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The orbital layer, inserts on the pulley, not on the globe. Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. [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. Divergence insufficiency associated with high myopia - PubMed Treatment options include correction with base-out prisms for distance, Tomasz A. Wiraszka, MD, and Praveena Gupta, OD, PhD, FAAO, Galveston, Texas, April 2015 Wills Eye Resident Case Series, Wills Eye Resident Case Series - Diagnosis and Discussion, November 2014 Wills Eye Resident Case Series, February 2016 Wills Eye Resident Case Series - Diagnosis & Discussion. 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 and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. Esotropia resolved within days of initiating corticosteroid treatment in both patients. Although each method has its advantages and disadvantages, they all suffer from being subjective. Sagging Eye Syndrome: Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients. Therefore, it forces the patient to use both eyes properly to see the image. Prism is gradually increased until a patient is able to appreciate the forms on the RDS test. DIVERGENCE INSUFFICIENCY :- Divergence insufficiency refers to a clinically defined acquired disorder of ocular horizontal version . Neena R, Giridhar A. 13. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. Exercises for double vision: 4 things to try - Medical News Today Different surgical approaches exist when dealing with the components of sagging eye syndrome including divergence insufficiency esotropia and cyclovertical strabismus. Of the 15 patients with secondary divergence insufficiency, an underlying neurologic or systemic disorder was either known or initially suspected in all based on the initial history and physical examination. changing the target) or by using multiple vectograms and making the patient look from one to another and quickly adapting the vergence system appropriately to each target (this is called jumping vectograms). What are the symptoms of Convergence Insufficiency? Reproduction in whole or in part without permission is prohibited. Arch Ophthalmol. JSLevy What lesion location is likely in the presence of horizontal conjugate deviation of the eyes to one side? 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. Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). 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). 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. 2008;126(10):1336-49. 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. Connective tissues reflect different mechanisms of strabismus over the life span. 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. 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. If a patient does not have good potential for sensory fusion, then the assistance that prism gives to the motor system wont allow for normal fusion, and it doesnt make sense to prescribe it. Krohel It is most often related to raised intracranial pressure or Chiari malformation. NJeds, Leigh Divergence Insufficiency/Excess | Vision Therapy Paducah Kentucky Divergence Insufficiency and Divergence Excess Symptom Checklist Vision Therapy: Alex's Success Story | Wow Vision Therapy Share Watch on Share this: Twitter Facebook Like this: Loading. This means the eyes do not like to move inward toward the nose and is problematic when trying to look at a near target. What causes divergence insufficiency? if you would like to learn more about convergence and divergence insufficiency. Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. JWStockbridge GMOcular divergence: its physiology and pathology. 4 Binocular Vision Problems that Cause Eyestrain Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). These studies were unrevealing in all patients. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. New York, NY Oxford University Press1999;405-610. 129. Committee on Aging. By continuing to use our site, or clicking "Continue," you are agreeing to our, Clinical Features of Patients With Primary and Secondary Divergence Insufficiency, Disorders Associated With Secondary Divergence Insufficiency. Divergence fusion amplitude had been measured in most patients by first neutralizing their distance esotropia using a handheld loose prism. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. IRT. Therapy will aim at increasing positive fusional vergence ranges to help strengthen the fusional vergence system and make near tasks more tolerable. Committee on Aging. Divergence Insufficiency Revisited: Natural History of - JAMA Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. Define divergence insufficiency. This problem is most commonly found in children. Ductions and versions are full. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. Primary divergence insufficiency is generally a benign condition. A 25-year-old female presented complaining of double vision and headaches that worsened with prolonged near work. Caloroso E, Rouse MW. While viewing the card, the patient reports what color line the black arrow is aligned with. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. AIs divergence active? Like the previously mentioned exercises, stereoscope exercises can also be made more complex as therapy advances. Clinical uses of prism: a spectrum of applications. Teitelbaum B, Pang Y, Krall J. . 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. Basic Esophoria and Exophoria. Many affected patients experience spontaneous resolution of double vision within several months. 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. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." 1993, Oxford, UK: Butterworth Heinemann Books. 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. Primary divergence insufficiency is generally a benign condition. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL "Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia." Scheiman M, Cotter S, Rouse M, et al. 130. 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. 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. None of these patients developed signs of an underlying neurologic disorder during follow-up. [2] If an intermittent horizontal strabismus patient has a primary vertical deviation, vertical prism may help improve their ability to fuse the horizontal deviation. Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. However, the cause of convergence insufficiency is often unknown. JLSharpe Questions: 125. Strabismus. Convergence Insufficiency. an electromyographic study. make average daily distance tasks more manageable with less frequent symptoms. Lyle Bothun ED, Archer SM. Lepore When prescribing ground-in prism, high index lenses, plastic frames and frames that are smaller in size help improve the weight and cosmesis of the lenses. 2. