Acquired Synergistic Divergence: Contrary to Current Literature

The British and Irish Orthoptic Journal
Martha Waters


Current literature reports synergistic divergence as a rare, congenital ocular motility pattern associated with adduction palsy. Its mechanism has been likened to Duane's syndrome, and some suggest it be referred to as Duane's Type 4 (Gupta et al. 2010; Schliesser et al. 2016; Wilcox et al. 1981; Khan et al. 2016). There are no published reports of synergistic divergence as an acquired condition, making this case report seemingly the first of its kind. This case report describes an 18-year-old female who presented to clinic in 2013 with symptoms of diplopia and left eye turning outwards. Orthoptic assessment and MRI confirmed a third nerve palsy secondary to cavernous sinus schwannoma. Further monitoring showed progression of the cranial nerve palsy but a stable schwannoma and no aberrant regeneration noted in five years of follow up. The patient was treated with multiple botulinum toxin injections and had squint correction surgery in 2017. Seven months later, synergistic divergence was first noted and remained stable in all following assessments. While the aetiology of acquired synergistic divergence in this case is unclear, we can be confident it is unlikely to be of congenital origin as it was not noted until adulthood and a...Continue Reading


Mar 1, 1978·Archives of Ophthalmology·J D TrobeJ D Post
Jan 1, 1981·American Journal of Ophthalmology·L M WilcoxG M Breinin
Jan 7, 2000·Strabismus·G N ShuttleworthR A Harrad
Feb 25, 2005·Journal of AAPOS : the Official Publication of the American Association for Pediatric Ophthalmology and Strabismus·Edward G BuckleyTimothy Saunders
Nov 17, 2007·Neurosurgical Focus·Eric D Weber, Steven A Newman
Jul 7, 2009·Investigative Ophthalmology & Visual Science·Darren T OystreckThomas M Bosley
Oct 1, 2009·Canadian Journal of Ophthalmology. Journal Canadien D'ophtalmologie·Caroline BelangerLuis H Ospina
Jul 7, 2016·Journal of AAPOS : the Official Publication of the American Association for Pediatric Ophthalmology and Strabismus·Joshua A SchliesserEugene M Helveston
Oct 30, 2016·Journal of AAPOS : the Official Publication of the American Association for Pediatric Ophthalmology and Strabismus·Arif O Khan
Oct 14, 2017·The British Journal of Ophthalmology·Ahmed Awadein, Rasha Hamdallah Zedan

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