[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. This means that in a vectogram the amount of convergence or divergence needed to fuse the image depends solely upon how far apart the two cards are held, i.e. None of these patients developed signs of an underlying neurologic disorder during follow-up. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. Arch Ophthalmol. Sometimes it is exacerbated by fatigue and improves with rest. 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. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). Extraocular muscles (EOM) are surrounded by connective tissue that serve as a functional support and a mechanical pulley. 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. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. Initial tenotomy 30% of tendon width was performed to avoid intraoperative overcorrection. A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. New York, NY Oxford University Press1999;405-610. Wall Kerala J Ophthalmol. JLSaccadic velocity analysis in patients with divergence paralysis. 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. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. What is divergence insufficiency? The opposite of divergence insufficiency is divergence excess. Prism is a powerful tool that can be used to successfully treat a variety of binocular vision conditions. 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. EHBilateral sixth-nerve paresis simulating divergence paralysis. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. Otherwise, neuroimaging can be deferred in patients with neurologically isolated divergence insufficiency, although careful follow-up is indicated to identify developing suspicious neurologic symptoms or signs. 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. Most trial lens sets come with prism lenses, but for larger angles of strabismus, it may be helpful to use a Fresnel prism trial set. 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) However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. 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. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. 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. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. If a patient sees four dots in free space or gives a diplopia response but is able to fuse with prism, perform a unilateral cover test. 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. unable to diverge appropriately to a given target. If the patient is only using one eyethe image will not be formed correctly. ALDemer GTDJohnston HS Then, a horizontal prism bar was used to place increasing strengths of base-in prism over the other eye until fusion could no longer be maintained, as assessed subjectively using a distant target for fixation. Ductions and versions are full. BBordaberry Distance esotropia in the elderly. Br J Ophthalmol. [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 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. You can schedule your next appointment with us online! THBird Primary divergence insufficiency is generally a benign condition. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. Rutar T, Demer JL. SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As In 2005 Thacker NM et al. MEBarrows For example, the right eye might see a lion while the left eye sees a cage. Although cosmesis can be an issue with prism glasses, educating your patients on proper frame and lens selection will help them choose a frame and lens combination for the best cosmetic outcome. 2012. Blurred vision. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. Home Vision Therapy Convergence Insufficiency Testing. 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. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. With the exception of the size of vertical fusion amplitude, ocular motor signs associated with divergence insufficiency did not distinguish patients with idiopathic from those with secondary disorders. 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. LRosenbaum DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. with a stereo image already pre-made onto the card. What are causes of convergence insufficiency? It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. J AAPOS. Drs. Double vision is a troublesome complication of otherwise successful cataract surgery. 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. This problem is most commonly found in children. Tamhankar MA, Ying GS, Volpe NJ. If the eyes do drift out, the person is likely to have double vision. Another historically reported feature of DI is significantly decreased negative fusional vergence (fusional divergence), along with the deficits direct relationship to distance of gaze. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. LDivergence insufficiency. From there, basic vergence exercises will be added in. Reference: 1. Near point convergence is the distance you can use both eyes without seeing double. Customize your JAMA Network experience by selecting one or more topics from the list below. All rights reserved. Jampolsky 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. 2000;118(9):1237-41. It is usually benign. Convergence 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. Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. Accepted for publication February 11, 2000. Arch Ophthalmol. 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. There are many different ways to do this, but the best method to use depends on the type of binocular vision disorder for which you are prescribing. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. Diagnosing convergence 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. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. Arch Ophthalmol. 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. Double vision. All rights reserved. Although no unsuspected neurologic disorder surfaced during the period of follow-up in these patients, I strongly recommend that a patient with isolated divergence insufficiency be followed closely to detect, for example, signs of developing intracranial hypertension or abducens nerve palsy. 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. Long-term Surgical Outcomes in the Sagging Eye Syndrome. The mirror stereoscope is one of the most commonly used types. NRNewman This page was last edited on January 26, 2023, at 08:42. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. 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. doi:10.1001/archopht.118.9.1237. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. Divergence insufficiency can vary in severity, from minor deficits to complete divergence paralysis. The author has no commercial or proprietary interest in any product or company mentioned in this manuscript, and has no financial interest nor receives payment as a consultant, reviewer, or evaluator. Parkinson disease 4. 2012;130:12801284. 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. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. What is divergence insufficiency? 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. This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. et al. 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. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Near point of convergence (NPC) is measured by bringing an object to the nose and observing when the patient sees double, or one eye deviates .