divergence insufficiency double vision

Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. 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. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. Histories reveal the possibility of a number of etiologic factors. Diplopia Developed in Later Life, An Ophthalmologic Approach PDF Divergence Insufficiency - Jama Divergence insufficiency - definition of divergence insufficiency by 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. This means the eyes do not like to move inward toward the nose and is problematic when trying to look at a near target. 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. Primary divergence insufficiency is generally a benign condition. Chang MY et al. 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. Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). The distance at which diplopia occurs is noted (near point of convergence). is variable. 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. Vertical deviations often cause patients to experience significant symptoms even when the deviation is small. A Maddox rod was also used to determine the near point of orthophoria in most patients. ARKline Concussion: Understanding Vision Problems Post-Injury - bocatc.org LBSharpe "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. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. 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. The Apt Lecture. BBordaberry 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. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. Prism prescriptions often greatly improve the quality of life of your patients by reducing asthenopia and diplopia. 2016;28(1):38-42. 2011;31(3):206-9. 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. 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. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. THBird Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. 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. Bedrossian Methods Individuals with convergence insufficiency often have a low AC/A ratio and a low near point of convergence. These exercises were discussed in detail in Part 6 of this series. In 2015 Chaudhuri and Demer published a retrospective observational study about utilizing Graded Vertical Rectus Tenotomy (GVRT) for treating incomitant vertical misalignment. Define divergence insufficiency. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. After a preliminary prescription of fusion prism is determined, it is recommended that you trial frame the patient and have them look around to see if they experience any diplopia when viewing objects in the room. 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. 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. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. 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. 2023 American Medical Association. [10] In 2013, Stager et al. Eight (40%) of the 20 patients recalled such an event, including a viral pro-drome in 3 patients, minor head trauma in 2 patients, and hospitalization for an unrelated illness in 3 pa-tients. What is divergence insufficiency? 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. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. What is the cause of convergence spasm? doi:10.1001/archopht.118.9.1237. Patients with non-strabismic binocular vision disorderssuch as divergence insufficiency, basic esophoria and vertical heterophoriacan often benefit from treatment with prism, particularly relieving prism, while othersincluding those with convergence excess, convergence insufficiency, divergence excess or basic exophoriaare better managed with other treatment modalities, such as vision therapy or lenses.1 An option for prism patients is prescribing prism to relieve diplopia and asthenopia and concurrently having the patient do vision therapy to attempt to decrease or eliminate the amount of prism needed. Success of prisms in the management of diplopia due to fourth nerve palsy. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. [5], In recent imaging studies, Patel et al. 133. 1. Sagging Eye Syndrome. 3rd ed. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. Sagging Eye Syndrome - EyeWiki Biousse V and Newman NJ. Abstract. 2005;9:36. DJDivergence insufficiency. 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. Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. While none of the patients had other symptoms to suggest giant cell arteritis or myasthenia gravis, erythrocyte sedimentation rate (performed in 7 patients) and acetylcholine receptor antibody assay (performed in 6 patients) were tested, and the results were normal in all. 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. 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. 1993, Oxford, UK: Butterworth Heinemann Books. . The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. use an approach called the SILO affect to work on increasing divergence or convergence ranges. RJZee Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. 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. Comparison of surgical dose response between divergence insufficiency [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. An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. doi:10.1136/bjophthalmol-2015-306783. 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. 128. 8. Lim Wednesday, March 15, 2023 | All Eyes On Evaporation, Thursday, April 13, 2023 | All Eyes On Evaporation, Tuesday, April 18, 2023 | All Eyes On Evaporation. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. 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. 133. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. To increase convergence, the two cards will be pushed inward, making the image smaller (Small In for the SI in SILO). MEBarrows FEDivergence paresis: a nonlocalizing cause of diplopia. If an intermittent horizontal strabismus patient has a primary vertical deviation, vertical prism may help improve their ability to fuse the horizontal deviation. What are causes of convergence insufficiency? Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. Moore NParalysis of divergence. 4. 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. In normal cases, the ocular axis length was 23.5 1.0 mm. If you have not read the previous portions of the vision therapy series it is highly advisable that you check them out first as they cover basics not explained here. AmblyoPlay is a vision therapy solution that is performed through playing therapeutic games and exercises on your tablet or computer for 30 minutes per day. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. 13.120). All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. Primary divergence insufficiency is generally a benign condition. DOI: Demer JL. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As 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. