Divergence Insufficiency Esotropia Research Articles

Clinical Characteristics of Acquired Diplopia in Adults

ABSTRACT Purpose To describe the common causes of symptomatic strabismus and treatment required to resolve diplopia in adult patients seen by one orthoptist. Patients and Methods Retrospective cross-sectional study of consecutive adult patients 18 years or older seen by one orthoptist over a 3-year period with a chief complaint of double vision. Results Two hundred twenty-four consecutive adult patients were examined by the author. Chief complaint was double vision, followed by blurred vision, monocular diplopia, and eye strain. Past ocular histories were significant for early-childhood strabismus in 23 patients. Amblyopia was identified in five patients. Hypertension was a medical risk factor most associated with symptomatic strabismus. Cranial nerve paresis was the most common cause of the strabismus followed by benign, age-related divergence insufficiency esotropia. Prism was the most common treatment in 53% of patients followed by Bangerter foil occlusion in 44 patients (20%). Strabismus surgery was recommended in 11 patients (5%). Manifest refraction was successful in resolving symptoms of binocular diplopia in nine heterophoric patients (5%). Opaque pirate style occlusion was not used for any patient in this series. Conclusions Symptomatic acquired esotropia was a common type of strabismus encountered by the author and trochlear nerve paresis a common cause of symptomatic strabismus in this retrospective cross-sectional study. Press-On™ or ground-in spectacle prism of 12 prism diopters or less resolved diplopia in 124 patients (55%).

Comparison of Unilateral and Bilateral Surgical Approaches for the Treatment of Age-Related Divergence Insufficiency Esotropia

ABSTRACT Purpose Age-related divergence insufficiency-esotropia (ARDIE) is characterized by greater esodeviation at distance than near. This study aims to compare the outcomes of unilateral and bilateral surgical approaches. Patients and Methods Sixty-two cases treated at the Kellogg Eye Center, the University of Michigan, from 1995 to 2018 were retrospectively reviewed. One surgeon used unilateral procedures including unilateral medial rectus recession (n = 24, group 1) or unilateral recession-resection (n = 18, group 2) with an adjustable suture. Another surgeon used bilateral medial rectus recession with fixed sutures (n = 20, group 3). Results For patients with distance esodeviation <15∆, postoperative distance deviations in both group 1 and group 3 were not statistically different (p = .352). For patients with esodeviations 15–20∆, postoperative distance deviations in all 3 groups were also not statistically different (p = .142). Similarly, patients with deviations >20∆ did not show significantly different postoperative distance alignment (p = .082) between group 2 and 3. Overall, group 2 had the highest overall success rate (90%) (mean at distance = 1.17∆ exodeviation, at near = 2.33∆ exodeviation). Conclusion Both unilateral medial rectus recession ± lateral rectus resection and bilateral medial rectus recession surgical approaches produced similar favorable outcomes in ARDIE.

Acute acquired comitant esotropia precipitated by excessive near work during the COVID-19-induced home confinement.

Purpose:To evaluate the causes of acute acquired comitant esotropia (AACE) in young adults and children in the setting of COVID-19-induced home confinement.Methods:A retrospective, clinical study of all patients, who presented to the Pediatric Ophthalmology and Strabismus services of a tertiary eye care center in South India from August 2020 to January 2021 during the COVID-19 pandemic, with acute-onset, comitant esotropia.Results:11 (73.3%) of the total 15 patients were students, above 10 years and with a mean age of 16.8 years. 12 patients (80%) had more than 8 hours of near activity a day with a mean duration of 8.6 hours per day. The most common near activity was online classes, followed by job-related work and mobile games, and 86.7% used smartphones for near work. The average esotropia was 22.73 prism diopter (PD) for distance and 18.73 PD for near. Majority (66.6%) had hyperopia with basic or divergence insufficiency esotropia, and the remaining 33.3% had myopia and fitted in to the Bielschowsky type AACE. There was no precipitating event other than sustained near work in all, except in one patient who also had fever prior to the onset of esotropiaConclusion:The habit of long-time and sustained near work, especially on smartphones, may increase the risk of inducement of AACE.

