Questions with answers: 125. 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. It is most often related to raised intracranial pressure or Chiari malformation. "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 Revisited: Natural History of Idiopathic Cases and Neurologic Associations. None of these patients underwent strabismus surgery. What is convergence spasm? Divergence insufficiency esotropia (DIE), originally described by Duane in 1896, is an acquired condition characterized by an esodeviation that measures at least 10 prism diopters (PD) greater at distant rather than near fixation [].Patients with DIE complain about double vision at distance. Wall
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. Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. 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. 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) 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. Their symptom was controlled using prisms. It is an unusual form of strabismus with esotropia and diplopia only at distance and single binocular vision at near. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. 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. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. Scheiman M, Cotter S, Rouse M, et al. In that study, strabismus surgery was performed in 50% of all SES cases. Barricks
[5], MRI measurements of horizontal EOM lengths in SES were approximately 40%, or 14 mm, longer than the EOMs of nonstrabismic younger and older controls. 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. ACSanders
All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). Schanzer
Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. Her research interests include strabismus and binocular vision disorders. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? To increase convergence, the two cards will be pushed inward, making the image smaller (Small In for the SI in SILO). [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. To begin therapy, many therapists will focus first on normalizing the accommodative system. use an approach called the SILO affect to work on increasing divergence or convergence ranges. 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. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. No such signs were identified in any of the patients in this series. Normalizing accommodation is important because the accommodative and vergence systems are tightly correlated. Similarly, the theories on mechanism of divergence itself have varied. It is most often related to raised intracranial pressure or Chiari malformation. While viewing the card, the patient reports what color line the black arrow is aligned with. 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. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. With exercises that adapt to each patient and their specific needs, it is an ideal solution for problems such as lazy eye, strabismus, convergence insufficiency, double vision, or other binocular problems. https://www.aao.org/interview/heavy-eye-vs-sagging-eye-syndrome, https://www.aao.org/audio/sagging-eye-syndrome, https://doi.org/10.1016/j.ajo.2019.09.006, https://eyewiki.org/w/index.php?title=Sagging_Eye_Syndrome&oldid=89033, Results from bilateral inferior shift of the LR pulleys, Characterized by esotropia at distance fixation, orthotropia or esophoria at near fixation, Normal horizontal duction range and normal horizontal saccadic velocities, Results from asymmetrical inferior shift of the LR pulley, Characteristically by hypotropia and excyclotortion of the lower eye, ARDE only: incomitant esotropia worse in distance and in side gaze with no strabismus or small phoria for near and, ARDE and CVS: incomitant esotropia with a small hypotropia in one side, CVS only: hypotropia with no horizontal deviation, Normal horizontal duction range, and normal horizontal saccadic velocities, Cranial nerve palsy (Third, Fourth or Sixth nerves). The EOM angles in these patients ranged from 100 to . Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. Prescribing relieving prism for horizontal, non-strabismic, binocular vision disorders can be done by calculating Sheards or Percivals criteria by using clinical data or analyzing fixation disparity and determining the associated phoria.1 At near, fixation disparity and the associated phoria can be found with a Wesson card. of negative and positive fusional vergence. The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. Convergence Insufficiency Testing. 1993, Oxford, UK: Butterworth Heinemann Books. 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. is variable. Pencil pushups may be effective in some cases. I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. 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 . Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. 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. 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. She had been previously diagnosed with esotropia and amblyopia but was not currently wearing any correction. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. LDivergence insufficiency. R. London. 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. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. 2013;97(11):1415-9. 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. 9. Krohel
All patients with double vision routinely were assessed for the speed of saccades and for the presence of nystagmus to identify signs of abducens nerve palsy or internuclear ophthalmoplegia. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. Vertical Heterophoria. 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. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. 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. Chamlin
133. What lesion location is likely in the presence of horizontal conjugate deviation of the eyes to one side? characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. None of the patients initially classified as having primary divergence insufficiency developed additional neurologic dysfunction during the period of follow-up. Abstract. Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. 1. 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. 4. Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. Lyle
The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). The first hurdle is ensuring your patient is comfortable with wearing spectacles. 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. [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). Long-term follow-up and clinical features of the 2 groups were compared. A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. More respect for connective tissues. American Academy of Ophthalmology. MDavidoff
The remainder of the neurological examination should be normal, without any cranial neuropathies. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? JSLevy
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). Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. Convergence Insufficiency Testing. In addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. It is very a common condition where there is a comitant exotropia greater at near than at distance by at least 10 prism diopters. 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.