Divergence Excess (DE) is a type of eye condition where one eye turns outward more when looking at things far away than when looking at something close. This means that when your child focuses on distant objects, one eye may drift outward, but it stays straight when they look at something up close.

What is Divergence Excess Intermittent Exotropia?

Divergence excess is a form of intermittent exotropia, which means the outward turning of the eye happens only sometimes. For DE to be diagnosed, there needs to be a noticeable difference in how the eyes align when looking at far and near objects—at least a 10 prism diopter difference.

Often, Divergence excess doesn’t show clear signs until a child is around six years old. This delay can make it hard to spot the condition early, which means some children might not get the help they need right away.

If you notice your child’s eye turning outward when they look at a distance, it’s important to have their eyes checked by an eye doctor.

Key characteristics: 

• Most common form of childhood exotropia
• Typically begins in the first few years of life
• More prevalent in females and individuals of African descent
• The outward eye turn is larger when looking far away compared to up close
• When eyes are aligned, patients usually have normal depth perception up close

Prevalence and Demographic Factors

A large 5 year study in Asia found a prevalence of  intermittent esotropia between 3%-5.7%. Divergence excess typically accounts for about 25% of all intermittent esotropia in children, or between .75%-1.4% of children. Studies show a higher prevalence among females (60-70% of cases) and those of African ancestry. The onset of noticeable symptoms often occurs in early childhood, typically before the age of three, which is a critical developmental period for binocular vision.

Common Signs of Divergence Excess

Noticeable eye turn, especially when:

• Tired or ill
• Looking into the distance
• Daydreaming or not focusing on a specific task

Visual discomfort:

• Headaches or eyestrain, particularly after prolonged visual tasks
• Difficulty maintaining focus while reading
• Blurred vision, especially at distance

Adaptation behaviors:

• Closing or covering one eye, especially in bright sunlight
• Head tilting or face turning to compensate for vision problems
• Squinting or rubbing eyes frequently

Binocular vision issues:

• Double vision (diplopia), which may be intermittent
• Difficulty with depth perception, especially at distance
• Clumsiness or poor hand-eye coordination

Reading and learning challenges:

• Losing place while reading
• Difficulty concentrating on near work
• Poor reading comprehension
• Slow reading speed

Psychological impacts:

• Decreased self-esteem due to noticeable eye turn
• Anxiety in social situations
• Frustration with visual tasks
• Avoidance of activities that require good binocular vision

It’s important to note that young children may not be able to articulate these symptoms clearly. Parents and caregivers should be observant of any unusual eye behaviors or complaints.

The Importance of Seeing a Developmental Optometrist

While all eye care professionals can diagnose divergence excess intermittent exotropia, developmental optometrists specialize in how vision develops and how it impacts learning and behavior. 

They are uniquely qualified to:

1. Perform a comprehensive binocular vision assessment
2. Evaluate how the visual system is impacting overall development and learning
3. Prescribe and manage non-surgical treatments, including vision therapy
4. Coordinate care with other healthcare providers and educators

Developmental optometrists take a functional approach to vision, considering not just eyesight, but how the eyes work together and integrate with other sensory systems. This holistic approach is particularly beneficial for children with divergence excess intermittent exotropia, as it addresses both the eye alignment issue and any related visual processing or learning challenges.

What to Expect During a Developmental Vision Evaluation

A comprehensive developmental vision evaluation typically includes:

• Case history: Detailed discussion of symptoms, developmental history, and any academic or behavioral concerns.
• Visual acuity testing: Measuring how clearly each eye can see at various distances.
• Refraction: Determining if there’s a need for glasses to correct nearsightedness, farsightedness, or astigmatism.
• Binocular vision assessment: Evaluating how well the eyes work together, including tests for eye alignment, depth perception, and fusion.
• Ocular motility testing: Assessing the accuracy and smoothness of eye movements.
• Accommodative testing: Checking the eyes’ ability to focus clearly at different distances.
• Visual information processing evaluation: Assessing how the brain interprets and uses visual information.
• Ocular health examination: Checking the overall health of the eyes.

Top Rated Pediatric Eye Doctors in Orange County

At Insight Vision Center Optometry, our pediatric eye care center is led by Dr. Valerie Lam and Dr. Ariel Chen, who bring specialized training in children’s vision to serve families across Orange County. From pediatric eye exams and myopia control to vision therapy and post-concussion care, our practice provides a compassionate, kid-friendly experience. Referrals from Irvine, Santa Ana, Huntington Beach, and beyond are a testament to our advanced technology, knowledgeable doctors, and dedication to children’s eye health.

Vision Therapy in Managing Divergence Excess

Goals of Vision Therapy

Vision therapy is a highly effective, non-surgical treatment option for divergence excess intermittent exotropia. It is a form of physical therapy for the eyes and brain, designed to develop or improve visual skills and abilities, eye coordination, and the eye’s ability to change focus.

