Pencil Push-ups Research Articles

Immediate Effects of Pencil Push-Up Exercise on Visual Accommodation Skills in Amateur Badminton Players: A Randomized Controlled Trial

Background Visual skills are crucial for peak athletic performance, with Visual Accommodation (VA) playing a vital role. However, the immediate effects of interventions on VA in sports remain unclear. Objective To investigate the acute effects of a 10-minute Pencil Push-Up (PPU) exercise on VA skills in amateur badminton players. Methods A two-arm, parallel, randomized controlled trial was conducted with twenty-eight amateur badminton players. Participants were matched by age, duration, and frequency of badminton practice, as well as visual health, and randomly assigned to either a Trained Group (TG) or an untrained group (NT). The TG performed a 10-minute PPU exercise, while the NT rested with closed eyes for the same duration. VA parameters, including Amplitude of Accommodation (AA), Accommodative Facility (AF), and Near Point of Convergence (NPC), were assessed before and after the intervention. Results Significant improvements in AA and AF were observed in the TG from pre- to post-intervention (AA: p < .0001, Cohen's d = 1.68; AF: p < .0001, Cohen's d = 3.10). However, no significant changes were observed in NPC (p= .45, Cohen's d =0.60). Furthermore, the TG exhibited greater improvements in AA and AF compared to the NT at post-intervention (AA: 95%CI= [-2.812 to -0.2314], p = .02; AF: 95%CI= [-8.363 to -3.680], p < .0001). No changes were observed in the NT group. Conclusion A single session of pencil push-up exercise acutely enhanced visual accommodation skills, specifically amplitude of accommodation and accommodative facility, in amateur badminton players. This suggests that visual accommodation training methods like pencil push-ups could improve visual performance in sports. Clinical Trials Registry TCTR20240531002 (https://www.thaiclinicaltrials.org/show/TCTR20240531002).

Comparison of alternate part-time patching and pencil push-up training for patients with intermittent exotropia

BackgroundTo compare the effect of alternate part-time patching and pencil push-up training on control ability in patients with intermittent exotropia.MethodsPatients (3–7 years old) with previously untreated intermittent exotropia were randomly assigned to receive alternate part-time patching, pencil push-up training, or observation. Control ability was assessed using the Office Control Score. Stereoacuity at 40 cm was evaluated with Titmus. Results were compared after a 12-week follow-up.ResultsNinety-two patients (28 in patching, 30 in pencil push-ups, and 34 in observation group) completed 12-week follow-up assessments. Based on 6-point scale, the mean deviation control was significantly better in patching and pencil push-up group after 12 weeks at distance (P = 0.002 and 0.026, respectively). Furthermore, there were greater control changes in patching and pencil push-up groups in comparison with observation group from baseline to 12 weeks (P<0.001; P = 0.003, respectively). After 12 weeks of treatment, stereoacuity and stereoacuity changes were not significantly different between either the intervention group or control group (P = 0.140 and 0.393, respectively).ConclusionsBased on the common office control scale, alternate part-time patching and pencil push-up training were effective treatment strategies for intermittent exotropia.

Home- and Office-Based Vergence and Accommodative Therapies for Treatment of Convergence Insufficiency in Children and Young Adults: A Report by the American Academy of Ophthalmology

To review home- and office-based vergence and accommodative therapies for treatment of convergence insufficiency (CI) in children and young adults up to 35 years of age. Literature searches were conducted through October 2020 in the PubMed database for English-language studies. The combined searches yielded 359 abstracts, of which 37 were reviewed in full text. Twelve of these were considered appropriate for inclusion in this assessment and assigned a level of evidence rating by the panel methodologist. Of the 12 studies included in this assessment, 8 were graded as level I evidence, 2 were graded as level II evidence, and 2 were graded as level III evidence. Two of the level I studies included older teenagers and young adults; the remainder of the studies exclusively evaluated children. Two randomized controlled trials found that office-based vergence and accommodative therapies were effective in improving motor outcomes in children with symptomatic CI. However, the studies reported conflicting results on the efficacy of office-based therapy for treating symptoms of CI. Data were inconclusive regarding the effectiveness of home-based therapies (including pencil push-ups and home computer therapy) compared with home placebo. In young adults, office-based vergence and accommodative therapies were not superior to placebo in relieving symptoms of CI. Level I evidence suggests that office-based vergence and accommodative therapies improve motor outcomes in children with symptomatic CI, although data are inconsistent regarding symptomatic relief.Evidence is insufficient to determine whether home-based therapies are effective.

