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Effectiveness of vision therapy for convergence dysfunctions and long-term stability after vision therapy
Abstract
Symptomatic convergence insufficiency (CI) is a common binocular dysfunction. It is often associated with accommodative insufficiency (AI). Optimum therapy for this condition was recently shown to be in-clinic vision therapy (VT). More scientific studies are needed to assess the effectiveness of VT and verify these evidence-based results.
Fifty-seven children aged 9-13 years were diagnosed with symptomatic CI (n = 27) or combined symptomatic CI and AI (n = 30). They were independently divided into a treatment and a control group, matched by age and gender. The treatment group received 12 weeks of VT while the control group received no therapy. A quality of life instrument documented the symptomatic patients and charted improvement in symptoms after therapy. Clinical aspects were also assessed to determine the treatment effects on clinical findings. Twenty children in the treatment group completed a 1 year follow-up examination.
Symptom scores and clinical measures of the treatment and control groups were not significantly different at baseline (p > 0.05), but showed significant differences after completion of 12 weeks of treatment (p < 0.001). No significant changes of either symptoms or signs were evident for the control group. One year follow-up examination revealed that most children maintained the improved symptom and clinical measures after VT.
This study supports the notion that VT is a successful method of treating CI and CI combined with AI.
... In the current study, 210 students were evaluated of age group 18-30 years (mean age 24). No participant was excluded: 147 (70%) were male and 63 (30%) were female. ...
... These findings suggest that in engineering students, it is important to conduct a thorough eye and binocular vision examination to detect NSBVD. Furthermore, these dysfunctions can be successfully managed through the art of lens prescribing and optometric vision therapy [21][22][23][24][25][26]. Therefore, timely diagnosis and management will positively impact their future and increase the productivity of life. ...
Background: Engineering is one of the disciples of science which needs tedious near works, long run
computer tasks and accurate focus and fixation. This study was carried out to assess the prevalence of
Non-Strabismic Binocular Vision Dysfunctions (NSBVD)among engineering students in Nepal.
Methodology: It was a cross-sectional study which was conducted among engineering students in
different engineering colleges in Kathmandu valley (Kathmandu, Lalitpur and Bhaktapur districts),
Nepal. Students in the age group of 18-30 years were included in the study. Each subject was examined to
investigate for the presence of an NSBVD.
Results: Of the 210 participants of age group 18 to 30 years examined,150 (71.41%) students presented
some form of NSBVD. The prevalence of accommodative dysfunction, vergence dysfunction and
oculomotor dysfunction was 21.42%, 28.57% and 10.00% respectively. The most common NSBVD was
accommodative insufficiency(12.85%) followed by convergence insufficiency (11.42%).
Conclusion: The present study indicates that non strabismic binocular vision dysfunctions are prevalent
among engineering students in Nepal and accommodative insufficiency was the most prevalent.
Keywords: Accommodative dysfunction; Engineering students; Oculomotor dysfunction; Vergence
dysfunction
... The questionnaire used in this study was adapted from the 19-item College of Optometrists in Vision Development (COVD) Quality of Life (QOL) assessment, which has good test-retest reliability in measuring subjects' visual symptoms in general [19,20]. It was translated into Chinese based on the Brislin translation model [21]. ...
... As shown in Fig. 1, regarding visual symptoms, the higher COVD-QOL scores in this study suggest that most pilots with ADs and/or BDs indeed experience many visual problems in their daily lives. These findings are consistent with the results of previous studies [20,31], which showed that individuals with binocular vision anomalies had more visual discomfort symptoms than those with normal binocular vision. These visual complaints may include asthenopia, headache, blurred vision, loss of concentration when reading or doing near work [6][7][8]. ...
