Treatment Of Symptomatic Convergence Insufficiency Research Articles

Vergence Eye Movements: From Basic Science to Clinical Application - Foreword to the Special Issue.

The abstract book of the last European Conference on Eye Movements [1] lists abstracts of 373 presentations, but less than five percent investigate vergence eye movements, i.e. the coordination of the right and left eye. Why then a special issue on this neglected issue? Human vision under natural conditions involves both eyes in coordination controlled by interacting processes subsumed under the concept of vergence.. Further, vergence is important for people in their daily lives since disorders of vergence can have serious consequences: ophthalmologists deal with squinting patients on the basis of heterophoria and heterotropia testing, eye strain or visual complaints can be related to impaired vergence dynamic or less accurate static vergence, remediation by optometrist includes vergence training or prism eye glasses, etc.

Changes in the disparity vergence main sequence after treatment of symptomatic convergence insufficiency in children

This study investigates the underlying physiological mechanisms that may lead to improved outcomes for symptomatic convergence insufficiency (CI) patients after 12 weeks of office-based vergence/accommodation therapy (OBVAT) by evaluating the change in the main sequence of vergence and saccadic eye movements. In this prospective trial, 12 participants with symptomatic CI were recruited and treated with 12 weeks of OBVAT. Outcome measures included the objective assessment of the following: peak velocity, time to peak velocity, latency, response amplitude, and clinical changes in the near point of convergence (NPC), positive fusional vergence (PFV) and symptoms via the Convergence Insufficiency Symptom Survey (CISS). Ten of the twelve participants (83%) were categorized as “successful” and two were “improved” based on pre-determined published criteria (CISS, NPC, PFV). There were statistically significant changes in peak velocity, time to peak velocity, and response amplitude for both 4° and 6° symmetrical convergence and divergence eye movements. There was a significant change in the main sequence ratio for convergence post-OBVAT compared to baseline measurements (P=0.007) but not for divergence or saccadic responses. Phasic/step vergence movements adjust the underlying neural control of convergence and are critical within a vision therapy program for CI patients.

Treatment of Symptomatic Convergence Insufficiency in Children Enrolled in the Convergence Insufficiency Treatment Trial-Attention & Reading Trial: A Randomized Clinical Trial.

ABSTRACTSIGNIFICANCEThese data confirm the effectiveness of office-based vergence/accommodative therapy for improving convergence in children with symptomatic convergence insufficiency. They also highlight the importance of using a primary outcome measure that is as objective as possible rather than relying solely on self-reported symptoms for studies of binocular vision in children.PURPOSEThe purpose of this study was to report changes in clinical signs and symptoms of convergence insufficiency (secondary outcome measures) from a multicenter clinical trial (Convergence Insufficiency Treatment Trial–Attention & Reading Trial [CITT-ART]) evaluating the effectiveness of vergence/accommodative therapy for improving reading and attention in children with symptomatic convergence insufficiency.METHODSThree hundred eleven children aged 9 to 14 years with symptomatic convergence insufficiency were randomly assigned to 16 weeks of office-based vergence/accommodative therapy or to placebo therapy. Improvements in (1) near point of convergence (NPC), (2) positive fusional vergence (PFV), and (3) self-reported symptoms (Convergence Insufficiency Symptom Survey [CISS] score) were compared after 16 weeks of treatment.RESULTSMean NPC improved 10.4 cm in the vergence/accommodative and 6.2 cm in the placebo therapy group (mean difference of −4.2 cm [95% confidence interval {CI}, −5.2 to −3.2 cm; P < .001]); mean PFV increased 23.2 and 8.8Δ in the vergence/accommodative and placebo therapy groups, respectively (mean difference of 14.4Δ [95% CI, 12.1 to 16.8Δ; P < .001]). The mean CISS score improved 11.8 and 10.4 points in the vergence/accommodative and placebo therapy groups, respectively (mean difference of 1.5 points [95% CI, −3.8 to +0.8 points; P = .21]).CONCLUSIONSOur results demonstrate that office-based vergence/accommodative therapy is effective for improving the NPC and PFV in children with symptomatic convergence insufficiency. However, given that both treatment groups had a similar reduction in self-reported symptoms, it may not be prudent to use the CISS alone as a measure of successful treatment.

Objective Assessment of Disparity Vergence after Treatment of Symptomatic Convergence Insufficiency in Children.

SIGNIFICANCEThis first report of the use of objective measures of disparity vergence as outcome measures for symptomatic convergence insufficiency in children provides additional information that is not accessible with clinical tests. The study results also demonstrate that objective measures of vergence could be used in future randomized clinical trials of binocular vision disorders with children.PURPOSEThis study was designed to evaluate changes in objective measures of disparity vergence after office-based vergence/accommodative therapy (OBVAT) for convergence insufficiency in children 12 to 17 years old.METHODSIn this prospective trial, we recruited 10 participants with normal binocular vision and 12 with convergence insufficiency. All participants with convergence insufficiency were treated with 12 weeks of OBVAT. The primary outcome measure was average peak velocity for 4° symmetrical convergence steps. Other objective outcome measures of disparity vergence included time to peak velocity, latency, and accuracy. Changes in clinical measures (near point of convergence, positive fusional vergence at near) and symptoms were evaluated.RESULTSThere was a statistically significant increase in peak velocity and more accurate response amplitude to 4° symmetrical convergence step stimuli after OBVAT compared with baseline measurements. Near point of convergence, positive fusional vergence, and symptoms also statistically significantly improved after OBVAT. Ten of the 12 participants met clinical success criteria.CONCLUSIONSIn this prospective study on the treatment of symptomatic convergence insufficiency in children in which both clinical and objective eye movement measurements were used to evaluate the results of treatment, significant changes were found in symptoms and both clinical and objective measures of disparity vergence after completion of OBVAT in children with symptomatic convergence insufficiency.

