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Part 2: Treatment of Convergence Insufficiency

Convergence Insufficiency

Have you read Part 1: What is Convergence Insufficiency?

Active treatment: A multi-site randomized clinical trial funded by the National Eye Institute has proven that the best treatment for convergence insufficiency is supervised vision therapy in a clinical office with home reinforcement (15 minutes of prescribed vision exercises done in the home five days per week). The scientific study showed that children responded quickly to this treatment protocol. 75% achieved either full correction of their convergence problems or they saw marked improvements within 12 weeks.

Passive treatment: Prismatic (prism) eyeglasses can be prescribed to decrease some of the symptoms. What are Prism Glasses – A special addition to normal lenses called prism can be put into an eyeglass prescription. Prism causes the images to be displaced so that a person with convergence insufficiency does not have to converge as much. This does not cure the condition but it does resolve many symptoms. The problem with prism is that some people can adapt to it. As a result, a higher amount of prism in following years must be prescribed to achieve the same effect. Although prism eyeglasses can relieve symptoms, they are not a “cure” and the patient typically remains dependent on the prism lenses. In addition, adaptation problems can lead to the need for stronger prescriptions in the future. Scientific research as well as optometric and ophthalmological textbooks agree that the primary treatment of convergence insufficiency should be vision therapy.

Pencil Push-ups: While a 2002 survey of ophthalmologists and optometrists indicated that home-based pencil-pushups therapy is the most common treatment, scientific research does not support this method. Studies done on pencil pushups have shown it to be ineffective in eliminating symptoms.

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Taking if further…

The main treatment, the gold standard for treatment, of convergence insufficiency is vision therapy. Vision therapy uses various exercises to train the connection between the eyes and the brain as more than 50% of the brain is dedicated to visual function. For individuals with convergence insufficiency, therapy focuses on training the eyes to converge and eventually in the end stages to switch between convergence and divergence. Results from a study by the Convergence Insufficiency Treatment Trial Group suggests that office-based vision therapy is the most effective method for improving measures of convergence as well as patient symptoms. This is compared to home-based computer therapy and pencil push-ups (following a pencil as it is moved towards the nose). Other options such as prism lenses are only used when an individual is either unable to do vision therapy or is unsuccessful at it. Prism lenses alone are successful at mildly treating symptoms caused by convergence insufficiency in children and adults. Surgery is never considered due to the effectiveness of vision therapy. Further, pencil push-up exercises has been proven as ineffective and a primary treatment option.

How Long Does it Take to Treat Convergence Insufficiency? Can Convergence Insufficiency Come Back?

In general, 12-24 in-office vision therapy sessions are recommended to treat convergence insufficiency. This will vary based on compliance, the degree of convergence insufficiency (and other binocular disorders if present), age, and if there are any coexisting developmental disorders. With respect to regression following vision therapy, the Convergence Insufficiency Treatment Trial Group has found that 87.5% of children aged 9-13 were still considered either improved or successful one year after receiving treatment. Severe infection and/or traumatic brain injury later in life can create a new case of CI independent of a previous diagnosis of CI in their childhood.

What about adults with Convergence insufficiency?

The Convergence Insufficiency Treatment Trial Group found that for adults aged 19-30, 50% receiving office-based vision therapy for CI were either “improved” or “cured” after 12 weeks based on symptoms and clinical measures. It is possible that with more sessions there would have been a larger number of adults with CI benefitting from vision therapy. Also, investigators noted that the adults in this study improved the same amount clinically as children in another study suggesting that adults rate their symptomology differently than children.

Don’t underestimate … the influence that a condition such as convergence insufficiency can have on a child’s or young adult’s reading ability, concentration, comprehension, and education. If a child is acting out in class, it could be due to a vision problem such as convergence insufficiency. Parents should know that convergence insufficiency can cause numerous symptoms that make it difficult to read and comprehend. However, it is proven that office-based vision therapy with a trained therapist plus at-home therapy reinforcement can treat the condition and eliminate symptoms.

