Disorders of Vergence Eye Movements

  • Anthony J. BruneIII
  • Eric R. EggenbergerEmail author
Neurologic Ophthalmology and Otology (R Shin and D Gold, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Neurologic Ophthalmology and Otology


Purpose of review

The purpose of this review is to summarize current understanding regarding disorders of gaze with comitant ocular misalignment at distance or near and a full range of extraocular movement. Emphasis is placed on clinical features that may be used to differentiate underlying neurologic disease from the more common benign causes. The approach to the diagnostic evaluation and treatment is discussed.

Recent findings

Randomized controlled trials and Cochrane review suggest the superiority of formal office-based vision therapy in treating convergence insufficiency in children. Divergence insufficiency in older adults is a common disorder caused by involution of connective tissues in the orbit. In contrast, divergence insufficiency in children may be a harbinger of central nervous system disease, particularly intracranial tumors.


Disorders of vergence are common in pediatric and aging adult populations. Benign causes are common but appropriate history and exam emphasizing ocular motility is essential to rule out more concerning diagnoses. Atypical presentations should prompt comprehensive evaluation including neuroimaging. Treatment of benign causes of vergence abnormalities should have a stepwise approach, beginning with the least invasive available intervention, though some patients may require surgery.


Convergence insufficiency Convergence spasm Divergence insufficiency Diplopia 


Compliance with Ethical Standards

Conflict of Interest

Eric R. Eggenberger and Anthony J. Brune III declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Leigh R, Zee D. The neurology of eye movements. 5th ed. New York: Oxford University Press; 2015.Google Scholar
  2. 2.
    Rouse MWO, Borsting EO, Hyman L, Hussein M, Cotter SAO, Flynn MO, et al. Frequency of convergence insufficiency among fifth and sixth graders. Optom Vis Sci. 1999;76(9):643–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Oguro H, Okada K, Suyama N, Yamashita K, Yamaguchi S, Kobayashi S. Decline of vertical gaze and convergence with aging. Gerontology. 2004;50(3):177–81.CrossRefPubMedGoogle Scholar
  4. 4.
    • Ghadban R, Martinez JM, Diehl NN, Mohney BG. The incidence and clinical characteristics of adult-onset convergence insufficiency. Ophthalmology. 201;122(5):1056–9. This is a population based cohort looking at the natural history of convergence insufficiency in adults.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Convergence Insufficiency Treatment Trial (CITT) Study Group. The convergence insufficiency treatment trial: design, methods, and baseline data. Ophthalmic Epidemiol. 2008;15(1):24–36.CrossRefGoogle Scholar
  6. 6.
    Racette BA, Gokden MS, Tychsen LS, Perlmutter JS. Convergence insufficiency in idiopathic Parkinson’s disease responsive to levodopa. Strabismus. 1999;7(3):169–74.CrossRefPubMedGoogle Scholar
  7. 7.
    Biousse V, Skibell BC, Watts RL, Loupe DN, Drews-Botsch C, Newman NJ. Ophthalmologic features of Parkinson’s disease. Neurology. 2004;62(2):177–80.CrossRefPubMedGoogle Scholar
  8. 8.
    Scheiman M, Cooper J, Mitchell GL, de LP, Cotter S, Borsting E, et al. A survey of treatment modalities for convergence insufficiency. Optom Vis Sci. 2002;79(3):151–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Gallaway M, Scheiman M, Malhotra K. The effectiveness of pencil pushups treatment for convergence insufficiency: a pilot study. Optom Vis Sci. 2002;79(4):265–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Pediatric Eye Disease Investigator Group. Home-based therapy for symptomatic convergence insufficiency in children: a randomized clinical trial. Optom Vis Sci. 2016;93(12):1457–65.CrossRefGoogle Scholar
