SEE RELATED: Binocular Vision Disorders: 6 Frequent Q&As These exercises were discussed in detail in Part 6 of this series. 2012;49(4):222-8. . GBTobin
The information below is from Neuro-ophthalmology Illustrated-2nd Edition. Kirkham
Divergence insufficiency patients are often symptomatic for diplopia and asthenopia at distance and may present with a decompensated distance phoria. Any patient presenting with divergence insufficiency and neurological symptoms should undergo a full neurological evaluation and imaging.2, Vision therapy aims to decrease symptoms of vergence anomalies by increasing the compensating fusional vergence range (base-in for esophoria and base-out for exophoria). 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. PJThompson
Information obtained from direct telephone interviews with the patients and review of office records of referring physicians who continued to follow up some patients were included in the determination of follow-up. [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). If the patient gives a fusion response with or without prism but movement on the unilateral cover test is seen, then anomalous correspondence is suspected and relieving or corrective prism is not an appropriate management option. This means the eyes do not like to move inward toward the nose and is problematic when trying to look at a near target. Lepore
After identifying a patient who stands to benefit from a prism prescription, the next step is deciding how much prism to prescribe. 3. 5. [10] In 2013, Stager et al. 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. Wall
At the follow-up examination, she reported no diplopia in her glasses, and, eventually, she was able to see 250 seconds of arc RDS stereoacuity. Divergence insufficiency is a rare ophthalmologic disorder manifesting itself among older adults. 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. Bender
enlisted 100 patients without strabismus, and readers graded the LR-SR band visible in 95% of orbits on non-fat-suppressed coronal T1-weighted sequences, 68% on coronal STIR sequences. 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. 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. Divergence insufficiency is characterized as follows: Comitant esotropia is present at distance but not at near. The patient places two transparent cards into the vectogram system. 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. It is most often related to raised intracranial pressure or Chiari malformation. An affected patient experiences double vision when viewing distant objects, but not when viewing objects up close. This ocular misalignment has two main types: esotropia and exotropia. Many affected patients experience spontaneous resolution of double vision within several months. Lim
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. PCBurian
RDInternuclear ophthalmoplegia in giant cell arteritis. What is convergence spasm? 13.121). 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. None of these patients underwent strabismus surgery. They concluded that these surgeries are less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery.[14]. Educating patients on the benefits of prism wear is key in helping get them on board in these cases. My practice represents a balance of primary care and referral-based consultative neuro-ophthalmology. If the dot becomes doubled, go back to the previous dot and try again. If you will recall, convergence insufficiency is the inability for one or both eye(s) to converge appropriately to a given target. [unreliable source?] A near card is brought toward the patients nose until the patient sees double. 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. Then, a horizontal prism bar was used to place increasing strengths of base-in prism over the other eye until fusion could no longer be maintained, as assessed subjectively using a distant target for fixation. What lesion locations are likely in the presence of horizontal conjugate deviation of the eyes to one side? This means that in a vectogram the amount of convergence or divergence needed to fuse the image depends solely upon how far apart the two cards are held, i.e. Patients were categorized into 2 groups, primary (ie, neurologically isolated based on clinical criteria) and secondary (ie, associated with a neurologic or systemic disorder). Bielchovsky and Duane favored the presence of a dedicated active divergence center, while Drs. 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The procedure is performed under topical anesthesia in the presence of an anesthesiologist. Fresnel prism, however, degrades visual acuity and contrast sensitivity, and some patients may not find it cosmetically appealing.12 A significant decrease in visual acuity through the Fresnel lens can be seen at larger prism powers, particularly at those greater than 12 PDs.13 When trialing Fresnel prism, it is advisable to only place the Fresnel over one eye so that the patient retains good binocular visual acuity with the prism in place. Neuro-ophthalmology Illustrated-2nd Edition. Antireflective coating is also beneficial for patients wearing prism lenses. They are low in cost and can be easily applied to a pair of spectacle lenses in-office to try out on a patient for several days or weeks, and refining the prism prescription is inexpensive and simple. Questions with answers: 125. . 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. All but 1 patient were older than 50 years. IRT. Their symptom was controlled using prisms. AIs divergence active? In high-myopia patients without double vision, the ocular axis length was 27.6 1.3 mm. While viewing the Worth Dot test, prism is gradually increased until the patient reports fusion. Only 1 of these patients, the one with a frontal lobe tumor, had a focal lesion. If the patient is only using one eyethe image will not be formed correctly. will be pushed inward, making the image smaller, will be pulled outward, making the image larger, Increasing or decreasing the distance between the two. [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. The use of MRI imaging is confirmatory rather than "required" to make the diagnosis, since diagnosis is mainly clinical. The normal amount of fusional divergence ability at distance is lower than that of fusional convergence ability, making it challenging to sufficiently increase ranges to compensate for esophoria or esotropia at distance. In many individuals with vergence problems, accommodation will be worked on first to ensure it is equal between the two eyes. DJDivergence insufficiency. RDDivergence paralysis. Esotropia is when an eye faces inward, and exotropia is when an eye faces outward. Chamlin
Extraordinary symptoms equivalent to diplopia 2.3.1. Lateral rectus resections in divergence palsy: Results of long-term follow-up. 126. Rutkowski
These questions are archived at https://neuro-ophthalmology.stanford.eduFollow https://twitter.com/NeuroOphthQandA to be notified of new neuro-ophthalmology questions of the week.Please send feedback, questions, and corrections to tcooper@stanford.edu. They concluded that GVRT performed with intraoperative monitoring under topical anaesthesia, precise correction of hypertropia up to 10 can be achievable. How is convergence insufficiency treated? Divergence insufficiency is associated with systemic and neurological disorders, so we must rule out any underlying conditions that may be causing it. 127. 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. 132. [2] Once the two images have been combined into one, the patient will be asked to hold the image in place for 10-15 seconds. 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.