CASE NUMBER ONE DIAGNOSIS? 8 year boy referred from school- - - PowerPoint PPT Presentation

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CONVERGENCE DIFFICIENCIES

Children vs. Adults Insufficiency vs. Paralysis

CASE NUMBER ONE

• 8 year boy referred from school- headaches, reading

difficulties and blurred vision

• MY EXAMINATION
• 20/20- with no correction
• Cycloplegic refraction OD +.50, OS +.75
• 14 prism exophoria at near, 4 prisms distance
• Fusional amplitudes at near – 18 (normal-36)

DIAGNOSIS?

• CONVERGENCE INSUFFICIENCY
• 1. near point of convergence >10cm)
• 2. reduced fusional convergence amplitudes
• 3. exophoria or intermittent exotropia- near fixation
• 4 symptoms- blur, diplopia, headache, fatigue

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CONVERGENCE INSUFFICIENCY

• 1. affects 2.25-8.3% of normal children
• 2. higher prevalence in attention deficit

hyperactive disorder (ADHD)

• 3. head trauma, illness, stress, lack of sleep

may precipitate symptoms

CONVERGENCE INSUFFICIENCY

• Increasingly common as adults age
• 70% of adults >80 years have reduced convergence
• Symptoms become progressively worse with age
• Bifocals may precipitate symptoms
• Exercises less effective than in children
• Prisms usually required

CASE NUMBER TWO

• 62 year old professor of surgery complaining of

difficulty reading- several pairs of readers

• 12 prism exophoria - near; 2 prism XP - distance
• 15 prism - fusional amplitude at near
• Symptom-free with 3 diopters base in each lens

after no response to exercises

CASE NUMBER TWO

• Two years later- symptoms return
• 18 prism exophoria – near; 2 prism XP – distance
• 11 prism – near convergence fusional amplitude
• Near point of convergence 12 cm
• Symptom-free with 5 diopter base in each lens
• Upgaze noted to be reduced 50%

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CASE NUMBER TWO

• One year later- constant diplopia at near
• 16 prism exotropia – near; 3 prism XP distance
• Near point of convergence- remote
• Adduction - normal; pupils - normal
• Upgaze limited – 75%
• Diagnosis: Convergence Paralysis

CONVERGENCE PARALYSIS

• Inability to converge
• Exotropia at near
• Pupils may be normal or abnormal
• Upgaze also commonly involved
• IMPLIES DORSAL MIDBRAIN DISORDER

CASE NUMBER TWO

• 9 months latter: Parkinson’s disease
• 1 year later- diagnosis changed to Progressive

Supranuclear Palsy

• Now all eye movements are restricted-

convergence, saccades and pursuits

CONVERGENCE PARALYSIS

• NEUROLOGIC CONDITIONS
• Parkinson’s
• Progressive supranuclear palsy
• Tumors- midbrain/third ventricle
• Head trauma
• Encephalitis

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Conclusions

• Convergence insufficiency- common
• Increasing problem over age 70
• Treatment- exercises or prisms
• Convergence insufficiency may evolve to be

convergence paralysis, especially in elderly

Conclusions

• Convergence paralysis implies neurologic

disease involving the midbrain

• Convergence paralysis is usually difficult to

treat even with surgery

• Follow carefully the patient with convergence

“insufficiency” and deficiency of upgaze

REFERENCES

• 1. Ghadban R, Martinez JM, Diehl NN, Moheny BG. The

incidence and clinical characteristics of adult-onset convergence insufficiency. Ophthalmology 2015; 122: 1056-9.

• 2. Almer Z, Klein KS, Marsh L, et al. Ocular motor and sensory

function in Parkinson disease. Ophthalmol 2012; 119: 172-82.

• Bruce AS, Atchinson DA, Bhoola H. Accommodative-

convergence relationships and age. Invest OphthalmolVis Sci 1995; 36: 406-13.

“Divergence” Insufficiency

Not What The Name Implies

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Interesting Case

• 80 year old man- gradual onset diplopia
• 6 prisms esotropia; ? mild limitation abduction OU
• Eye/lid movements otherwise normal
• MRI, myasthenia antibodies, blood work- normal
• Neurologic examination- normal
• Presumed diagnosis- myasthenia gravis

Interesting Case

• Mestinon pushed to toxicity- no effect
• Prednisone 60mg/day- no effect
• Immunomodulation therapy x’s 2- no effect
• Thymectomy considered
• Maintained on prednisone- 6 years
• Diplopia persisted unchanged

Interesting Case

• MY EXAMINATION:
• 6 prisms esotropia- distance; small exophoria-near
• No limitation of abduction in either eye
• No ptosis
• Patient has mild myopia- -2.00 sphere each eye

NOT MYASTHENIA

• No ptosis
• No history of increase with fatigue
• No variability of strabismus
• No response to any therapy
• ! Most important- the pattern of his strabismus!

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“DIVERGENCE” INSUFFICIENCY

• 1. Esotropia greater at distance than near
• 2. Decreased divergence fusional amplitudes
• 3. Esotropia at distance- usually stable
• 4. Esotropia at near- all most never

“DIVERGENCE” INSUFFICIENCY

• In contrast to convergence- no active brainstem

divergence center has been identified

• Jampolsky- “these are subclinical sixth nerve palsies”
• Abduction-saccadic velocities decreased
• CONCLUSION: “DIVERGENCE INSUFFICIENCY IS A

SERIOUS NEUROLOGIC PROBLEM?

SERIOUS PROBLEM?

• IN CHILDREN-YES!
• 14/15 - serious neurologic associations
• Hydrocephalus, meningitis, brain tumors,

Guillain-Barre syndrome (descending polyneuropathy), encephalocele

REFERENCE

Herlihy EP, Phillips JO, Weiss AH. Esotropia greater at distance. Children vs. Adults. JAMA Ophthalmology 2013; 131 (3):370-5

NOTE: Most of the children did not have clinically

evident lateral incomitance suggesting a sixth nerve palsy; eye movement recordings- reduced saccades

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SERIOUS PROBLEM?

• IN ADULTS-NO!
• 4/17- serious neurologic associations
• BUT all of the patients with neurologic disorders

had other neurologic findings- nystagmus in all 4.

CONCLUSIONS

• “Divergence” insufficiency is a misnomer
• Preferred “EsotropiaGreater at Distance”
• In Children- strongly suggests neurologic problem
• In Adults over 60 as an isolated finding-benign
• Treatment- prisms in most patients; surgery

References

• 1. JampolskyA. Ocular divergence mechanisms. Trans Am

Ophthalmol Soc 1970;68:730-822.

• 2. Godts D, Mathysen DG. Distance esotropia in the elderly.

Br J Ophthalmol 2013; 97: 1415-9.

• 3. Guyton DL. Changes in strabismus over time; the role of

vergence tonus and muscle length adaptation. Bin Vis Strabismus Q. 2006; 21: 81-92.