2016;28(1):38-42. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . Pencil pushups may be effective in some cases. Jacobson DM.
4 Binocular Vision Problems that Cause Eyestrain What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Histologic studies showed that each rectus pulley consists of an encircling ring of collagen located near the globe equator in tenon fascia, coupled to the orbital wall, adjacent EOMs, and equatorial Tenon fascia by bands containing densely woven collagen, elastin, and smooth muscle. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. 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.
Recognizing TBI-related Vision Disorders - Review of Optometry To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line.
PDF CLINICAL SCIENCES Divergence Insufficiency Revisited - JAMA In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. FEDivergence paresis: a nonlocalizing cause of diplopia. Wiggins
Demer JL et al. 2012;49(4):222-8. None of these patients underwent strabismus surgery. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. With CI, the eyes do not point together inward as one looks at objects close-up. Typically, patients note that they do not have any diplopia at near. SDiagnosis and management of divergence weakness in adults. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. 2012;95(2):192-7. 1993, Oxford, UK: Butterworth Heinemann Books. 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. 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 . 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. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. These exercises were discussed in detail in Part 6 of this series. Jacobson DM. Clin Exp Optom. 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. The orbital layer, inserts on the pulley, not on the globe. Godts D, Mathysen DG. Arch Ophthalmol. PCBurian
Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. What is convergence insufficiency? Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all.
Divergence Insufficiency: An Ongoing Challenge - Review of Ophthalmology The main treatment for convergence insufficiency is vision therapy. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging.2, Vision therapy aims to decrease symptoms of vergence anomalies by increasing the compensating fusional vergence range (base-in for esophoria and base-out for exophoria). Effectiveness of base in prism for presbyopes with convergence insufficiency.
Convergence Insufficiency/Vision Therapy - Eye Docs For Kids Lyle
This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. Tamler
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. If the dot becomes doubled, go back to the previous dot and try again. 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. GBurde
Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. GTDJohnston
[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. 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. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. On initial presentation, her best-corrected visual acuities were 20/40 OD and 20/25 OS. 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. Unfortunately, since the ocular ductions appear full in a patient with suspected divergence insufficiency, objective means to assess the state of ocular comitancy do not exist for office determination. Convergence Insufficiency Symptoms. In addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. NParalysis of divergence. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. Chang MY, Pineles SL, Velez FG. RMDiagnosis and management of divergence paresis. 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. MBSavitsky
What are causes of convergence insufficiency? 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. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. Committee on Aging. What are the symptoms of Convergence Insufficiency? JAInman
ALDemer
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.
2014;18(4):309-15. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations. What Are the Symptoms of Convergence Insufficiency? 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. What is the cause of convergence spasm? During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. DBGlaser
2023 Stanford School of Medicine | Terms of Use | RLMagnetic resonance images in a case of "divergence paralysis.". 3rd ed. Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. Convergence Insufficiency. of negative and positive fusional vergence. Divergence excess is an over-divergence when attempting to look at distant objects. Patients will be able to work on fusing the images of one. Moore
Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. Of the 15 patients with secondary divergence insufficiency, an underlying neurologic or systemic disorder was either known or initially suspected in all based on the initial history and physical examination. It is a disorder involving binocular vision vision using both eyes. 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. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). 2011;31(3):206-9. In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. ), headaches, double vision at near, eye fatigue, and sometimes avoidance of near tasks all together. What is congenital ocular motor apraxia? 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. 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]. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Vision therapy uses various exercises to train the connection between the eyes and the brain as more than 50% of the brain is dedicated to visual function. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. Many affected patients experience spontaneous resolution of double vision within several months. 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. Eye - Diplopia following cataract surgery . Motion sickness or dizziness ( vertigo) Headache . 13.121). The cyclotorsion component of SES was present in 65% of patients. The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder).
Divergence insufficiency: characteristics, diagnosis, and treatment REBaumgartner
J Neuroophthalmol. 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. Double vision. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. Strabismus. Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. Scheiman M, Cotter S, Rouse M, et al. All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). . 2012;130:12801284. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. 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. Retrospective survey of patients with divergence insufficiency. Committee on Aging. What is convergence spasm? Electronic charts are now routinely used in practice, and many of them have an available distance target for determining fixation disparity and the associated phoria. Theme. . 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. 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. Antireflective coating is also beneficial for patients wearing prism lenses. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. 2000;118(9):1237-41. The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. J AAPOS. [5], In recent imaging studies, Patel et al.
Customize your JAMA Network experience by selecting one or more topics from the list below. 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. GMOcular divergence: its physiology and pathology. SHarbison
Depending on the clinical circumstances, the imaging, and the course, clinicians should consider evaluating for other etiologies prior to making the diagnosis of HES or SES. 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. 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. Near point convergence is the distance you can use both eyes without seeing double. Br J Ophthalmol. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. This page has been accessed 63,795 times. Esotropia resolved within days of initiating corticosteroid treatment in both patients. Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). One patient was followed up for only 1 month, but her esotropia resolved during that time. What is the cause of convergence spasm? Conclusions
They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). 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. Due to the degenerative etiology of this syndrome, the connective tissue involution may progress after surgery, up to 20% of patients[15], therefore is important to inform the patient of this possibility prior to surgery.
3 Advanced Exercises for Convergence and Divergence Insufficiency Biousse V and Newman NJ. Arch Ophthalmol. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. an electromyographic study. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. 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. With a trial frame, she was not able to appreciate RDS stereoacuity in-office. Chaudhuri Z, Demer JL. Rather, treatment for a secondary vertical deviation should aim to improve horizontal sensory and motor fusion through vision therapy so the patient is not in the strabismic position as often, thus eliminating the vertical deviation. Optom Vis Sci. Reproduction in whole or in part without permission is prohibited. What lesion location is likely in the presence of horizontal conjugate deviation of the eyes to one side? AJNR Am J Neuroradiol. Long-term follow-up and clinical features of the 2 groups were compared. Convergence Insufficiency Testing. unable to diverge appropriately to a given target. The remainder of the neurological examination should be normal, without any cranial neuropathies. I reviewed the medical records of patients with divergence insufficiency that I had evaluated from July 1987 through April 1999 in my neuro-ophthalmology practice at a single institution. From there, basic vergence exercises will be added in. ACSanders
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. Demer JL. A 5-year-old female initially presented for a strabismus and amblyopia evaluation. 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. 132.
Sagging Eye Syndrome - EyeWiki 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. Although successfully prescribing it can sometimes seem like a time-consuming and daunting task, the following tips can help you smoothly incorporate the use of prism for binocular vision conditions into your practice for the best outcomes. LBSharpe
Progressive supranuclear palsy.
Lewis
Accessibility Statement, Our website uses cookies to enhance your experience. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. 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. In many cases, individuals with convergence insufficiency will notice that their symptoms worsen as they get tired or after attempting to do near tasks for a prolonged period of time. Common symptoms include: headaches; blurred vision ; double vision 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. 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. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. Although each method has its advantages and disadvantages, they all suffer from being subjective. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. METraviesa
EDivergence insufficiency: characteristics, diagnosis, and treatment. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. 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. More advanced exercises for vergence insufficiencies include. 130. Cotter SA. Chaudhuri Z, Demer JL. divergence excess eyewikibc kutaisi vs energy invest rustavi. 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 . 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.