The Surgical Effects of Medial Rectus Recession on Divergence Insufficiency Esotropia

To study the surgical effects of medial rectus recession (MRR) on divergence insufficiency esotropia (DIE). Nine DIE patients who were admitted to and had MRR at Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University between December 2017 and June 2020 were included in this retrospective study. All patients were followed up for 1 year at least. The postoperative esodeviation, near-distant disparity (NDD) and visual function were observed and compared. The mean age of the 9 patients was 28.8 years old (10-49 yr.), including 3 adolescent patients (≤18 yr.). The mean preoperative esodeviation was (19.8±13.2) PD for near and (32.6±15.3) PD at distance, while, the mean postoperative esodeviation 1 year after MMR was (-0.2±3.5) PD for near and (6.0±2.2) PD at distance, showing significant improvement over the mean preoperative esodeviation ( P=0.012, P=0.007). NDD dropped from (12.8±2.4) PD before the surgery to (6.0±2.2) PD 1 year after the surgery, showing significant improvement ( P=0.008), and remained stable 1 year after the surgery ( F=0.075, P=0.900). There was no significant improvement of near stereopsis ( P=0.306). Binocular function at distance was significantly improved after surgery (Worth 4 dots test : P=0.017; Bagolini striated glasses: P=0.035). The patients were divided into two groups, the adolescent group (age≤18 yr., n=3) and the adult group (age>18 yr., n=6). Prior to the operation, the mean spherical diopter of the adolescent group (OD -1.75 D, OS -1.92 D) was lower than that of the adult group (OD -6.17 D, OS -6.04 D) ( P=0.012). The average value of preoperative AC/A of the adolescent group was 4.33. It was 2.33 in the adult group, which was lower than the normal value, and significantly lower than that of the adolescent group ( P=0.12). There was no significant difference in esodeviation or NDD between the adolescent group and the adult group before and after operation. Medial rectus muscle recession can effectively improve the NDD and the binocular function at distance of patients with divergence insufficiency esotropia. Postoperative esodeviations both for near and at distance tend to regress after the surgery. Therefore, it is recommended that the amount of MRR be increased in the treatment of DIE.

Increasing incidence and risk factors for divergence insufficiency esotropia

To document the increasing incidence of divergence insufficiency (DI) esotropia and to identify risk factors for DI. All patients with a diagnosis of esotropia seen by one provider (DLG) over 41years were identified from the medical record. Patients with onset of strabismus before age 10years or with prior strabismus surgery were excluded. Cases of esotropia associated with thyroid eye disease, scleral buckles, trauma, neurological diseases, or atypical misalignment were included but not labeled as DI regardless of the distance versus near deviation. The remaining patients, whatever the original diagnosis, were retrospectively categorized as having, or not having, DI, using a uniform criterion: distance esotropia ≥5Δ more than near esotropia. The percentage of DI patients among acquired esotropia patients increased significantly between the first and second half of the 41-year period, from 11.8% to 29.4% (P<0.001). Multivariate logistic regression identified advancing age and the use of progressive addition lenses as risk factors for the development of DI. The incidence of DI is increasing. DI's association with age and progressive addition lenses may help us to understand its etiology and to decrease the prevalence of this condition in the future.

