Randomized controlled trials and Cochrane review suggest the superiority of formal office-based vision therapy in treating convergence insufficiency in children. Divergence insufficiency in older adults is a common disorder caused by involution of connective tissues in the orbit. In contrast, divergence insufficiency in children may be a harbinger of central nervous system disease, particularly intracranial tumors. Disorders of vergence are common in pediatric and aging adult populations. Benign causes are common but appropriate history and exam emphasizing ocular motility is essential to rule out more concerning diagnoses. Atypical presentations should prompt comprehensive evaluation including neuroimaging. Treatment of benign causes of vergence abnormalities should have a stepwise approach, beginning with the least invasive available intervention, though some patients may require surgery.

Background: Because there are no head-to-head studies of the efficacy of surgical options in the treatment of medicallyintractable idiopathic intracranial hypertension (IIH), procedure selection is often based on expected complications. Cerebrospinal fluid (CSF) diversion by shunting has been reported to have a 23%-67% rate of shunt failure. But thesefigures derive from small cohorts or studies that do not separate the complication rates of the different shunt options-ventriculoperitoneal (VP), lumboperitoneal (LP), and ventriculoatrial (VA). The complication rate of LP shunts seems to be higher than that for VP shunts, the procedure currently in widest use. Our experience with VP shunts for IIH over the past decades suggests that the complication rate for that option is lower than reported series would suggest. Methods: Retrospective single-institutional study using a search engine that finds all text mentions of particular terms. We searched for the terms ("IIH" OR "Idiopathic intracranial hypertension" OR "PTC OR "pseudotumor") AND ("VP Shunt" OR "ventriculoperitoneal") over the period 1998 to 2018. From 490 "hits," only 32 patients met entry criteria: diagnosis of IIH confirmed at our institution, including examination in a neuro-ophthalmology clinic showing papilledema, elevated opening pressure on lumbar puncture or a consistently elevated intraparenchymal pressure on Codman intracranial pressure (ICP) monitoring, neuroimaging and CSF studies consistent with a diagnosis of IIH, and at least 1 year of follow-up in our neuroophthalmology or neurosurgery clinics. Results: Shunt failures occurred in 6 (18.7%) of 32 patients, which included elevated ICP due to obstruction or discontinuity of the shunt, over-drainage, infection of the shunt system, or intractable abdominal pain or infection. None of these failures caused permanent worsening of vision, neurologic morbidity, or death. But they entailed considerable medical care. Placement of VP shunts also aroused patient fear of complications, precipitating 38 emergency visits in 14 patients for "false alarms."Conclusions: In this series of 32 patients, the largest retrospective study of VP shunts for IIH, there was an 18.7% failure rate, lower than previously published smaller series have disclosed. But among patients who suffered complications, a saga of intensive medical care often occurred. Placement of the shunt also aroused patient fear of complications, leading to many medical encounters required to rule out complications.

The evaluation of the dizzy patient is complicated by many common pitfalls. The patient's description of symptoms and the standard neurologic examination are often nonspecific or unrevealing, and neuroimaging is most often normal. Over the past several years, research has demonstrated that a refocusing of history taking results in more reliable and diagnostically helpful information. This can guide a targeted expansion of the exam, often with an emphasis on eye movements.

Normal vision requires coordination of precisely controlled and coordinated eye movements and normal function of a large cortical and subcortical sensory network. Given the required precision of the system and wide anatomic distribution of the motor and sensory visual systems, vision can be disrupted by a variety of central and peripheral nervous system disorders. While many of these may be relatively benign or have no proven therapy, several may be isolated presentations or harbingers of more serious neurologic conditions. Both monocular and binocular vision losses may be isolated presentations of stroke or its equivalent. Other etiologies of monocular vision loss may represent the initial presentation of potentially disabling conditions. Binocular diplopia, caused by impaired movement of one or both eyes, may represent a condition with no acute therapy and a benign natural history, or a progressive potentially life-threatening syndrome. Most people are heavily reliant upon vision, so that even a subtle change in vision due to disturbed afferent or efferent pathways is invariably noticed, and presentation to the emergency department for eye symptoms is common. The accurate evaluation of these patients in the acute setting is essential to identify the patients requiring immediate testing or treatment.