Michael Gallaway

Frequency of Convergence Insufficiency Among Fifth and Sixth Graders

PURPOSE To estimate the frequency of convergence insufficiency (CI) and its related clinical characteristics among 9- to 13-year-old children. METHODS Fifth and sixth graders were screened in school settings at three different study sites. Eligible children with 20/30 or better visual acuity, minimal refractive error, no strabismus, and exophoria at near were evaluated according to a standardized protocol to determine the presence and severity of CI. These children were classified according to the presence and number of the following clinical signs: (1) exophoria at near > or =4delta than far, (2) insufficient fusional convergence, and (3) receded nearpoint of convergence. Also, children were classified as accommodative insufficient (AI) if they failed Hofstetters minimum amplitude formula or had greater than a + 1.00 D lag on Monocular Estimate Method retinoscopy. RESULTS Of 684 children screened, 468 (68%) were eligible for further evaluation. Of these, 453 had complete data on CI measurements and were classified as: no CI (nonexophoric at near or exophoric at near and < 4delta difference between near and far) (78.6%); low suspect CI (exophoric at near and one clinical sign: exophoria at near > or =4delta than far) (8.4%); high suspect CI (exophoric at near and two clinical signs) (8.8%); and definite CI (exophoric at near and three clinical signs) (4.2%). CI status varied according to ethnicity and study site (p < 0.0005), but not gender. The frequency of AI increased with the number of CI-related signs. For CI children with three signs, 78.9% were classified as also having AI. CONCLUSIONS These findings suggest that CI (defined as high suspect and definite) is frequent (13%) among fifth and sixth grade children. In addition, there is a high percentage of CI children with an associated AI.

Randomized clinical trial of treatments for symptomatic convergence insufficiency in children

OBJECTIVE To compare home-based pencil push-ups (HBPP), home-based computer vergence/accommodative therapy and pencil push-ups (HBCVAT+), office-based vergence/accommodative therapy with home reinforcement (OBVAT), and office-based placebo therapy with home reinforcement (OBPT) as treatments for symptomatic convergence insufficiency. METHODS In a randomized clinical trial, 221 children aged 9 to 17 years with symptomatic convergence insufficiency were assigned to 1 of 4 treatments. MAIN OUTCOME MEASURES Convergence Insufficiency Symptom Survey score after 12 weeks of treatment. Secondary outcomes were near point of convergence and positive fusional vergence at near. RESULTS After 12 weeks of treatment, the OBVAT groups mean Convergence Insufficiency Symptom Survey score (15.1) was statistically significantly lower than those of 21.3, 24.7, and 21.9 in the HBCVAT+, HBPP, and OBPT groups, respectively (P < .001). The OBVAT group also demonstrated a significantly improved near point of convergence and positive fusional vergence at near compared with the other groups (P <or= .005 for all comparisons). A successful or improved outcome was found in 73%, 43%, 33%, and 35% of patients in the OBVAT, HBPP, HBCVAT+, and OBPT groups, respectively. CONCLUSIONS Twelve weeks of OBVAT results in a significantly greater improvement in symptoms and clinical measures of near point of convergence and positive fusional vergence and a greater percentage of patients reaching the predetermined criteria of success compared with HBPP, HBCVAT+, and OBPT. Application to Clinical Practice Office-based vergence accommodative therapy is an effective treatment for children with symptomatic convergence insufficiency. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00338611.

Nearpoint of convergence: test procedure, target selection, and normative data.

Background. The purpose of this study was to help determine the most appropriate target to be used for the assessment of the nearpoint of convergence, normative data for the break and recovery in adults, and the diagnostic value of the red-glass modification and repetition of the nearpoint of convergence. Methods. A total of 175 subjects with normal binocular vision and 38 subjects with convergence insufficiency were evaluated. The nearpoint of convergence was measured three ways, with an accommodative target, a penlight, and a penlight with red and green glasses. The nearpoint of convergence was also measured using a penlight for 10 repetitions. Results. Results suggest a clinical cutoff value of 5 cm for the nearpoint of convergence break and 7 cm for the nearpoint of convergence recovery with either an accommodative target or a penlight with red and green glasses. Conclusion. This study establishes normative data for the nearpoint of convergence break and recovery in the adult population and supports the value of various test modifications when other testing is equivocal.