Interventions for convergence insufficiency: a network meta-analysis.

Interventions for convergence insufficiency: a network meta-analysis.

DO ORTHOPTIC EXERCISES HAVE ANY INFLUENCE ON CHILDREN AND ADOLESCENTS DIAGNOSED WITH CONVERGENCE INSUFFICIENCY AND ATTENTION DEFICIT/HYPERACTIVITY DISORDER?

SUMMARYThe aim was to determine whether improvement of near point of convergence (NPC) and binocular vision after orthoptic exercises had any impact on children and adolescents diagnosed with attention deficit/hyperactivity disorder (ADHD) and convergence insufficiency (CI). In this clinical trial, 50 children and adolescents aged 6 to 18 years diagnosed with ADHD and CI received orthoptic therapy that included home-based exercises (pencil push-ups and stereograms) and office-based therapy on synoptophore. Binocular vision and NPC were measured before, during and after therapy. Study subjects showed significant improvement (p<0.05) in NPC and binocular vision after orthoptic exercises. We found statistically significant correlation between stereovision improvement (Lang I) and near point of convergence, suggesting that improvement of binocular function is possible in children with ADHD and CI. Our results showed that NPC enhancement improved stereovision in patients with ADHD. Since progress of binocular function has positive effect on near work and diminishes visual symptoms in children and adolescents with ADHD and CI, it might be reasonable to suppose that orthoptic therapy helps these children improve concentration as well. Further studies are needed to determine whether it might have positive impact on attention.

2017 Glenn A. Fry Award Lecture: Establishing an Evidence-based Literature for Vision Therapy - A 25-year Journey.

In this article, I summarize the 2017 Glenn A. Fry Award Lecture and my journey from student, to clinician, to optometric educator, and finally researcher/vision scientist. Although content for many years of teaching and practicing vision therapy, the era of evidence-based health care created a level of discomfort, as it became evident that my area of interest, vision therapy, had minimal quality evidence to support its use. Joining forces with a group of exceptional colleagues, we established the Convergence Insufficiency Treatment Trial Investigator group, and we were able to achieve funding from the National Eye Institute for multiple randomized clinical trials. The results of our studies demonstrate that vision therapy is an effective treatment option for convergence insufficiency in children, and office-based therapy is more effective than home-based therapy. These studies also demonstrated that home-based pencil push-ups commonly used by both optometrists and ophthalmologists are no more effective than placebo therapy. More recently, working in a new arena of objective recording of vergence, accommodative, and versional eye movements, my research has demonstrated that objective outcome measures of vergence are feasible for future randomized clinical trials. In pilot studies with both naturally occurring convergence insufficiency and concussion-related convergence insufficiency, statistically significant and clinically meaningful changes have been found in both disparity vergence peak velocity and response amplitude after office-based vision therapy. With new evidence about the high prevalence of concussion-related convergence insufficiency, there is much work to be accomplished to study the effectiveness of vision therapy for convergence insufficiency as well as the underlying mechanisms for how and why vision therapy is effective.

Near Point of Convergence after Concussion in Children.

To determine the incidence of abnormal near point of convergence (NPC) after acute concussion in pediatric patients and to describe the clinical course of such patients. A retrospective cohort study of 275 pediatric patients 5 to 18 years of age presenting to a tertiary care children's hospital subspecialty concussion program with a new concussion between July 1, 2014 and June 30, 2015 was conducted. Sixty-seven out of 275 pediatric patients presenting to a subspecialty concussion referral program were found to have abnormal NPC on physical examination as measured by an accommodative rule. Twenty-six (46%) patients recovered with standard clinical care over a median time frame of 4.5 weeks (range 1-18), including a brief period of cognitive and physical rest followed by gradual return to school and physical activities without any formal interventions. An additional 23 (41%) patients recovered a median of 11 weeks post-injury after referral for formal vestibular therapy, including interventions for abnormal convergence, such as Brock string and pencil pushups. Seven (13%) patients with persistent abnormal NPC and concomitant symptoms that necessitated referral for formal office-based vision therapy with developmental optometry recovered a median of 23 weeks post-injury and a median of 16 weeks after referral to vision therapy. Assessment for NPC is a diagnostic entity that warrants consideration in children with concussion. Concussion questionnaires may not be sensitive to detect vision symptoms in children, making an accurate assessment for convergence important in the evaluation of concussion. Some children with abnormal NPC will recover without any formal intervention after concussion; however, a subset of patients with persistent abnormal NPC after concussion may benefit from interventions including vestibular and/or vision therapy.