Effect of treatment of symptomatic convergence insufficiency on reading in children: a pilot study

BackgroundTo evaluate the impact of treatment of symptomatic convergence insufficiency using office‐based vergence/accommodative therapy on reading skills in children.MethodsChildren (n = 44) ages nine to 17-years with symptomatic convergence insufficiency were administered the following four reading tests: Wechsler Individual Achievement Test II; Test of Word Reading Efficiency; Test of Silent Word Reading Fluency; and the Gray Oral Reading Test, at baseline and eight-weeks after completion of a 16‐week program of office‐based vergence/accommodative therapy. To determine whether significant change occurred with therapy, change in performance was compared to zero. Treatment response was determined using a composite score of symptoms and signs at the conclusion of treatment and at the 24‐week outcome visit. Participants were classified as early responders, late responders, or non‐responders based upon whether criteria for successful treatment were met at the completion of 16-weeks of treatment, at the 24‐week outcome visit, or not met at either visit, respectively.ResultsAfter treatment for convergence insufficiency, statistically significant improvements were found for reading comprehension (mean = 4.2, p = 0.009) and the reading composite score (mean = 2.4, p = 0.016) as measured by the Wechsler Individual Achievement Test at the 24‐week visit. These improvements were related to the clinical treatment outcome measures (p = 0.011) with the largest improvements occurring in those who were early responders to treatment. Reading speed (words per minute) increased significantly on the Gray Oral Reading Test (p < 0.0001). No significant improvements were observed for single word reading or reading fluency as measured by the Test of Word Reading Efficiency, the Test of Silent Word Reading Fluency or the Gray Oral Reading Test.ConclusionImprovements in reading comprehension and reading composite were found after office‐based vergence/accommodative therapy, with the greatest improvements in those who responded early to treatment.

Efficacy of home-based vision therapy for convergence insufficiency in secondary schools' students

Background: Convergence insufficiency (CI) is one of the most common causes of ocular discomfort among students that it may have a negative effect on the student's school performance. Although various treatments are prescribed for patients with CI, there is a lack of studies regarding the most effective treatment. Aim: The aim of this study is to determine the efficacy of four home-based vision therapy (VT) techniques in the treatment of symptomatic CI. Materials and Methods: A Convergence Insufficiency Treatment Trial was conducted in Central Khartoum North (Central Bahri) in Sudan. A total of 273 students with mean age of 15.5 ± 2.5 years with symptomatic CI were assigned to one of the four TV groups: Pencil push-Up (n = 66), Cat card (n = 65), Brock string (n = 66), Dot card (n = 66) against placebo control group (n = 66). Data were collected using three outcome measurements: Convergence Insufficiency Symptom Survey score, Near Point of Convergence (NPC), and Positive Fusional Vergence (PFV) at near. Data were collected at baseline, after 3 weeks and at the end 6 weeks of treatment. The participants were advised to do this exercise at home 10 min per day, for 5 days a week for 6 weeks. Results: After 6 weeks of treatment, Dot card therapy group showed the best result in eliminating CI symptoms score by the mean value of 13.59 points (P

Convergence Insufficiency Treatment Trial – Attention and Reading Trial (CITT-ART): Design and Methods

To describe the design and methodology of the Convergence Insufficiency Treatment Trial: Attention and Reading Trial (CITT-ART), the first randomized clinical trial evaluating the effect of vision therapy on reading and attention in school-age children with symptomatic convergence insufficiency (CI). CITT-ART is a multicenter, placebo-controlled, randomized clinical trial of 324 children ages 9 to 14 years in grades 3 to 8 with symptomatic CI. Participants are randomized to 16 weeks of office-based vergence/accommodative therapy (OBVAT) or placebo therapy (OBPT), both supplemented with home therapy. The primary outcome measure is the change in the Wechsler Individual Achievement Test-Version 3 (WIAT-III) reading comprehension subtest score. Secondary outcome measures are changes in attention as measured by the Strengths and Weaknesses of Attention (SWAN) as reported by parents and teachers, tests of binocular visual function, and other measures of reading and attention. The long-term effects of treatment are assessed 1 year after treatment completion. All analyses will test the null hypothesis of no difference in outcomes between the two treatment groups. The study is entering its second year of recruitment. The final results will contribute to a better understanding of the relationship between the treatment of symptomatic CI and its effect on reading and attention. The study will provide an evidence base to help parents, eye professionals, educators, and other health care providers make informed decisions as they care for children with CI and reading and attention problems. Results may also generate additional hypothesis and guide the development of other scientific investigations of the relationships between visual disorders and other developmental disorders in children.

