Journal presentation about convergence insufficiency

Convergence insufficiency

Prepared by:

Anis Suzanna Binti Mohamad

Optometrist

Hospital Langkawi

Content

Introduction

Journal

Comments

Suggestions

Conclusions

References

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

Symptoms

Symptoms associated with close work:Asthenopia= Symptoms related to the effort to

maintain BSVHeadaches, Intermittent blur vision Inability to sustain and concentrateDiscomfort of the eyes (burning,tearing) and

etc.

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

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!

CI symptoms masquerade as ADD/ADHD, reading and learning problems

Journal

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.

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/orthopticsOffice-based placebo vision therapy/orthopticsHome-based pencil push-ups therapy.

Main outcome measures:

1. The primary outcome a. Measure was the symptom score on the

Convergence Insufficiency Symptom Survey (CISS)

2. The secondary outcomea. 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 deviates out.

NPC ( receded 5cm or recovery greater than 7cm)

How to test NPC? Penlight Red/Green- Near Point of

Convergence Test (PLRG NPC) for screening

Results:

GroupsMean 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.

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.

Related journal

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.

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.

Suggestions What we can do in our clinic?

ScreenRecognize Inform

1. Screen

PLRG NPC

Symptom Checklist

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

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

Office-based optometric vision therapy in action!

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 awareness2. Feedback

3. Loading -Action, movement and relevance

NEI YouTube Videos: Convergence Insufficiency

ReferencesConvergence 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 clinical trial of vergence/accommodative therapy. Invest Ophthalmol Vis Sci. 2009 Jun;50(6):2560-6. Epub 2009 Jan 17.

Birnbaum MH, Soden R, Cohen AH. Efficacy of vision therapy for convergence insufficiency in an adult male population. Journal of the American Optometric Association, April; 70(4): 225-232, 1999.