What is convergence insufficiency?
A sensory and neuromuscular anomaly of
binocular vision system, characterized by an
inability to converge the eyes or sustain
CI=Abnormally poor convergence amplitude
Convergence insufficiency is a binocular
vision problem…but it is NOT strabismus
Symptoms associated with close work:
Asthenopia= Symptoms related to the effort to
Intermittent blur vision
Inability to sustain and concentrate
Discomfort of the eyes (burning,tearing) and
Convergence insufficiency is
routinely missed in vision screening
CI patients routinely have 6/6
Children with CI may not complain about their eyes to
their parents or tell the family physician
Most CI patients have “quality of life” symptoms which
are over looked in routine screenings
Facts about CI
A disease that affects over 21 million in the
Massive research effort over 10 years by the
Latest study (2008) NEI funded $6.1 M.
multicenter including: The Mayo Clinic, Bascom
Palmer and 6 Colleges of Optometry around the
Can cause behaviors that appear to be
ADD/ADHD, reading and learning problems
There is a cure!
CI symptoms masquerade as ADD/ADHD,
reading and learning problems
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 CI were randomly assign to
received 12 weeks of:-
Office-based vision therapy/orthoptics
Office-based placebo vision
Home-based pencil push-ups therapy.
Main outcome measures:
1. The primary outcome
a. Measure was the symptom score on the
Convergence Insufficiency Symptom Survey
2. The secondary outcome
a. Measures were the near point of
convergence (NPC) and positive fusional
vergence (PFV) at near.
What to test?
Near Point of Convergence (NPC)
The (NPC) is measured by bringing the
test target to the nose and observing when
the patient sees double, or one eye
NPC ( receded 5cm or recovery greater
How to test NPC?
Penlight Red/Green- Near Point of
Convergence Test (PLRG NPC) for screening
Mean symptom score decreased
therapy/orthoptics (32.1 to 9.5)
NPC (from 13.7cm to
PFV (from 12.5PD to
vision therapy/orthoptics (30.7 to 24.2)
push-ups therapy (29.3 to 25.9)
Symptoms, which were similar in all groups at baseline, and after the
**only patients in the office-based vision therapy/orthoptics group demonstrated
both clinically and statistically significant changes for the NPC and PFV at near.
In this study, office based 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.
Groups Successful rate
In-office and home
Home therapy only 30%
Control group (placebo) 10.5%
-Vision therapy is effective in eliminating asthenopia
and improving convergence function in adult patients.
- Combination in-office and home therapy tends to
produce better results than does home therapy alone.
o Office-based vergence accommodative therapy is an
effective treatment for children and adults with
symptomatic convergence insufficiency.
o Although among children they might experienced
symptomatic CI at the end of the treatment, but the
recurrence rate is about a year (89%, no significant
differences between group with p=0.26).
o The combination treatment in-office vision therapy and
home based therapy are the best solution among adults
What we can do in our clinic?
Recognize the symptoms
Avoids near centered visual tasks like reading
Eyes hurt or strain with sustained reading
Headaches associated with sustained reading
Words have illusory movement or overlap (double) when reading
Diagnose receded NPC
Provide CI literature
**Point to ponder
Optometric Vision Therapy IS NOT eye exercises!!
Vision Therapy is rehabilitation treatment of the visual
brain with proven applications in neuroscience
Office-based optometric vision therapy
Convergence insufficiency is a sensory and
neuromuscular anomaly of binocular vision
system, characterized by an inability to
converge the eyes or sustain convergence.
Office-based vision therapy utilizes principles
of neuroscience research:-
1. Visual awareness
3. Loading -Action, movement and relevance
Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial
of treatments for symptomatic convergence insufficiency in children. Arch
Ophthalmol. 2008 Oct;126(10):1336-49.
Barnhardt C, Cotter SA, Mitchell GL, Scheiman M, Kulp MT; CITT Study Group.
Symptoms in children with convergence insufficiency: before and after
treatment. Optom Vis Sci. 2012 Oct;89(10):1512-20.
Scheiman M, Kulp MT, Cotter S, Mitchell GL, Gallaway M, Boas M, Coulter R,
Hopkins K, Tamkins S; Convergence Insufficiency Treatment Trial Study
Group. Vision therapy/orthoptics for symptomatic convergence insufficiency in
children: treatment kinetics. Optom Vis Sci. 2010 Aug;87(8):593-603.
Rouse M, Borsting E, Mitchell GL, Kulp MT, Scheiman M, Amster D, Coulter R,
Fecho G, Gallaway M; CITT Study Group. Academic behaviors in children with
convergence insufficiency with and without parent-reported ADHD. Optom Vis
Sci. 2009 Oct;86(10):1169-77.
Convergence Insufficiency Treatment Trial Study Group. Long-term effectiveness
of treatments for symptomatic convergence insufficiency in children. Optom Vis
Sci. 2009 Sep;86(9):1096-103.
Kulp M, Mitchell GL, Borsting E, Scheiman M, Cotter S, Rouse M, Tamkins S,
Mohney BG, Toole A, Reuter K; Convergence Insufficiency Treatment Trial
Study Group. Effectiveness of placebo therapy for maintaining masking in a