Evaluation and Prism Management of Divergence Insufficiency Esotropia

An esodeviation that is greater at distance than near in an adult patient requires a full sensorimotor exam to rule out any cofounding neurological conditions. Many etiologies are described in the literature to cause an esodeviation that is greater at distance than near in adult patients and some exist in conjunction with a neurological condition. However, many adult patients present to the adult strabismus clinic with no other findings on exam and have a purely benign divergence insufficiency esotropia. A review of the literature on divergence insufficiency reveals a few attempts of classifying these entities, but none have been completely accepted. Recently benign non-neurological divergence insufficiency esotropia has been described as a resulting condition due to a mechanical etiology. Currently, the literature only describes a couple of different etiologies. Regardless of the etiology, these patients are quite symptomatic and present to the adult strabismus clinic with various complaints and require a thorough examination. The primary focus of the exam is to first rule out the need for further neurological work-up, but secondly, to also determine the best treatment option for the patient. To determine the best treatment plan, a thorough evaluation, including a sensorimotor exam with proper testing, can help. Many of these patients do very well with base-out prism management; however, some have decompensated to a larger angle and prefer surgical intervention. However, the focus of this paper will be on nonsurgical prism management of patients with divergence insufficiency that is not associated with any neurological disorder.