Divergence Insufficiency - Binocular Vision Anomaly

A case report on Divergence Insufficiency in Binocular Vision Anomaly

1. CASE PRESENTATION Vipin.G M.Optom

2. A 32 year male Reported to our clinic with complaint of Double vision since 1 year, slowly increased, Consulted E/W and prescribed Prism glasses and not used, Hence came for second opinion C/o Double vision binocularly ,Horizontal splitting of image all the time with glasses

3. PROCEDURE FINDINGS PREVIOUS GLASS PRESCRIPTION OD : -3.25DS/-1.25DCX100 Single vision OS : -3.00DS/-1.25DCX90 Single vision VISUAL ACITY AIDED OD : 6/6, N6@30-35cm OS : 6/6, N6@30-35cm

4. ORTHOPTIC EVALUATION PROCEDURE FINDINGS COVER TEST Distance : Esophoria Near : Esophoria PBCT Distance : Horizontal 30Prism/BI Near : Horizontal 16Prism/BI AC/A Method Gradient 2:1 NPA OD : 9cm/11.76D OS : 8cm/11.76D OU : 8.5cm/11.76D NRA/PRA NRA : +2.50D PRA :-0.75D

5. PROCEDURE FINDINGS ACCOMMODATIVE RESPONSE Method : Open field OD : +1.25D OS : +1.25D Remarks : OU : High Lag of Accommodation FUSIONAL VERGENCE Method : Step Distance Near NFV : x/diplopia/ NFV : x/4/2 PFV : x/diplopia/ PFV : x/40/35 VERGENCE FACILITY Prism power 12BO/3BI CPM : 5 Remarks : Difficulty in Fusing BI ACCOMMODATIVE FACILITY +2.OOD OD : 8CPM OS : 6CPM OU:0CPM Remarks : Fails Minus lens

6. IMPRESSION DIAGNOSIS : Divergence Insufficiency Prism trial done Able to fuse with 4BO prism in either eye Saladin card tried, complaints of diplopia DIAGNOSIS : Alternating esotropia

7. ADVICE First line management of DI, prism glasses can be prescribe Can start using prism glasses, Review after 1 month to BVC for vision therapy to improve divergence amplitude

8. POST PROCEDURE FINDINGS STEREOPSIS Randot RDS : 125 Arc sec Animals : 100 Arc sec Wirt circles :12.5 Arc sec COVER TEST Distance : Esophoria Near : Esophoria PBCT Distance : Horizontal 12Prism/BO Near : Horizontal 12Prism/BO NPC ACC.TARGET BREAK : TTN R/G TARGET BREAK : >3OCM OBJECTIVE BREAK : TTN NPA Method : Push up OD : 8CM/11.11D OS :10CM/11.11D OU :9CM/11.11D

9. PROCEDURE FINDINGS ACCOMMODATIVE RESPONSE Method : Open field OD : +1.00D OS : +1.00D Remarks : High lag of Accommodation FUSIONAL VERGENCE Method : Step DISTANCE NEAR NFV : X/2/1 NFV : X/4/2 PFV :X/>40/ PFV : X/>40/ VERGENCE FACILITY Prism power 12BO/3BI CPM : 14 Remarks : Equally fused BO and BI ACCOMMODATIVE FACILITY +2.OOD OD : 12CPM OS : 0CPM OU : 5CPM

10. IMPRESSION Prism glasses prescribed in last visit No complaints of diplopia with Prism glasses DIAGNOSIS :Esophoria

11. ADVICE IVT REMARKS No complaint of diplopia in free spaces Continue Therapy for another 2 sessions

12. Divergence Insufficiency Divergence insufficiency is the least common type of vergence anomaly where the patients complaint of the following -

13. S ymptoms of Divergence insufficiency Intermittent diplopia Headache Eyestrain Difficulty focusing from far to near Nausea Dizziness Motion sickness Sensitivity to light

14. Divergence insufficiency sign s Esophoria greater at distance Low ac/a Decreased nfv at distance Comitant deviation Low pra Difficulty in clearing minus lens during binocular accommodative facility

15. Treatment of Divergence insufficiency Refractive error correction Prism Vision therapy : ivt , hvt

16. Take home message The main trouble a patient with divergence insufficiency will face is diplopia which has to be managed by using prisms.

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