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  • 1. Convergence insufficiency Prepared by: Anis Suzanna Binti Mohamad Optometrist Hospital Langkawi
  • 2. Content Introduction Journal Comments Suggestions Conclusions References
  • 3. Introduction  What is convergence insufficiency? A sensory and neuromuscular anomaly of binocular vision system, characterized by an inability to converge the eyes or sustain convergence. CI=Abnormally poor convergence amplitude Convergence insufficiency is a binocular vision problem…but it is NOT strabismus
  • 4. Symptoms  Symptoms associated with close work: Asthenopia= Symptoms related to the effort to maintain BSV Headaches, Intermittent blur vision Inability to sustain and concentrate Discomfort of the eyes (burning,tearing) and etc.
  • 5. Convergence insufficiency is routinely missed in vision screening  Why???  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
  • 6. Facts about CI  A disease that affects over 21 million in the United States  Massive research effort over 10 years by the CITT Group  Latest study (2008) NEI funded $6.1 M. multicenter including: The Mayo Clinic, Bascom Palmer and 6 Colleges of Optometry around the US.  Can cause behaviors that appear to be ADD/ADHD, reading and learning problems  There is a cure!
  • 7. CI symptoms masquerade as ADD/ADHD, reading and learning problems
  • 8. Journal
  • 9. Objective:  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.
  • 10. Methods:  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 therapy/orthoptics Home-based pencil push-ups therapy.
  • 11. Main outcome measures: 1. The primary outcome a. Measure was the symptom score on the Convergence Insufficiency Symptom Survey (CISS) 2. The secondary outcome a. Measures were the near point of convergence (NPC) and positive fusional vergence (PFV) at near.
  • 12. 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 deviates out.  NPC ( receded 5cm or recovery greater than 7cm)
  • 13. How to test NPC?  Penlight Red/Green- Near Point of Convergence Test (PLRG NPC) for screening
  • 14. Results: Groups Mean symptom score decreased Statistically Clinically Office-based vision therapy/orthoptics (32.1 to 9.5) NPC (from 13.7cm to 4.5cm; p<0.001) PFV (from 12.5PD to 31.8PD; p<0.001). Office-based placebo vision therapy/orthoptics (30.7 to 24.2) X Home-based pencil push-ups therapy (29.3 to 25.9) X Symptoms, which were similar in all groups at baseline, and after the treatment:- **only patients in the office-based vision therapy/orthoptics group demonstrated both clinically and statistically significant changes for the NPC and PFV at near.
  • 15. Discussion  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.
  • 16. Related journal
  • 17. Results: Groups Successful rate In-office and home therapy 61.9% 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.
  • 18. Conclusions 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 with CI.
  • 19. Suggestions  What we can do in our clinic?  Screen Recognize  Inform
  • 20. 1. Screen  PLRG NPC  Symptom Checklist
  • 21. 2. Recognize  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
  • 22. 3. Inform  Provide CI literature  Advise further diagnostic evaluation  Prescribe treatment **Point to ponder  Optometric Vision Therapy IS NOT eye exercises!!  Vision Therapy is rehabilitation treatment of the visual brain with proven applications in neuroscience
  • 23. Office-based optometric vision therapy in action!
  • 24. Conclusion  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 2. Feedback 3. Loading -Action, movement and relevance
  • 25. NEI YouTube Videos: Convergence Insufficiency
  • 26. References 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