 

References: Arnoldi, K., & Reynolds, J.D. (2007). A Review of Convergence Insufficiency: What Are We Really Accomplishing with Exercises? American Orthoptic Journal, 57, pp. 123-130. Retrieved from http://aoj.uwpress.org/content/57/1/123.full.pdf

Cacho-Martinez, P. Garcia-Munoz, & A. Ruiz-Cantero, M.T. Do we really know the prevalence of accommodative and nonstrabismic binocular dysfunctions? Journal of Optometry, 3(4), pp. 185-197. Retreived from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3974377/pdf/main.pdf

Convergence Insufficiency Treatment Trial Investigator Group. (2009). A Randomized Clinical Trial of Treatments for Symptomatic Convergence Insufficiency in Children. Arch Ophthalmol, 126 (10), pp. 1336-1349. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779032/pdf/nihms-148199.pdf

Convergence Insufficiency Treatment Trial Study Group. (2009). Long-Term Effectiveness of Treatments for Symptomatic Convergence Insufficiency in Children. Optom Vis Sci, 86 (9), pp. 1096-1103. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780441/pdf/nihms153856.pdf

Cooper, J., & Jamal, N. (2012) Convergence Insufficiency—a major review. American Optometric Association. Retrieved from http://www.coopereyecare.com/studies/CI%20Major%20Review%20copy.pdf

Scheiman, M. & Wick, B. (2014). Clinical Management of Binocular Vision. Philadelphia: Lippincott Williams & Wilkins.

Scheiman et al. (2005). A Randomized Clinical Trial of Vision Therapy/Orthoptics versus Pencil Pushups for the Treatment of Convergence Insufficiency in Young Adults. Optometry and Vision Science, 82 (7), pp. E583-595. Retrieved from http://www.convergenceinsufficiency.net/uploads/citt_adult_pilot_study_manuscript_ovs_82_583-593.pdf

Part 1: What is Convergence Insufficiency?

Convergence insufficiency (CI) is a common condition that is characterized by the inability to maintain proper binocular eye alignment on near objects. An eye teaming problem in which the eyes have a strong tendency to drift outward when reading or doing close work. To prevent double vision, the individual exerts extra effort to make the eyes turn back in (converge). This extra effort can lead to a number of frustrating symptoms which interfere with the ability to read and work comfortably at near.

Under normal circumstances, the eyes must turn inwards to view objects at near. Convergence insufficiency results when an individual has an outward natural or resting eye posture at near which means that they must exert more effort to bring the eyes in while reading. This can make it appear as though words are moving while reading as well as lead to blurred/double vision, impaired concentration, eyestrain, drowsiness, and headaches. It is important to note that individuals with CI can and often have 20/20 vision. Clarity does not guarantee comfort when it comes to vision.

 

Convergence Insufficiency

What Causes Convergence Insufficiency?

The exact cause of primary convergence insufficiency is unknown. Convergence insufficiency can arise following infection, traumatic brain injury, certain medications, neurodegenerative diseases (e.g. Parkinson’s), myasthenia gravis, or Graves ophthalmopathy. Diagnosis of primary convergence insufficiency is most common in children and young adults when they begin to experience symptoms from prolonged periods of near work.

What are the Symptoms of Convergence Insufficiency?
It may not always be evident that someone suffers from convergence insufficiency because the symptoms may vary. People with convergence insufficiency often complain of the following symptoms when reading or doing intense near work:

• Eyestrain or tired eyes (especially with or after reading)
• Headaches
• Moving or overlapping words
• Blurred vision
• Double vision
• Inability to concentrate
• Short attention span
• Frequent loss of place
• Squinting, rubbing, closing or covering an eye
• Sleepiness during the activity
• Trouble remembering what was read
• Words appear to move, jump, swim or float
• Problems with motion sickness and/or vertigo

 

Words Look like this with Convergence Insufficiency

 

It is not unusual for a person with convergence insufficiency to cover or close one eye while reading to relieve the blurring or double vision. Symptoms will be worsened by illness, lack of sleep, anxiety, and/or prolonged close work.

Many people who would test as having convergence insufficiency (if tested) may not complain of double vision or the other symptoms listed above because vision in one eye has shut down. In other words, even though both eyes are open and are healthy and capable of sight, the person’s brain ignores one eye to avoid double vision. This is a neurologically active process called suppression.