Vision Therapy and Computer Orthoptics: Evidence-Based Approach to Use in Your Practice

Convergence insufficiency is a commonly seen disorder of the vergence system. Its clinical characteristics and symptoms have been well described by Duane and von Graefe. Laboratory studies have clarified the vergence pathway, which includes a bi-phasic response. Several recent randomized controlled trials show the effectiveness of common treatment modalities, including pencil pushups, computer orthoptics, and office-based therapy. More studies are needed to investigate the possibility that other treatments may treat convergence insufficiency in a more profound way by acting on other parts of the vergence system.

Short-term adaptation of accommodation, accommodative vergence and disparity vergence facility

Previous studies have found that subjects can increase the velocity of accommodation using visual exercises such as pencil push ups, flippers, Brock strings and the like and myriad papers have shown improvement in accommodation facility (speed) and sufficiency (amplitude) using subjective tests following vision training but few have objectively measured accommodation before and after training in either normal subjects or in patients diagnosed with accommodative infacility (abnormally slow dynamics). Accommodation is driven either directly by blur or indirectly by way of neural crosslinks from the vergence system. Until now, no study has objectively measured both accommodation and accommodative–vergence before and after vision training and the role vergence might play in modifying the speed of accommodation. In the present study, accommodation and accommodative–vergence were measured with a Purkinje Eye Tracker/optometer before and after normal subjects trained in a flipper-like task in which the stimulus stepped between 0 and 2.5diopters and back for over 200 cycles. Most subjects increased their speed of accommodation as well as their speed of accommodative vergence. Accommodative vergence led the accommodation response by approximately 77ms before training and 100ms after training and the vergence lead was most prominent in subjects with high accommodation and vergence velocities and the vergence leads tended to increase in conjunction with increases in accommodation velocity. We surmise that volitional vergence may help increase accommodation velocity by way of vergence–accommodation cross links.

Improvement in Academic Behaviors After Successful Treatment of Convergence Insufficiency

To determine whether treatment of symptomatic convergence insufficiency (CI) has an effect on Academic Behavior Survey (ABS) scores. The ABS is a six-item survey developed by the Convergence Insufficiency Treatment Trial Group that quantifies the frequency of adverse school behaviors and parental concern about school performance on an ordinal scale from 0 (never) to 4 (always) with total scores ranging from 0 to 24. The ABS was administered at baseline and after 12 weeks of treatment to the parents of 218 children aged 9 to 17 years with symptomatic CI, who were enrolled in the Convergence Insufficiency Treatment Trial and randomized into (1) home-based pencil push-ups; (2) home-based computer vergence/accommodative therapy and pencil push-ups; (3) office-based vergence/accommodative therapy with home reinforcement; and (4) office-based placebo therapy with home reinforcement. Participants were classified as successful (n = 42), improved (n = 60), or non-responder (n = 116) at the completion of 12 weeks of treatment using a composite measure of the symptom score, nearpoint of convergence, and positive fusional vergence. Analysis of covariance methods were used to compare the mean change in ABS between response to treatment groups while controlling for the ABS score at baseline. The mean ABS score for the entire group at baseline was 12.85 (SD = 6.3). The mean ABS score decreased (improved) in those categorized as successful, improved, and non-responder by 4.0, 2.9, and 1.3 points, respectively. The improvement in the ABS score was significantly related to treatment outcome (p < 0.0001), with the ABS score being significantly lower (better) for children who were successful or improved after treatment as compared to children who were non-responders (p = 0.002 and 0.043, respectively). A successful or improved outcome after CI treatment was associated with a reduction in the frequency of adverse academic behaviors and parental concern associated with reading and school work as reported by parents.

Non-surgical interventions for convergence insufficiency.