Treatment of symptomatic convergence insufficiency with home-based computerized vergence system therapy in children

To evaluate the efficacy of a home-based computer orthoptic program for symptomatic convergence insufficiency (CI) in children. The medical records of participants aged 5 to <18 years who were diagnosed with symptomatic CI and were treated with the Computerized Vergence System (CVS) program were retrospectively reviewed. All participants were prescribed 9 or 15 minutes of daily convergence exercises with the CVS program, 5 days per week, for the initial 6 weeks. Near point of convergence (NPC) and near convergence amplitude (NCA) were measured at baseline, 6 week, and final examinations. The presence or absence of diplopia and asthenopia with reading were recorded at baseline and final examinations. A total of 186 participants were included. At diagnosis, 72 participants (39%) reported diplopia and 182 (98%), reported asthenopia. At final examination, 172 participants (92%) were asymptomatic. Twelve participants (6%) subsequently received other treatment modalities. Mean NPC at baseline (5.9 cm) improved after 6 weeks of CVS therapy (3.3 cm) and at final examination (2.9 cm; P < 0.0005). Mean NCA at baseline (20.3(Δ)) improved after 6 weeks of CVS therapy (37.0(Δ)) and at the final examination (38.0(Δ); P < 0.0005). In this study, home-based CVS therapy reduced symptoms related to CI and improved the NPC and NCA of most children aged 5 to <18 years with symptomatic CI.

Treatment of symptomatic convergence insufficiency (CI) with home-based computerized vergence system (CVS) therapy in children age 5 to 18 years

Treatment of symptomatic convergence insufficiency (CI) with home-based computerized vergence system (CVS) therapy in children age 5 to 18 years

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.

Treatment of symptomatic convergence insufficiency with a home-based computer orthoptic exercise program

To determine the efficacy of a home-based computer orthoptic program to treat symptomatic convergence insufficiency. A retrospective review of consecutive patients with symptomatic convergence insufficiency treated with a home-based computer orthoptic program was performed. Symptomatic convergence insufficiency was defined as: near point of convergence (NPC) >6 cm, decreased positive fusional vergence, exophoria at near at least 4(Δ) greater than at far, and documented complaints of asthenopia, diplopia, or headaches with reading or near work. The Computer Orthoptics CVS program was used for this study. Before beginning the computer orthoptic program, patients with an NPC >50 cm were given 4 base-in prisms and push-up exercises (NPC exercises with an accommodative target) for 2 weeks. A total of 42 patients were included. Mean treatment duration was 12.6 weeks; mean follow-up, 8.5 months. Of the 42 patients, 35 were treated with the home-based computer orthoptic program and push-up exercises; the remaining 7 only used the computer orthoptic program. Because of a remote NPC, 5 patients were given base-in Fresnel prism before starting treatment. Baseline mean NPC was 24.2 cm; posttreatment mean NPC improved to 5.6 cm: 39 patients (92.8%) achieved an NPC of ≤6 cm (p < 0.001). Positive fusional vergence improved in 39 patients (92.8%). Fourteen patients reduced their near exophoria by ≥5(Δ). A total of 27 patients (64.2%) reported resolution of symptoms after treatment. In our study, home-based computer orthoptic exercises reduced symptoms and improved NPC and fusional amplitudes. The computer orthoptic program is an effective option for treating symptomatic convergence insufficiency.

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+.

109: Treatment of symptomatic convergence insufficiency with a home-based computer orthoptic exercise program

109: Treatment of symptomatic convergence insufficiency with a home-based computer orthoptic exercise program

Effectiveness of Base in Prism for Presbyopes with Convergence Insufficiency

Although the treatment of symptomatic convergence insufficiency (CI) with base-in (BI) prism in adults has a strong theoretical foundation, there have been very few studies addressing its efficacy. The purpose of this study was to investigate whether the application of BI prism, using a novel progressive addition lens design which incorporates BI prism in the near portion only, could help alleviate the symptoms in presbyopes with CI. A total of 29 symptomatic CI subjects aged 45 to 68 years were examined. All subjects took the CI Symptom Survey V-15 (CISS) and scored >or=16 points. Each subject was assigned two pairs of progressive addition glasses made by the same manufacturer in a randomized sequence, one with BI prism and one with the same lens prescription but no prism (placebo). Subjects wore each pair of glasses for 3 weeks and completed the CISS at the end of the 3rd week. Symptom level measured with CISS was the major outcome measure. The mean (standard deviation) CISS score was 30.21 (9.30) at baseline and decreased to 13.38 (9.44) with the BI-prism glasses, vs. 23.62 (10.76) with the placebo glasses. There were significant differences between the baseline survey score and the score with the BI-prism glasses (p < 0.0001) and between the score with placebo glasses and the one with BI-prism glasses (p = 0.001). The progressive addition glasses with BI-prism were found to be effective in alleviating symptoms of presbyopes with symptomatic CI.

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.