  11. 11.
    Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. 2008;126(10):1336–49.
  12. 12.
    Scheiman M, Cotter S, Rouse M, Mitchell GL, Kulp M, Cooper J, et al. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. Br J Ophthalmol. 2005 Oct;89(10):1318–23.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Alvarez TL. A pilot study of disparity vergence and near dissociated phoria in convergence insufficiency patients before vs. after vergence therapy. Front Hum Neurosci [Internet]. 2015;9. Available from:
  14. 14.
    Alvarez TL, Jaswal R, Gohel S, Biswal BB. Functional activity within the frontal eye fields, posterior parietal cortex, and cerebellar vermis significantly correlates to symmetrical vergence peak velocity: an ROI-based, fMRI study of vergence training. Front Integr Neurosci. 2014;8:50.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Scheiman M, Gwiazda J, Li T. Non-surgical interventions for convergence insufficiency. In: Cochrane Database of Systematic Reviews [Internet]. John Wiley & Sons, Ltd; 2011. Available from:
  16. 16.
    Teitelbaum B, Pang Y, Krall J. Effectiveness of base in prism for presbyopes with convergence insufficiency. Optom Vis Sci. 2009;86(2):153–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Farid MF, Abdelbaset EA. Surgical outcomes of three different surgical techniques for treatment of convergence insufficiency intermittent exotropia. Eye Lond Engl. 2017;32(4):693–700. Scholar
  18. 18.
    Donahue SP. Pediatric strabismus. N Engl J Med. 2007;356(10):1040–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Rutstein RP. Update on accommodative esotropia. Optometry. 2008;79(8):422–31.CrossRefPubMedGoogle Scholar
  20. 20.
    Dagi LR, Chrousos GA, Cogan DC. Spasm of the near reflex associated with organic disease. Am J Ophthalmol. 1987;103(4):582–5.CrossRefPubMedGoogle Scholar
  21. 21.
    Fekete R, Baizabal-Carvallo JF, Ha AD, Davidson A, Jankovic J. Convergence spasm in conversion disorders: prevalence in psychogenic and other movement disorders compared with controls. J Neurol Neurosurg Psychiatry. 2012;83(2):202–4.CrossRefPubMedGoogle Scholar
  22. 22.
    • Kaski D, Bronstein AM. Chapter 30 - Functional eye movement disorders. In: Hallett M, Stone J, Carson A, editors. Handbook of clinical neurology. Elsevier; 2016. p. 343–51. (Functional Neurologic Disorders; vol. 139). Available from: This is a recent review of functional eye movements, including convergence spasm.
  23. 23.
    Kaski D, Bronstein AM, Edwards MJ, Stone J. Cranial functional (psychogenic) movement disorders. Lancet Neurol. 2015;14(12):1196–205.CrossRefPubMedGoogle Scholar
  24. 24.
    Laria C, Merino-Suárez ML, Piñero DP, Gómez-Hurtado A, Pérez-Cambrodí RJ. Botulinum toxin as an alternative to treat the spasm of the near reflex. Semin Ophthalmol. 2015;30(5–6):393–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Hyun HJ, Chung US, Chun BY. Early resolution of convergence spasms following the addition of antipsychotic medications. Korean J Ophthalmol. 2011;25(1):66–8.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Kaczmarek BB, Dawson E, Lee JP. Convergence spasm treated with Botulinum toxin. Strabismus. 2009;17(1):49–51.CrossRefPubMedGoogle Scholar
  27. 27.
