J AAPOS. 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 tcooper@stanford.edu. RMDiagnosis and management of divergence paresis. Long-term follow-up and clinical features of the 2 groups were compared. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. SDiagnosis and management of divergence weakness in adults. Sagging eye syndrome (SES) was first described by Rutar and Demer in 2009, as a potential leading cause of strabismus in older adult population as a combination of horizontal and vertical strabismus in addition to bilateral blepharoptosis (ptosis with high lid creases) and deepening of the sulcus. 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. 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. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). 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. Neuroimaging was not performed in 4 of these patients so it is possible that some of them had unsuspected lesions. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. 1. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. 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. 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. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. 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. 2023 American Medical Association. Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation The mirror stereoscope is one of the most commonly used types. Eye - Diplopia following cataract surgery . 2012;49(4):222-8. Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. is fixed. Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. 2014;18(4):309-15. Our eye doctors. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. 13.121). Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. 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. 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. A Maddox rod was also used to determine the near point of orthophoria in most patients. JAInman A 5-year-old female initially presented for a strabismus and amblyopia evaluation. 127. PCBurian Scheiman M, Wick B. Arch Ophthalmol. Schedule Appointment Our Doctors Contact UsAccepted Providers, Comprehensive Eye Exams Glasses Contact Lens Exams Dry Eye Emergency Care, 801 East Newport Pike, Wilmington, DE 19804 | (302) 999-1286, If you have not read the previous portions of the vision therapy. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. A new prescription for prism lenses was dispensed to the patient at the follow-up examination. 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 . What causes divergence insufficiency? They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. Primary divergence insufficiency is generally a benign condition. Audio blog post. SHarbison NRNewman Biousse V and Newman NJ. To begin therapy, many therapists will focus first on normalizing the accommodative system. DOI: Demer JL. 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. Divergence insufficiency can also result in headaches, motion sickness and sensitivity to bright lights. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. Strabismus. It is also possible that the 3 patients who died and did not undergo long-term follow-up had some unsuspected neurologic disorder at the time they were evaluated. If the eyes do drift out, the person is likely to have double vision. 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. 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. DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. . They use head thrusts to shift fixation. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. Drs. 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. This problem is most commonly found in children. 128. 1993, Oxford, UK: Butterworth Heinemann Books. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. [4]The pulleys inflect rectus and inferior oblique paths by the exact same way that the trochlea inflects the path of the superior oblique (SO) tendon. [1][5][8] The patients may also present with bilateral ptosis. 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 insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. 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. Other training exercises include base-out prisms for near viewing and convergence exercises. American Academy of Ophthalmology. None of these patients underwent strabismus surgery. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. Head trauma 3. 2005;9:36. The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. Corbett Divergence insufficiency was also observed in 2 patients, each with idiopathic cerebellar degeneration and progressive supranuclear palsy, an association that is generally not recognized in either condition.30 This did not cause clinical confusion, however, since divergence insufficiency was overshadowed in each patient by the cardinal signs that characterized their underlying neurologic conditions. 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. Cotter SA. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. 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. Certain factors are associated with exotropia, including genetics and health conditions. 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. In the remaining 17 patients who were still alive, the total duration of follow-up extended from 1 month to 16 years (median, 35 months). If the dot becomes doubled, go back to the previous dot and try again. 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. of negative and positive fusional vergence. Convergence Insufficiency. REBaumgartner After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. 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. The patient places two transparent cards into the vectogram system. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. 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. SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As 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. Antireflective coating is also beneficial for patients wearing prism lenses. 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. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. 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. 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. [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. 6. With CI, the eyes do not point together inward as one looks at objects close-up. IRT. It is usually benign. Heavy Eye vs. the accommodative and vergence systems are tightly correlated. Divergence excess is an over-divergence when attempting to look at distant objects. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Symptoms of vergence disorders occur only under binocular viewing conditions and may include eyestrain, double vision and headaches.4,7,9,10,15 Interventions: Vision Training Many TBI patients respond well to efforts to improve vision, cope with impairment, or both. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. The following information was abstracted from the medical records: current medical history, past medical history, details of the ocular motor and general neurologic examinations, results of radiographic and laboratory tests, and long-term follow-up of those cases that were classified as idiopathic. The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. Blurred vision. 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. 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 LR-SR band vertically supports the LR pulley against the downward force of the inferior oblique muscle to maintain the LR pulleys vertical position. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. Initial tenotomy 30% of tendon width was performed to avoid intraoperative overcorrection. Lateral rectus resections in divergence palsy: Results of long-term follow-up. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established.