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Different cards with different images will require different amounts of negative and positive fusional vergence. This period included the duration of diplopia prior to the first evaluation in addition to the duration of diplopia until either resolution of it or until the last follow-up evaluation. Lyle The SR was chosen when hypertropia was greatest in sursumversion or absent in infraversion. AJNR Am J Neuroradiol. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. 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. J AAPOS. Only 2 patients were followed up for less than 6 months. 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. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. 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. [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). 128. Repka MX and Eric Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. Mosbys Optometric Problem Solving Series, ed. Optom Vis Sci. ALDemer Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. Her research interests include strabismus and binocular vision disorders. 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. The use of topical anaesthesia does not abolish this surgical risk. Pencil pushups may be effective in some cases. 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. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. Methods To begin therapy, many therapists will focus first on normalizing the accommodative system. Fresnel prism, however, degrades visual acuity and contrast sensitivity, and some patients may not find it cosmetically appealing.12 A significant decrease in visual acuity through the Fresnel lens can be seen at larger prism powers, particularly at those greater than 12 PDs.13 When trialing Fresnel prism, it is advisable to only place the Fresnel over one eye so that the patient retains good binocular visual acuity with the prism in place. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. How is convergence insufficiency treated? EDivergence insufficiency: characteristics, diagnosis, and treatment. J AAPOS. Chaudhuri Z, Demer JL. 133. With a trial frame, she was not able to appreciate RDS stereoacuity in-office. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. Biousse V and Newman NJ. Jacobson DM. The mechanical properties of pulleys are critical for the support and rotational properties of the eye. 129. 2000;118(9):1237-41. 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. 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. 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. Chang MY, Pineles SL, Velez FG. 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. DRHartnett Posted by . While viewing the card, the patient reports what color line the black arrow is aligned with. 2023 Stanford School of Medicine | Terms of Use | Although ophthalmoplegia associated with temporal arteritis has been rarely attributed to brainstem23 or ocular motor nerve injury,24 most cases are thought to result from extraocular muscle ischemia.25,26 The association of divergence insufficiency and temporal arteritis in these 2 cases emphasizes that the diagnostic signs of this ocular motor disturbance are not localizing and could occur in other disorders associated with local injury of extraocular muscles, such as myasthenia gravis, as was identified in 1 of the patients of Lepore.15, Divergence insufficiency was observed in 4 patients with pseudotumor cerebri. 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). 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. If the patient is still symptomatic, combining prism and vision therapy may help improve convergence and divergence ranges. 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. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. 2008;126(10):1336-49. Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. Divergence excess is an over-divergence when attempting to look at distant objects. Distance esotropia in the elderly. et al. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. 2000;118(9):12371241. Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. DJDivergence insufficiency. Demer JL. The most successful prism cases are often patients who have intermittent strabismus and good potential for normal fusion or patients with strabismus who have not developed any sensory anomalies. is fixed. 2012. Sagging Eye Syndrome. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. A 5-year-old female initially presented for a strabismus and amblyopia evaluation. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. Symptoms of vergence disorders occur only under binocular viewing conditions and may include eyestrain, double vision and headaches.4,7,9,10,15 Interventions: Vision Training Many TBI patients respond well to efforts to improve vision, cope with impairment, or both. In this example, the patient will be asked to either relax his or her eyes to put the lion in the cage (diverge) or stimulate his or her eyes to put the lion in the cage (converge). What is convergence insufficiency? Wall Since most of the patients have good fusional capacities they do not experience double vision for near with that said these patient can likely manage without the need for intervention. Schanzer 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. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. The tool itself can be calibrated to work on increasing divergence or convergence, depending on, Our eye doctors at Wilmington Family Eye Care in Wilmington, DE excel in prescription of glasses, contact lenses and the diagnosis of a variety of eye diseases. Although this seems like a very basic requirement for prism use, it can present an obstacle if not done appropriately or at all. DOI: Demer JL. 11. Chaudhuri Z, Demer JL. NParalysis of divergence. In 2005 Thacker NM et al. Chaudhuri Z, Demer JL. AOcular divergence mechanisms. The two prevalent hypotheses put forth so far include altered cerebrospinal fluid flow in the posterior cranial fossa, and involvement of the abducens nucleus or infranuclear portion. