divergence insufficiency double vision

Mosbys Optometric Problem Solving Series, ed. All Rights Reserved. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. However, the cause of convergence insufficiency is often unknown. Drs. Sensory Anomalies. All rights reserved. Near point convergence is the distance you can use both eyes without seeing double. Arch Ophthalmol. 2008;126(10):1336-49. Patients will be able to work on fusing the images of one card and move on to a more difficult card as their fusional vergence ranges expand. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. MGallaway It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. With CI, the eyes do not point together inward as one looks at objects close-up. Home Vision Therapy Convergence Insufficiency Testing. characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . Customize your JAMA Network experience by selecting one or more topics from the list below. with a stereo image already pre-made onto the card. 12. 128. Dr. Jenewein is an assistant professor at Salus University, Salus Universitys Principal Site Investigator for the Pediatric Eye Disease Investigator Group, a Fellow of the American Academy of Optometry and a Diplomate of the Binocular Vision, Perception and Pediatric Optometry Section of the Academy. FDDutton 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. This is the brain's answer to coping with double vision and the stress of eyes not working as a . 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. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. Divergence Insufficiency/Excess | Vision Therapy Paducah Kentucky Divergence Insufficiency and Divergence Excess Symptom Checklist Vision Therapy: Alex's Success Story | Wow Vision Therapy Share Watch on Share this: Twitter Facebook Like this: Loading. Effectiveness of base in prism for presbyopes with convergence insufficiency. Convergence Insufficiency. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. Br J Ophthalmol. No such signs were identified in any of the patients in this series. Conclusions Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. ALDemer 2012;130:12801284. 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. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . Roughly half of the patients experienced spontaneous resolution of diplopia after several months. A common a daily, home rehabilitation technique is to have the patient do push-up exercises (looking at an object intermittently moved in and out from the bridge of the nose) to decrease the near point of convergence. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. Heavy Eye vs. 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. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. Patients and methods. Smith This problem is most commonly found in children. 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. Jacobson DM. Introduction. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Reference: 1. DIdiopathic intracranial hypertension: a prospective study of 50 patients. 2013;97(11):1415-9. Many affected patients experience spontaneous resolution of double vision within several months. Sagging Eye Syndrome. 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. . CI affects children and adults. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. If your patient is still experiencing diplopia, additional prism may be needed to help them achieve fusion. Chang MY et al. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. How is convergence insufficiency treated? It is idiopathic most often in children or young adults 2. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Pencil pushups may be effective in some cases. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. Instead they turn their head briskly (head thrust) to shift fixation. Smooth pursuit and vertical eye movements are usually preserved. Eye movements are usually bilateral and symmetric in the horizontal plane. It is often idiopathic, but it has also been associated with several cerebral malformations and genetic disorders.Acquired Ocular Motor Apraxia Occurs in older children Associated with mostly metabolic disorders (Gaucher disease, ataxia-telangiectasia, spinocerebellar ataxias, NiemannPick disease) Convergence SpasmAlso called spasm of the near triad (Fig. 133. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. 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. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. 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. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. With exercises that adapt to each patient and their specific needs, it is an ideal solution for problems such as lazy eye, strabismus, convergence insufficiency, double vision, or other binocular problems. It was found that the mean distance-esotropia deviation in Prism was 6.9 0.7 and it resolved to 0.3 0.3 after surgery, while mean vertical deviation went from 3.0 0.3 to 0.7 0.2. [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. 2005;9:711. 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. Divergence excess is an over-divergence when attempting to look at distant objects. Lyle Neuro-ophthalmology Illustrated-2nd Edition. Distance esotropia in the elderly. Only 2 patients were followed up for less than 6 months. In 2005 Thacker NM et al. Therefore, it forces the patient to use both eyes properly to see the image. 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. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. 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. 2016. . 1978;76:610-53. GMOcular divergence: its physiology and pathology. Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. Divergence insufficiency is the opposite problem, accommodation will be worked on first to ensure it is equal between the two eyes, basic vergence exercises will be added in. 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. 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. Six patients underwent CT and 10 underwent MRI. Results from this study also supported previously published evidence of normal age-related connective tissue degeneration as there was a positive age effect in correlation to supero-temporal bowing of the LR-SR band.[9]. RJZee This page was last edited on January 26, 2023, at 08:42. 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. MCiner 2005;9:36. Tamler Pang Y, Teitelbaum B, Krall J. Results 2016 May; 100(5): 648651. [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). The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. 1993, Oxford, UK: Butterworth Heinemann Books. LMDivergence paralysis with increased intracranial pressure: further observations. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. Chang MY, Pineles SL, Velez FG. Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. HMDivergence paralysis following head trauma. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. The patients with primary divergence insufficiency in this retrospective survey were most often middle-aged or elderly persons with neurologically isolated double vision for distance who, not uncommonly, developed symptoms following a nonspecific illness or minor head trauma. NADivergence paralysis. 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. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. Success of prisms in the management of diplopia due to fourth nerve palsy. Audio blog post. 134. The remainder of the neurological examination should be normal, without any cranial neuropathies. 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. Clin Exp Optom. 129. 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). American Academy of Ophthalmology. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . 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. Strabismus. MGeorge Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. No signs of orbital ischemia were present in the second patient. Divergence insufficiency esotropia (DIE), originally described by Duane in 1896, is an acquired condition characterized by an esodeviation that measures at least 10 prism diopters (PD) greater at distant rather than near fixation [].Patients with DIE complain about double vision at distance. To begin therapy, many therapists will focus first on normalizing the accommodative system. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. They include: double vision (diplopia) headaches blurry vision while reading squinting or closing one eye while reading words appearing to move around or float on the page while reading eyestrain or fatigue (asthenopia) MEBarrows Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. What Are the Symptoms of Convergence Insufficiency? 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. 2018 Jan 3:1-5. doi: 10.1080/09273972.2017.1421676. 13.119). It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying 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 . It is an unusual form of strabismus with esotropia and diplopia only at distance and single binocular vision at near. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Questions: 125. The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. 126. Divergence insufficiency is the opposite problem of convergence insufficiency. Typically, patients note that they do not have any diplopia at near. 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. 13. . Extraordinary symptoms equivalent to diplopia 2.3.1. 134. 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. He usually volunteers the infor mation that he has no trouble in reading or close use of his eyes. 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. 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. 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. 2012;49(4):222-8. 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 many of these cases, the initial management strategy is prescribing vertical prism.1 Often, if the vertical deviation is decreased or eliminated, the patient may be able to comfortably fuse the horizontal deviation. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. In addition, all patients underwent examination of ocular motility using a Maddox rod to demonstrate that the angle of uncrossed deviation increased as the viewing distance increased, remained the same or decreased in right and left gazes at distance, and decreased as the viewing distance decreased. 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. Another area of controversy concerns whether divergence insufficiency is a localizing sign referable to injury of a "divergence center," or is a nonlocalizing sign associated with a variety of focal and diffuse brain insults. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. Arch Ophthalmol. 2005;89(10):1318-23. 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]. The distance at which diplopia occurs is noted (near point of convergence). Corbett This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. 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 . 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. Divergence excess is an over-divergence when attempting to look at distant objects. 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. If the dot becomes doubled, go back to the previous dot and try again. 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]. However, it seems unlikely, since divergence insufficiency resolved in all 4 patients and no other neurologic problems developed during the time of each patient's follow-up of 1 month, 5.5 months, 34 months, and 44 months, respectively. For example, the right eye might see a lion while the left eye sees a cage. Motion sickness or dizziness ( vertigo) Headache . How is convergence insufficiency treated? Esotropia resolved within days of initiating corticosteroid treatment in both patients. More respect for connective tissues. American Academy of Ophthalmology. 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. 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. Supported by Many affected patients experience spontaneous resolution of double vision within several months. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. Objectives 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 . 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. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. Bruce It is very a common condition where there is a comitant exotropia greater at near than at distance by at least 10 prism diopters. J Pediatr Ophthalmol Strabismus. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. Privacy Policy| During the total period of follow-up, none of the patients developed an alternative neurologic disorder. Jacobson DM. Our eye doctors. 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 glassestranaglyphs are made similarly. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. REBaumgartner 132. Common symptoms include: headaches; blurred vision ; double vision Arch Ophthalmol. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. 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. At the follow-up examination, she reported no diplopia in her glasses, and, eventually, she was able to see 250 seconds of arc RDS stereoacuity. While viewing the card, the patient reports what color line the black arrow is aligned with. In fact, when the vergence system is struggling, the accommodative system often picks up the slack and becomes overworked, which can also play a role in some of the symptoms of eye strain, fatigue, and headaches. Other associated symptoms can include asthenopia of panoramic type. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Prism is a powerful tool that can be used to successfully treat a variety of binocular vision conditions. 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.