This recommendation is based on the small size of the study population, the problems inherent in a retrospective investigation, and the grave consequences of failing to identify other neurologic signs. Convergence Insufficiency. 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. 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. Terms of Use| 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}. Diagnosing convergence insufficiency Bender
Reproduction in whole or in part without permission is prohibited. Divergence excess is an over-divergence when attempting to look at distant objects. 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 period of time. A 5-year-old female initially presented for a strabismus and amblyopia evaluation. Visual loss in pseudotumor cerebri: follow-up of 57 patients from five to 41 years and a profile of 14 patients with permanent severe visual loss. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. 2016 May; 100(5): 648651. PJThompson
Retrospective survey of patients with divergence insufficiency. 8 (89%) had successful with postoperative vertical alignment and 4 (50%) were successfully corrected, with <5 of cyclotorsion postoperatively. Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. J AAPOS. Common symptoms include: headaches blurred vision double vision eye strain or fatigue sore or watery eyes after a near or far task Long-term follow-up and clinical features of the 2 groups were compared. Wednesday, March 15, 2023 | All Eyes On Evaporation, Thursday, April 13, 2023 | All Eyes On Evaporation, Tuesday, April 18, 2023 | All Eyes On Evaporation. Other associated symptoms can include asthenopia of panoramic type. Convergence and Divergence - Vivid Vision 2012;95(2):192-7. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. Patients with constant strabismus may need corrective prism, or an amount of prism that completely neutralizes their strabismus, in order to obtain good levels of fusion. Br J Ophthalmol. Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place. Br J Ophthalmol. Between the polarizing glasses and the patients fusional vergence system, he or she will be asked to either converge or diverge to fuse the two partial images into one 3-D image. 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. 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. 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. Convergence insufficiency (CI) is a vision disorder. It was found that the mean distance-esotropia deviation in Prism was 6.9 0.7 and it resolved to 0.3 0.3 after surgery, while mean vertical deviation went from 3.0 0.3 to 0.7 0.2. The association with refractive errors (and high myopia in particular) has been a point of contention for some time. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. These arguments do not preclude the possibility that some patients with comitant esotropia at distance and full-appearing ocular ductions might be suffering from sixth cranial nerve palsy, not divergence insufficiency. 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. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. Another method used for prescribing for patients with intermittent strabismus, particularly for those who have difficulty with fusion in free space, is Calorosos Residual Vergence Demand (RVD).7 RVD criteria look at the direction and size of the deviation and determine how much residual vergence demand the patient should have after prescribing relieving prism. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. 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. Effectiveness of base in prism for presbyopes with convergence insufficiency. There are many different ways to do this, but the best method to use depends on the type of binocular vision disorder for which you are prescribing. 2016. 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. Convergence insufficiency is a common problem with the eyes, and is the main culprit behind eyestrain, blurred vision, and headaches. Strabismus. No such signs were identified in any of the patients in this series. To determine the natural history of primary divergence insufficiency and to identify clinical features that distinguish patients with this neurologically isolated form of divergence insufficiency from those harboring neurologic disorders. What lesion location is likely in the presence of horizontal conjugate deviation of the eyes to one side? This page was last edited on January 26, 2023, at 08:42. Prescribing for some patients with intermittent strabismus can be done by using Sheards or Percivals criteria or determining the associated phoria as with heterophoric patients. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). Nonparetic Diplopia - EyeWiki Neuro-ophthalmology Illustrated Chapter 13 Diplopia 10 - Convergence 2000;118(9):12371241. Methods
Tamler
. The opposite of divergence insufficiency is divergence excess. GNCurrent concepts in giant cell (temporal) arteritis. Other patients without known neurologic disorder (eg, midbrain metastasis) were referred to evaluate double vision. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. Biousse V and Newman NJ. RDInternuclear ophthalmoplegia in giant cell arteritis. Recent trauma These exercises were discussed in detail in Part 6 of this series. 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 . 2012;130:12801284. Pang Y, Teitelbaum B, Krall J. In normal cases, the ocular axis length was 23.5 1.0 mm. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. 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. Arch Ophthalmol. 2011;31(3):206-9. The remainder of the neurological examination should be normal, without any cranial neuropathies. In that study, strabismus surgery was performed in 50% of all SES cases. Diplopia following cataract surgery: a review of 150 patients Posted by . The use of topical anaesthesia does not abolish this surgical risk. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. Antireflective coating is also beneficial for patients wearing prism lenses. People notice symptoms while reading or doing other near work. 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. The patient places two transparent cards into the vectogram system. 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. Diplopia at Distance in Older Patients: Is It Sagging Eye Syndrome? Trans Am Ophthalmol Soc. Divergence insufficiency can vary in severity, from minor deficits to complete divergence paralysis. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Kirkham
Pencil pushups may be effective in some cases. Jampolsky
Divergence Insufficiency: An Ongoing Challenge - Review of Ophthalmology In the 17 patients with primary divergence insufficiency who had adequate information to ascertain long-term follow-up, double vision persisted in 9 individuals. During a follow-up examination three months later, the patient noted increased comfort and resolved diplopia and headaches while wearing the Fresnel prism. 2023 Stanford School of Medicine | Terms of Use | Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. JJSavino
New York, NY Oxford University Press1999;405-610. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. Tamhankar MA, Ying GS, Volpe NJ. J AAPOS. Through her full plus spectacles, she still had a 14 PD constant right esotropia and a 2 PD constant right hypotropia. The patient with divergence insufficiency presents himself complaining of double vision for distance, which increases with distance. Barricks
[5] Initially, most patients only notice intermittent binocular diplopia at long distances, such as in the theater or while driving. 2012. JAAcquired esotropia due to Arnold-Chiari I malformation. 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. Her cover test revealed a 25 PD constant right esotropia with a 2 PD constant right hypotropia. It can also decrease distance judgement, coordination, and sports performance. What are causes of convergence insufficiency? To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). How to test convergence eyes | Math Index Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. This problem is most commonly found in children. She had been previously diagnosed with esotropia and amblyopia but was not currently wearing any correction. [5] In addition, patients may have had eyelid surgery, face lifting,[6] or even apparently uncomplicated refractive or cataract surgery.[6][8]. Customize your JAMA Network experience by selecting one or more topics from the list below. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. 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. In divergence insufficiency, one or both eye(s) are unable to diverge appropriately to a given target. 2012. In many individuals with, Normalizing accommodation is important because. along with the fusional vergence system to create a 3-D object. Moore
