What is convergence insufficiency? Diplopia following cataract surgery: a review of 150 patients The author has no commercial or proprietary interest in any product or company mentioned in this manuscript, and has no financial interest nor receives payment as a consultant, reviewer, or evaluator. Long-term follow-up and clinical features of the 2 groups were compared. 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. Their patients all had satisfactory results, with no patients initially over-corrected or requiring additional prisms. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. Divergence insufficiency is the opposite problem, accommodation will be worked on first to ensure it is equal between the two eyes, basic vergence exercises will be added in. During the total period of follow-up, none of the patients developed an alternative neurologic disorder. Vision suppression stops you from seeing double, but it doesn't fix the problem. In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Bothun ED, Archer SM. 10. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. Different cards with different images will require different amounts of negative and positive fusional vergence. GNCurrent concepts in giant cell (temporal) arteritis. This decreases the motor fusion demand, allowing the patient to fuse more comfortably. 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. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. 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. What is convergence spasm? 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 opposite of divergence insufficiency is divergence excess. 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. 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. While viewing the card, the patient reports what color line the black arrow is aligned with. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Smith The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. 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. Extraordinary symptoms equivalent to diplopia 2.3.1. DSDiagnosis of Central Disorders of Ocular Motility: The Neurology of Eye Movements. No signs of orbital ischemia were present in the second patient. et al. Accessibility Statement, Our website uses cookies to enhance your experience. Primary divergence insufficiency is generally a benign condition. Common symptoms include: headaches; blurred vision ; double vision MEBarrows Tamler 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. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. [3], from 945 patients complaining of double vision, majority of patients between 60 and 80 years, approx 31% had SES and were older, ~71 years old, with ~60% female predominance. With CI, the eyes do not point together inward as one looks at objects close-up. 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. 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}. ACSanders Chang MY, Pineles SL, Velez FG. 2014;18(4):309-15. Actually it's not synonymous with divergence paralysis, but it is a separate clinical entity The Apt Lecture. While none of the patients had other symptoms to suggest giant cell arteritis or myasthenia gravis, erythrocyte sedimentation rate (performed in 7 patients) and acetylcholine receptor antibody assay (performed in 6 patients) were tested, and the results were normal in all. These exercises were discussed in detail in Part 6 of this series. Perfecting Prism - Review of Optometry What lesion location is likely in the presence of horizontal conjugate deviation of the eyes to one side? You can schedule your next appointment with us online! 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) Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence. Br J Ophthalmol. It is seen in young children who have a defect or absence of voluntary horizontal saccades to visual stimuli. We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. JLSharpe The patient places two transparent cards into the vectogram system. MGallaway 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. Questions with answers: 125. The first hurdle is ensuring your patient is comfortable with wearing spectacles. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. 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. Similarly, the theories on mechanism of divergence itself have varied. No clear sex predilection has been identified for the primary form of the condition. Stager DR, Sr, Black T, Felius J. [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). Esodeviation is comitant in all fields of . If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. 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. All rights reserved. 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. The most common symptoms are: Tired or sore eyes Blurry vision Double vision Headaches Trouble concentrating You may also have trouble reading. Lateral rectus resections in divergence palsy: Results of long-term follow-up. Jampolsky Since divergence is an active process, not a passive one associated with relaxation of the medial rectus muscles,5 some investigators hypothesize that a "divergence center" must exist. 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. 1. METraviesa SHarbison Basic Esophoria and Exophoria. 132. Recent trauma ARKline When patients are spectacle independent and want to remain independent, surgical approach could be offered. The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. It is an unusual form of strabismus with esotropia and diplopia only at distance and single binocular vision at near. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." Diplopia at Distance in Older Patients: Is It Sagging Eye Syndrome? Cotter SA. 4. 132. Our eye doctors. 2011;31(3):206-9. 5. Prism can be used alone or in combination with vision therapy to treat basic esophoria and exophoria. Therapists can make this activity more advanced by increasing the amount the, changing the target) or by using multiple, and making the patient look from one to another, , however instead of there being two different transparent image, that need to be fused into one, there is one image. What Is Convergence Insufficiency? Symptoms, Causes, and Treatments - WebMD Call our optometrists at 302-299-1286 or. 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. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. If your patient is still experiencing diplopia, additional prism may be needed to help them achieve fusion. . 13.119). 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. Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. Clinical uses of prism: a spectrum of applications. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. Exercises for double vision: 4 things to try - Medical News Today Convergence and Divergence - Vivid Vision
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