Disorders of Vergence Eye Movements
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.
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.
KeywordsConvergence 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.Leigh R, Zee D. The neurology of eye movements. 5th ed. New York: Oxford University Press; 2015.Google Scholar
- 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
- 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. https://doi.org/10.1001/archopht.126.10.1336.
- 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.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: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4515554/.
- 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.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: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006768.pub2/abstract.
- 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: http://www.sciencedirect.com/science/article/pii/B9780128017722000308. This is a recent review of functional eye movements, including convergence spasm.
- 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.•• 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
- 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
- 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.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.• 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