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Divergence Insufficiency


A sensorimotor anomaly of the binocular visual system characterized by a tendency for the eyes to over-converge at distance.


The signs and symptoms associated with divergence insufficiency may include, but are not limited to, the following:

  1. reduced efficiency and productivity/diminished accuracy/inconsistent work product
  2. diminished performance with time on task
  3. diplopia (ICD: H53.2)/tendency to close or cover one eye
  4. inaccurate/inconsistent depth judgment
  5. pain in or around the eye (ICD: H57.13)
  6. avoidance of visually demanding tasks
  7. spatial disorientation
  8. photophobia (ICD: H53.149)
  9. inconsistent visual attention/concentration and/or awareness
  10. dizziness/vertigo (ICD: R42); especially during/after sustained visually demanding tasks
  11. motion sickness (ICD: T75.3XXA)
  12. incoordination/clumsiness (ICD: R27.8)
  13. awareness of the need for volitional control of eyes
  14. asthenopia (ICD: H53.149)
  15. headaches (ICD: R51)
  16. eye turn, deviation (ICD: H51.9)
  17. transpositions when copying from one source document to another
  18. transient blurred vision


Divergence insufficiency encompasses one or more of the following diagnostic findings:

  1. higher than expected esophoria at distance
  2. low AC/A ratio
  3. low distance negative fusional vergence ranges/ facility/ flexibility
  4. eso fixation disparity at distance



The doctor of optometry determines appropriate diagnostic and therapeutic modalities, and frequency of evaluation and follow-up, based on the urgency and nature of the patient’s conditions and unique needs. Vision disorders that are not totally cured through vision therapy may still be ameliorated with significant improvement in visual function and quality of life. The management of the case and duration of treatment would be affected by:

  1. the severity of symptoms and diagnostic factors, including onset and duration of the problem
  2. the complications of associated visual conditions
  3. implications of patient’s general health, cognitive development, physical development, and effects of medications taken
  4. etiological factors
  5. extent of visual demands placed upon the individual
  6. patient compliance and involvement in the prescribed therapy regimen
  7. type, scope, and results of prior interventions


Some cases are successfully managed by the prescription of therapeutic lenses and/or prisms. Most divergence insufficiency cases require optometric vision therapy, which incorporates the prescription of specific treatments in order to:

  1. reduce esophoria
  2. enhance and develop fusional vergence ranges, stability, and flexibility
  3. enhance accommodative/convergence relationships
  4. integrate binocular function with information processing
  5. integrate binocular skills with accurate motor responses
  6. integrate binocular skills with other sensory skills (vestibular, kinesthetic, tactile, and auditory)
  7. increase visual stamina/integrate newly established skills with information processing


The following treatment ranges are provided as a guide. Treatment duration will depend upon the particular patient’s condition and associated factors. When duration of treatment beyond these ranges is required, documentation of the medical necessity for additional treatment services may be warranted for third-party claims processing and review purposes.

  1. The most commonly encountered divergence insufficiency usually requires 35 hours of office
  2. Divergence insufficiency may require substantially more office therapy, if complicated by associated factors such as cerebral vascular accident, head trauma, and systemic and/or neurologic conditions.


At the conclusion of the active treatment regimen, periodic follow-up evaluation is required. Should signs, symptoms, or other diagnostic factors recur, further therapy may be medically necessary. Therapeutic lenses may be prescribed during or at the conclusion of active vision therapy to assist in the maintenance of long-term stability.