    Rhatigan M, Byrne C, Logan P. Spasm of the near reflex: a case report. Am J Ophthalmol Case Rep. 2017;6:35–7.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Griffin JF, Wray SH, Anderson DP. Misdiagnosis of spasm of the near reflex. Neurology. 1976;26(11):1018–20.CrossRefPubMedGoogle Scholar
  29. 29.
    •• Kaas BM, Zee DS, Kheradmand A, Gold DR. Midbrain infarction resulting in bilateral pseudoabducens palsies. The Neurologist. 2017;22(3):72–6. This is a recent presentation of a case with a detailed discussion of proposed pathophysiology and involved anatomy.CrossRefPubMedGoogle Scholar
  30. 30.
    Pullicino P, Lincoff N, Truax BT. Abnormal vergence with upper brainstem infarcts: pseudoabducens palsy. Neurology. 2000;55(3):352–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Ghasemi M, Riaz N, Bjornsdottir A, Paydarfar D. Isolated pseudoabducens palsy in acute thalamic stroke. Clin Imaging. 2017;43:28–31.CrossRefPubMedGoogle Scholar
  32. 32.
    Gomez CR, Gomez SM, Selhorst JB. Acute thalamic esotropia. Neurology. 1988;38(11):1759–62.CrossRefPubMedGoogle Scholar
  33. 33.
    Choi K-D. Specificity of “peering at the tip of the nose” for a diagnosis of thalamic hemorrhage. Arch Neurol. 2004;61(3):417–22.CrossRefPubMedGoogle Scholar
  34. 34.
    Anlıaçık S, Uca AU, Kozak HH, Akpınar Z. A very rare paroxysmal symptom in multiple sclerosis: convergence spasm. Am J Emerg Med. 2016;34(1):117.e5–6.CrossRefGoogle Scholar
  35. 35.
    Postert T, McMonagle U, Büttner T, Pöhlau D, Meves S, Przuntek H. Paroxysmal convergence spasm in multiple sclerosis. Acta Neurol Scand. 1996 Jul 1;94(1):35–7.CrossRefPubMedGoogle Scholar
  36. 36.
    Özçelik P, Tanriverdizade T, Men S, Akdal G. Convergence spasm due to aquaporin-positive neuromyelitis optica spectrum disorder. eNeurologicalSci. 2017;7:7–8.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Shabbir S, Tong O, Gluck L, Robbins M. Convergence spasm in Wernicke encephalopathy. The Neurohospitalist. 2018;8(1):NP1–2.CrossRefPubMedGoogle Scholar
  38. 38.
    Moster ML, Hoenig EM. Spasm of the near reflex associated with metabolic encephalopathy. Neurology. 1989;39(1):150.CrossRefPubMedGoogle Scholar
  39. 39.
    Weber KP, Thurtell MJ, Halmagyi GM. Teaching NeuroImage: convergence spasm associated with midbrain compression by cerebral aneurysm. Neurology. 2008;70(15):e49–50.CrossRefPubMedGoogle Scholar
  40. 40.
    Shahar E, Andraus J. Near reflex accommodation spasm: unusual presentation of generalized photosensitive epilepsy. J Clin Neurosci. 2002;9(5):605–7.CrossRefPubMedGoogle Scholar
  41. 41.
    Liu GT, Hertle RW, Quinn GE, Schaffer DB. Comitant esodeviation resulting from neurologic insult in children. J AAPOS. 1997;1(3):143–6.CrossRefPubMedGoogle Scholar
  42. 42.
    • Gilbert AL, Koo EB, Heidary G. Evaluation and management of acute acquired comitant esotropia in children. Semin Ophthalmol. 2017;32(1):8–13. This is a recent review of acute acquired comitant esoptropia, including clinical features indicating underlying neurologic disease and a discussion of factors to consider when considering neuroimaging.CrossRefPubMedGoogle Scholar
  43. 43.
    •• Helena B, Troels V. Acute acquired comitant esotropia of childhood: a classification based on 48 children. Acta Ophthalmol (Copenh). 2015;93(6):568–74. This case series identified the typical features of children with benign acute acquired comitant esotropia and those who had underlying neurologic disease. This information should be integrated into diagnostic decision makingCrossRefGoogle Scholar
  44. 44.
