[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). Results from this study also supported previously published evidence of normal age-related connective tissue degeneration as there was a positive age effect in correlation to supero-temporal bowing of the LR-SR band.[9]. Arch Ophthalmol. 2016;28(1):38-42. RJZee 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 . Once this can be repeated multiple times, the amount of required divergence or convergence can be increased, thus expanding the vergence range and strengthening the problem area. Another condition commonly treated with prism is vertical heterophoria, or vertical strabismus. After these patients are evaluated for any underlying systemic or neurological disease, which must always be ruled out in any case of new-onset strabismus, they are often good candidates for a prism prescription. Lim 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. 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. In patients with a secondary vertical deviation, however, vertical prism is not an appropriate treatment. 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. Patients with sagging eye syndrome can be treated surgically if they do not respond to or do not desire prism therapy. 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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. This distinction is especially problematic in patients with other neurologic signs, most importantly those associated with intracranial hypertension. CI affects children and adults. However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. Sagging eye syndrome (SES) was first described by Rutar and Demer in 2009, as a potential leading cause of strabismus in older adult population as a combination of horizontal and vertical strabismus in addition to bilateral blepharoptosis (ptosis with high lid creases) and deepening of the sulcus. Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. AJNR Am J Neuroradiol. 8. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging. RLMagnetic resonance images in a case of "divergence paralysis.". R. London. 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. They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. 2013;251:16411644. Our eye doctors. Interestingly very little has been written on the mechanism of divergence insufficiency or frank paralysis in the above settings. This concept was first championed by Bruce,6 whose reasoning for its existence was admittedly "guided by deduction rather than influenced by definite proof." The mechanical properties of pulleys are critical for the support and rotational properties of the eye. The association with refractive errors (and high myopia in particular) has been a point of contention for some time. AOcular divergence mechanisms. DIVERGENCE INSUFFICIENCY - Optography The EOM angles in these patients ranged from 100 to . Many affected patients experience spontaneous resolution of double vision within several months. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. Krohel In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. 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. [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. It is also stated that primary divergence insufficiency does not possess any other neurological symptoms as well as signs. Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. Histories reveal the possibility of a number of etiologic factors. [7] The typical presentation in an older individual is one of gradual or subacute onset of diplopia. I trialed 2 PDs of base-down prism using a Fresnel prism over the right eye and dispensed at the initial visit. Intermittent convergence Always with accommodation and pupillary constrictionClassic causes of convergence spasm include the following: Most often nonorganic Excessive accommodation from uncorrected refractive error Lesions at the diencephalicmesencephalic junction (very rare)Convergence InsufficiencyConvergence insufficiency is a very common condition, characterized by the following: Exotropia greater at near than at distance (at least 10 prism diopters difference) Causes symptoms of asthenopia (fatigue with reading, diplopia at near, intermittent blurred vision when reading) Usually benign; may improve with orthoptic exercises Sometimes requires prisms in reading glasses or strabismus surgeryClassic causes of convergence insufficiency include the following: Idiopathic most often (in children or young adults) Head trauma Parkinson disease Progressive supranuclear palsyThe ability to converge can be measured (Fig. The preferred method for prescribing prism for vertical heterophoria is determining the vertical associated phoria.12 This can be done at near using the Wesson card or at distance. 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. Recognizing TBI-related Vision Disorders - Review of Optometry Mosbys Optometric Problem Solving Series, ed. Customize your JAMA Network experience by selecting one or more topics from the list below. 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}. They concluded that medial rectus recession is as effective as lateral rectus resection and suggested that double the distance angle of esotropia should be used as the surgical target. People with convergence insufficiency often have vision problems when they do close-up activities, like reading or using a computer. Smith 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. Most pertinent from a clinical point of view is the controversy surrounding whether divergence insufficiency is a distinct entity, or is a sign of subtle abducens nerve palsy. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, 2000;118(9):1237-1241. doi:10.1001/archopht.118.9.1237. Signs typical of divergence insufficiency were identified in 9 patients without intracranial hypertension (Table 2), including 2 with temporal arteritis. The orbital layer, inserts on the pulley, not on the globe. ISOphthalmoplegia in cranial arteritis. 2012;95(2):192-7. One of these patients had posterior ischemic optic neuropathy, but no other signs of orbital ischemia. In many of these cases, the initial management strategy is prescribing vertical prism.1 Often, if the vertical deviation is decreased or eliminated, the patient may be able to comfortably fuse the horizontal deviation. Chaudhuri Z, Demer JL. Lets continue the conversation over on your social network of choice. Copyright 2023 Jobson Medical Information LLC unless otherwise noted. 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. 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. Certain factors are associated with exotropia, including genetics and health conditions. Sensory Anomalies. 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. Sagging Eye Syndrome. There were 20 patients classified as having primary and 15 patients classified as having secondary divergence insufficiency. Fresnel membrane prisms can be very useful for many aspects of prescribing prism. Patients will be able to work on fusing the images of one card and move on to a more difficult card as their fusional vergence ranges expand. Esodeviation is comitant in all fields of . The opposite of divergence insufficiency is divergence excess. Patients with sensory anomalies, such as suppression or anomalous correspondence, cannot be treated with prism until they have been eliminated. Each card contains a partial view of the complete image. Tamhankar MA, Ying GS, Volpe NJ. It is spasm of the near triad: 1. Chang MY, Pineles SL, Velez FG. Tranaglyphs are similar to vectograms, however instead of there being two different transparent image cards that need to be fused into one, there is one image card with a stereo image already pre-made onto the card. Br J Ophthalmol. is variable. 1. Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS} , Volume 19 , Issue 6 , 500 - 506. One patient was followed up for only 1 month, but her esotropia resolved during that time. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). Other training exercises include base-out prisms for near viewing and convergence exercises. Corbett Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. [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. make average daily distance tasks more manageable with less frequent symptoms. Stager DR, Sr, Black T, Felius J. Most importantly, the esotropia remained the same or decreased in lateral gaze to either side in all patients, even those evaluated acutely. Chaudhuri Z, Demer JL. Jacobson DM. METraviesa 2012;49(4):222-8. it is highly advisable that you check them out first as they cover basics not explained here.
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