Key benefits of vision therapy for divergence excess intermittent exotropia include:

• Improved control of eye alignment: Vision therapy can help patients gain better conscious and unconscious control over their eye position.
• Enhanced binocular vision: Exercises are designed to strengthen the brain’s ability to use both eyes together effectively.
• Increased vergence ranges: Vision therapy can improve the eyes’ ability to turn in (convergence) and out (divergence) together, which is crucial for maintaining alignment.
• Better sensory fusion: Vision therapy often includes activities to enhance the brain’s ability to fuse the images from both eyes into a single, clear picture.
• Improved accommodative (focusing) ability: Many vision therapy programs include exercises to enhance focusing skills, which can indirectly help with eye alignment.
• Long-lasting results: Studies have shown that the effects of vision therapy can last long after the therapy is completed. 
• Non-invasive: Unlike surgery, vision therapy doesn’t carry risks associated with anesthesia or potential surgical complications.
• Skill development: Vision therapy not only treats the eye turn but also develops visual skills that can improve overall visual performance in school, sports, and daily life.
• Customized treatment: Vision therapy programs are tailored to each patient’s specific needs and abilities.

What to Expect During Vision Therapy

A typical vision therapy program for divergence excess intermittent exotropia might include:

• In-office sessions: Weekly or bi-weekly sessions with a vision therapist, usually lasting 45-60 minutes.
• Home exercises: Daily exercises to reinforce skills learned in the office.
• Use of specialized equipment: Such as stereoscopes, prism lenses, and computer programs designed for vision therapy.
• Progress evaluations: Regular assessments to monitor improvement and adjust the therapy program as needed.
• Duration: A full course of therapy typically lasts 6-12 months, depending on the individual case.

Insight Vision Center Optometry, located in Costa Mesa, is a trusted provider of pediatric eye care, specializing in treating divergence excess and other binocular vision challenges. Families from all across Orange County, including Irvine, Huntington Beach, and Santa Ana, rely on our expertise to support their children’s vision health and development.

Treatment Options and Approach

A comprehensive treatment plan for divergence excess intermittent exotropia may include:

1. Glasses or Contacts to Correct underlying refractive error (nearsightedness, farsightedness, or astigmatism).
2. Vision therapy
3. Use of special lenses or prisms
4. Patching or occlusion therapy
5. Surgery

The best treatment approach depends on factors such as the patient’s age, severity of the condition, and symptoms. Often, a combination of approaches yields the best results.

Surgery for Divergence Excess (DE): When is it Needed?

Surgery for Divergence Excess (DE) is considered when a child’s eye turns occur more than half the time during waking hours, affecting daily activities and social interactions. Typically recommended around age three, early surgery helps maintain normal binocular vision and prevent the development of strabismus, which can lead to reduced depth perception.

Indications for Surgery:

• Frequent and persistent eye turns
• Impact on quality of life and self-esteem
• Ineffectiveness of non-surgical treatments

Combining Surgery with Therapy

Surgery alone does not fix the functional issues of DE. Combining it with vision therapy enhances visual performance and eye alignment. Vision therapy should start before or after surgery to improve eye coordination and vergence skills, leading to better long-term outcomes.

When to Seek Professional Help

If you or your child experience any of the following, it’s important to schedule an evaluation with a developmental optometrist:

• Noticeable eye turn, even if it does not occur all the time
• Frequent eye closing or covering, especially in bright light
• Complaints of double vision
• Difficulty with depth perception or clumsiness
• Headaches or eyestrain associated with visual tasks
• Difficulty concentrating on near work or reading
• Underperformance in school or sports that seems inconsistent with overall abilities

Early detection and treatment provide the best opportunity for developing normal binocular vision and preventing long-term visual and developmental issues.

Long-Term Outlook

With appropriate treatment, the prognosis for divergence excess intermittent exotropia is generally good. However, it’s important to understand that:

• Treatment may be ongoing or require periodic “tune-ups”
• Early intervention typically leads to better outcomes
• Some patients may still experience occasional symptoms, especially during times of stress or fatigue
• Regular follow-up with an eye care professional is important to monitor progress and address any changes

 Remember, regular comprehensive eye exams are crucial for all children, even those without obvious symptoms, to ensure optimal visual development and overall well-being. For children with divergence excess intermittent exotropia, these check-ups are even more critical to monitor the condition and adjust treatment as needed.

 By working closely with a developmental optometrist and following through with recommended treatments, most patients with divergence excess intermittent exotropia can achieve improved eye alignment, better binocular vision, and enhanced quality of life.

Comprehensive Care for Divergence Excess in Orange County

At Insight Vision Center Optometry in Costa Mesa, our experienced pediatric eye care team specializes in treating divergence excess and other binocular vision challenges with advanced, personalized solutions. Led by Dr. Lam and Dr. Chen, we provide specialized services, including vision therapy, developmental eye exams, and customized treatment plans to address conditions like divergence excess, amblyopia (lazy eye), and convergence insufficiency. Families from Irvine, Huntington Beach, and Santa Ana rely on our compassionate care and expertise in children’s eye health. Schedule your child’s appointment today by calling us at (714) 942-1361 or book online.