    Schwartz MA, Selhorst JB, Ochs AL, Beck RW, Campbell WW, Harris JK, et al. Oculomasticatory myorhythmia: a unique movement disorder occurring in Whipple’s disease. Ann Neurol. 1986 Dec;20(6):677–83.CrossRefPubMedGoogle Scholar
  45. 45.
    Averbuch-Heller L, Zivotofsky AZ, Remler BF, Das VE, Dell’Osso LF, Leigh RJ. Convergent-divergent pendular nystagmus: possible role of the vergence system. Neurology. 1995;45(3 Pt 1):509–15.CrossRefPubMedGoogle Scholar
  46. 46.
    Mossman SS, Bronstein AM, Gresty MA, Kendall B, Rudge P. Convergence nystagmus associated with Arnold-Chiari malformation. Arch Neurol. 1990;47(3):357–9.CrossRefPubMedGoogle Scholar
  47. 47.
    Thurtell MJ, Joshi AC, Leone AC, Tomsak RL, Kosmorsky GS, Stahl JS, et al. Crossover trial of gabapentin and memantine as treatment for acquired nystagmus. Ann Neurol. 2010;67(5):676–80.PubMedPubMedCentralGoogle Scholar
  48. 48.
    Chaudhuri Z, Demer JL. Sagging eye syndrome: connective tissue involution as a cause of horizontal and vertical strabismus in older patients. JAMA Ophthalmol. 2013;131(5):619–25.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Bothun ED, Archer SM. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. J Am Assoc Pediatr Ophthalmol Strabismus. 2005;9(1):3–6.CrossRefGoogle Scholar
  50. 50.
    • Ridley-Lane M, Lane E, Yeager LB, Brooks SE. Adult-onset chronic divergence insufficiency esotropia: clinical features and response to surgery. J Am Assoc Pediatr Ophthalmol Strabismus. 2016;20(2):117–20. This is a retrospective review looking at the clincial features, treatment approaches and outcomes for patients with divergence insufficiency.CrossRefGoogle Scholar
  51. 51.
    Haller T. Evaluation and prism management of divergence insufficiency esotropia. Am Orthopt J. 2015;65(1):40–3.CrossRefPubMedGoogle Scholar
  52. 52.
    Breidenstein BG, Robbins SL, Granet DB, Acera EC. Comparison of the efficacy of medial rectus recession and lateral rectus resection for treatment of divergence insufficiency. J Pediatr Ophthalmol Strabismus. 2015;52(3):173–6.CrossRefPubMedGoogle Scholar
  53. 53.
    Wright KW, Corradetti G. Wright central plication of lateral rectus versus standard medial rectus recession in adult divergence insufficiency esotropia. J AAPOS. 2017;21(2):94–6.CrossRefPubMedGoogle Scholar
  54. 54.
    • Chaudhuri Z, Demer JL. Long-term surgical outcomes in the sagging eye syndrome. Strabismus. 2018;26(1):6–10. This retrospective study looked at twenty years of patients with sagging eye syndrome and their post-operative natural history. Progression or recurrence over time supports the proposed mechanism.CrossRefPubMedGoogle Scholar
  55. 55.
    Lim L, Rosenbaum AL, Demer JL. Saccadic velocity analysis in patients with divergence paralysis. J Pediatr Ophthalmol Strabismus Thorofare. 1995;32(2):76–81.Google Scholar
  56. 56.
    • Hüfner K, Frenzel C, Kremmyda O, Adrion C, Bardins S, Glasauer S, et al. Esophoria or esotropia in adulthood: a sign of cerebellar dysfunction? J Neurol. 2015;262(3):585–92. A discussion of divergence insufficiency in patients with cerebellar disease and the underlying pathophysiologic mechanisms.CrossRefPubMedGoogle Scholar
  57. 57.
    Versino M, Hurko O, Zee DS. Disorders of binocular control of eye movements in patients with cerebellar dysfunction. Brain J Neurol. 1996;119(Pt 6):1933–50.CrossRefGoogle Scholar
  58. 58.
    Herlihy EP, Phillips JO, Weiss AH. Esotropia greater at distance: children vs adults. JAMA Ophthalmol. 2013;131(3):370–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of NeurologyJohns Hopkins UniversityBaltimoreUSA
  2. 2.Departments of Ophthalmology and NeurologyMayo Clinic FloridaJacksonvilleUSA

Personalised recommendations