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. 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 and Divergence The only way to diagnose CI is with an eye exam 1. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. Horizontal conjugate deviation of the eyes may be found with acute lesions of either hemisphere or the brainstem. Interestingly, they found that the relative proportion of SES was just 4.7% in patients younger than 50 years but it increased to 60.9% in patients older than 90. 2023 American Medical Association. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). J Pediatr Ophthalmol Strabismus. Motion sickness or dizziness ( vertigo) Headache . Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. PMDivergence paralysis. Eye - Diplopia following cataract surgery . [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. Diagnosing convergence insufficiency METraviesa Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. The remainder of the neurological examination should be normal, without any cranial neuropathies. 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. These exercises were discussed in detail in Part 6 of this series. Define divergence insufficiency. Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. All Rights Reserved. Bothun and Archer reported a series of 8 patients who underwent bilateral medial rectus recessions for distance esotropias of 1235; 5 patients had satisfactory results with collapse of the distance-near deviation from 15 pre-operatively to 5 postoperatively. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. the amount of convergence or divergence needed to fuse the image depends, upon how far apart the two cards are held, . Cunningham The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. To increase convergence, the two cards will be pushed inward, making the image smaller (Small In for the SI in SILO). 1995, St. Louis, Missouri: Mosby. RTOcular muscle paresis and cranial arteritisan unusual case. 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. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. 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) unable to diverge appropriately to a given target. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? 132. It produces symptoms of asthenopia, fatigue with reading, diplopia at near, and intermittent blurred vision when reading. Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. Thomson PJThompson The LR-SR band vertically supports the LR pulley against the downward force of the inferior oblique muscle to maintain the LR pulleys vertical position. It is idiopathic most often in children or young adults 2. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. Bruce Then, a horizontal prism bar was used to place increasing strengths of base-in prism over the other eye until fusion could no longer be maintained, as assessed subjectively using a distant target for fixation. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. Six patients underwent CT and 10 underwent MRI. Many affected patients experience spontaneous resolution of double vision within several months. Convergence Insufficiency. JAAcquired esotropia due to Arnold-Chiari I malformation. Many of these patients had an established underlying disorder (eg, cerebellar degeneration) and were referred because of double vision. [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). It is also possible that the 3 patients who died and did not undergo long-term follow-up had some unsuspected neurologic disorder at the time they were evaluated. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. 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. To prevent double vision, the individual exerts extra effort to make the eyes turn back in. It may be seen with excessive accommodation from uncorrected refractive error and very rarely with lesions at the diencephalicmesencephalic junction. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. 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. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. However, it seems unlikely, since divergence insufficiency resolved in all 4 patients and no other neurologic problems developed during the time of each patient's follow-up of 1 month, 5.5 months, 34 months, and 44 months, respectively. In the 2 patients with temporal arteritis, the rapid resolution of esotropia coincident with initiation of corticosteroid treatment, along with the development of posterior ischemic optic neuropathy in 1 case, point to ischemic injury of extraocular muscles as the cause of ophthalmoplegia. JAInman The distance at which diplopia occurs is noted (near point of convergence). If the eyes do drift out, the person is likely to have double vision. JLSharpe 1993, Oxford, UK: Butterworth Heinemann Books. Roper-Hall The patient is also instructed to keep the words around the lines clear to control accommodation. Methods: We investigated 20 cases of high myopia (>-6 D) with divergence insufficiency, 20 cases of high myopia without double vision, and 10 normal cases as controls. None of these patients underwent strabismus surgery. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. [1][5][8] The patients may also present with bilateral ptosis. GTDJohnston Convergence Insufficiency Testing. 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. In 2015 Chaudhuri and Demer published a retrospective observational study about utilizing Graded Vertical Rectus Tenotomy (GVRT) for treating incomitant vertical misalignment. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Esotropia resolved within days of initiating corticosteroid treatment in both patients. 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.