Convergence insufficiency is a common eye muscle co-ordination problem in which the eyes have a strong tendency to drift outward (exophoria) when reading or doing close work. Symptoms may include eye strain, headaches, double vision, print moving on the page, frequent loss of place when reading, inability to concentrate, and short attention span. To systematically assess and synthesize evidence from randomized controlled trials (RCTs) on the effectiveness of non-surgical interventions for convergence insufficiency. We searched The Cochrane Library, MEDLINE, EMBASE, Science Citation Index, the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov ) on 7 October 2010. We manually searched reference lists and optometric journals. We included RCTs examining any form of non-surgical intervention against placebo, no treatment, sham treatment, or each other. Two authors independently assessed eligibility, risk of bias, and extracted data. We performed meta-analyses when appropriate. We included six trials (three in children, three in adults) with a total of 475 participants. We graded four trials at low risk of bias.Evidence from one trial (graded at low risk of bias) suggests that base-in prism reading glasses was no more effective than placebo reading glasses in improving clinical signs or symptoms in children.Evidence from one trial (graded at high risk of bias) suggests that base-in prism glasses using a progressive addition lens design was more effective than progressive addition lens alone in decreasing symptoms in adults. At three weeks of therapy, the mean difference in Convergence Insufficiency Symptoms Survey (CISS) score was -10.24 points (95% confidence interval (CI) -15.45 to -5.03).Evidence from two trials (graded at low risk of bias) suggests that outpatient (or office-based as used in the US) vision therapy/orthoptics was more effective than home-based convergence exercises (or pencil push-ups as used in the US) in children. At 12 weeks of therapy, the mean difference in change in near point of convergence, positive fusional vergence, and CISS score from baseline was 3.99 cm (95% CI 2.11 to 5.86), 13.13 diopters (95% CI 9.91 to 16.35), and 9.86 points (95% CI 6.70 to 13.02), respectively.In a young adult population, evidence from one trial (graded at low risk of bias) suggests outpatient vision therapy/orthoptics was more effective than home-based convergence exercises in improving positive fusional vergence at near (7.7 diopters, 95% CI 0.82 to 14.58), but not the other outcomes.Evidence from one trial (graded at low risk of bias) comparing four interventions, also suggests that outpatient vision therapy/orthoptics was more effective than home-based computer vision therapy/orthoptics in children. At 12 weeks, the mean difference in change in near point of convergence, positive fusional vergence, and CISS score from baseline was 2.90 cm (95% CI 0.96 to 4.84), 7.70 diopters (95% CI 3.94 to 11.46), and 8.80 points (95% CI 5.26 to 12.34), respectively. Evidence was less consistent for other pair-wise comparisons. Current research suggests that outpatient vision therapy/orthoptics is more effective than home-based convergence exercises or home-based computer vision therapy/orthoptics for children. In adult population, evidence of the effectiveness of various non-surgical interventions is less consistent.

Effectiveness of home-based pencil push-ups (HBPP) for patients with symptomatic convergence insufficiency.

PurposeTo report the effectiveness of home-based pencil push-ups (HBPP) therapy for patients with symptomatic convergence insufficiency.MethodsData was collected prospectively on 16 patients who were diagnosed with convergence insufficiency beginning in January 2009. The study group was composed of ten male and six female patients. The duration of symptoms, refractive error, distant and near deviation angles, and near point of convergence (NPC) prior to and after 12 weeks of HBPP therapy were measured in all patients.ResultsThe mean age of the patients was 19.3 years. The mean deviation angle of exophoria was 3 prism diopters (PD) at distant and 11.2 PD at near. The mean value of NPC prior to HBPP therapy was 36.3 cm; however, the near point of accommodation was within the normal range. After 12 weeks of HBPP therapy, the mean deviation angle of exophoria decreased to orthophoric at distant and 4 PD at near. The mean value of NPC decreased to 14.4 cm.ConclusionsTwelve weeks of HBPP therapy appears to be an easy, cost-free and effective therapy for patients with symptomatic convergence insufficiency.

