Clinical Manifestations and Prognosis of Convergence Insufficiency after Craniofacial Trauma

Min Ho Shin; Dae Hyun Kim

doi:10.3341/jkos.2015.56.10.1604

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Shin and Kim: Clinical Manifestations and Prognosis of Convergence Insufficiency after Craniofacial Trauma

Original Article

J Korean Ophthalmol Soc 2015;56(10):1604-1609.

Published online: 29 August 2015

DOI: https://doi.org/10.3341/jkos.2015.56.10.1604

Clinical Manifestations and Prognosis of Convergence Insufficiency after Craniofacial Trauma

Min Ho Shin, M.D, Dae Hyun Kim, M.D, PhD

Department of Ophthalmology, Chosun University School of Medicine, Gwangju, Korea

Address reprint requests to Dae Hyun Kim, MD, PhD Department of Ophthalmology, Chosun University Hospital, #365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea Tel: 82-62-220-3190, Fax: 82-62-225-9839 E-mail: eyelovehyun@hanmail.net

‗ This study was presented as an e-poster at the 113th Annual Meeting of the Korean Ophthalmological Society 2015.

‗ This study was supported by research funds from Chosun University Hospital 2015.

Received 12 June 201521 July 2015 Accepted 4 September 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the clinical manifestation and prognosis of convergence insufficiency after craniofacial trauma. Methods: Twelve patients injured by craniofacial trauma were analyzed for the cause of trauma, ocular and accompanied non-ocular symptoms, presence of loss of consciousness, presence of craniofacial fracture and intracranial hemorrhage, treat-ment modality for ocular symptoms, change in strabismic angle and near point of convergence (NPC) after treatment and prog-nosis using clinical records from April 2008 to December 2014.

Results

Traffic accidents (8 patients) were the leading cause of trauma. Near diplopia (11 patients) was the leading type of ocu-lar symptom and other following symptoms included headache, asthenopia and reading difficulty. Ten patients experienced loss of consciousness and craniofacial fracture and intracranial hemorrhage were observed in 7 patients. Intracranial hemorrhage and craniofacial fracture occurred in 3 patients and only 1 patient had neither intracranial hemorrhage nor craniofacial fracture. All 12 patients performed orthoptic exercises, but no improvement of near strabismic angle, NPC and ocular symptoms was observed. However, 4 patients who received surgery demonstrated improvement in near strabismic angle, NPC and ocular symptoms.

Conclusions

Convergence insufficiency after craniofacial trauma occurred by relatively strong traumatic force and had a poor outcome in non-surgical methods such as orthoptic exercise. Surgery was an effective treatment method rather than orthoptic exercise.

Keywords: Convergence insufficiency, Craniofacial trauma, Near point of convergence, Orthoptic exercise, Surgery

References

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Table 1.

Demographics and initial evaluation of 12 patients

Case No.	Sex/ age	Cause of trauma	Ocular symptom	Accompanied non-ocular symptom	LOC duration	Presence of craniofacial fx. and ICH	NPC & near strabismic angle at 1st exam		NPA (cm) (R, L, B)
Case No.	Sex/ age	Cause of trauma	Ocular symptom	Accompanied non-ocular symptom	LOC duration	Presence of craniofacial fx. and ICH	NPC (cm)	Near (PD)	NPA (cm) (R, L, B)
1	M/29	TA	Diplopia at near, asthenopia	Depression, insomnia, dysphasia, hemiplegia	1 hour	Intracerebral hrr.	15	25 RXT	11, 11, 12
2	M/33	TA	Diplopia at near, asthenopia	Depression		30 min	20	25 RXT	14, 14, 14
3	F/14	TA	Diplopia at near		14 days	Frontoparietal fx. & SDH	25	16 XT	10, 10, 10
4	M/14	Sport accident	Diplopia at near, reading difficulty		30 min	Med. orbital wall fx.	15	14 XT
5	M/26	TA	Diplopia at near, asthenopia	Hemiplegia	7 days	Intracerebral hrr.	60	12 XT	11, 11, 12
6	M/22	Assault	Diplopia at near fx.	Depression	0^*	Inf. orbital wall	30	14 XT
7	M/34	TA	Diplopia at near fx.	PTSD	0^*	Maxillozygoma	50	12 XT
8	M/15	Assault	Diplopia at near headache		3 hours	Med. & Inf. orbital wall fx.	90	16 XT	9, 9, 10
9	M/41	TA	Diplopia and headache at near	PTSD	2 hours	Panorbital fx. & EDH	20	12 XT
10	F/46	TA	Headache, reading difficulty	PTSD	3 days	Intracerebral hrr.	50	18 XT
11	M/45	TA	Diplopia at near, reading difficulty		2 hours	SDH	50	12 XT
12	F/53	Slip down	Diplopia at near		1 hour	OMZ fx. & SAH	30	15 XT

LOC = loss of consciousness; fx. = fracture; ICH = intracranial hemorrhage; NPC = near point of convergence; PD = prism diopter; NPA = near point of accommodation; R = right eye; L = left eye; B = both eye; M = male; F = female; TA = traffic accident; hrr. = hemor-rhage; RXT = right eye exodeviation; min = minute; SDH = subdural hematoma; XT = exodeviation; Med. = medial; Inf. = inferior; PTSD = post traumatic stress disorder; EDH = epidural hemorrhage; OMZ = orbitomaxillozygoma; SAH = subarachnoid hemorrhage.

^* Absence of loss of consciousness.

Table 2.

Treatment modality and change of near point of convergence and strabismic angle between initial and final evaluation

Case No.	Initial treatment	Operation	NPC (cm)		Initial angle (PD)		Final angle (PD)
Case No.	Initial treatment	Operation	Initial	Final	Distance	Near	Distance	Near
1	PT	LR rec, MR res OD	15	10	10 XT	25 RXT	8 ET	Ortho
2	PT	1st (LR rec OU)	20	10	10 XT	25 RXT	2 ET	4 XT
		2nd (MR res OU)
3	PT	MR res (slanted) OS	25	8	4 XT	16 XT	Ortho	6 XT
4	PT	MR res (slanted) OS	15	5	Ortho	14 XT	Ortho	Ortho
5	PT		60		Ortho	12 XT
6	PT		30	30	4 XT	14 XT	6 ET	18 XT
7	PT		50	50	Ortho	12 XT	Ortho	12 XT
8	PT & BI prism		90	90	4 XT	16 XT	Ortho	12 XT
9	PT		20	20	4 XT	12 XT	Ortho	12 XT
10	PT & BI prism		50	50	Ortho	18 XT	Ortho	14 XT
11	PT		50	30	Ortho	12 XT	Ortho	12 XT
12	PT		30	30	Ortho	15 XT	Ortho	12 XT

NPC = near point of convergence; PD = prism diopter; PT = pencil push-ups training; LR = lateral rectus muscle; rec = recession; MR = medial rectus muscle; res = resection; OD = oculus dexter; OU = oculus unitas; XT = exodeviation; RXT = right eye exodeviation; ET = esodeviation; Ortho = orthophoria; OS = oculus sinister; BI = base in.

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