Mitchell Scheiman

Validity and Reliability of the Revised Convergence Insufficiency Symptom Survey in Children Aged 9 to 18 Years

Purpose. To assess the validity and reliability of the Convergence Insufficiency Symptom Survey (CISS) in children aged 9 to 18 years. The CISS is the primary outcome measure for a pilot study evaluating two different treatments for convergence insufficiency (CI). Methods. Children with CI were given the CISS twice to assess reliability. CISS scores for the first administration were also compared with scores from children with normal binocular vision to assess the validity of the CISS. Results. Forty-seven children with CI and 56 children with normal binocular vision participated in the study. Reliability was assessed using intraclass correlation and 95% limits of agreement for the children with CI. For children with CI, the intraclass correlation was 0.77 (95% confidence interval, 0.613 to 0.873), and the 95% limits of agreement were −10.2 to +12.1. The mean (±SD) CISS score was 30.8 ± 8.4 for the children with CI and 8.4 ± 6.4 for the children with normal binocular vision. These means were significantly different (p < 0.0001). Good discrimination (sensitivity, 96%; specificity, 88%) was obtained using a score of ≥16. Conclusions. Children with CI showed a significantly higher CISS symptom score than children with normal binocular vision. The results of the study indicate that the CISS is a valid and reliable instrument to use as an outcome measure for children aged 9 to 18 who are enrolled in clinical research concerning CI.

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.

Validity and reliability of the revised convergence insufficiency symptom survey in adults

Purpose:  To assess the validity and reliability of the revised Convergence Insufficiency Symptom Survey (CISS) in adults aged 19–30 years. The CISS was developed to be the primary outcome measure for studies evaluating various treatments for convergence insufficiency (CI).

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.

Patching vs atropine to treat amblyopia in children aged 7 to 12 years: A randomized trial

OBJECTIVE To compare patching with atropine eyedrops in the treatment of moderate amblyopia (visual acuity, 20/40-20/100) in children aged 7 to 12 years. METHODS In a randomized, multicenter clinical trial, 193 children with amblyopia were assigned to receive weekend atropine or patching of the sound eye 2 hours per day. Main Outcome Measure Masked assessment of visual acuity in the amblyopic eye using the electronic Early Treatment Diabetic Retinopathy Study testing protocol at 17 weeks. RESULTS At 17 weeks, visual acuity had improved from baseline by an average of 7.6 letters in the atropine group and 8.6 letters in the patching group. The mean difference between groups (patching - atropine) adjusted for baseline acuity was 1.2 letters (ends of complementary 1-sided 95% confidence intervals for noninferiority, -0.7, 3.1 letters). This difference met the prespecified definition for equivalence (confidence interval <5 letters). Visual acuity in the amblyopic eye was 20/25 or better in 15 participants in the atropine group (17%) and 20 in the patching group (24%; difference, 7%; 95% confidence interval, -3% to 17%). CONCLUSIONS Treatment with atropine or patching led to similar degrees of improvement among 7- to 12-year-olds with moderate amblyopia. About 1 in 5 achieved visual acuity of 20/25 or better in the amblyopic eye. CLINICAL RELEVANCE Atropine and patching achieve similar results among older children with unilateral amblyopia. TRIAL REGISTRATION (clinicaltrials.gov) Identifier: NCT00315328.

A Randomized Clinical Trial of Vision Therapy/ Orthoptics versus Pencil Pushups for the Treatment of Convergence Insufficiency in Young Adults

Purpose. The purpose of this article is to compare vision therapy/orthoptics, pencil pushups, and placebo vision therapy/orthoptics as treatments for symptomatic convergence insufficiency in adults 19 to 30 years of age. Methods. In a randomized, multicenter clinical trial, 46 adults 19 to 30 years of age with symptomatic convergence insufficiency were randomly assigned to receive 12 weeks of office-based vision therapy/orthoptics, office-based placebo vision therapy/orthoptics, or home-based pencil pushups. The primary outcome measure was the symptom score on the Convergence Insufficiency Symptom Survey. Secondary outcome measures were the near point of convergence and positive fusional vergence at near. Results. Only patients in the vision therapy/orthoptics group demonstrated statistically and clinically significant changes in the near point of convergence (12.8 cm to 5.3 cm, p = 0.002) and positive fusional vergence at near (11.3&Dgr; to 29.7&Dgr;, p = 0.001). Patients in all three treatment arms demonstrated statistically significant improvement in symptoms with 42% in office-based vision therapy/orthoptics, 31% in office-based placebo vision therapy/orthoptics, and 20% in home-based pencil pushups achieving a score <21 (our predetermined criteria for elimination of symptoms) at the 12-week visit. Discussion. In this study, 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.

Risk of amblyopia recurrence after cessation of treatment.

BACKGROUND Although amblyopia can be successfully treated with patching or atropine, there have been few prospective studies of amblyopia recurrence once treatment is discontinued. METHODS We enrolled 156 children with successfully treated anisometropic or strabismic amblyopia (145 completed follow-up), who were younger than 8 years of age and who received continuous amblyopia treatment for the previous 3 months (prescribed at least 2 hours of daily patching or prescribed at least one drop of atropine per week) and who had improved at least 3 logMAR levels during the period of continuous treatment. Patients were followed off treatment for 52 weeks to assess recurrence of amblyopia, defined as a 2 or more logMAR level reduction of visual acuity from enrollment, confirmed by a second examination. Recurrence was also considered to have occurred if treatment was restarted because of a nonreplicated 2 or more logMAR level reduction of visual acuity. RESULTS Recurrence occurred in 35 (24%) of 145 cases (95% confidence interval 17% to 32%) and was similar in patients who stopped patching (25%) and in patients who stopped atropine (21%). In patients treated with moderately intense patching (6 to 8 hours per day), recurrence was more common (11 of 26; 42%) when treatment was not reduced prior to cessation than when treatment was reduced to 2 hours per day prior to cessation (3 of 22; 14%, odds ratio 4.4, 95% confidence interval 1.0 to 18.7). CONCLUSIONS Approximately one fourth of successfully treated amblyopic children experience a recurrence within the first year off treatment. For patients treated with 6 or more hours of daily patching, our data suggest that the risk of recurrence is greater when patching is stopped abruptly rather than when it is reduced to 2 hours per day prior to cessation. A randomized clinical trial of no weaning versus weaning in successfully-treated amblyopia is warranted to confirm these observational findings.

Anisometropic amblyopia: is the patient ever too old to treat?

Amblyopia is an example of abnormal visual development that is clinically defined as a reduction of best corrected Snellen acuity to less than 6/9 (20/30) in one eye or a two-line difference between the two eyes, with no visible signs of eye disease. We describe a sequential management program for anisometropic amblyopia that consists of four steps: (1) the full refractive correction, (2) added lenses or prism when needed to improve alignment of the visual axes, (3) 2 to 5 h/day of direct occlusion, and (4) active vision therapy to develop monocular acuity and improve binocular visual function. We examined records of 19 patients over 6 years of age who had been treated using this sequential management philosophy. After 15.2 (±7.7) weeks of treatment the Amblyopia Success Index (ASI) documented an average improvement in visual acuity of 92.1% ± 8.1 with a range from a low of 75% by a 49-year-old patient to a maximum of 100% achieved by 42.1% of the patients (8 of 19). Patients who had completed therapy 1 or more years ago (N=4) maintained their acuity improvement. From these results we conclude that following a sequential management plan for treatment of anisometropic amblyopia can yield substantial long-lasting improvement in visual acuity and binocular function for patients of any age.

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.