The convergence insufficiency treatment trial: Design, methods, and baseline data

Objective: This report describes the design and methodology of the Convergence Insufficiency Treatment Trial (CITT), the first large-scale, placebo-controlled, randomized clinical trial evaluating treatments for convergence insufficiency (CI) in children. We also report the clinical and demographic characteristics of patients. Methods: We prospectively randomized children 9 to 17 years of age to one of four treatment groups: 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, 4) office-based placebo therapy. Outcome data on the Convergence Insufficiency Symptom Survey (CISS) score (primary outcome), near point of convergence (NPC), and positive fusional vergence were collected after 12 weeks of active treatment and again at 6 and 12 months posttreatment. Results: The CITT enrolled 221 children with symptomatic CI with a mean age of 12.0 years (SD = +2.3). The clinical profile of the cohort at baseline was 9Δ exophoria at near (+/− 4.4) and 2Δ exophoria (+/−2.8) at distance, CISS score = 30 (+/−9.0), NPC = 14 cm (+/− 7.5), and near positive fusional vergence break = 13 Δ (+/− 4.6). There were no statistically significant nor clinically relevant differences between treatment groups with respect to baseline characteristics (p > 0.05).Conclusion: Hallmark features of the study design include formal definitions of conditions and outcomes, standardized diagnostic and treatment protocols, a placebo treatment arm, masked outcome examinations, and the CISS score outcome measure. The baseline data reported herein define the clinical profile of those enrolled into the CITT.

Validity of the convergence insufficiency symptom survey: a confirmatory study.

Purpose. The objectives of the present study were to evaluate whether investigator bias influenced the Convergence Insufficiency Symptom Survey (CISS) scores of children with normal binocular vision (NBV) in our original validation study, reevaluate the usefulness of the cutoff score of 16, and reexamine the validity of the CISS. Methods. Six clinical sites participating in the Convergence Insufficiency Treatment Trial (CITT) enrolled 46 children 9 to <18 years with NBV. Examiners masked to the child’s binocular vision status administered the CISS. The mean CISS score was compared with that from the children with NBV in the original, unmasked CISS study and also to that of the 221 symptomatic convergence insufficiency (CI) children enrolled in the CITT. Results. The mean (±standard deviation) CISS score for 46 subjects with NBV was 10.4 (±8.1). This was comparable with our prior unmasked NBV study (mean = 8.1 (±6.2); p = 0.11) but was significantly different from that of the CITT CI group (mean = 29.8 ± 9.0; p < 0.001). Eighty-three percent of these NBV subjects scored <16 on the CISS, which is not statistically different from the 87.5% found in the original unmasked study (p = 0.49). Conclusions. Examiner bias did not affect the CISS scores for subjects with NBV in our prior study. The CISS continues to be a valid instrument for quantifying symptoms in 9 to <18-year-old children. These results also confirm the validity of a cut-point of ≥16 in distinguishing children with symptomatic CI from those with NBV.

Vision Diagnoses Are Common After Concussion in Adolescents

Objective. To determine the prevalence of vision diagnoses after concussion in adolescents. Methods. Cross-sectional study from July 1, 2013 to February 28, 2014, of patients aged 11 to 17 years with concussion evaluated in a comprehensive concussion program. Results. A total of 100 adolescents were examined, with a mean age of 14.5 years. Overall, 69% had one or more of the following vision diagnoses: accommodative disorders (51%), convergence insufficiency (49%), and saccadic dysfunction (29%). In all, 46% of patients had more than one vision diagnosis. Conclusions. A high prevalence of vision diagnoses (accommodative, binocular convergence, and saccadic eye movement disorders) was found in this sample of adolescents with concussion, with some manifesting more than one vision diagnosis. These data indicate that a comprehensive visual examination may be helpful in the evaluation of a subset of adolescents with concussion. Academic accommodations for students with concussion returning to the classroom setting should account for these vision diagnoses.

