When you try to focus on something close to your eyes, you may have: Tired eyes. 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. 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 results of CT or magnetic resonance imaging (MRI), available at the time of initial evaluation, were not initially considered since one of the aims of this study was to identify clinical features that might be helpful in predicting which patient was harboring a neurologic disorder. Biousse V and Newman NJ. Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. Long-term follow-up and clinical features of the 2 groups were compared. 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. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. Lim Divergence insufficiency can also result in headaches, motion sickness and sensitivity to bright lights. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). 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. 129. 2008;12(1):56. Patients with DI typically complain of gradual onset, variable frequency, homonymous diplopia, which is worse at distance. 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. RMDiagnosis and management of divergence paresis. If a patient sees four dots in free space or gives a diplopia response but is able to fuse with prism, perform a unilateral cover test. Privacy Policy| If your patient is still experiencing diplopia, additional prism may be needed to help them achieve fusion. MCiner Other training exercises include base-out prisms for near viewing and convergence exercises. Many patients were first evaluated within 1 month of the onset of symptoms, far sooner than the expected time course for the spread of comitance to convert a sixth cranial nerve palsy to a comitant esotropia. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. She had been previously diagnosed with esotropia and amblyopia but was not currently wearing any correction. BBordaberry Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. Primary divergence insufficiency is generally a benign condition. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. FDDutton [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. 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). It is idiopathic most often in children or young adults 2. In a recent study by Goseki et.al. Tamhankar MA, Ying GS, Volpe NJ. Testing for suppression and anomalous correspondence can be easily done with the Worth Dot test. None of these patients developed signs of an underlying neurologic disorder during follow-up. 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. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. 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. The epidemiology of primary and secondary form appears similar, with highest incidence among adults, but pediatric cases are reported sporadically as well. Distance esotropia in the elderly. This means the eyes do not like to move inward toward the nose and is problematic when trying to look at a near target. Cotter SA. LMDivergence paralysis with increased intracranial pressure: further observations. After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. 2000;118(9):12371241. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. 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. Sagging Eye Syndrome. HMDivergence paralysis following head trauma. It can also decrease distance judgement, coordination, and sports performance. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. It is possible that with longer follow-up, the number of patients with resolution of diplopia might increase. AOcular divergence mechanisms. Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. Audio blog post. Per some observations, its is more common in Caucasian females. Duane 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 glassestranaglyphs are made similarly. What are causes of convergence insufficiency? If the eyes do drift out, the person is likely to have double vision. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. To be enrolled in the study, patients had to meet the following 5 criteria: 1) relatively sudden onset of double vision at far vision, 2) no double vision at near vision, 3) high myopia >6.0 diopters (D) in both eyes, 4) no other neurological symptoms, and 5) a normal . it is highly advisable that you check them out first as they cover basics not explained here. 8. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. NRNewman Diagnosing convergence insufficiency Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. What is divergence insufficiency? An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. GMOcular divergence: its physiology and pathology. Stager DR, Sr, Black T, Felius J. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. [1]SES should be differentiated from heavy eye syndrome (HES) which is an association of axial high myopia, esotropia, and hypotropia. Although no unsuspected neurologic disorder surfaced during the period of follow-up in these patients, I strongly recommend that a patient with isolated divergence insufficiency be followed closely to detect, for example, signs of developing intracranial hypertension or abducens nerve palsy. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. Strabismus, or hypertropia, is a condition when one or both of the eyes are not properly aligned. CI affects children and adults. 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. Committee on Aging. Therapy will aim at increasing negative fusional vergence ranges to strengthen the fusional vergence system and. Magnetic resonance imaging did not identify hydrocephalus or involvement of the lesion along the anatomic course of the abducens nerve. 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 LR-SR band vertically supports the LR pulley against the downward force of the inferior oblique muscle to maintain the LR pulleys vertical position. Pencil pushups may be effective in some cases. Similarly, another dense band is found from the Superior rectus to the lateral rectus pulleys (LRSR band). published a case series of long-term follow up for 29 patients with divergence insufficiency esotropia underwent lateral rectus resection. Retrospective survey of patients with divergence insufficiency. Convergence and Divergence The only way to diagnose CI is with an eye exam 1. Goldberg "The term divergence insufficiency implies a problem at the level of the brainstem, suggesting that there is decreased neural output to the extraocular muscles," said Prem S. Subramanian, MD, PhD, at the University of Colorado in Aurora. Similarly, the theories on mechanism of divergence itself have varied. AJNR Am J Neuroradiol. 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.