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Divergence Insufficiency

Esotropia: Surgical Treatment

Stacy L. Pineles, M.D., M.S.

ABSTRACT
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 re-
section and medial rectus recession. These surgeries can
be performed unilaterally or bilaterally. New surgical tech-
niques such as lateral rectus equatorial myopexy are under
investigation and may hold promise as future therapies.

INTRODUCTION imply insufficient divergence amplitudes


as the cause of this disease-state. Addition-
Divergence insufficiency esotropia is ally, the pattern of divergence insufficiency
most commonly defined as an acquired co- esotropia can be seen in a wide range of
mitant esotropia that is at least 10Δ larger ages, and likely has a differing underlying
at distance than at near.1 Recently, the etiology in young patients compared with
term “divergence insufficiency” has been older adults.2 Given that the pattern of
challenged, since alternate etiologies have divergence insufficiency esotropia is more
been introduced that do not necessarily often related to a neurological problem
when it occurs in young children, the fo-
cus of this discussion will be on divergence
From the Jules Stein Eye Institute, University of California—
insufficiency pattern esotropia in older
Los Angeles, Los Angeles, California. adults, also known as “age-related distance
esotropia.”
Requests for reprints should be addressed to: Stacy L.
Pineles, M.D., M.S., Jules Stein Eye Institute, UCLA, 100
Stein Plaza, Los Angeles, CA 90095. TYPICAL PRESENTATION
Presented as part of a Symposium of the Joint Meeting of the
American Orthoptic Council, the American Association of
Divergence insufficiency esotropia typi-
Certified Orthoptists, and the American Academy of Oph- cally presents in older individuals. In
thalmology, Chicago, Illinois, October 20, 2014. a study of the Rochester Epidemiology
© 2015 Board of Regents of the University of Wisconsin System, American Orthoptic Journal, Volume 65, 2015, ISSN 0065-955X, E-ISSN 1553-4448

American Orthoptic Journal 35


DIVERGENCE INSUFFICIENCY

Project, divergence insufficiency esotropia have attempted to localize this “divergence


was present in 10.6% of adult strabismus center” to various locations in the pons,
cases, at a median age of 74 years (range midbrain, or cranio-vertebral junction.7-11
19-92 years).3 In the same population, This theory was never fully accepted, and
as age increased, the proportion of adult new theories were later introduced. In
strabismus patients with divergence insuf- 2006, Guyton introduced the idea that in-
ficiency also increased, with a significant creased convergence tonus over time may
age trend for both men and women.3 lead to medial rectus muscle shortening,
The typical presentation in an older in- thereby causing esotropia to be worse at
dividual is one of gradual or subacute on- distance.12 Recently, a paradigm shift has
set of horizontal diplopia. Initially, most been suggested by Chaudhuri and Demer13
patients only notice intermittent horizon- in which they assert that the underlying
tal binocular diplopia at long distances, etiology of “divergence insufficiency eso-
such as in the theater or while driving. tropia” (which they and Mittleman14 also
Over a period of several months, the dip- call “adult onset age-related distance eso-
lopia becomes more constant and is noticed tropia”) may be due to mechanical changes
while driving, watching television, and in in the orbital connective tissues. As they
other long-distance vision situations. Typi- describe, orbital connective tissues degen-
cally, patients note that they do not have erate with age similarly to other periocular
any diplopia at near. The deviation at dis- structures. In 2013, Chaudhuri and Demer
tance is most often in the range of 10-20Δ presented a series of twenty-eight elderly
and at near, patients are often orthotropic patients with acquired diplopia suspected
or may have a controlled esophoria.4 The to be due to orbital connective tissue de-
esotropia at distance is horizontally co- generation, or “sagging eye syndrome.”13
mitant and may be associated with either Magnetic resonance imaging of these pa-
normal or reduced divergence amplitudes.4 tients revealed significant lateral rectus
The remainder of the neurological exami- pulley displacement inferiorly due to de-
nation should be normal, without any cra- generation of the lateral rectus-superior
nial neuropathies or abduction deficits. rectus band. With inferior displacement of
It is important to rule out a neurological both lateral rectus muscles, patients are
cause of esotropia, as unilateral and bilat- left with diminished abducting power in
eral abducens palsies can present with a the lateral rectus, and a divergence insuf-
similar pattern. The presence of lateral ficiency pattern of esotropia.
incomitance or other associated cranial
neuropathies should prompt a work-up for SURGICAL TREATMENT
neurological abnormalities.2, 5 In addition,
one should consider ruling out thyroid eye Patients with divergence insufficiency
disease and myasthenia gravis when mak- pattern of esotropia can be treated sur-
ing this diagnosis. gically if they do not respond to or do not
desire prism therapy. The surgical treat-
ETIOLOGY ment of divergence insufficiency esotropia
can be approached by several differing
Our understanding of the underlying techniques, all of which have satisfactory
pathogenesis of this disorder is currently in results. As the etiology of divergence in-
evolution. Historically, divergence insuffi- sufficiency is further elucidated, surgical
ciency was thought to be due to inadequate treatments may evolve as well, in order
functioning of a “divergence center” in the to target the underlying pathological fea-
brain.6 Several investigators in the past tures.