Abstract Background To analyze whether corneal refractive surgery (CRS) is associated with the distribution of different accommodative dysfunctions (ADs) and binocular dysfunctions (BDs) in civilian pilots. A further aim was to analyze the percentages and visual symptoms associated with ADs and/or BDs in this population. Methods One hundred and eight civilian pilots who underwent CRS from January 2001 to July 2012 (age: 30.33 ± 4.60 years) were enrolled, the mean preoperative SE was − 1.51 ± 1.15 D (range: − 1.00- − 5.00 D). Ninety-nine emmetropic civilian pilots (age: 29.64 ± 3.77 years) who were age- and sex-matched to the CRS group were also enrolled. Refractive status, accommodative and binocular tests of each subject were performed. Visually related symptoms were quantified using the 19-item College of Optometrists in Vision Development Quality of Life (COVD-QOL) questionnaire. The 19 items were summed to obtain visual symptom scores that might indicate visual dysfunctions. The chi-square test was used to analyze differences in percentages of ADs and/or BDs between the CRS and emmetropic groups. The Mann-Whitney U test was used to compare visual symptom scores between pilots with ADs and/or BDs and pilots with normal binocular vision. Results No significant difference was observed between the CRS and emmetropic groups in the overall prevalence of ADs and BDs (15.7% and 15.2% in the CRS and emmetropic groups, respectively; P = 0.185). ADs were present in 4.63% and 3.03% of the CRS and emmetropic group, respectively. BDs were observed in 11.1% and 12.1% of the CRS and emmetropic group, respectively, yielding no significant differences between the groups in the prevalence of ADs or BDs (AD: P = 0.094; BD: P = 0.105). Pilots with ADs and/or BDs had significantly more visual symptoms than pilots with normal binocular vision (p
... The questionnaire used in this study was adapted from the 19-item College of Optometrists in Vision Development (COVD) Quality of Life (QOL) assessment, which has good test-retest reliability in measuring subjects' visual symptoms in general [19][20]. It was translated into Chinese based on the Brislin translation model [21]. ...
... As shown in Figure 1, regarding visual symptoms, the higher COVD-QOL scores in this study suggest that most pilots with ADs and/or BDs indeed experience many visual problems in their daily lives. These ndings are consistent with the results of previous studies [20,31], which showed that individuals with binocular vision anomalies had more visual discomfort symptoms than those with normal binocular vision. These visual complaints may include asthenopia, headache, blurred vision, loss of concentration when reading or doing near work [6][7][8]. ...
Background: To analyze whether corneal refractive surgery (CRS) is associated with the distribution of different accommodative dysfunctions (ADs) and binocular dysfunctions (BDs) in civilian pilots. A further aim was to analyze the percentages and visual symptoms associated with ADs and/or BDs in this population.
Methods: One hundred and eight civilian pilots who underwent CRS from January 2001 to July 2012 (age: 30.33±4.60 years) were enrolled, the mean preoperative SE was −1.51±1.15 D (range: −1.00- −5.00 D). Ninety-nine emmetropic civilian pilots (age: 29.64±3.77 years) who were age- and sex-matched to the CRS group were also enrolled. Refractive status, accommodative and binocular tests of each subject were performed. Visually related symptoms were quantified using the 19-item College of Optometrists in Vision Development Quality of Life (COVD-QOL) questionnaire. The 19 items were summed to obtain visual symptom scores that might indicate visual dysfunctions. The chi-square test was used to analyze differences in percentages of ADs and/or BDs between the CRS and emmetropic groups. The Mann-Whitney U test was used to compare visual symptom scores between pilots with ADs and/or BDs and pilots with normal binocular vision.
Results: No significant difference was observed between the CRS and emmetropic groups in the overall prevalence of ADs and BDs (15.7% and 15.2% in the CRS and emmetropic groups, respectively; P=0.185). ADs were present in 4.63% and 3.03% of the CRS and emmetropic group, respectively. BDs were observed in 11.1% and 12.1% of the CRS and emmetropic group, respectively, yielding no significant differences between the groups in the prevalence of ADs or BDs (AD: P=0.094; BD: P=0.105). Pilots with ADs and/or BDs had significantly more visual symptoms than pilots with normal binocular vision (p < 0.001).
Conclusions: CRS for civilian pilots with low-moderate myopia might not impact binocular functions. ADs and/or BDs commonly occur in both emmetropia pilots and pilots who undergo CRS, and pilots with ADs and/or BDs are associated with increased symptoms. This study confirms the importance of a full assessment of binocular visual functions in detecting and remedying these dysfunctions in this specific population.
... The questionnaire used in this study was adapted from the 19-item College of Optometrists in Vision Development (COVD) Quality of Life (QOL) assessment, which has good test-retest reliability in measuring subjects' visual symptoms in general [19][20]. It was translated into Chinese based on the Brislin translation model [21]. ...
