Professional Documents
Culture Documents
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.
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
REFERENCES
as effective as lateral rectus resection in
this population of patients. However, they
1. Kirkeby L: Update on divergence insufficiency.
did note larger amounts of recession were Int Ophthalmol Clin 2014; 54:21-31.
required in this population, and suggested 2. Herlihy EP, Phillips JO, Weiss AH: Esotropia
that double the distance angle of esotropia greater at distance: Children vs. adults. JAMA
should be used as the surgical target. Ophthalmol 2013; 131:370-375.
3. Martinez-Thompson JM, Diehl NN, Holmes JM,
Mohney BG: Incidence, types, and lifetime risk
Future Directions of adult-onset strabismus. Ophthalmology 2014;
121:877-882.
Given the advancements in our under- 4. Godts D, Mathysen DG: Distance esotropia in the
standing of this pattern of esotropia, new elderly. Br J Ophthalmol 2013; 97:1415-1419.
surgical techniques will likely be explored 5. Jacobson DM: Divergence insufficiency revis-
ited: Natural history of idiopathic cases and
and reported. Chaudhuri and Demer’s elu- neurologic associations. Arch Ophthalmol 2000;
cidation of the inferiorly displaced lateral 118:1237-1241.
rectus muscle pulley in patients with lat- 6. Bruce GM: Ocular divergence: Its physiology and
eral rectus-superior rectus band degenera- pathology. Arch Ophthalmol 1935; 13:639-660.
tion will likely lead to new techniques ad- 7. Bender MB, Savitsky N: Paralysis of divergence.
Arch Ophthalmol 1940; 23:1046-1051.
dressing this mechanical problem. At the 8. Moller PM: Divergence paralysis. Acta Ophthal-
2014 Jules Stein Eye Institute Apt Meet- mol 1970; 48:325-330.
ing, Dr. Robert Clark presented a series of 9. Stern RM, Tomsak RL: Magnetic resonance im-
patients undergoing lateral rectus equato- ages in a case of “divergence paralysis.” Surv
rial myopexy for sagging eye syndrome/ Ophthalmol 1986; 30:397-401.
10. Schanzer B, Bordaberry M, Jeffery AR, McNeil
age-related distance esotropia.25 Although DE, Phillips PC: The child with divergence pare-
this technique shows promise, it is still un- sis. Surv Ophthalmol 1998; 42:571-576.
der active investigation. 11. Lewis AR, Kline LB, Sharpe JA: Acquired eso-
tropia due to Arnold-Chiari I malformation. J
CONCLUSIONS Neuroophthalmol 1996; 16:49-54.
12. Guyton DL: The 10th Bielschowsky Lecture.
Changes in strabismus over time: The roles of
Divergence insufficiency esotropia may vergence tonus and muscle length adaptation.
be better described as “age-related distance Binocul Vis Strabismus Q 2006; 21:81-92.
esotropia.” The underlying pathogenesis of 13. Chaudhuri Z, Demer JL: Sagging eye syndrome:
this disease entity is still under active in- Connective tissue involution as a cause of hori-
zontal and vertical strabismus in older patients.
vestigation, but may be related to mechani- JAMA Ophthalmol 2013; 131:619-625.
cal factors such as degeneration of the lat- 14. Mittelman D: Age-related distance esotropia. J
eral rectus-superior rectus band leading to AAPOS 2006; 10:212-213.
15. Thacker NM, Velez FG, Bhola R, Britt MT, Rosen- 21. Thomas AH: Divergence insufficiency. J AAPOS
baum AL: Lateral rectus resections in divergence 2000; 4:359-361.
palsy: Results of long-term follow-up. J AAPOS 22. Archer SM: The effect of medial versus lateral
2005; 9:7-11. rectus muscle surgery on distance-near incomi-
16. Lim L, Rosenbaum AL, Demer JL: Saccadic ve- tance. J AAPOS 2009; 13:20-26.
locity analysis in patients with divergence pa- 23. Bothun ED, Archer SM: Bilateral medial rectus
ralysis. J Pediatr Ophthalmol Strabismus 1995; muscle recession for divergence insufficiency pat-
32:76-81. tern esotropia. J AAPOS 2005; 9:3-6.
17. Hoover DL, Giangiacomo J: Results of a single 24. Chaudhuri Z, Demer JL: Medial rectus recession
lateral rectus resection for divergence and par- is as effective as lateral rectus resection in di-
tial sixth nerve paralysis. J Pediatr Ophthalmol vergence paralysis esotropia. Arch Ophthalmol
Strabismus 1993; 30:124-126. 2012; 130:1280-1284.
18. Wiggins RE Jr, Baumgartner S: Diagnosis and 25. Clark R: Lateral rectus equatorial myopexy for
management of divergence weakness in adults. sagging eye syndrome. Leonard Apt Meeting:
Ophthalmology 1999; 106:1353-1356. Advanced Topics in Pediatric Ophthalmology
19. Krohel GB, Tobin DR, Hartnett ME, Barrows NA: and Strabismus; 2014; Jules Stein Eye Institute,
Divergence paralysis. Am J Ophthalmol 1982; University of California, Los Angeles.
94:506-510.
20. Stager DR Sr, Black T, Felius J: Unilateral lateral Key words: esotropia, age-related dis-
rectus resection for horizontal diplopia in adults
with divergence insufficiency. Graefes Arch Clin tance esotropia, diplopia, strabismus
Exp Ophthalmol 2013; 251:1641-1644.