Convergence excess associated with neurological diseases: surgical treatment

Background: Lesions of the supranuclear pathways for convergence control can lead to convergence deficit or convergence excess. Whereas pathophysiology of acquired convergence excess is now fully covered in the literature, no specific paper on its surgical treatment could be found. Patients: Cases 1 and 2: Parinaud's syndrome with convergence excess in attempted upgaze (+ convergence retraction nystagmus and Vlth nerve palsy in case 2). Case 3: opsoclonus and convergence excess due to hysterical conversion after head trauma. Case 4: acquired nystagmus, accommodative spasm due to hyperopia. Case 5: functional spasm of the near reflex (dubious medical history of multiple sclerosis). Case 6: medial recti palsy after artificial divergence surgery for congenital nystagmus, substitutive convergence. Cases 3 and 5 were not operated on, recession of the four horizontal recti in case 4, recession of the lateral recti in case 6, complex surgical procedure in cases 1 and 2. Discussion: The following guidelines are suggested: Functional spasm of the near reflex: medical therapy. Organic spasm of the near reflex: retroequatorial myopexia on the medial recti. Parinaud's syndrome with convergence excess (spastic) or convergence retraction nystagmus (rhythmic): restoration of upgaze motility with a vertical Kestenbaum-type procedure, retroequatorial myopexia if insufficient. Thalamic esotropia (tonic): botulinum toxin injection, recession of the medial recti if insufficient, Conclusion: Convergence excess associated with neurological diseases should be looked for since it can be improved by effective surgical procedures.