A Case Report of Successful Vision Therapy in Divergence Insufficiency Esotropia

Purpose : This case report describes the successful results of vision therapy (VT) in divergence insufficiency esotropia (DI). Methods : A 19-year-old woman had diplopia with visual discomfort in daily life. At the first visit, she was judged intermittent DI with distance diplopia from binocular visual function tests. The VT program was designed to improve the patient’s negative fusional vergence including focus control, coordination training, ocular movement training, and visual function tests such as refraction, eye deviation, fusional ability, vergence facility, convergence near point, Bagolini lens test, Worth 4 dot test, and stereoacuity. Results : The deviation of eyes changed from 16 prism diopter(△) esotropia to 3 △ esophoria at distance after 9 months. At near, the deviation also changed from 7△ esotropia to 1 △ esophoria after VT. Fusional ability improved from X/4/1 to X/4/3 at distance and from BI X/8/2 to BI X/16/14 at near after VT of 9 months. Homonymous diplopia improved to single binocular vision by Bagolini striated glasses test. In the Bagolini striated glasses test, diplopia that appeared before VT was improved to single vision at all distances after training. The diplopia at distance, which complained severely at the first visit, gradually improved over the 9 months of VT, resulting in a stable single binocular vision. Conclusion : The binocular functions of the DI were successfully improved after VT of 9 months.

Young patients with divergence insufficiency related to excessive near work

ABSTRACT The purpose of this study is to explore the relationships between excessive near work and divergence insufficiency esotropia in young adults. A prospective study described a series of young patients with divergence insufficiency esotropia related to excessive near work between 2012 and 2017. The medical records of twelve young patients with divergence insufficiency esotropia and a history of excessive near work were reviewed, and the duration of near work, angle of primary position deviations at distance and at near, and angle of primary position deviations after refraining from near work for 3 months were analyzed. All patients with divergence insufficiency esotropia (age range: 21–35 years) showed an initial esodeviation ranging from 18 to 35 prism diopters for distance fixation and ranging from 8 to 20 prism diopters for near. Neurological evaluation in all cases was normal. Myopic refractive errors were detected in twelve patients. Every patient persisted near work for more than 6 h a day over a period of several months (minimum 4 months). Reductions in esodeviation were noted in twelve patients after refraining from near work for more than 3 months. Only one patient was diplopia free in all positions of gaze. The remaining eleven patients were treated successfully, six with prisms and five with surgery. They were all orthophoric and demonstrated restored binocularity at the post-treatment examinations. Our findings suggested that excessive near work might influence the development of divergence insufficiency esotropia in young adults. Refraining from excessive near work could decrease the degree of esodeviation in these patients.

A prospective observational study of adult divergence insufficiency esotropia

This study was designed to assess treatment outcomes for adult onset divergence insufficiency distance esotropia.

Wright central plication of lateral rectus versus standard medial rectus recession in adult divergence insufficiency esotropia

Wright central plication is a new minimally invasive tightening procedure. We compare outcomes of lateral rectus central plication (LRCP) to standard medial rectus recession (MRR) in the treatment of diplopia associated with adult divergence insufficiency esotropia (ADIE).

Wright central plication of lateral rectus versus standard medial rectus recession in adult divergence insufficiency esotropia

Wright central plication is a minimally invasive tightening procedure described for the first time by Wright and colleagues in 2012. We compare outcomes of lateral rectus central plication (LRCP) to medial rectus recession (MRR) in the treatment of adult divergence insufficiency esotropia (ADIE). A retrospective chart review of 30 consecutive patients with ADIE, who underwent either LRCP or MRR between 2010 and 2015 was performed. age ≥45years, LRCP or MRR surgery fixed suture technique, esotropia (ET) at least 10Δ greater at distance than at near, subjective diplopia at distance, fusion at near fixation, follow-up of at least 6months. Primary outcome was postoperative single binocular vision. Secondary outcome was postoperative deviation of <5Δ. A total of 28 patients (15 females) met inclusion criteria: 15 had LRCP and 13 MRR. Primary outcome of no diplopia was not significantly different between LRCP and MRR group having a success rate of 93.3% versus 92.3%, respectively (P≤0.01). Secondary outcome of a deviation of ≤5Δ at distance was better in the LRCP group than the MRR group (15/15 vs 11/13 [P≥0.01]). One patient in LRCP group had an early overcorrection corrected by in-office suture lysis. Both procedures had excellent primary outcomes eliminating diplopia in over 90% of cases. The LRCP group had statistically better postoperative alignment of <5Δ. The Wright LRCP has the advantage of being minimally invasive, semi-reversible, vessel sparing, and can be done with topical anesthesia.