The Effectiveness of Irlen Filters for Improving Reading Performance: A Pilot Study

The objectives of this pilot study were to investigate the effectiveness of Irlen filters for improving comfort and reading performance and to determine whether traditional optometric intervention would be effective in relieving the symptoms commonly reported by people seeking help through the use of Irlen filters. Thirty subjects were included in the study: 12 males and 18 females. The ages of the subjects ranged from 9 to 51 (mean = 23.6). They were randomly placed in either an Irlen filter treatment group (n = 11), a vision therapy treatment group (n = 11), or a control group (n = 8). Pre- and posttesting on all subjects included a vision evaluation, reading and intelligence testing, the Irlen scotopic sensitivity screening test, and a symptom questionnaire. Results revealed that subjects in both treatment groups were more comfortable after treatment, although only the vision therapy group showed improvement in vision functioning. The subjects in the Irlen filter group did not show any significant gains in reading rate, word recognition in context, or comprehension.

Academic Behaviors in Children with Convergence Insufficiency with and without Parent-Reported ADHD

Purpose. To determine if children with symptomatic Convergence Insufficiency without the presence of parent-reported Attention Deficit Hyperactivity Disorder (ADHD) have higher scores on the academic behavior survey (ABS). Methods. The ABS is a 6-item survey that evaluates parent concern about school performance and the parents’ perceptions of the frequency of problem behaviors that their child may exhibit when reading or performing schoolwork (such as difficulty completing work, avoidance, and inattention). Each item is scored on an ordinal scale from 0 (Never) to 4 (Always) with a total score ranging from 0 to 24. The survey was administered to the parents of 212 children 9- to 17-year old (mean age 11.8 years.) with symptomatic convergence insufficiency before enrolling into the Convergence Insufficiency Treatment Trial and to 49 children with normal binocular vision (NBV) (mean age 12.5 years). The parents reported whether the child had ADHD, and this information was used to divide the symptomatic convergence insufficiency group into the convergence insufficiency with parent report of ADHD or convergence insufficiency with parent report of no ADHD groups. Results. Sixteen percent of the convergence insufficiency group and 6% of the NBV group were classified as ADHD by parental report. An analysis of covariance showed that the total ABS score for the symptomatic convergence insufficiency with parent report of ADHD group (15.6) was significantly higher than the symptomatic convergence insufficiency with parent report of no ADHD group (11.7, p = 0.001) and the NBV group (8.7, p < 0.0001). Children with convergence insufficiency with parent report of no ADHD scored significantly higher on the ABS than the NBV group (p = 0.036). Conclusions. Children with symptomatic convergence insufficiency with parent report of no ADHD scored higher on the ABS, when compared to children with NBV. Children with parent report of ADHD or related learning problems may benefit from comprehensive vision evaluation to assess for the presence of convergence insufficiency.

The effectiveness of pencil pushups treatment for convergence insufficiency: a pilot study.

Purpose. To study the effectiveness of pencil pushups treatment (PPT) for the treatment of convergence insufficiency in a clinical situation. Methods. PPT was prescribed for use at home for 6 weeks for 25 subjects with convergence insufficiency. Results. Twelve of the subjects returned for follow-up. Seven of 12 (58%) subjects showed a clinically significant improvement in nearpoint of convergence and positive fusional vergence, and 11 of 12 reported improvement in symptoms. Only one subject became asymptomatic. Conclusions. PPT resulted in some improvement in both objective findings and symptoms for some subjects. Compliance with the recommended home therapy protocol was poor.

Improvement in Academic Behaviors After Successful Treatment of Convergence Insufficiency

Purpose. To determine whether treatment of symptomatic convergence insufficiency (CI) has an effect on Academic Behavior Survey (ABS) scores. Methods. 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. Results. 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). Conclusions. 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.