Convergence insufficiency and its current treatment

Considerable uncertainty and controversy has existed concerning the management of convergence insufficiency. Only recently there have been significant scientific studies published that compare the effectiveness of the commonly prescribed treatments. This paper reviews the most recent research and literature on convergence insufficiency and its treatment. The first large-scale placebo-controlled, randomized clinical trials to study the various treatments of convergence insufficiency have recently been published. Current research compares the effectiveness of base-in prism glasses, pencil push-ups, and vision therapy in reducing the signs and symptoms of convergence insufficiency and suggests that orthoptic therapy is the most efficacious treatment for convergence insufficiency. Intensive orthoptic therapy is the treatment of choice for convergence insufficiency. Pencil push-ups and use of accommodative targets have a role in the treatment of convergence insufficiency when used as part of a more intensive orthoptic program. Base-in prism glasses should be reserved for reduction of symptoms in the presbyopic population.

Vision Therapy/Orthoptics for Symptomatic Convergence Insufficiency in Children: Treatment Kinetics

To evaluate the kinetics of change in symptoms and signs of convergence insufficiency (CI) during 12 weeks of treatment with commonly prescribed vision therapy/orthoptic treatment regimens. In a randomized clinical trial, 221 children aged 9 to 17 years with symptomatic CI were assigned to home-based pencil push-ups (HBPP), home-based computer vergence/accommodative therapy and pencil push-ups (HBCVAT+), office-based vergence/accommodative therapy with home reinforcement (OBVAT), or office-based placebo therapy with home reinforcement (OBPT). Symptoms and signs were measured after 4, 8, and 12 weeks of treatment. The outcome measures were the mean CI Symptom Survey (CISS), near point of convergence (NPC), positive fusional vergence (PFV), and proportions of patients who were classified as successful or improved based on a composite measure of CISS, NPC, and PFV. Only the OBVAT group showed significant improvements in symptoms between each visit (p < 0.001). Between weeks 8 and 12, all groups showed a significant improvement in symptoms. Between-group differences were apparent by week 8 (p = 0.037) with the fewest symptoms in the OBVAT group. For each group, the greatest improvements in NPC and PFV were achieved during the first 4 weeks. Differences between groups became apparent by week 4 (p < 0.001), with the greatest improvements in NPC and PFV in the OBVAT group. Only the OBVAT group continued to show significant improvements in PFV at weeks 8 and 12. The percentage of patients classified as "successful" or "improved" based on our composite measure increased in all groups at each visit. The rate of improvement is more rapid for clinical signs (NPC and PFV) than for symptoms in children undergoing treatment for CI. OBVAT results in a more rapid improvement in symptoms, NPC and PFV, and a greater percentage of patients reaching pre-determined criteria of success when compared with HBPP, HBCVAT+, or OBPT.

Long-Term Effectiveness of Treatments for Symptomatic Convergence Insufficiency in Children

To assess the long-term stability of improvements in symptoms and signs in 9- to 17-year-old children enrolled in the Convergence Insufficiency Treatment Trial who were asymptomatic after treatment for convergence insufficiency. Seventy-nine patients who were asymptomatic after a 12-week therapy program for convergence insufficiency were followed for 1 year [33/60 in office-based vergence/accommodative therapy (OBVAT), 18/54 in home-based pencil push-ups (HBPP), 12/57 in home-based computer vergence/accommodative therapy and pencil push-ups (HBCVAT+), and 16/54 in office-based placebo therapy (OBPT)]. Symptoms and clinical signs were measured 6 months and 1 year after completion of the 12-week therapy program. The primary outcome measure was the mean change on the Convergence Insufficiency Symptom Survey (CISS). Secondary outcome measures were near point of convergence, positive fusional vergence at near, and proportions of patients who remained asymptomatic or who were classified as successful or improved based on a composite measure of CISS, near point of convergence, and positive fusional vergence. One-year follow-up visit completion rate was 89% with no significant differences between groups (p = 0.26). There were no significant changes in the CISS in any treatment group during the 1-year follow-up. The percentage who remained asymptomatic in each group was 84.4% (27/32) for OBVAT, 66.7% (10/15) for HBPP, 80% (8/10) for HBCVAT+, and 76.9% (10/13) for OBPT. The percentage who remained either successful or improved 1-year posttreatment was 87.5% (28/32) for OBVAT, 66.6% (10/15) for HBPP, 80% (8/10) for HBCVAT+, and 69.3% (9/13) for OBPT. Most children aged 9 to 17 years who were asymptomatic after a 12-week treatment program of OBVAT for convergence insufficiency maintained their improvements in symptoms and signs for at least 1 year after discontinuing treatment. Although the sample sizes for the home-based and placebo groups were small, our data suggest that a similar outcome can be expected for children who were asymptomatic after treatment with HBPP or HBCVAT+.

