Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. AParalysis of divergence. This problem is most commonly found in children. FDDutton GMOcular divergence: its physiology and pathology. The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. Near point convergence is the distance you can use both eyes without seeing double. doi:10.1136/bjophthalmol-2015-306783. What is the cause of convergence spasm? DIVERGENCE insufficiency refers to a clinically defined acquired disorder of ocular horizontal version, characterized by full-appearing ocular ductions and comitant esotropia at distance. Clinical uses of prism: a spectrum of applications. RLMagnetic resonance images in a case of "divergence paralysis.". I doubt that assessment of the size of vertical fusion amplitude would be a helpful discriminating tool, however, since the size of it was small in most patients in both groups, it was measured using a subjective end point, and there was considerable overlap of values. [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. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. Abstract. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. Esodeviation is comitant in all fields of . In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. 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 . Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. 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. If no movement is seen on the unilateral cover test, the patient has normal correspondence. Reproduction in whole or in part without permission is prohibited. 130. AJNR Am J Neuroradiol. All but 1 patient were older than 50 years. Chaudhuri Z, Demer JL. Progressive supranuclear palsy. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. Simultaneous injury of the medial longitudinal fasciculus has been postulated as another reason sixth cranial nerve palsy may appear comitant.4 However, none of the patients classified as primary had clinical signs of internuclear ophthalmoplegia. J Neuroophthalmol. You can schedule your next appointment with us online! Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. Convergence insufficiency (CI) is a vision disorder. 2005;89(10):1318-23. Other training exercises include base-out prisms for near viewing and convergence exercises. A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. Graefes Arch Clin Exp Ophthalmol. 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. If the dot becomes doubled, go back to the previous dot and try again. 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. The most effective treatment for this condition is office-based vision therapy, but prism can be considered in patients who are unable to undergo this treatment modality.1,8 A study did not find a significant difference in the signs or symptoms of children with convergence insufficiency who wore base-in prism compared with children who wore placebo lenses.9 Although prism has not been shown to be beneficial in children with this condition, adult presbyopic patients with convergence insufficiency may benefit from prism treatment.10,11. GTDJohnston 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. Audio blog post. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). The distance at which diplopia occurs is noted (near point of convergence). Her research interests include strabismus and binocular vision disorders. JAAcquired esotropia due to Arnold-Chiari I malformation. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. What is the cause of convergence spasm? 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. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. Differentiating sagging eye syndrome (SES) from other causes of strabismus is not always a straight forward task given that patients with SES may have risk factors for strokes or tumors. ISOphthalmoplegia in cranial arteritis. 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. 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. "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. 2016. 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. NADivergence paralysis. EDivergence insufficiency: characteristics, diagnosis, and treatment. It is a disorder involving binocular vision vision using both eyes. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. The main treatment for convergence insufficiency is vision therapy. Tamhankar MA, Ying GS, Volpe NJ. What is congenital ocular motor apraxia? They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. DIdiopathic intracranial hypertension: a prospective study of 50 patients. Esotropia resolved within days of initiating corticosteroid treatment in both patients. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. Instead, the initial history and physical examination proved to be powerful tools to distinguish those patients with a primary disorder from those with an underlying neurologic or systemic (ie, secondary) cause of divergence insufficiency. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre-determined, i.e. The global layer of each rectus EOM, passes through the pulley and becomes contiguous with the tendon to insert on the globe. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. is variable. A Maddox rod was also used to determine the near point of orthophoria in most patients. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Classically convergence spasm is nonorganic. 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. They concluded that medial rectus recession is as effective as lateral rectus resection and suggested that double the distance angle of esotropia should be used as the surgical target. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or esotropia, meaning the eyes like to sit in an inward position. 131. Convergence Insufficiency. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. 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. 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. Other associated symptoms can include asthenopia of panoramic type. Drs. 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. New York, NY Oxford University Press1999;405-610. 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. Eight (40%) of the 20 patients recalled such an event, including a viral prodrome in 3 patients, minor head trauma in 2 patients, and hospitalization for an unrelated illness in 3 patients. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. 128. Prism can be a powerful treatment for many conditions and for many patients, specifically for those who suffer from asthenopia or diplopia. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. 127. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. J AAPOS. 134. Her cycloplegic retinoscopy was +3.00sph OD and +2.25sph OS. 12. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. The remainder of the neurological examination should be normal, without any cranial neuropathies. with a stereo image already pre-made onto the card. If a patient does not have good potential for sensory fusion, then the assistance that prism gives to the motor system wont allow for normal fusion, and it doesnt make sense to prescribe it. 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. 8. Chaudhuri Z, Demer JL. [5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. [12]Later Chaudhuri and Demer reported 24 patients and compared the results of those undergoing lateral rectus resection (n = 8) to those undergoing medial rectus recession (n = 16). I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. As a . 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. When you try to focus on something close to your eyes, you may have: Tired eyes. 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. This decreases the motor fusion demand, allowing the patient to fuse more comfortably. 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. Reproduction in whole or in part without permission is prohibited. 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. With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). 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. This page was last edited on January 26, 2023, at 08:42. 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. Lets continue the conversation over on your social network of choice. et al. 13. Of note among this cohort of patients without strabismus, noncontinuous LR-SR bands were found in 5% of cases, and superotemporal bowing in 24% of cases. Ductions and versions are full. 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. Similarly, the theories on mechanism of divergence itself have varied. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. The orbital layer, inserts on the pulley, not on the globe. Another historically reported feature of DI is significantly decreased negative fusional vergence (fusional divergence), along with the deficits direct relationship to distance of gaze. All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). Corresponding author: Daniel M. Jacobson, MD, Neuro-ophthalmology (4F-2), Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (email: jacobsod@mfldclin.edu). Tranaglyphs are similar to vectograms, however instead of there being two different transparent image cards that need to be fused into one, there is one image card with a stereo image already pre-made onto the card. unable to diverge appropriately to a given target. 129. The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. Many affected patients experience spontaneous resolution of double vision within several months. Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. Ghanchi 2013;97(11):1415-9. Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. If an intermittent horizontal strabismus patient has a primary vertical deviation, vertical prism may help improve their ability to fuse the horizontal deviation. Three patients with primary divergence insufficiency continued to have esotropia at the time of their last evaluation, although 2 had shown improvement. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. The mirror stereoscope is one of the most commonly used types. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. 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 . Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. 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. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? The other patient with focal brainstem injury, a stroke with double vision, vertigo, and left arm numbness, did not have the responsible lesion identified by the CT. Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. 2008;126(10):1336-49. 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. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. make average daily distance tasks more manageable with less frequent symptoms. 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.
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