divergence insufficiency double vision

Divergence insufficiency is the opposite problem of convergence insufficiency. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. 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. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. JAInman We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. 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. use an approach called the SILO affect to work on increasing divergence or convergence ranges. Although prescribing it can seem intimidating at first, with practice and a bit of trial and error, you can perfect your ability to prescribe prism for your patients in no time. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. 2000;118(9):12371241. This ocular misalignment has two main types: esotropia and exotropia. 2005;9:36. Biousse V and Newman NJ. 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). Convergence insufficiency is a common problem with the eyes, and is the main culprit behind eyestrain, blurred vision, and headaches. Divergence Insufficiency. 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. is variable. 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. Vertical Heterophoria. Accepted for publication February 11, 2000. Caloroso E, Rouse MW. When patients are spectacle independent and want to remain independent, surgical approach could be offered. In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. Chaudhuri Z, Demer JL. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. 131. DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. New York, NY Oxford University Press1999;405-610. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. 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. 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%. EHBilateral sixth-nerve paresis simulating divergence paralysis. People notice symptoms while reading or doing other near work. The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. 133. You can schedule your next appointment with us online! Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. 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. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. Convergence Insufficiency. 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. These exercises were discussed in detail in Part 6 of this series. Barricks Biousse V and Newman NJ. Near point convergence is the distance you can use both eyes without seeing double. Other training exercises include base-out prisms for near viewing and convergence exercises. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. [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. 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. 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. Pencil pushups may be effective in some cases. RLMagnetic resonance images in a case of "divergence paralysis.". MGeorge 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. 2012;49(4):222-8. The eyes deviate horizontally toward a cortical lesion, the eyes deviate horizontally away from a cortical seizure focus, and the eyes deviate horizontally away from a pontine lesion. After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. It can also decrease distance judgement, coordination, and sports performance. Methods Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. 9. Long-term follow-up and clinical features of the 2 groups were compared. Individuals with convergence insufficiency often have a low AC/A ratio and a low near point of convergence. make average daily distance tasks more manageable with less frequent symptoms. To begin therapy, many therapists will focus first on normalizing the accommodative system. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. AJNR Am J Neuroradiol. Abstract. All but 1 patient were older than 50 years. Visual loss in pseudotumor cerebri: follow-up of 57 patients from five to 41 years and a profile of 14 patients with permanent severe visual loss. 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. Convergence Insufficiency Symptoms. The Apt Lecture. Stager DR, Sr, Black T, Felius J. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. Questions with answers: 125. What is convergence insufficiency? The remainder of the neurological examination should be normal, without any cranial neuropathies. with a stereo image already pre-made onto the card. 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. 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. Esodeviation is comitant in all fields of . 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. 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. 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. SDiagnosis and management of divergence weakness in adults. 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. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. 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. ARKline reported a case series of 9 patients with vertical strabismus incomitant in horizontal gaze positions and cyclotorsion who underwent Adjustable small-incision selective tenotomy and plication. If no movement is seen on the unilateral cover test, the patient has normal correspondence. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. 3rd ed. CHNuclear and infranuclear ocular motility disorders. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. I doubt that assessment of the size of vertical fusion amplitude would be a helpful discriminating tool, however, since the size of it was small in most patients in both groups, it was measured using a subjective end point, and there was considerable overlap of values. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. 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. Bruce Vertical deviations often cause patients to experience significant symptoms even when the deviation is small. Ghanchi Rutkowski Kerala J Ophthalmol. The patient will wear a pair of polarizing glasses (similar to what is worn in modern 3-D movies) to create depth within the image (stereopsis). Thomson No signs of orbital ischemia were present in the second patient. These patients often present with horizontal and vertical deviations. NRNewman 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. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. Rutar T, Demer JL. Convergence Insufficiency. Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. The main treatment for convergence insufficiency is vision therapy. None of these patients underwent strabismus surgery. Reproduction in whole or in part without permission is prohibited. No clear sex predilection has been identified for the primary form of the condition. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. 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. 2012;130:12801284. HMDivergence paralysis following head trauma. if you would like to learn more about convergence and divergence insufficiency. 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. With a trial frame, she was not able to appreciate RDS stereoacuity in-office. Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. 126. [2] unable to diverge appropriately to a given target. Simultaneous injury of the medial longitudinal fasciculus has been postulated as another reason sixth cranial nerve palsy may appear comitant.4 However, none of the patients classified as primary had clinical signs of internuclear ophthalmoplegia. 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. Although small amounts of vertical prism can be prescribed in contact lenses, patients who need prism usually have to wear it on a spectacle lens. Sometimes it is exacerbated by fatigue and improves with rest. 2013;97(11):1415-9. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. 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). Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. Br J Ophthalmol. 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. Blurred vision. J AAPOS 2014;18:370-373. [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. J AAPOS. American Academy of Ophthalmology. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or. 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. Although each method has its advantages and disadvantages, they all suffer from being subjective. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. 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. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. it is highly advisable that you check them out first as they cover basics not explained here. With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. 5. Objectives 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. 13.120). It is spasm of the near triad: 1. Divergence insufficiency can also result in headaches, motion sickness and sensitivity to bright lights. Distance esotropia in the elderly. Prism can be a powerful treatment for many conditions and for many patients, specifically for those who suffer from asthenopia or diplopia. [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. Scheiman The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. The use of topical anaesthesia does not abolish this surgical risk. When you try to focus on something close to your eyes, you may have: Tired eyes. divergence insufficiency synonyms, divergence insufficiency pronunciation, divergence insufficiency translation, English dictionary definition of divergence insufficiency. The results of CT or magnetic resonance imaging (MRI), available at the time of initial evaluation, were not initially considered since one of the aims of this study was to identify clinical features that might be helpful in predicting which patient was harboring a neurologic disorder. 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. Reference: 1. Treatment options include correction with base-out prisms for distance, Tomasz A. Wiraszka, MD, and Praveena Gupta, OD, PhD, FAAO, Galveston, Texas, April 2015 Wills Eye Resident Case Series, Wills Eye Resident Case Series - Diagnosis and Discussion, November 2014 Wills Eye Resident Case Series, February 2016 Wills Eye Resident Case Series - Diagnosis & Discussion. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. 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 . 2012. Double vision. 1978;76:610-53. 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. If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. In the 17 patients with primary divergence insufficiency who had adequate information to ascertain long-term follow-up, double vision persisted in 9 individuals. It is most often related to raised intracranial pressure or Chiari malformation. This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. 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. Lim 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. 2014;18(4):309-15. IRT. 7. . 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). In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. In that study, strabismus surgery was performed in 50% of all SES cases. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. THBird However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. 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. In a recent study by Goseki et.al. REBaumgartner 2023 American Medical Association. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. Although younger patients may not be able to give good, subjective feedback, older children and adult patients should wear the trial prism set while engaging in an activity that normally causes them to experience diplopia or asthenopia (reading or distance viewing) to see if it eliminates diplopia and improves comfort. Pang Y, Teitelbaum B, Krall J. 1. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. Lewis Corresponding author: Daniel M. Jacobson, MD, Neuro-ophthalmology (4F-2), Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (email: jacobsod@mfldclin.edu). published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. What is the cause of convergence spasm? 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. 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. Fusion prism is the minimum amount of prism needed to see a change from diplopia or suppression to normal binocular vision.12 To determine prism using this method, use the Worth Dot test to find a preliminary prism amount. What causes divergence insufficiency? 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. Only 2 patients were followed up for less than 6 months. However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. FDDutton In normal cases, the ocular axis length was 23.5 1.0 mm. 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. 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.