Treatment of Convergence Insufficiency in Childhood: A Current Perspective

To provide a current perspective on the management of convergence insufficiency (CI) in children by summarizing the findings and discussing the clinical implications from three recent randomized clinical trials in which we evaluated various treatments for children with symptomatic CI. We then present an evidence-based treatment approach for symptomatic CI based on the results of these trials. Finally, we discuss unanswered questions and suggest directions for future research in this area. We reviewed three multi-center randomized clinical trials comparing treatments for symptomatic (CI) in children 9 to 17 years old (one study 9 to 18 years old). Two trials evaluated active therapies for CI. These trials compared the effectiveness of office-based vergence/accommodative therapy, office-based placebo therapy, and home-based therapy [pencil push-ups alone (both trials), home-based computer vergence/accommodative therapy, and pencil push-ups (large-scale study)]. One trial compared the effectiveness of base-in prism reading glasses to placebo reading glasses. All studies included well-defined criteria for the diagnosis of CI, a placebo group, and masked examiners. The primary outcome measure was the Convergence Insufficiency Symptom Survey score. Secondary outcomes were near point of convergence and positive fusional vergence at near. Office-based vergence/accommodative therapy was significantly more effective than home-based or placebo therapies. Base-in prism reading glasses were no more effective than placebo reading glasses for the treatment of symptomatic CI in children. Recent clinical trials showed that office-based vision therapy was successful in about 75% of patients (resulting in normal or significantly improved symptoms and signs) and was the only treatment studied which was more effective than placebo treatments for children with symptomatic CI. Eye care providers who do not currently offer this treatment may consider referring these patients to a doctor who provides this treatment or consider expanding the treatment options available within their practice to manage this condition.

The Convergence Insufficiency Treatment Trial: Design, Methods, and Baseline Data

Objective: This report describes the design and methodology of the Convergence Insufficiency Treatment Trial (CITT), the first large-scale, placebo-controlled, randomized clinical trial evaluating treatments for convergence insufficiency (CI) in children. We also report the clinical and demographic characteristics of patients. Methods: We prospectively randomized children 9 to 17 years of age to one of four treatment groups: 1) home-based pencil push-ups, 2) home-based computer vergence/accommodative therapy and pencil push-ups, 3) office-based vergence/accommodative therapy with home reinforcement, 4) office-based placebo therapy. Outcome data on the Convergence Insufficiency Symptom Survey (CISS) score (primary outcome), near point of convergence (NPC), and positive fusional vergence were collected after 12 weeks of active treatment and again at 6 and 12 months posttreatment. Results: The CITT enrolled 221 children with symptomatic CI with a mean age of 12.0 years (SD = +2.3). The clinical profile of the cohort at baseline was 9Δ exophoria at near (+/− 4.4) and 2Δ exophoria (+/−2.8) at distance, CISS score = 30 (+/−9.0), NPC = 14 cm (+/− 7.5), and near positive fusional vergence break = 13 Δ (+/− 4.6). There were no statistically significant nor clinically relevant differences between treatment groups with respect to baseline characteristics (p > 0.05).Conclusion: Hallmark features of the study design include formal definitions of conditions and outcomes, standardized diagnostic and treatment protocols, a placebo treatment arm, masked outcome examinations, and the CISS score outcome measure. The baseline data reported herein define the clinical profile of those enrolled into the CITT.

