The patient places two transparent cards into the vectogram system. 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. Convergence insufficiency is a common eye coordination problem in which the eyes drift outward when reading or doing near point work. However, age-associated degeneration of the ligaments interconnecting the EOM pulleys permits inferior sag of the LR pulley, causing esotropia, cyclovertical strabismus, or both. Patients with convergence insufficiency will often complain of eye strain when looking at near objects (reading, writing, computer work, etc. It can also decrease distance judgement, coordination, and sports performance. 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. Ultimately, the diagnosis of DI, particularly in the primary form, tends to be elusive. In those patients without an established disorder, additional clinical clues indicated the need for neuroimaging or additional diagnostic studies, independent of the signs of divergence insufficiency. Individuals with convergence insufficiency often have a low AC/A ratio and a low near point of convergence. FDDutton All patients had undergone a general neurologic examination by a board-certified neurologist (D.M.J.). 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. Each patient was classified into 1 of 2 categories of divergence insufficiency based on results of the general neurologic assessment at their initial evaluation. For example, many investigators propose criteria to differentiate divergence insufficiency from divergence paralysis or paresis.1-3 However these arbitrarily defined criteria more likely describe varying severity of symptoms and ocular motor signs along a continuum of the same condition. 11. JWStockbridge The clinical neurologic evaluation is a powerful tool that distinguishes those with a primary disorder from those harboring an underlying neurologic or systemic condition. Eye - Diplopia following cataract surgery . They tend to be older pediatric or adult patients with new-onset or decompensated strabismus. Convergence describes the way our eyes move together and point inward when we look at near objects. 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. 133. HMDivergence paralysis following head trauma. LBSharpe 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. In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. One of the most important aspects of successfully prescribing prism is choosing patients who will benefit the most from it. Symptoms resolved in 8 (40%) of 20 patients after a median of 5 months. Questions: 125. 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. Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Pencil pushups may be effective in some cases. Upon examination, she had a small exophoria and a 3 PD right hyperphoria at distance and near. Ductions should be tested with the fellow eye covered. A primary vertical deviation is the same in presence and size whether the patient is strabismic or aligned. When nonisolated, divergence insufficiency is most often reported in patients with intracranial hypertension, a neurologic condition often associated with sixth cranial nerve palsy.8,12-14,16 Some investigators have recorded slow abducting saccades in patients with signs consistent with divergence insufficiency, suggesting that abducens palsy was the cause of esotropia in these individuals.14 However, this finding has not been reproduced.11,17. How is convergence insufficiency treated? Relieving prism is often prescribed for patients with intermittent strabismus and sometimes for those with constant strabismus. Parkinson disease 4. 632. Since the cardinal symptom of divergence insufficiency is double vision, this symptom was used to establish the total duration of the follow-up. 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. Intermittent convergence 2. with accommodation 3. pupillary constriction When the patient is asked to look to each side, the eyes do not move. Bender The test can identify and characterize suppression based on the rooms illumination and the distance of the test from the patient. 134. The procedure is performed under topical anesthesia in the presence of an anesthesiologist. More advanced exercises for vergence insufficiencies include Vectograms, Tranaglyphs, and Stereoscopes. Fresnel membrane prisms can be very useful for many aspects of prescribing prism. 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. 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. MDavidoff Dr. Jenewein is an assistant professor at Salus University, Salus Universitys Principal Site Investigator for the Pediatric Eye Disease Investigator Group, a Fellow of the American Academy of Optometry and a Diplomate of the Binocular Vision, Perception and Pediatric Optometry Section of the Academy. , 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. 1978;76:610-53. Depending on the clinical circumstances, the imaging, and the course, clinicians should consider evaluating for other etiologies prior to making the diagnosis of HES or SES. In normal cases, the ocular axis length was 23.5 1.0 mm. Many affected patients experience spontaneous resolution of double vision within several months. The mechanical properties of pulleys are critical for the support and rotational properties of the eye. . American Journal of Ophthalmology, Volume 209, January 2020, Pages 55-61. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). A Maddox rod was also used to determine the near point of orthophoria in most patients. A new prescription for prism lenses was dispensed to the patient at the follow-up examination. 3rd ed. Factors associated with base-in prism treatment outcomes for convergence insufficiency in symptomatic presbyopes. The patient looks into the stereoscope to see two imagesthe right eye will see one image and the left eye will see the other. It involves a specialty optical system and a uniquely created image book. In addition, patients with SES usually have normal horizontal saccades and normal horizontal ductions. use an approach called the SILO affect to work on increasing divergence or convergence ranges. Also found significant displacement of all four rectus pulleys away from the orbital center, lateral displacement of the inferior rectus pulley and obliquely angulated lateral rectus pulley. 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. This means the eyes do not like to move inward toward the nose and is problematic when trying to look at a near target. Heavy Eye vs. 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. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.. In some circumstances, individuals with divergence insufficiency will also suffer from high esophoria or. No such signs were identified in any of the patients in this series. SHarbison Prism prescriptions often greatly improve the quality of life of your patients by reducing asthenopia and diplopia. This ocular misalignment has two main types: esotropia and exotropia. 20-20-20 Still Not Enough to Alleviate Eye Strain, Binocular Vision and Sports Concussions: A Bad Combo, Vision Impairment Increases Risk of Cardiovascular Disease, Monocular Eye Closure Common with Epiretinal Membrane. What is convergence spasm? 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.. As her vision improved with amblyopia treatment, I continued to monitor her sensory fusion. Teitelbaum B, Pang Y, Krall J. Jampolsky Objectives 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). Divergence insufficiency can vary in severity, from minor deficits to complete divergence paralysis. At distance, the American Optical vectographic slide is commonly used to determine the associated phoria. The following information was abstracted from the medical records: current medical history, past medical history, details of the ocular motor and general neurologic examinations, results of radiographic and laboratory tests, and long-term follow-up of those cases that were classified as idiopathic. GBTobin For example, the right eye might see a lion while the left eye sees a cage. Weird vision divergence upon waking at night User Name: Remember Me: Password . , In recent imaging studies, Patel et al. The Apt Lecture. Roughly half of the patients experienced spontaneous resolution of diplopia after several months. Sagging Eye Syndrome. It is most often related to raised intracranial pressure or Chiari malformation. Wall It is reasonable to initially defer further investigation, including neuroimaging, in patients who have no other neurologic symptoms or signs. A dense band iss present from the medial rectus to the inferior pulleys (MRIR band) and from the medial rectus to the superior rectus pulleys (MRSR band). These conditions that affect convergence or divergence may cause symptoms such as seeing double at near or far while viewing an object. Bergman, Pugh and Duke-Elder favored the view of divergence as a passive result of relaxation of convergence.