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. The mechanical properties of pulleys are critical for the support and rotational properties of the eye. Convergence describes the way our eyes move together and point inward when we look at near objects. Demer JL. The most successful prism cases are often patients who have intermittent strabismus and good potential for normal fusion or patients with strabismus who have not developed any sensory anomalies. Exotropia (Eyes Turning Outward): Types, Signs & Treatment However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. PDF CLINICAL SCIENCES Divergence Insufficiency Revisited - JAMA In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. 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. Scheiman M, Cotter S, Rouse M, et al. [5] The ligament was ruptured in 64% of orbits with DPE and 91% of orbits with CVS. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. 2012;130:12801284. . DBGlaser The preferred method for prescribing prism for vertical heterophoria is determining the vertical associated phoria.12 This can be done at near using the Wesson card or at distance. 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. 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 insufficiency associated with high myopia | OPTH 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). Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. 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. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. 2012. These patients often present with horizontal and vertical deviations. 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. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. 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. Cotter SA. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. It is possible that with longer follow-up, the number of patients with resolution of diplopia might increase. CHNuclear and infranuclear ocular motility disorders. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. as their fusional vergence ranges expand. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . Per some observations, its is more common in Caucasian females. Many affected patients experience spontaneous resolution of double vision within several months. 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]. Patients may also present with ductional deficits depending on the grade of muscle displacement. A Vectogram is a tool which utilizes specialized imaging along with the fusional vergence system to create a 3-D object. Rutkowski Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Heavy Eye vs. This recommendation is based on the small size of the study population, the problems inherent in a retrospective investigation, and the grave consequences of failing to identify other neurologic signs. Terms of Use| Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying All Rights Reserved. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. Convergence Insufficiency - American Academy of Ophthalmology 2023 Stanford School of Medicine | Terms of Use | What causes divergence insufficiency? MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. 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. How is convergence insufficiency treated? Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. GBurde unable to diverge appropriately to a given target. 10. To be enrolled in the study, patients had to meet the following 5 criteria: 1) relatively sudden onset of double vision at far vision, 2) no double vision at near vision, 3) high myopia >6.0 diopters (D) in both eyes, 4) no other neurological symptoms, and 5) a normal . 13.119). 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. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." 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. Prism in reading glasses or strabismus surgery may be required. The patient is also instructed to keep the words around the lines clear to control accommodation. If the dot becomes doubled, go back to the previous dot and try again. Scheiman 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. 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). 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. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. Lateral rectus resections in divergence palsy: Results of long-term follow-up. 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. Classically convergence spasm is nonorganic. Chaudhuri Z, Demer JL. 7. DIVERGENCE INSUFFICIENCY - Optography 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. They use head thrusts to shift fixation. 1978;76:610-53. 132. When you try to focus on something close to your eyes, you may have: Tired eyes. While viewing the card, the patient reports what color line the black arrow is aligned with. Trans Am Ophthalmol Soc. 4 Binocular Vision Problems that Cause Eyestrain Questions: 125. [unreliable source?] Each card contains a partial view of the complete image. J AAPOS. 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. J AAPOS. Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. Distance esotropia in the elderly. 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). characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . 1995, St. Louis, Missouri: Mosby. 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. [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). DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. Diplopia following cataract surgery: a review of 150 patients They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. American Academy of Ophthalmology. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. 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. PMDivergence paralysis. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. Therapists can make this activity more advanced by increasing the amount the, changing the target) or by using multiple, and making the patient look from one to another, , however instead of there being two different transparent image, that need to be fused into one, there is one image. Although each method has its advantages and disadvantages, they all suffer from being subjective. What is the cause of convergence spasm? NJeds, Leigh 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. [1][5][8] The patients may also present with bilateral ptosis. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. FDDutton This is the brain's answer to coping with double vision and the stress of eyes not working as a . 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. 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%. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Convergence Insufficiency | National Eye Institute Tamler What is Convergence Insufficiency? Symptoms, Treatments - Healthline Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. if you would like to learn more about convergence and divergence insufficiency. Divergence Insufficiency Revisited: Natural History of - JAMA GMOcular divergence: its physiology and pathology. ISOphthalmoplegia in cranial arteritis. In 2005 Thacker NM et al. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or.