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Divergence insufficiency is a comitant esotropia that is present at distance but not at near, with full ductions and versions. All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). Divergence fusion amplitudes were significantly larger in patients with secondary divergence insufficiency compared with those with primary divergence insufficiency, although there was considerable overlap of values between the 2 groups. Double vision is a troublesome complication of otherwise successful cataract surgery. Patients with divergence insufficiency may complain of intermittent double vision (diplopia) when looking at something in the distance, frequent "wandering" of the eyes, headaches, motion sickness, and eye fatigue that comes and goes and can vary from day-to-day depending on how tired the individual is. Our normal supraduction and infraduction abilities are limited, so improving these ranges to compensate for a vertical deviation can be challenging. What is convergence insufficiency? Different cards with different images will require different amounts of negative and positive fusional vergence. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. HMDivergence paralysis following head trauma. Therapists can make this activity more advanced by increasing the amount the cards are moved (i.e. RTOcular muscle paresis and cranial arteritisan unusual case. Graefes Arch Clin Exp Ophthalmol. Methods Per some observations, its is more common in Caucasian females. It can also decrease distance judgement, coordination, and sports performance. This decreases the motor fusion demand, allowing the patient to fuse more comfortably. 2023 Stanford School of Medicine | Terms of Use | More advanced exercises for vergence insufficiencies include. 13.120). PJThompson 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. Godts D, Mathysen DG. ISOphthalmoplegia in cranial arteritis. Chaudhuri and Demer used MRI to evaluate rectus EOMs, pulleys, and the LR-superior rectus (SR) band ligament in SES. As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. Divergence fusion amplitudes were significantly larger in patients with secondary divergence insufficiency compared with those with primary divergence insufficiency, although there was considerable overlap of values between the 2 groups. Cotter SA. Patients and methods. 132. Vision therapy exercises aimed at strengthening and normalizing accommodation can be found in Part 4 of this series. 2008;12(1):56. If your patient is still experiencing diplopia, additional prism may be needed to help them achieve fusion. In this study, they reiterate that a topical anesthesia with intra-operative re-assessment of deviation[15]. 2013;251:16411644. Theme. 1995, St. Louis, Missouri: Mosby. The radiographic and laboratory evaluation of the 20 patients with primary divergence insufficiency did not reveal any unsuspected disorders. Fresnel membrane prisms can be very useful for many aspects of prescribing prism. If an intermittent horizontal strabismus patient has a primary vertical deviation, vertical prism may help improve their ability to fuse the horizontal deviation. Arch Ophthalmol. Other associated symptoms can include asthenopia of panoramic type. ARKline NParalysis of divergence. She was able to fuse on the Worth Dot test with 12 PDs base-out and 3 PDs base-up OD. [Epub ahead of print] https://doi.org/10.1080/09273972.2017.1421676. 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. Prisms arent as successful in treating convergence insufficiency and are used less frequently than other treatment modalities. The main treatment for convergence insufficiency is vision therapy. Neuro-ophthalmology Illustrated-2nd Edition. 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. After a preliminary prescription of fusion prism is determined, it is recommended that you trial frame the patient and have them look around to see if they experience any diplopia when viewing objects in the room. Primary divergence insufficiency is generally a benign condition. This problem is most commonly found in children. [15]Linear regression analysis of hypertropia correction with tenotomy showed that for a 36 hypertropia, a 3090% tenotomy is recommended. 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. What are the symptoms of Convergence Insufficiency? RVD states that esotropic patients of magnitude 6 to 20 PDs should be left with 4 to 6 PDs of residual vergence demand. With the exception of the size of vertical fusion amplitude, ocular motor signs associated with divergence insufficiency did not distinguish patients with idiopathic from those with secondary disorders. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. Regardless of whether their underlying responsible disorder was established or not, additional neurologic symptoms and signs were readily apparent in all of these patients. 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. 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. Wiggins In 2005 Thacker NM et al. Using magnetic resonance imaging (MRI), a coronal image 6 mm anterior to the eyeball-optic nerve junction was measured and used to examine the extraocular muscle (EOM) path shift . To increase divergence, the two cards will be pulled outward, making the image larger (Large Out for the LO in SILO). Jampolsky Extraordinary symptoms equivalent to diplopia 2.3.1. 129. Individuals with convergence insufficiency often have a low AC/A ratio and a low near point of convergence. The diverse conditions and sites of associated lesions of the patients with secondary divergence insufficiency in this series imply that secondary divergence insufficiency is not particularly localizing, nor is it necessarily specific for intracranial hypertension. 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. In this exercise, the patient is asked to wear a pair of red/green glassesone eye sees red and the other eye sees green. Long-term follow-up and clinical features of the 2 groups were compared. Jacobson DM. A similar technique is used for rehabilitation: the patient is instructed to do push-up exercises (looking at an object intermittently moved in and out from the bridge of the nose) daily at home to decrease the near point of convergence.Divergence InsufficiencyDivergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. Ductions and versions are full. It is most often related to raised intracranial pressure or Chiari malformation.Classic causes of divergence insufficiency include the following: Raised intracranial pressure Chiari malformation Head trauma Intracranial hypotension (low CSF pressure syndrome) Cerebellar lesions Midbrain massAbnormal Horizontal Conjugate DeviationsGaze deviations are relatively common in large cerebral and pontine lesions (Fig. Miller 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. RDDivergence paralysis. Before settling on a final prism prescription, it is often helpful to trial frame the amount of prism you are about to prescribe to ensure that it will help you achieve your goals. The tool itself can be calibrated to work on increasing divergence or convergence, depending on what it is set to. Effectiveness of prisms in the management of diplopia in patients due to diverse etiologies. GBurde A common a daily, home rehabilitation technique is to have the patient do push-up exercises (looking at an object intermittently moved in and out from the bridge of the nose) to decrease the near point of convergence. Connective tissues reflect different mechanisms of strabismus over the life span. Bedrossian Supported by When looking at the image on the card, patients will be required to use their fusional vergence system to fuse the red and green images into one 3-D image. 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. Convergence describes the way our eyes move together and point inward when we look at near objects. Audio blog post. 2005;9:711. 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. 2012;49(4):222-8. Bradley J. Katz, MD; Joseph L. Demer, MD, PhD; Robert A. Clark, MD: Sagging Eye Syndrome. The mirror stereoscope is one of the most commonly used types. Accordingly, a patient with divergence insufficiency who has additional neurologic symptoms or signs should undergo a comprehensive neurologic evaluation that includes neuroimaging. Usually the sensorimotor exam is helpful, as in SES the misalignment does not map similar to cranial nerve palsies or skew deviation. To determine the associated phoria, add prism in the appropriate direction until the patient reports that the arrow is aligned with the center line. Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion. Primary and secondary forms exist, with the latter more urgently addressed due to neurologic comorbidities. 2023 American Medical Association. Duane Tamhankar MA, Ying GS, Volpe NJ. Pencil pushups may be effective in some cases. AmblyoPlay is a vision therapy solution that is performed through playing therapeutic games and exercises on your tablet or computer for 30 minutes per day. I prescribed 12 PDs base-out and 3 PDs vertical prism, split between her eyes. Motion sickness or dizziness ( vertigo) Headache . Lateral rectus resections in divergence palsy: Results of long-term follow-up.