Adult divergence insufficiency esotropia: a comparison of lateral rectus resection, medial rectus recession, and miniplication of lateral rectus

Purpose The aim of this study was to compare the outcomes and efficacy of three surgical procedures for correction of adult divergence insufficiency esotropia: lateral rectus resection (LRR), medial rectus recession (MRR), and Wright lateral rectus miniplication (LRMP). Patients and methods A retrospective study was conducted on 22 patients with adult divergence insufficiency esotropia who were operated between 2012 and 2016; eight of them underwent LRR, six underwent MRR, and eight underwent LRMP. Their age ranged from 45 to 68 years. Esotropia was at least 10Δ greater at distance than at near. All patients did not have significant esotropia at near [0–6 prism diopter (PD)] with fusion at near; all of them complained of diplopia for far with no underlying neurological diseases. The mean follow-up period was 24 (12–40) months. Achieving single vision at far and postoperative deviation of up to 5 PD was considered a successful result. Results Age at presentation was 45–68 years, with mean age of 56.8±7.7 years. All the cases underwent bilateral surgeries. In group LRR, the preoperative angle of deviation at far was 20.5±5.8 prism diopter(PD) and for near was 2.9±2.4 PD. In group MRR, the preoperative angle of deviation at far was 21.7±6.1 PD and for near was 3.5±2.8 PD. In group LRMP, the preoperative angle of deviation at far was 21.4±8.5 PD and for near was 3.1±2.7 PD. Postoperative, no cases of diplopia were reported along the follow-up period in groups MRR and LRMP, whereas one case of the eight cases of group LRR showed diplopia. The postoperative angles for far in LRR, MRR, and LRMP groups were 2.38±2.1, 2.5±2.3, and 2.25±1.8 PD, respectively. Conclusion The three procedures had excellent outcomes in eliminating diplopia and postoperative alignment, but LRMP has the advantage to be vessel sparing, less invasive, reversible, and being able to be done with topical anesthesia.

Adult-onset chronic divergence insufficiency esotropia: clinical features and response to surgery

To analyze the clinical and demographic features and surgical outcomes of a series of patients with adult-onset chronic divergence insufficiency esotropia to investigate novel associations of this condition with race, sex, and surgical dose-response. The medical records from a single practice were retrospectively reviewed to identify patients with adult-onset chronic divergence insufficiency esotropia who underwent strabismus surgery over a 12-year period. Demographic, clinical, surgical, and outcome data were analyzed to determine statistically significant findings with respect to race, sex, and surgical results. A total of 27 patients (all white; 23 females) were identified. The average age was 72years. All patients underwent medial rectus recession bilaterally or unilaterally. The dose-response to surgery (1.6(Δ)/mm) was significantly less than that predicted by standard surgical nomograms; however the individual dose-responses varied directly with preoperative angle. Adult-onset chronic divergence insufficiency esotropia occurs predominantly in white women in our experience. Medial rectus recession is an effective surgical treatment when augmented recession amounts are employed. The findings that surgical dose-response was relatively low but increased with preoperative angle suggest a mixed mechanism of chronic lateral rectus weakness combined with reduced medial rectus elasticity.

Surgical treatment of divergence insufficiency esotropia

Several surgical protocols for divergence insufficiency pattern of esotropia (DPE) have been reported. We aim to compare the effectiveness of isolated unilateral medial rectus (MR) recession with unilateral MR recession–lateral rectus (LR) resection.