Preferred clinical practice in convergence insufficiency in India: A survey

Convergence insufficiency (CI) is a common binocular vision disorder. However, there is a lack of consensus regarding the treatment most appropriate for CI. The aim of the study was to investigate the treatment for CI by surveying the ophthalmologists regarding the most common treatment modalities used in India. Four hundred questionnaires were distributed amongst ophthalmologists attending different sessions of the Delhi Ophthalmological Society annual conference held in April 2007. Two hundred and three ophthalmologists responded (response rate 50.75%). The responders included 109 private practitioners, 57 consultants attached to teaching institutes and 37 residents. The majority of ophthalmologists (66.7%) claimed encountering > 5% outpatient department patients with CI. Pencil push-ups therapy (PPT) was the most common first line of treatment offered by ophthalmologists (79%) followed by synoptophore exercises (18%). Only 3% referred the patients to optometrists. Thirty per cent ophthalmologists claimed good results with PPT, which was significantly higher in private practitioners (35%). Only 26% ophthalmologists explained physiological diplopia to patients on a regular basis and reported significantly higher percentage of patients (46.3%) with good results. Only 12.3% ophthalmologists needed to refer > 30% patients for synoptophore exercises. For failure of PPT 86.7% considered lack of compliance as the major reason as perceived by ophthalmologists. This survey suggested that most ophthalmic practitioners prescribed PPT as the initial treatment for CI and had satisfactory results with PPT. The majority of the practitioners did not explain to the patient about physiological diplopia. Explaining physiological diplopia may improve outcome, as perceived from the survey.

A Randomized Clinical Trial of Vision Therapy/Orthoptics versus Pencil Pushups for the Treatment of Convergence Insufficiency in Young Adults

: The purpose of this article is to compare vision therapy/orthoptics, pencil pushups, and placebo vision therapy/orthoptics as treatments for symptomatic convergence insufficiency in adults 19 to 30 years of age. : In a randomized, multicenter clinical trial, 46 adults 19 to 30 years of age with symptomatic convergence insufficiency were randomly assigned to receive 12 weeks of office-based vision therapy/orthoptics, office-based placebo vision therapy/orthoptics, or home-based pencil pushups. The primary outcome measure was the symptom score on the Convergence Insufficiency Symptom Survey. Secondary outcome measures were the near point of convergence and positive fusional vergence at near. : Only patients in the vision therapy/orthoptics group demonstrated statistically and clinically significant changes in the near point of convergence (12.8 cm to 5.3 cm, p = 0.002) and positive fusional vergence at near (11.3Delta to 29.7Delta, p = 0.001). Patients in all three treatment arms demonstrated statistically significant improvement in symptoms with 42% in office-based vision therapy/orthoptics, 31% in office-based placebo vision therapy/orthoptics, and 20% in home-based pencil pushups achieving a score <21 (our predetermined criteria for elimination of symptoms) at the 12-week visit. : In this study, vision therapy/orthoptics was the only treatment that produced clinically significant improvements in the near point of convergence and positive fusional vergence. However, over half of the patients in this group (58%) were still symptomatic at the end of treatment, although their symptoms were significantly reduced. All three groups demonstrated statistically significant changes in symptoms with 42% in office-based vision therapy/orthoptics, 31% in office-based placebo vision therapy/orthoptics, and 20% in home-based pencil push-ups meeting our criteria for elimination of symptoms.

A Randomized Clinical Trial of Treatments for Convergence Insufficiency in Children

To compare vision therapy/orthoptics, pencil push-ups, and placebo vision therapy/orthoptics as treatments for symptomatic convergence insufficiency in children 9 to 18 years of age. In a randomized, multicenter clinical trial, 47 children 9 to 18 years of age with symptomatic convergence insufficiency were randomly assigned to receive 12 weeks of office-based vision therapy/orthoptics, office-based placebo vision therapy/orthoptics, or home-based pencil push-ups therapy. The primary outcome measure was the symptom score on the Convergence Insufficiency Symptom Survey. Secondary outcome measures were the near point of convergence and positive fusional vergence at near. Symptoms, which were similar in all groups at baseline, were significantly reduced in the vision therapy/orthoptics group (mean symptom score decreased from 32.1 to 9.5) but not in the pencil push-ups (mean symptom score decreased from 29.3 to 25.9) or placebo vision therapy/orthoptics groups (mean symptom score decreased from 30.7 to 24.2). Only patients in the vision therapy/orthoptics group demonstrated both statistically and clinically significant changes in the clinical measures of near point of convergence (from 13.7 cm to 4.5 cm; P < .001) and positive fusional vergence at near (from 12.5 prism diopters to 31.8 prism diopters; P < .001). In this pilot study, vision therapy/orthoptics was more effective than pencil push-ups or placebo vision therapy/orthoptics in reducing symptoms and improving signs of convergence insufficiency in children 9 to 18 years of age. Neither pencil push-ups nor placebo vision therapy/orthoptics was effective in improving either symptoms or signs associated with convergence insufficiency.