What Are the Symptoms of Convergence Insufficiency? American Academy of Ophthalmology. The diverse conditions and sites of associated lesions of the patients with secondary divergence insufficiency in this series imply that secondary divergence insufficiency is not particularly localizing, nor is it necessarily specific for intracranial hypertension. If no movement is seen on the unilateral cover test, the patient has normal correspondence. EJampolsky et al. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. Goldberg Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. 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. The preferred method for prescribing prism for vertical heterophoria is determining the vertical associated phoria.12 This can be done at near using the Wesson card or at distance. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. Convergence Insufficiency Testing. Patients who wear contact lenses the majority of the time or who have undergone refractive, cataract or strabismus surgery may not be happy with the idea of moving or going back to spectacle wear even if it relieves asthenopia or diplopia. If the dot becomes doubled, go back to the previous dot and try again. What is convergence spasm? What is congenital ocular motor apraxia? 3rd ed. This decreases the motor fusion demand, allowing the patient to fuse more comfortably. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. 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 . 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. No such signs were identified in any of the patients in this series. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. Heavy Eye vs. Lepore 2023 Stanford School of Medicine | Terms of Use | Double vision, eye strain, blurred vision, fatigue, headache, dizziness and pain around the eye are common signs and symptoms between the two conditions. Clin Exp Optom. In some circumstances, individuals with convergence insufficiency will also suffer from high exophoria or, 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. is variable. 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. Methods Call our optometrists at 302-299-1286 or. Wiggins Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. SDiagnosis and management of divergence weakness in adults. While viewing the card, the patient reports what color line the black arrow is aligned with. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. 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. This problem is most commonly found in children. All Rights Reserved. Biousse V and Newman NJ. Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. 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. 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. More respect for connective tissues. Bedrossian However, the cause of convergence insufficiency is often unknown. Increasing or decreasing the distance between the two cards 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. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. 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. 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. Six patients underwent CT and 10 underwent MRI. 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. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. Chang MY et al. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. 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. Demer JL. Prism in reading glasses or strabismus surgery may be required. EHBilateral sixth-nerve paresis simulating divergence paralysis. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. What is convergence insufficiency? It can also decrease distance judgement, coordination, and sports performance. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. Weird vision divergence upon waking at night User Name: Remember Me: Password . Theme. Patients will be able to work on fusing the images of one. J Neuroophthalmol. NParalysis of divergence. 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. 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. Clinical management of strabismus. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. Divergence excess is an over-divergence when attempting to look at distant objects. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. When their medical records were reviewed at the time this study was being designed, I learned that they had since died of unrelated illnesses, so the course of their disorder could not be completely ascertained. 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. Sagging eye syndrome rarely gives a deviation of more than 10 PD (Prisms Deviation) [5]. What are causes of convergence insufficiency? What is convergence spasm? Krohel Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. A 5-year-old female initially presented for a strabismus and amblyopia evaluation. [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. The association with refractive errors (and high myopia in particular) has been a point of contention for some time. Patients with non-strabismic binocular vision disorderssuch as divergence insufficiency, basic esophoria and vertical heterophoriacan often benefit from treatment with prism, particularly relieving prism, while othersincluding those with convergence excess, convergence insufficiency, divergence excess or basic exophoriaare better managed with other treatment modalities, such as vision therapy or lenses.1 An option for prism patients is prescribing prism to relieve diplopia and asthenopia and concurrently having the patient do vision therapy to attempt to decrease or eliminate the amount of prism needed. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. Define divergence insufficiency. if you would like to learn more about convergence and divergence insufficiency. All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). On the other hand, it remains possible that these events were casual and not pathogenetically important. The main treatment for convergence insufficiency is vision therapy. 