Evaluation and Prism Management of Divergence Insufficiency Esotropia

An esodeviation that is greater at distance than near in an adult patient requires a full sensorimotor exam to rule out any cofounding neurological conditions. Many etiologies are described in the literature to cause an esodeviation that is greater at distance than near in adult patients and some exist in conjunction with a neurological condition. However, many adult patients present to the adult strabismus clinic with no other findings on exam and have a purely benign divergence insufficiency esotropia. A review of the literature on divergence insufficiency reveals a few attempts of classifying these entities, but none have been completely accepted.Recently benign non-neurological divergence insufficiency esotropia has been described as a resulting condition due to a mechanical etiology. Currently, the literature only describes a couple of different etiologies.Regardless of the etiology, these patients are quite symptomatic and present to the adult strabismus clinic with various complaints and require a thorough examination. The primary focus of the exam is to first rule out the need for further neurological work-up, but secondly, to also determine the best treatment option for the patient. To determine the best treatment plan, a thorough evaluation, including a sensorimotor exam with proper testing, can help. Many of these patients do very well with base-out prism management; however, some have decompensated to a larger angle and prefer surgical intervention. However, the focus of this paper will be on nonsurgical prism management of patients with divergence insufficiency that is not associated with any neurological disorder.

Divergence Insufficiency Esotropia: Surgical Treatment

Divergence insufficiency esotropia, or acquired comitant esotropia that is at least 10Δ larger at distance than at near, is most often seen in older adults, and may also be known as “age-related distance esotropia.” Surgical treatment is often indicated for patients who do not tolerate prism therapy, or for those with large angles of esotropia. Surgical treatments have evolved with our understanding of the disease-state. Currently, accepted treatments include lateral rectus resection and medial rectus recession. These surgeries can be performed unilaterally or bilaterally. New surgical techniques such as lateral rectus equatorial myopexy are under investigation and may hold promise as future therapies.

Characteristics and surgical results in patients with age-related divergence insufficiency esotropia

To describe the clinical characteristics and surgical outcomes of a group of patients at least 40 years of age with adult-onset divergence insufficiency esotropia. The medical records of consecutive adult patients diagnosed with divergence insufficiency between 1977 and 2011 were retrospectively reviewed. Clinical features evaluated included age at diagnosis, visual acuity, primary position deviations at distance and near, treatment offered, postsurgical deviations, and presence of neurological diagnosis based on medical history. A total of 85 patients (52 females [61%]) were identified. The mean age at diagnosis was 74years. The mean visual acuity in the better-seeing eye was 20/23; in the worse-seeing eye, 20/27. The mean initial esodeviation was 12(Δ) at distance and 5.4(Δ) at near. Seven patients (8%) had been diagnosed with neurological disease and 5 with bilateral abducens nerve pareses without limitation of abduction. Therapeutic prism was used by 60 patients (69%). Bilateral medial rectus muscle recessio (mean, 4.3 mm per muscle) was performed on 37 patients. The average postoperative deviations were 0.6(Δ) of esodeviation at distance and 3(Δ)of exodeviation at near. Few patients with age-related distance esotropia have accompanying neurological disease. Bilateral medial rectus muscle recessions effectively reduced esotropia at distance, with a slight tendency for overcorrection at near.

