Objectives A 5-year-old female initially presented for a strabismus and amblyopia evaluation. 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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. it is highly advisable that you check them out first as they cover basics not explained here. 1. EDivergence insufficiency: characteristics, diagnosis, and treatment. Over a period of several months, the diplopia becomes more constant and is noticed while driving, watching television, and in other long-distance vision situations. Other training exercises include base-out prisms for near viewing and convergence exercises. In some circumstances, individuals with convergence insufficiency will also suffer from high exophoria or, 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. 2013;97(11):1415-9. Sometimes it is exacerbated by fatigue and improves with rest. It involves a specialty optical system and a uniquely created image book. To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). These exercises were discussed in detail in Part 6 of this series. Arch Ophthalmol. Determining how much prism is required for improved fusion, or fusion prism, is another method for prescribing prism for your strabismic patients. 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. is fixed. Convergence Insufficiency Testing. Some patients report double pictures, but when checked with the torch, only one light is seen. One of the most important aspects of successfully prescribing prism is choosing patients who will benefit the most from it. Schanzer This is part 7 of the vision therapy series and will focus on vergence insufficienciesConvergence Insufficiency and Divergence Insufficiency. Individuals with divergence insufficiency often have a low AC/A ratio with a high near point of convergence. What is the cause of convergence spasm? J AAPOS. Although successfully prescribing it can sometimes seem like a time-consuming and daunting task, the following tips can help you smoothly incorporate the use of prism for binocular vision conditions into your practice for the best outcomes. Divergence excess is an over-divergence when attempting to look at distant objects. 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. From the Departments of Neurology and Ophthalmology, Marshfield Clinic, Marshfield, Wis. Questions with answers: 125. FEDivergence paresis: a nonlocalizing cause of diplopia. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. This means the eyes do not like to move outward toward the ears and is problematic when trying to view a distant target. Heavy Eye Syndrome in the Absence of High Myopia: A Connective Tissue Degeneration in Elderly Strabismic Patients. 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. Primary divergence insufficiency is generally a benign condition. 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. Patients will be able to work on fusing the images of one. Common symptoms include: headaches; blurred vision ; double vision 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. Her research interests include strabismus and binocular vision disorders. 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 . Her vertical associated phoria, which I determined using the Wesson card, was 2 PD right hyperphoria. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. 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. 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. Duane With one eye covered, the patient is able to move the open eye laterally and the pupil will dilate. J AAPOS. It can also decrease distance judgement, coordination, and sports performance. LMDivergence paralysis with increased intracranial pressure: further observations. Define divergence insufficiency. Cotter SA. Results: In high-myopia patients with divergence insufficiency, ocular axis measurements ranged from 24.8 to 31.0 (mean SD: 27.6 1.6) mm. Vronneau-Troutman S. Fresnel prisms and their effects on visual acuity and binocularity. 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. This page has been accessed 63,795 times. Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. 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. No unsuspected CT or MRI abnormality was identified in those patients whose only presenting neurologic symptom and sign was double vision and divergence insufficiency. Double vision is a troublesome complication of otherwise successful cataract surgery. MDDivergence paralysis with raised intracranial pressure: an electro-oculographic study. 2005;9:711. RLMagnetic resonance images in a case of "divergence paralysis.". Divergence insufficiency is the opposite problem of convergence insufficiency. Hold focus on this dot for 10 seconds. FDDutton Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. This problem is most commonly found in children. 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. The main treatment for convergence insufficiency is vision therapy. Although it has been described for more than a century,1 divergence insufficiency remains a controversial entity. Divergence excess is an over-divergence when attempting to look at distant objects. RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. 2012;130:12801284. 128. GBTobin 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. Head trauma 3. How is convergence insufficiency treated? If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. 131. Lepore 2014;35(9):1830-5. Temporal GVRT was chosen for the IR and nasal GVRT for the SR. However, they had a recurrence rate of almost 7% over their mean follow-up period of 39 months. 3rd ed. fine-tuned to work on strengthening either negative fusional vergence or positive fusional vergence. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. Lim 2012;49(4):222-8. Convergence Insufficiency. 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. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. 2005;9:36. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. Heavy Eye vs. However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. Convergence insufficiency is an anomaly that causes the eye to under-converge at near. 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. Differentiating sagging eye syndrome (SES) from other causes of strabismus is not always a straight forward task given that patients with SES may have risk factors for strokes or tumors. 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. NJeds, Leigh 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. [5], In recent imaging studies, Patel et al. Reference: 1. 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. Vision suppression stops you from seeing double, but it doesn't fix the problem. 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. 3. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. What is divergence insufficiency? Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. 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. reported a case series of 9 patients with vertical strabismus incomitant in horizontal gaze positions and cyclotorsion who underwent Adjustable small-incision selective tenotomy and plication. 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. In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. [5], MRI measurements of horizontal EOM lengths in SES were approximately 40%, or 14 mm, longer than the EOMs of nonstrabismic younger and older controls. 2008;12(1):56. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. REBaumgartner Br J Ophthalmol. More advanced exercises for vergence insufficiencies include. Jampolsky 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. New York, NY Oxford University Press1999;405-610. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. Ductions and versions are full. Neuro-ophthalmology Illustrated-2nd Edition. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. One patient was followed up for only 1 month, but her esotropia resolved during that time. As a . Vectograms use an approach called the SILO affect to work on increasing divergence or convergence ranges. Teitelbaum B, Pang Y, Krall J. On the other hand, it remains possible that these events were casual and not pathogenetically important. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Blurred vision. Since true paralysis of divergence generally cannot be documented in most affected patients,4 I prefer the term divergence insufficiency to describe this disorder, regardless of the severity of associated symptoms and signs. 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. Committee on Aging. The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. No such signs were identified in any of the patients in this series. Convergence Insufficiency Symptoms. The characteristics of the patients in this series who have an idiopathic disorder suggest that if certain rules of diagnosis are obeyed, divergence insufficiency can be distinguished from sixth cranial nerve palsy in most cases using clinical techniques. 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. 632. When patients are spectacle independent and want to remain independent, surgical approach could be offered. 2014;18(4):309-15. It can also be seen with head trauma, intracranial hypotension, cerebellar lesions, and a midbrain mass. Although the entity of divergence insufficiency was described as early as 1886 by Duane, it has received relatively little attention in the literature. Many affected patients experience spontaneous resolution of double vision within several months. 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. Customize your JAMA Network experience by selecting one or more topics from the list below. The differential includes: It can be difficult to adjudicate small angle deviations such as HES and SES from mild myasthenia gravis, incompletely resolved sixth nerve palsy, thyroid eye disease, and decompensated prior phorias. What is convergence insufficiency? characterized by a turning inwards or outwards from the nose thus preventing parallel vision: caused by paralysis of an eye muscle, etc . PCBurian Beginning treatment, the patient suppressed on Worth Dot testing and had no RDS stereoacuity, even with corrective prism in place.
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