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. With a trial frame, she was not able to appreciate RDS stereoacuity in-office. Heavy eye syndrome versus sagging eye syndrome in high myopia. Divergence insufficiency associated with high myopia | OPTH 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. HS Convergence Insufficiency | National Eye Institute Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. Patients with primary divergence insufficiency were those who had no other neurologic symptoms or signs, and patients with secondary divergence insufficiency were those who had additional symptoms or signs of neurologic dysfunction. 133. One of the most important aspects of successfully prescribing prism is choosing patients who will benefit the most from it. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. A Maddox rod was also used to determine the near point of orthophoria in most patients. A Vectogram is a tool which utilizes specialized imaging along with the fusional vergence system to create a 3-D object. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. The patient will wear a pair of polarizing, 3-D movies) to create depth within the image. Chaudhuri Z, Demer JL. The use of topical anaesthesia does not abolish this surgical risk. We studied cases with divergence insufficiency and high myopia in our neuro-ophthalmology clinic. 134. This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near. Duane A stereoscope is a tool used to help expand fusional vergence ranges once a baseline has been established. Extraordinary symptoms equivalent to diplopia 2.3.1. The inferior rectus (IR) was chosen when hypertropia was vertically concomitant or greatest in infraversion. None of these patients developed signs of an underlying neurologic disorder during follow-up. Graded Vertical Rectus Tenotomy For Small Angle Cyclovertical Strabismus in Sagging Eye Syndrome. Vision therapy uses various exercises to train the connection between the eyes and the brain as more than 50% of the brain is dedicated to visual function. 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. In a Tranaglyph, the amount of convergence or divergence needed to fuse the image is pre, 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 glasses, In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees, Different cards with different images will require different amount. 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. The other patient was followed up for 5.5 months, and his esotropia resolved during the first month of that period. Conclusions The main treatment for convergence insufficiency is vision therapy. 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. Divergence insufficiency: characteristics, diagnosis, and treatment reported a series of 57 patients underwent unilateral lateral rectus resection for distance esotropia deviations of 530 with 96.5% did not require further surgery.[11]. I reviewed the medical records of patients with divergence insufficiency that I had evaluated from July 1987 through April 1999 in my neuro-ophthalmology practice at a single institution. Some of the most common introductory exercises for vergence insufficiencies include Brock String, Barrel Cards, Stick-In-Straw, and Lifesaver cards. created image book. This conclusion was recently confirmed by Wiggins and Baumgartner,22 who characterized a benign long-term prognosis in their cohort of patients with neurologically isolated divergence insufficiency. . The information below is from Neuro-ophthalmology Illustrated-2nd Edition. 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. Heavy Eye vs. Our eye doctors. A few comments are warranted regarding some of the disorders associated with secondary divergence insufficiency. A new prescription for prism lenses was dispensed to the patient at the follow-up examination. Histories reveal the possibility of a number of etiologic factors. Clin Exp Optom. Comparison of surgical dose response between divergence insufficiency Miller What is Convergence Insufficiency? Symptoms, Treatments - Healthline Educating patients on the benefits of prism wear is key in helping get them on board in these cases. NADivergence paralysis. The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. 2016 May; 100(5): 648651. EJampolsky 11. Methods Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. Stern No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. 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. Theme. Arch Ophthalmol. [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. Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. Divergence Paralysis - Optography If hypertropia persisted, further 5%10% increments of GVRT up to a maximum of 90% were added with monitoring of alignment. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Motion sickness or dizziness ( vertigo) Headache . FDDutton None of the patients initially classified as having primary divergence insufficiency developed additional neurologic dysfunction during the period of follow-up. Neuro-ophthalmology Illustrated Chapter 13 Diplopia 10 - Convergence Prism is prescribed to these patients to partially or completely eliminate the motor demand so they are able to fuse. In 2005 Thacker NM et al. 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. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. 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. 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. 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. She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. 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. Nonparetic Diplopia - EyeWiki In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. The duration of time to resolution of double vision in the remaining 8 patients was 1 week to 26 months (median, 5 months). In support of that hypothesis, some investigators have reported clinical-radiographic and clinical-pathologic correlations of patients with divergence insufficiency associated with focal lesions, usually of the pons and midbrain,7-10 but also in other locations, such as the craniovertebral junction.8,11 On the other hand, patients with divergence insufficiency and a variety of diffuse brain injuries have also been described.8,12-15 The site of this elusive region, if in fact such a region exists, remains undefined. [10] In 2013, Stager et al. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. What is convergence spasm? They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. The distance at which diplopia occurs is noted (near point of convergence). Convergence Insufficiency. RLMagnetic resonance images in a case of "divergence paralysis.". Blur and discomfort can result from eyes that cannot properly point to a target, such as a book or computer. Only 2 patients were followed up for less than 6 months. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. 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. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. Godts D, Mathysen DG. Effectiveness of prisms in relieving diplopia in superior oblique palsies. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to.