Divergence Insufficiency Esotropia Is a Misnomer—Reply

We thank Mittelman for his thoughtful comments emphasizing points that he has previously published.1 We agree that the terms divergence paralysis esotropia (DPE) and divergence insufficiency esotropia are misnomers. In our article, we noted the existence of multiple terms for this form of strabismus and that we had used the term DPE to permit convenient reference to the prior literature.2 We further agree with Mittelman that the term age-related distance esotropia (ARDE) is better suited than the foregoing terms to describe small-angle distance esotropia in older patients. However, is ARDE the optimal term for the field to adopt for future use? Changes in nomenclature are difficult owing to factors such as a large existing literature using older terms and the association of older terms with presumed pathophysiological mechanisms that may still be embraced by a large number of clinicians.3 Optimal terminology should be descriptive of findings when pathophysiological mechanisms are unknown but should be related to mechanisms when mechanisms have been clearly demonstrated. The controversial consideration is the level of evidence necessary to persuade a professional field of the correctness of a particular mechanism vs that field’s natural reticence to change longstanding practice. Even when there is overwhelming evidence of a particular mechanism, professionals tend to change nomenclature only slowly, often as generational replacement limits the rate of paradigm shift.4 In the case of DPE/ARDE, we believe that application of high-resolution magnetic resonance imaging has now unequivocally revealed the mechanism of the strabismus to be an involutional effect of orbital connective tissue degeneration, not a neurological deficit. Even another term, sagging eye syndrome, has been proposed,5 for which DPE/ARDE is only one manifestation to which may be added aponeurotic blepharoptosis and cyclovertical strabismus.6 We recently published findings that patients with DPE/ARDE nearly always have bilateral rupture of the lateral rectus–superior rectus band ligament that supports the lateral rectus muscle, along with lengthening and alteration in the paths of the rectus extraocular muscles.6 These alterations reflect extremes of gradual effects of aging on orbital connective tissues and are not always limited to adults in the age range considered elderly.6 Moreover, acute connective tissue rupture can even produce sudden-onset distance diplopia, simulating a neurological condition. We agree with Mittelman that as our population ages, ophthalmologists will increasingly encounter patients with esotropia limited to distance viewing. Mittelman has correctly recognized that DPE/ARDE is not a neurological disorder but is instead a mechanical disorder, and he has done a service to our patients by emphasizing that it does not involve a neurological deficit of divergence. Now that we know ARDE is one important manifestation of sagging eye syndrome, we agree that it would be appropriate to adopt Mittelman’s suggested term ARDE in future studies.

Comparison of the efficacy of medial rectus recession and lateral rectus resection for treatment of divergence insufficiency

Purpose Surgical approaches for divergence insufficiency esotropia include medial rectus recession and lateral rectus resection. A retrospective chart review compared the efficacy of each. Methods Eighteen patients older than 50 years with divergence insufficiency esotropia who were operated on between 2005 and 2012 by two surgeons were reviewed. Results Nine patients underwent medial rectus recession and nine underwent lateral rectus resection. The average distance esotropia decreased from 19.75 to 3.2 prism diopters in the medial rectus recession group (P = .001) and from 17.7 to 2.6 prism diopters in the lateral rectus resection group (P = .0002). The disparity between distance and near alignment decreased from 7.3 to 3.4 in the medial rectus recession group (P = .019) and from 9 to 5.4 prism diopters in the lateral rectus resection group (P = .004). Conclusions Both medial rectus recession and lateral rectus resection are effective treatment for divergence insufficiency, with both decreasing distance-near disparity.

Progressive cerebellar tonsillar herniation with recurrent divergence insufficiency esotropia

The Chiari malformations are characterized by herniation of posterior fossa contents through the foramen magnum. Chiari I malformation is currently defined as ectopia of the cerebellar tonsils more than 5 mm below the foramen magnum. Extension of the cerebellar tonsils up to 3 mm may be found in the normal population. Although Chiari malformations are congenital, symptoms often do not manifest until the third and fourth decades of life, or even later. Patients usually present with headache, lower cranial nerve palsies, downbeat nystagmus, ataxia, or dissociated anesthesia of the trunk and extremities. Definitive diagnosis is made by magnetic resonance imaging (MRI), which shows the compressed tonsils extending through the foramen magnum into the cervical subarachnoid space. One of the rare presenting signs of Chiari I malformations is acquired esotropia with a divergence insufficiency pattern. We report such a case in which the initial neuroimaging showed tonsillar herniation, but of insufficient magnitude to meet diagnostic criteria for Chiari I malformation. When the strabismus recurred after initially successful eye muscle surgery, follow-up scan showed progressive tonsillar herniation.