2005;9:36. Retrospective survey of patients with divergence insufficiency. 4. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Lets continue the conversation over on your social network of choice. Distance esotropia in the elderly. It is a disorder involving binocular vision vision using both eyes. with a stereo image already pre-made onto the card. 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 . Her medical history was unremarkable, and her ocular history was remarkable only for low myopia, for which she wore glasses. 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. Tamhankar MA, Ying GS, Volpe NJ. 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 radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. Progressive supranuclear palsy. Fresnel membrane prisms can be very useful for many aspects of prescribing prism. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. Demer JL et al. 2016. ACSanders Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. In some circumstances, individuals with convergence insufficiency will also suffer from high exophoria or exotropia, meaning the eyes like to sit in an outward position. Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. JJSavino This means the eyes do not like to move inward toward the nose and is problematic when trying to look at a near target. [2] 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. 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. RTOcular muscle paresis and cranial arteritisan unusual case. It is very a common condition where there is a comitant exotropia greater at near than at distance by at least 10 prism diopters. Accessibility Statement, Our website uses cookies to enhance your experience. Terms of Use| Jampolsky Long-term follow-up and clinical features of the 2 groups were compared. 128. Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. After a preliminary prescription of fusion prism is determined, it is recommended that you trial frame the patient and have them look around to see if they experience any diplopia when viewing objects in the room. 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. To increase convergence, the two cards will be pushed inward, making the image smaller (Small In for the SI in SILO). With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. JLSharpe What causes divergence insufficiency? p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 10.0px Sabon} p.p2 {margin: 0.0px 0.0px 0.0px 0.0px; text-indent: 10.0px; line-height: 12.0px; font: 10.0px Sabon} p.p3 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #867245; min-height: 12.0px} p.p4 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #b87c4c} p.p5 {margin: 0.0px 0.0px 0.0px 0.0px; line-height: 12.0px; font: 12.0px 'Helvetica Neue'; color: #b37749} span.s1 {letter-spacing: -0.2px}. Certain factors are associated with exotropia, including genetics and health conditions. 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 . 133. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. As a . LMDivergence paralysis with increased intracranial pressure: further observations. Biousse V and Newman NJ. 126. Reproduction in whole or in part without permission is prohibited. The mirror stereoscope is one of the most commonly used types. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. Effectiveness of base in prism for presbyopes with convergence insufficiency. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. FEDivergence paresis: a nonlocalizing cause of diplopia. To prevent double vision, the individual exerts extra effort to make the eyes turn back in. Pencil pushups may be effective in some cases. Kirkham The eyes deviate horizontally toward a cortical lesion, the eyes deviate horizontally away from a cortical seizure focus, and the eyes deviate horizontally away from a pontine lesion. Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. What is divergence insufficiency? 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. 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. Convergence Insufficiency Testing. Our eye doctors. The remainder of the neurological examination should be normal, without any cranial neuropathies. Sensory Anomalies. Customize your JAMA Network experience by selecting one or more topics from the list below. Thomson Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, 2000;118(9):1237-1241. doi:10.1001/archopht.118.9.1237. At the follow-up examination, she reported no diplopia in her glasses, and, eventually, she was able to see 250 seconds of arc RDS stereoacuity. All patients with primary divergence insufficiency had been specifically asked whether their double vision was preceded by a specific event. Although small amounts of vertical prism can be prescribed in contact lenses, patients who need prism usually have to wear it on a spectacle lens. Rutkowski In 2015 Chaudhuri and Demer published a retrospective observational study about utilizing Graded Vertical Rectus Tenotomy (GVRT) for treating incomitant vertical misalignment. Only 2 patients were followed up for less than 6 months. Before settling on a final prism prescription, it is often helpful to trial frame the amount of prism you are about to prescribe to ensure that it will help you achieve your goals. The disorders associated with the 15 patients with secondary divergence insufficiency are listed in Table 2. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. [10] In 2013, Stager et al. A secondary vertical deviation, on the other hand, presents when the patients eyes are strabismic but disappears when the patient aligns their eyes to the ortho position.7 Secondary vertical deviations are common in strabismic patients, particularly in those with intermittent exotropia.