To begin therapy, many therapists will focus first on normalizing the accommodative system. [10] In 2013, Stager et al. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. Another historically reported feature of DI is significantly decreased negative fusional vergence (fusional divergence), along with the deficits direct relationship to distance of gaze. 1978;76:610-53. Intermittent convergence Always with accommodation and pupillary constrictionClassic causes of convergence spasm include the following: Most often nonorganic Excessive accommodation from uncorrected refractive error Lesions at the diencephalicmesencephalic junction (very rare)Convergence InsufficiencyConvergence insufficiency is a very common condition, characterized by the following: Exotropia greater at near than at distance (at least 10 prism diopters difference) Causes symptoms of asthenopia (fatigue with reading, diplopia at near, intermittent blurred vision when reading) Usually benign; may improve with orthoptic exercises Sometimes requires prisms in reading glasses or strabismus surgeryClassic causes of convergence insufficiency include the following: Idiopathic most often (in children or young adults) Head trauma Parkinson disease Progressive supranuclear palsyThe ability to converge can be measured (Fig. Convergence insufficiency is a common problem with the eyes, and is the main culprit behind eyestrain, blurred vision, and headaches. 132. Goldberg 8. Pencil pushups may be effective in some cases. To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. Keep moving to the next dot along the card, gradually getting closer to the nose. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. All Rights Reserved. Arch Ophthalmol. Also found significant displacement of all four rectus pulleys away from the orbital center, lateral displacement of the inferior rectus pulley and obliquely angulated lateral rectus pulley. Retrospective case reviews of patients with an acquired hyper deviation secondary to a superior oblique palsy found that 76% to 92% of participants were successfully treated with prism alone.5,6. Chaudhuri Z, Demer JL. 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. published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. It involves a specialty optical system and a uniquely created image book. 131. Strabismus. 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 . 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. 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. In 2015 Chaudhuri and Demer published a retrospective observational study about utilizing Graded Vertical Rectus Tenotomy (GVRT) for treating incomitant vertical misalignment. 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. Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. If the patient gives a fusion response with or without prism but movement on the unilateral cover test is seen, then anomalous correspondence is suspected and relieving or corrective prism is not an appropriate management option. The Apt Lecture. It is most often related to raised intracranial pressure or Chiari malformation. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. The orbital layer, inserts on the pulley, not on the globe. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. 134. American Academy of Ophthalmology. The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. 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) The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. What is congenital ocular motor apraxia? created image book. Since true paralysis of divergence generally cannot be documented in most affected patients,4 I prefer the term divergence insufficiency to describe this disorder, regardless of the severity of associated symptoms and signs. The patient will wear a pair of polarizing glasses (similar to what is worn in modern 3-D movies) to create depth within the image (stereopsis). AOcular divergence mechanisms. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. JAAcquired esotropia due to Arnold-Chiari I malformation. It is a disorder involving binocular vision vision using both eyes. At the follow-up examination after nine weeks of patching and vision therapy for amblyopia, her visual acuities were equal in both eyes, and all testing showed normal correspondence. American Journal of Ophthalmology, Volume 209, January 2020, Pages 55-61. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. 2014;35(9):1830-5. Home Vision Therapy Convergence Insufficiency Testing. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Actually it's not synonymous with divergence paralysis, but it is a separate clinical entity 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. make average daily distance tasks more manageable with less frequent symptoms. Most pertinent from a clinical point of view is the controversy surrounding whether divergence insufficiency is a distinct entity, or is a sign of subtle abducens nerve palsy. 11. [1][5][8] The patients may also present with bilateral ptosis. 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. 133. Convergence Insufficiency Testing. Divergence excess is an over-divergence when attempting to look at distant objects. Results from this study also supported previously published evidence of normal age-related connective tissue degeneration as there was a positive age effect in correlation to supero-temporal bowing of the LR-SR band.[9]. Other associated symptoms can include asthenopia of panoramic type. What is convergence spasm? When looking at the image on the card, patients will be required to use their fusional vergence system to fuse the red and green images into one 3-D image. Progressive supranuclear palsy. 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 . Divergence Insufficiency. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. This problem is most commonly found in children. A common a daily, home rehabilitation technique is to have the patient do push-up exercises (looking at an object intermittently moved in and out from the bridge of the nose) to decrease the near point of convergence. BBordaberry If the patient is still symptomatic, combining prism and vision therapy may help improve convergence and divergence ranges. 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. Diagnosing convergence insufficiency Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). 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. 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. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. After these patients are evaluated for any underlying systemic or neurological disease, which must always be ruled out in any case of new-onset strabismus, they are often good candidates for a prism prescription. DOI: Demer JL. 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. Chamlin Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. . Strabismus. 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. Lim Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. Divergence Insufficiency Revisited: Natural History of Idiopathic Cases and Neurologic Associations | Neurology | JAMA Ophthalmology | JAMA Network ObjectivesTo determine the natural history of primary divergence insufficiency and to identify clinical features that distinguish patients with this neurologica [Skip to Navigation] Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task NRNewman Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. Smith 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. Introduction. Chaudhuri Z, Demer JL. An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. 10. Magnetic resonance imaging resolution showed superotemporal bowing of the LR-SR band in milder cases and abrupt termination of an attenuated band remnant in the superolateral orbit in more severe cases. 2000;118(9):1237-41. If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. Their symptom was controlled using prisms. Jacobson DM. The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Typically, patients note that they do not have any diplopia at near. Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. Moller It is usually benign. What is the cause of convergence spasm? 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. 131. 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. This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. Terms of Use| However, the cause of convergence insufficiency is often unknown. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Prism can be a powerful treatment for many conditions and for many patients, specifically for those who suffer from asthenopia or diplopia. 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. This combined with the success of prism treatment in patients with divergence insufficiency makes prescribing prism the ideal initial treatment for this condition. Biousse V and Newman NJ. 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. The patient is also instructed to keep the words around the lines clear to control accommodation. Lepore Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. PMDivergence paralysis. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. HS In many individuals with, Normalizing accommodation is important because. 132. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Committee on Aging. RLMagnetic resonance images in a case of "divergence paralysis.". Accordingly, I would recommend deferring consideration of strabismus surgery in this population for a sufficiently prolonged period of time to determine whether the esotropia might resolve spontaneously. NADivergence paralysis. use an approach called the SILO affect to work on increasing divergence or convergence ranges. 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. 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. Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. I prescribed glasses (+3.00 sph OD, +2.25 sph OS) for the patient, and she returned for follow-up care, eventually patching and undergoing vision therapy for her amblyopia. It is an unusual form of strabismus with esotropia and diplopia only at distance and single binocular vision at near. Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. enlisted 100 patients without strabismus, and readers graded the LR-SR band visible in 95% of orbits on non-fat-suppressed coronal T1-weighted sequences, 68% on coronal STIR sequences.