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. Divergence insufficiency revisited: natural history of idiopathic cases Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and help make average daily distance tasks more manageable with less frequent symptoms. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. Miller Abstract. [unreliable source?] Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. 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. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. 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. The use of topical anaesthesia does not abolish this surgical risk. Arch Ophthalmol. 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. [2] Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. 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. Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task Convergence insufficiency (CI) is a vision disorder. Chaudhuri Z, Demer JL. 133. 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. These patients often present with horizontal and vertical deviations. They use head thrusts to shift fixation. 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. . PCBurian Primary divergence insufficiency is generally a benign condition. 6. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. Recent trauma 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. In 2005 Thacker NM et al. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. It is spasm of the near triad: 1. "The term divergence insufficiency implies a problem at the level of the brainstem, suggesting that there is decreased neural output to the extraocular muscles," said Prem S. Subramanian, MD, PhD, at the University of Colorado in Aurora. Lets continue the conversation over on your social network of choice. Lepore A near card is brought toward the patients nose until the patient sees double. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. Head trauma 3. divergence excess eyewiki 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. With a trial frame, she was not able to appreciate RDS stereoacuity in-office. AIs divergence active? Divergence Insufficiency: An Ongoing Challenge - Review of Ophthalmology A Maddox rod was also used to determine the near point of orthophoria in most patients. Basic Esophoria and Exophoria. the accommodative and vergence systems are tightly correlated. Jacobson DM. 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. Vision Therapy with AmblyoPlay - Learn about your path to better vision! Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. 2016 May; 100(5): 648651. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. It is usually benign. MCiner ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. RDDivergence paralysis. Sagging Eye Syndrome - EyeWiki Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. 11. 131. If an intermittent horizontal strabismus patient has a primary vertical deviation, vertical prism may help improve their ability to fuse the horizontal deviation. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. 2011;31(3):206-9. Clin Exp Optom. Histories reveal the possibility of a number of etiologic factors. 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). Wiggins It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. Diplopia at Distance in Older Patients: Is It Sagging Eye Syndrome? Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation 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. AOcular divergence mechanisms. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. In this example, the patient will be asked to either relax his or her eyes to put the lion in the cage (diverge) or stimulate his or her eyes to put the lion in the cage (converge). 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. ISOphthalmoplegia in cranial arteritis. Certain factors are associated with exotropia, including genetics and health conditions. [5], In recent imaging studies, Patel et al. 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 with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. NADivergence paralysis. They had experienced double vision for 5 weeks, 5 months, and 6 months, respectively, up to the time of their last evaluation, but did not return for further follow-up. Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. [10] In 2013, Stager et al. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. 2005;89(10):1318-23. Prism prescriptions often greatly improve the quality of life of your patients by reducing asthenopia and diplopia. The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. 13. He usually volunteers the infor mation that he has no trouble in reading or close use of his eyes. Hold focus on this dot for 10 seconds. Rutar T, Demer JL. Fresnel membrane prisms can be very useful for many aspects of prescribing prism. What are causes of convergence insufficiency? 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. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. J AAPOS 2014;18:370-373. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. 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. A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. 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? 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. 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. All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). DRHartnett 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. Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. RMDiagnosis and management of divergence paresis. 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. After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. 2012;95(2):192-7. This ocular misalignment has two main types: esotropia and exotropia. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. None of these patients underwent strabismus surgery. 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. To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. DOI: Demer JL. It is most often related to raised intracranial pressure or Chiari malformation. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. 10. Theme. 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. along with the fusional vergence system to create a 3-D object. EJampolsky Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. 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. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. Although each method has its advantages and disadvantages, they all suffer from being subjective.