Suppression of vision in one eye causes loss of binocular (two-eyed) vision and depth perception. Poor binocular vision can have a negative impact on many areas of life, such as coordination, sports, judgment of distances, eye contact, motion sickness, etc. Consequently, a person with convergence insufficiency who is suppressing one eye can show some or all of the following symptoms:

• Trouble catching balls and other objects thrown through the air
• Avoidance of tasks or sports that require depth perception
• Frequently clumsy due to misjudgment of physical distances
• Trips and stumbles on uneven surfaces, stairs, and curbs, etc.
• Frequent spilling or knocking over of objects
• Bumping into doors, furniture and other stationary objects
• Sports and/or car parking accidents
• Avoidance of eye contact
• Poor posture while doing activities requiring near vision
• One shoulder noticeably higher
• Frequent head tilt
• Problems with motion sickness and/or vertigo

If untreated, in some cases, convergence insufficiency can lead to an outward eye turn that comes and goes (intermittent exotropia).

How Common is Convergence Insufficiency?
Convergence insufficiency is present in one out of every 20 children. Most likely one to two children in every classroom have this condition. Convergence insufficiency has a reported prevalence among children and adults in the United States of 2.5 to 13%. Children with convergence insufficiency are often thought to be lazy or disruptive in the classroom. They tend to have poor attention and often tire more easily when reading.

Detection and Diagnosis of Convergence Insufficiency
Convergence insufficiency is not usually detected on regular vision screenings. Often, the only way it can be properly diagnosed is to see an eye doctor (Optometrist). In fact, Pediatric or Behavioral (Developmental) Optometrists are better experts in dealing with this condition (see covd.org).

There are several characteristics that eye doctors look for when properly diagnosing convergence insufficiency.

Convergence (eye teaming) and accommodation (focusing) tests are the important diagnostic tools. A basic eye exam or screening with the 20/20 eye chart is not adequate for the detection of convergence insufficiency (and many other visual conditions). A person can pass the 20/20 test and still have convergence insufficiency. A comprehensive vision evaluation by an eye doctor who tests binocular (two-eyed) vision and who can refer or provide for in-office vision therapy is recommended for all individuals who do reading and deskwork.

Convergence insufficiency disorder frequently goes undetected in school age children because proper testing is not included in (1) eye tests in a pediatrician’s office; (2) school eye screenings; and/or (3) standard eye exams in an optometrist’s or ophthalmologist’s office.

The good news is that convergence insufficiency responds well to proper treatment, the bad news is that — due to pervasive lack of testing for convergence insufficiency — many people are not getting the help they need early in life. And many are never helped. Children, teenagers and adults who remain undiagnosed and untreated tend to avoid reading and close work as much as possible or use various strategies to combat symptoms (such as, using a ruler or finger to keep one’s place while reading or taking frequent breaks, etc.).

A Word from Dr. Fulton
Don’t underestimate the influence that a condition such as convergence insufficiency can have on a child’s or young adult’s reading ability, concentration, comprehension, and education. If a child is acting out in class, it could be due to a vision problem such as convergence insufficiency. Parents should know that convergence insufficiency can cause numerous symptoms that make it difficult to read and comprehend. However, it is proven that office-based vision therapy with a trained therapist plus at-home therapy reinforcement can treat the condition and eliminate symptoms.

READ NEXT >>>>> Part 2: Treatment of Convergence Insufficiency

 

References:
Arnoldi, K., & Reynolds, J.D. (2007). A Review of Convergence Insufficiency: What Are We Really Accomplishing with Exercises? American Orthoptic Journal, 57, pp. 123-130. Retrieved from http://aoj.uwpress.org/content/57/1/123.full.pdf

Cacho-Martinez, P. Garcia-Munoz, & A. Ruiz-Cantero, M.T. Do we really know the prevalence of accommodative and nonstrabismic binocular dysfunctions? Journal of Optometry, 3(4), pp. 185-197. Retreived from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3974377/pdf/main.pdf