... Regarding visual symptoms, the higher COVD-QOL scores in this study suggest that most pilots with ADs and/or BDs indeed experience many visual problems in their daily lives. These ndings are consistent with the results of previous studies [20,31], which showed that individuals with binocular vision anomalies had more visual discomfort symptoms than those with normal binocular vision. These visual complaints may include asthenopia, headache, blurred vision, loss of concentration when reading or doing near work [6][7][8]. ...
Background: To analyze whether corneal refractive surgery (CRS) is associated with the distribution of different accommodative dysfunctions (ADs) and binocular dysfunctions (BDs) in civilian pilots. A further aim was to analyze the percentages and visual symptoms associated with ADs and/or BDs in this population.
Methods: One hundred and eight civilian pilots who underwent CRS from January 2001 to July 2012 (age range: 23-35 years) and 99 emmetropic civilian pilots (age range: 23-35 years) were included in this study. Visual symptoms, refractive status, accommodative and binocular tests of each subject were performed.
Results: No significant difference was observed between the CRS and emmetropic groups in the overall prevalence of ADs and BDs (15.7% and 15.2% in the CRS and emmetropic groups, respectively; P=0.185). ADs were present in 4.63% and 3.03% of the CRS and emmetropic group, respectively. BDs were observed in 11.1% and 12.1% of the CRS and emmetropic group, respectively, yielding no significant differences between the groups in the prevalence of ADs or BDs (AD: P=0.094; BD: P=0.105). Pilots with ADs and/or BDs had significantly more visual symptoms than pilots with normal binocular vision (p < 0.001).
Conclusions: CRS for civilian pilots with low-moderate myopia might not impact binocular functions. ADs and/or BDs commonly occur in both emmetropia pilots and pilots who undergo CRS, and pilots with ADs and/or BDs are associated with increased symptoms. This study confirms the importance of a full assessment of binocular visual functions in detecting and remedying these dysfunctions in this specific population.
Trial registration number: ChiCTR1900027235 (date: 6 Nov 2019) Available at www.medresman.org
... Furthermore, we cannot assess whether symptoms recurred in our subjects from the experimental group after successful EHBVT. Nevertheless, it has been reported that recurrence is rare when normal convergence and fusion are achieved [21,50]. ...
... It is hard to predict whether EHBVT would be effective with large eye deviation as intermittent or constant CI exotropia. It has been demonstrated that extraocular surgery could bring a positive/desired effect in subjects with high angle exotropia [34,[50][51][52][53][54]. However, as MARUO et al. communicated [34], after the eye muscle surgery some angle of eye deviation (from +2 deg to -10 deg) is usually observed. ...
The purpose of this study was to investigate the effectiveness of extended home-based vision therapy as a treatment for symptomatic convergence insufficiency (Cl) in young exophoric adults. Twenty-four adults with symptomatic exophoria at near with convergence insufficiency were divided into an experimental and a control group. The experimental group received 24 weeks of vision training, while the control group received no therapy. The three major outcome measures were the scores on the convergence insufficiency symptom survey V15 (CISS-V15), the near point of convergence and the positive fusional vergence at near. Only subjects from the experimental group demonstrated statistically and clinically significant changes in the CISS-V15 score (improvement of 20 points), near point of convergence (improvement of 5.5 cm) and positive fusional vergence at near (improvement of 15 A). No significant changes of either symptoms or signs were evident for the control group. The results presented in this study showed that extending the time and number of home based therapy techniques might be an effective treatment modality in adult subjects with CI. This therapy might be an alternative way for treatment of symptomatic exophoric CI subjects, who cannot attend office sessions.
... Nevertheless, the standard teaching is that negative fusional vergence therapy procedures should be included as a component of the therapy protocol when treating patients with convergence insufficiency. 2,3,11 Most convergence insufficiency treatment studies either have not reported negative fusional vergence measures [12][13][14][15][16][17][18][19][20][21][22][23] or have only reported them before treatment. [4][5][6] Recent randomized clinical trials evaluating treatments for childhood convergence insufficiency have included negative fusional vergence therapy as a component of the therapy protocol [4][5][6]17 ; however, the change in this visual function has not been reported. ...
