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Divergence paralysis — Clinical Guidelines

Overview

Divergence paralysis refers to the impairment of outward eye movements, often associated with cranial nerve palsies or certain pharmacological agents, such as diazepam 6.

Diagnosis

Clinical Presentation: Presence of diplopia, particularly on attempted lateral gaze 6.

Neurological Examination: Focus on cranial nerve function, particularly the abducens nerve (CN VI) 6.

Imaging: Unremarkable cerebrospinal fluid findings and brain CT scans in reported cases 6.

Laboratory Tests: Not typically required unless to rule out other causes 6.

Management

Drug Withdrawal/Adjustment: If drug-induced, discontinue or adjust diazepam dosage 6.

Supportive Measures: Prism glasses or other optical aids to manage diplopia 6.

Surgical Interventions: Consider in cases refractory to conservative management, such as tendon transfers for associated hand paralysis 7 8.

Special Populations

Pregnancy: No specific data provided in the abstracts 1 2 3 4 5 6 7 8.

Pediatrics: No specific data provided in the abstracts 1 2 3 4 5 6 7 8.

Elderly: No specific data provided in the abstracts 1 2 3 4 5 6 7 8.

Comorbidities: Management considerations may include addressing underlying conditions affecting cranial nerve function 6.

Key Recommendations

Evaluate for Drug-Induced Causes: Suspect diazepam or similar agents in cases of acute onset divergence paralysis (Evidence: Weak) 6.

Utilize Supportive Optical Aids: Implement prism glasses or other visual aids to alleviate diplopia symptoms (Evidence: Expert opinion) 6.

Consider Surgical Options for Refractory Cases: Explore surgical interventions like tendon transfers for persistent functional deficits (Evidence: Expert opinion) 7 8.

References

1 Hull DB. When Change Chooses You: My Journey With Paralysis. Clinical obstetrics and gynecology 2024. link 2 Deguchi M, Yokoyama H, Hongu N, Watanabe H, Ogita A, Imai D et al.. Eating Perception, Nutrition Knowledge and Body Image among Para-Athletes: Practical Challenges in Nutritional Support. Nutrients 2021. link 3 Jeoung B, Kim J. Analysis and Evaluation of Nutritional Intake and Nutrition Quotient of Korean Athletes with Disabilities in the Tokyo Paralympic Games. Nutrients 2021. link 4 Bantjes J, Swartz L. Social Inclusion Through Para sport: A Critical Reflection on the Current State of Play. Physical medicine and rehabilitation clinics of North America 2018. link 5 Burkett B. Paralympic sports medicine--current evidence in winter sport: considerations in the development of equipment standards for paralympic athletes. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 2012. link 6 Arai M, Fujii S. Divergence paralysis associated with the ingestion of diazepam. Journal of neurology 1990. link 7 Smith RJ. Indications for tendon transfers to the hand. Hand clinics 1986. link 8 Riordan DC. Intrinsic paralysis of the hand. Bulletin of the Hospital for Joint Diseases Orthopaedic Institute 1984. link 9 Taylor AW, McDonnell E, Royer D, Loiselle R, Lush N, Steadward R. Skeletal muscle analysis of wheelchair athletes. Paraplegia 1979. link

Divergence paralysis