J Pediatr Ophthalmol Strabismus. What Are the Symptoms of Convergence Insufficiency? Certain factors are associated with exotropia, including genetics and health conditions. 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. Eye - Diplopia following cataract surgery . These patients often present with horizontal and vertical deviations. 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. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. 129. The remaining 6 patients with secondary divergence insufficiency had symptoms and obvious signs of intracranial hypertension (eg, papilledema) (Table 2). 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. Bedrossian
Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). 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. Exercises for double vision: 4 things to try - Medical News Today 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) Lyle
Long-term follow-up and clinical features of the 2 groups were compared. The difficulty of training vertical vergence ranges along with the success in treating vertical deviations with prism make prism the most appropriate initial management tool in these patients. From a practical point of view, it seems reasonable to defer further investigation, including neuroimaging, in an affected patient who has no other neurologic or systemic symptoms or 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. DOI: Demer JL. None of these patients developed signs of an underlying neurologic disorder during follow-up. Divergence insufficiency can also result in headaches, motion sickness and sensitivity to bright lights. Prism is a powerful tool that can be used to successfully treat a variety of binocular vision conditions. 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. 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. Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. All Rights Reserved. 632. An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. 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. The cyclotorsion component of SES was present in 65% of patients. 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] if you would like to learn more about convergence and divergence insufficiency. Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. 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. 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. 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. How is convergence insufficiency treated? GTDJohnston
unable to diverge appropriately to a given target. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. It is possible that with longer follow-up, the number of patients with resolution of diplopia might increase. Six patients underwent CT and 10 underwent MRI. As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. 130. 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. J Neuroophthalmol. Divergence excess is an over-divergence when attempting to look at distant objects. This ocular misalignment has two main types: esotropia and exotropia. Of the 20 patients with primary divergence insufficiency, 19 (95%) were older than 50 years. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying Different cards with different images will require different amounts of negative and positive fusional vergence. 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. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and help make average daily distance tasks more manageable with less frequent symptoms. While viewing the card, the patient reports what color line the black arrow is aligned with. Divergence Insufficiency Revisited: Natural History of - JAMA The orbital layer, inserts on the pulley, not on the globe. 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. Graefes Arch Clin Exp Ophthalmol. . Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. NRNewman
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. Divergence insufficiency associated with high myopia | OPTH 10. Surgical effect was assessed immediately by sitting the patient up and repeating the measurements at near and distance. If the dot becomes doubled, go back to the previous dot and try again. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. Although cosmesis can be an issue with prism glasses, educating your patients on proper frame and lens selection will help them choose a frame and lens combination for the best cosmetic outcome. 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. Divergence Insufficiency/Excess | Vision Therapy Paducah Kentucky Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. Progressive supranuclear palsy. Godts D, Mathysen DG. [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. Esodeviation is comitant in all fields of . 132. 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. Abstract. JSLevy
131. 128. I still have mild double vision and . The procedure is performed under topical anesthesia in the presence of an anesthesiologist. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. In the remaining 17 patients who were still alive, the total duration of follow-up extended from 1 month to 16 years (median, 35 months). RJZee
Diplopia Developed in Later Life, An Ophthalmologic Approach A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. Convergence describes the way our eyes move together and point inward when we look at near objects. 13.120). 2014;18(4):309-15. 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. PCBurian
2009;86(2):153-6. A person with divergence insufficiency may have double vision at a distance, which mainly occurs with severe exhaustion and fatigue. Introduction. Common symptoms include: headaches; blurred vision ; double vision DIVERGENCE INSUFFICIENCY - Optography Convergence Insufficiency - American Academy of Ophthalmology Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. 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. Retrospective survey of patients with divergence insufficiency. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy? To determine the natural history of primary divergence insufficiency and to identify clinical features that distinguish patients with this neurologically isolated form of divergence insufficiency from those harboring neurologic disorders. 2018 Jan 3:1-5. doi: 10.1080/09273972.2017.1421676. JWStockbridge
In addition, all patients underwent examination of ocular motility using a Maddox rod to demonstrate that the angle of uncrossed deviation increased as the viewing distance increased, remained the same or decreased in right and left gazes at distance, and decreased as the viewing distance decreased. Chang MY, Pineles SL, Velez FG. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. Questions: 125. 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. 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. Thomson
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. Fresnel membrane prisms can be very useful for many aspects of prescribing prism. Heavy eye syndrome versus sagging eye syndrome in high myopia. No clear sex predilection has been identified for the primary form of the condition. American Journal of Ophthalmology, Volume 209, January 2020, Pages 55-61. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. [1][5][8] The patients may also present with bilateral ptosis. Reference: 1. Long-term Surgical Outcomes in the Sagging Eye Syndrome. On initial presentation, her best-corrected visual acuities were 20/40 OD and 20/25 OS. Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. From there, basic vergence exercises will be added in. One patient was followed up for only 1 month, but her esotropia resolved during that time. an electromyographic study. Convergence Insufficiency/Vision Therapy - Eye Docs For Kids 132. Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. Chamlin
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.