Significance:
Deficits of disparity divergence found with objective eye movement recordings may not be apparent with standard clinical measures of negative fusional vergence (NFV) in children with symptomatic convergence insufficiency.
Purpose:
This study aimed to determine whether NFV is normal in untreated children with symptomatic convergence insufficiency and whether NFV improves after vergence/accommodative therapy.
Methods:
This secondary analysis of NFV measures before and after office-based vergence/accommodative therapy reports changes in (1) objective eye movement recording responses to 4° disparity divergence step stimuli from 12 children with symptomatic convergence insufficiency compared with 10 children with normal binocular vision (NBV) and (2) clinical NFV measures in 580 children successfully treated in three Convergence Insufficiency Treatment Trial studies.
Results:
At baseline, the Convergence Insufficiency Treatment Trial cohort's mean NFV break (14.6 ± 4.8Δ) and recovery (10.6 ± 4.2Δ) values were significantly greater (P < .001) than normative values. The post-therapy mean improvements for blur, break, and recovery of 5.2, 7.2, and 1.3Δ, respectively, were statistically significant (P < .0001). Mean pre-therapy responses to 4° disparity divergence step stimuli were worse in the convergence insufficiency group compared with the NBV group for peak velocity (P < .001), time to peak velocity (P = .01), and response amplitude (P < .001). After therapy, the convergence insufficiency group showed statistically significant improvements in mean peak velocity (11.63°/s; 95% confidence interval [CI], 6.6 to 16.62°/s), time to peak velocity (-0.12 seconds; 95% CI, -0.19 to -0.05 seconds), and response amplitude (1.47°; 95% CI, 0.83 to 2.11°), with measures no longer statistically different from the NBV cohort (P > .05).
Conclusions:
Despite clinical NFV measurements that seem greater than normal, children with symptomatic convergence insufficiency may have deficient NFV when measured with objective eye movement recordings. Both objective and clinical measures of NFV can be improved with vergence/accommodative therapy.
... Therefore, detecting and managing CI is an important issue in the field of binocular vision [7] . Considerable uncertainty and disagreement has existed regarding the management of convergence insufficiency [4,8,9]. There a clinical evidence for the efficiency of vision therapy for CI [10,11]. ...
Background
Convergence Insufficiency (CI) is a common binocular vision disorder characterized by exophoria more at near than at far, a receded Near Point of Convergence (NPC), and decreased Positive Fusional Vergence (PFV) at near. This disorder is often associated with several symptoms that may disturb the person’s quality of life. Therefore, diagnosis and treatment of CI is a vital issue.
Objectives
To compare therapeutic yield of Office Based Vision Therapy (OBVT) and combined OBVT with Home Therapy System (HTS) in patients with CI.
Methods
The study included 102 patients with age range of 7-13 years. All patients underwent Convergence Insufficiency Symptom Survey (CISS) scoring, estimation of Near Point of Convergence (NPC) and determination of Positive Fusional Vergence at near (PFV) using Sheard’s criterion. Patients were randomly allocated in two groups: Group I: received Office-based Vision Therapy (OBVT) and Group II: received OBVT with home reinforcement using the Home Therapy System (HTS). At the end of 12th week of therapy; outcome was determined as Successful (all the following: CISS score of <16, NPC <6 cm and PFV >15Δ), Improved (CISS score of <16 or a 10 points-decrease and one of the following: NPC <6cm or improved by >4 cm, PFV >15Δ or increased by > 10Δ), Insufficient response (NPC <6cm or improved by >4 cm, PFV >15Δ or increased by > 10Δ) and non-responders.
Results
At the end of the 12th week of therapy, the applied therapeutic polices were successful in 48 patients (47.1%), the symptoms were improved in 30 patients (29.4%), improvement was insufficient in 13 patients (12.7%) and 11 patients (10.8%) were considered as non-responders. There was significantly higher frequency of patients with improved outcome in group II (86%) compared to group I (69.2%).
Conclusion
OBVT with home supplement using HTS provided a high success rate, and it seems to be superior to OBVT alone in treatment of children with convergence insufficiency after 12-week course of therapy.
