divergence insufficiency
An inward deviation of the eyes that is larger at distance than at near. The patient may see double for distant objects and single for near ones1.
It is a low AC/A pattern. The esophoria at distance is high, fusional divergence at distance is reduced, and the near esophoria is small2,3. Base-out prism is the first-line treatment.
More detail
In older adults most cases are now understood as part of sagging eye syndrome, the age-related distance esotropia caused by stretching of the connective tissue bands between the extraocular muscles4.
Sources (7)
- von Noorden and Campos, Binocular Vision and Ocular Motility, ch. 22
- Scheiman and Wick, Clinical Management of Binocular Vision, ch. 9
- AOA, Care of the Patient with Accommodative and Vergence Dysfunction
- Kanski, Clinical Ophthalmology (2024), ch. 18
- Rutstein, R., Daum, K. (1997). Anomalies of Binocular Vision: Diagnosis & Management, Mosby.
- Mohney, B. G. (2014). Common forms of childhood esotropia. Ophthalmology, 121(1), 376-380.
- Lavrich, J. B. (2010). Divergence insufficiency revisited: a review of its characteristics and interventions. Optometry and Vision Science, 87(7), 513-520.
Reviewed October 2026