Convergence Insufficiency Treatment Trial Investigator Group. (2009). A Randomized Clinical Trial of Treatments for Symptomatic Convergence Insufficiency in Children. Arch Ophthalmol, 126 (10), pp. 1336-1349. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779032/pdf/nihms-148199.pdf

Convergence Insufficiency Treatment Trial Study Group. (2009). Long-Term Effectiveness of Treatments for Symptomatic Convergence Insufficiency in Children. Optom Vis Sci, 86 (9), pp. 1096-1103. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780441/pdf/nihms153856.pdf

Cooper, J., & Jamal, N. (2012) Convergence Insufficiency—a major review. American Optometric Association. Retrieved from http://www.coopereyecare.com/studies/CI%20Major%20Review%20copy.pdf

Scheiman, M. & Wick, B. (2014). Clinical Management of Binocular Vision. Philadelphia: Lippincott Williams & Wilkins.

Scheiman et al. (2005). A Randomized Clinical Trial of Vision Therapy/Orthoptics versus Pencil Pushups for the Treatment of Convergence Insufficiency in Young Adults. Optometry and Vision Science, 82 (7), pp. E583-595. Retrieved from http://www.convergenceinsufficiency.net/uploads/citt_adult_pilot_study_manuscript_ovs_82_583-593.pdf

Signs That Your Child Has a Vision Problem

Healthy eyes and good vision are essential for your child’s growth and development. In fact, learning is 80% visual, which means a child’s success in school, athletics and many other aspects of life can be impacted by poor vision. Good vision goes beyond how far you can see, and also includes a number of other skills such as visual processing and eye movement abilities.

Often times vision deficiencies are at the root of learning problems and behavioral issues and may unfortunately go unchecked and misdiagnosed. Remember, if your child is having trouble in school, an eye exam and a pair of prescription glasses is a much easier solution than treating a learning disorder or ADHD; yet many people fail to check that first.

It is common for children to think that their vision deficiency is normal and therefore they often won’t report it to parents or teachers. That is why it is even more important to know what to look for. Here are some signs that your child may have a vision problem:

Vision Signs

  • Squinting or blinking often
  • Eye rubbing
  • Tilting the head to the side
  • Covering one eye
  • One eye that turns out or in
  • Reporting double vision
  • Holding books or reading materials very close to the face

 

Behavioral Signs

  • Complaining of headaches or eye fatigue
  • Short attention span
  • Difficulty reading
  • Losing their place frequently when reading
  • Avoiding reading or any activity that requires close work
  • Problems with reading comprehension or recall
  • Behavioral issues that stem from frustration and/or boredom
  • Poor performance and achievement in school or athletics
  • Working twice as hard to achieve minimal performance in school

Another issue is that many parents and teachers think that a school vision screening is sufficient to assess a child’s vision, so if that test comes back okay, they believe there is no vision problem. This however, is far from the case. A school vision test usually only assesses visual acuity for distance vision or how far a child can see. Even a child with 20/20 vision can have significant vision problems that prevent them from seeing, reading and processing visual information.

Every child of school age should have comprehensive eye and vision exams on a regular, yearly basis to assess their eye and vision health, and ensure that any issues are addressed as soon as possible. It’s also important to have an exam prior to entering kindergarten, as undetected lazy eye may be more complicated to treat past seven years of age.

Some of the issues the eye doctor may look for, in addition to good visual acuity, are the ability to focus, eye teaming and tracking, visual perception, hand-eye coordination, depth perception and peripheral vision. They will also assess the health of the eye and look for any underlying conditions that may be impairing vision. Depending on the problem the eye doctor may prescribe eyeglasses, contact lenses or vision therapy to correct the issue.

During the school years a child’s eyes and vision continue to develop and change so it is important to continually check in on your child’s vision. If you have a family history of vision problems, follow-ups are even more important. Progressive conditions like progressive myopia, strabismus (crossed eyes), amblyopia (lazy eye) or astigmatism can be treated and monitored for changes with early treatment so it’s important to seek a doctor’s diagnosis as soon as signs or symptoms are present.

Make sure that your child has the best possible chances for success in school and add a comprehensive eye exam to your back to school to-do list.