raised intracranial pressure or Chiari malformation.Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation Head trauma Intracranial hypotension (low CSF pressure syndrome) Cerebellar lesions Midbrain massAbnormal Horizontal Conjugate DeviationsGaze deviations are relatively common in large cerebral and pontine lesions (Fig. The normal amount of fusional divergence ability at distance is lower than that of fusional convergence ability, making it challenging to sufficiently increase ranges to compensate for esophoria or esotropia at distance. Divergence Insufficiency: An Ongoing Challenge - Review of Ophthalmology Convergence and Divergence - Vivid Vision 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. 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. Scheiman M, Cotter S, Rouse M, et al. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. et al. Clin Exp Optom. One of the most important aspects of successfully prescribing prism is choosing patients who will benefit the most from it. Ghanchi Exotropia (Eyes Turning Outward): Types, Signs & Treatment 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. an electromyographic study. What is convergence insufficiency? In 2015 Chaudhuri and Demer published a retrospective observational study about utilizing Graded Vertical Rectus Tenotomy (GVRT) for treating incomitant vertical misalignment. if you would like to learn more about convergence and divergence insufficiency. changing the target) or by using multiple vectograms and making the patient look from one to another and quickly adapting the vergence system appropriately to each target (this is called jumping vectograms). [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). 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. [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. AOcular divergence mechanisms. Jacobson DM. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Results AParalysis of divergence. In 2005 Thacker NM et al. Fresnel membrane prisms can be very useful for many aspects of prescribing prism. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. GBTobin Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. 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. Esotropia resolved within days of initiating corticosteroid treatment in both patients. DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. Otherwise, neuroimaging can be deferred in patients with neurologically isolated divergence insufficiency, although careful follow-up is indicated to identify developing suspicious neurologic symptoms or signs. DOI: Demer JL. In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. Near point of convergence test: This test will . 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. The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. The EOM angles in these patients ranged from 100 to . Scheiman M, Wick B. RTOcular muscle paresis and cranial arteritisan unusual case. Distance esotropia in the elderly. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. Divergence Insufficiency/Excess | Vision Therapy Paducah Kentucky 3rd ed. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. The procedure is performed under topical anesthesia in the presence of an anesthesiologist. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. 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. Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. Conclusions 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. NRNewman with a stereo image already pre-made onto the card. [5], There has been an increased awareness and diagnosis of these degenerative strabismic disorders after 2000. The characteristics of the patients in this series who have an idiopathic disorder suggest that if certain rules of diagnosis are obeyed, divergence insufficiency can be distinguished from sixth cranial nerve palsy in most cases using clinical techniques. 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. 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. Tranaglyphs are similar to vectograms, however instead of there being two different transparent image cards that need to be fused into one, there is one image card with a stereo image already pre-made onto the card. Graefes Arch Clin Exp Ophthalmol. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? 131. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. 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. MGallaway What is divergence insufficiency? Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. 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. 2012;95(2):192-7. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. 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. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. What Is Convergence Insufficiency? Symptoms, Causes, and Treatments - WebMD 2008;126(10):1336-49. 130. Parkinson disease 4. Typically, the band appears as an uninterrupted, arc-like structure extending from the lateral rectus to the superior rectus/levator palpebrae complex. What is convergence insufficiency? Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, 2000;118(9):1237-1241. doi:10.1001/archopht.118.9.1237. Convergence Insufficiency Testing. Information obtained from direct telephone interviews with the patients and review of office records of referring physicians who continued to follow up some patients were included in the determination of follow-up. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. No clear sex predilection has been identified for the primary form of the condition. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. RMTomsak In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. The association with refractive errors (and high myopia in particular) has been a point of contention for some time. 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. 2023 Stanford School of Medicine | Terms of Use | 129. FEDivergence paresis: a nonlocalizing cause of diplopia. While viewing the card, the patient reports what color line the black arrow is aligned with. 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. Clinical management of strabismus. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. 1. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. Concussion: Understanding Vision Problems Post-Injury - bocatc.org 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. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. 127. You can also use Random Dot Stereo (RDS) testing to determine fusion prism. 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. If the patient gives a fusion response with or without prism but movement on the unilateral cover test is seen, then anomalous correspondence is suspected and relieving or corrective prism is not an appropriate management option. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. 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.