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PINELES

Lateral Rectus Resection of them had a satisfactory result with no


diplopia and no residual esotropia. Four
Lateral rectus muscle resection has been patients required prism treatment to
advocated by many authors.6, 15-18 Propo- achieve diplopia-free vision, and two pa-
nents of lateral rectus muscle resection tients required additional surgery for re-
claim that this surgical approach is more current esotropia.
likely to improve the distance esotropia
without causing convergence insufficiency Medial Rectus Recession
at near. One of the earliest case series was
in 1982 by Krohel et al.19 This series in- As the understanding of divergence in-
cluded eleven patients undergoing bilat- sufficiency advanced, some surgeons be-
eral lateral rectus resection. Their success gan to advocate the use of medial rectus
rate could be considered low, with only 4 recession as an alternative treatment. In
of 11 patients achieving satisfactory re- 2000, Thomas reported seven patients
sults. In 1995, Lim et al. reported five pa- with divergence insufficiency pattern eso-
tients undergoing bilateral lateral rectus tropia, albeit a younger population (aged
resection, with satisfactory results of no 7-41 years).21
over-corrections at near.16 Thacker et al. Prompted by questions related to the
described the largest series of patients collapse of distance-near deviations, Ar-
with long-term follow-up who underwent cher studied the effect of medial vs. lat-
lateral rectus resection.15 In their group of eral rectus muscle surgery for strabismic
twenty-nine patients, twenty-four under- deviations with distance- near incomi-
went bilateral lateral rectus resection and tance.22 Evaluating 267 patients who un-
five underwent unilateral lateral rectus derwent medial rectus recessions for eso-
resection. The amount of resection ranged tropia, he found an exoshift of only 9% at
from 4.5 to 7.5 mm for unilateral surgery near overall. Interestingly, he reported
for deviations of 6-18Δ and 3-7 mm for bi- that a larger preoperative distance-near
lateral surgery for deviations of 10-30Δ. incomitance was associated with greater
Their patients all had satisfactory results, reduction in the incomitance irrespective
with no patients initially over-corrected or of which muscles underwent surgery. He
requiring additional prisms. However, they concluded that distance-near incomitance
had a recurrence rate of almost 7% over might not be an important indicator of
their mean follow-up period of 39 months.15 which muscles should be operated. This
Various authors have also reported re- study was preceded by Archer’s group’s
sults for unilateral lateral rectus resection report23 of a series of eight patients aged
only. Hoover et al. reported the results of 44-77 years who underwent bilateral me-
six patients undergoing a single lateral dial rectus recessions ranging from 3 to
rectus resection for deviations of 12-20Δ.17 4.25 mm for distance esotropias of 12-35Δ.
Their results were deemed satisfactory Of their eight patients, three required
and there were no over-corrections re- prisms postoperatively, but the remain-
ported. In 2013, Stager et al. reported a ing five patients had satisfactory results.
series of fifty-seven patients aged 54-89 Although they did not report symptomatic
years undergoing unilateral lateral rectus convergence insufficiency, the mean near
resection for distance esotropia deviations deviation postoperatively was 1.8Δ of exo-
of 5-30Δ.20 Surgery was performed using phoria (range 8Δ exophoria to 10Δ esotropia
local anesthesia on the non-dominant eye at near). They also reported a collapse of
with the amount of resection ranging from the distance-near deviation from 15Δ pre-
5 to 9 mm. Of the fifty-seven patients, 86% operatively to 5Δ postoperatively.

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DIVERGENCE INSUFFICIENCY

Most recently, Chaudhuri and Demer24 lateral rectus muscle pulley displacement.
reported twenty-four patients with diver- Surgical treatment is often successful and
gence paralysis pattern of esotropia and may include unilateral or bilateral medial
compared the results of those undergoing rectus recession or lateral rectus resection.
lateral rectus resection (n = 8) to those un- Complications such as recurrence of dis-
dergoing medial rectus recession (n = 16). tance esotropia or new-onset convergence
Patients undergoing medial rectus reces- insufficiency are rare, and patients are
sion had their surgery performed mostly generally satisfied. Lateral rectus equato-
under topical anesthesia. In both groups, rial myopexy may be used in the future for
there was no postoperative diplopia or con- this category of patients, but this technique
vergence insufficiency, with follow-up time is still under investigation.
ranging from 8.5 to 40 months. The authors
concluded that medial rectus recession is
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American Orthoptic Journal 39

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