... More importantly, students who performed the eye exercises seriously, followed the instructions when performing the eye exercises, and were acquainted with the eye exercises, tended to have a lower CISS score, i.e., were less symptomatic when performing near work activities, even after adjusting for the same confounders [1]. Convergence insufficiency is associated with visual symptoms at near, including general eyestrain, blurred vision, diplopia, difficulty concentrating, and reduced comprehension after short periods of reading or performing or other near activities [11,17,18]. Studies have demonstrated that the CISS questionnaire is a valid instrument for quantifying near visual symptoms in 9 to 18 year-old children and teenagers [11,19]. ...
Background
Chinese traditional “eye exercises of acupoints” have been advocated as a compulsory measure to reduce visual symptoms, as well as to retard the development of refractive error, among Chinese students for decades. The exercises are comprised of a 5-min, bilateral eye acupoint self-massage. This study evaluated the possible effect of these eye exercises among Chinese rural students. Methods
Eight hundred thirty-six students (437 males, 52.3 %), aged 10.6 ± 2.5 (range 6–17) years from the Handan Offspring Myopia Study (HOMS) who completed the eye exercises and vision questionnaire, the convergence insufficiency symptom survey (CISS) questionnaire, and had a cycloplegic refraction were included in this study. Results121 (14.5 %) students (64 males, 52.9 %) performed the eye exercises of acupoints in school. The multiple odds ratio (OR) and 95 % confidence interval (CI) for those having a “serious attitude” towards performing the eye exercises (0.12, 0.03–0.49) demonstrated a protective effect for myopia, after adjusting for the children’s age, gender, average parental refractive error, and the time spent on near work and outdoor activity. The more frequently, and the more seriously, the students performed the eye exercises each week, the less likely was their chance of being myopic (OR, 95 % CI: 0.17, 0.03–0.99), after adjusting for the same confounders. However, neither the “seriousness of attitude” of performing the eye exercises (multiple β coefficients: -1.58, p = 0.23), nor other related aspects of these eye exercises, were found to be associated with the CISS score in this sample. Conclusions
The traditional eye exercises of acupoints appeared to have a modest protective effect on myopia among these Chinese rural students aged 6–17 years. However, no association between the eye exercises and near vision symptoms was found.
... Many studies have reported different symptoms, such as blurred vision, difficulty focusing at different distances, headache and ocular pain, among others. [1][2][3][4][5][6][7][8][9][10][11][12] According to the methods for identification of symptoms, on which diagnosis of these visual conditions is based, the authors have used different criteria, 3,4,[13][14][15][16][17][18][19] from simply considering the presence or absence of visual symptoms, to a description of the frequency of symptoms reported by patients or the use of symptoms questionnaires. Some authors have related these dysfunctions to problems with reading or academic performance. ...
Background:
The aim was to analyse the prevalence of symptomatic accommodative and non-strabismic binocular dysfunctions in a randomised population of university subjects.
Methods:
A cross-sectional study was conducted with a randomised sample of 175 university students aged between 18 and 35 years. All subjects were given a visual examination in which their symptoms were recorded, as well as performing objective and subjective refractive examinations and accommodative and binocular tests. Each subject was tested for the presence of uncorrected refractive error. Accommodative dysfunctions (AD) and binocular dysfunctions (BD) were diagnosed according to the number of clinical signs associated with each disorder, considering the signs that could be associated with each dysfunction as fundamental or complementary. An accommodative or binocular dysfunction was diagnosed when the subjects met two conditions: presenting with any kind of visual symptom in their clinical history and presenting the fundamental sign associated with each dysfunction as well as two or more complementary signs. Those subjects who presented with only an uncorrected refractive error were considered within the group called refractive dysfunction (RD).
Results:
The overall prevalence of accommodative and/or binocular dysfunctions was 13.15 per cent and for refractive dysfunction it was 45.14 per cent. Accommodative dysfunctions were present in 2.29 per cent of the population, binocular dysfunctions were observed in eight per cent and accommodative dysfunctions together were found in 2.86 per cent of the university students. Within the accommodative and binocular disorders, the most prevalent dysfunctions were convergence insufficiency, with a prevalence of 3.43 per cent and convergence excess and accommodation excess, both with a prevalence of 2.29 per cent.
Conclusion:
Binocular dysfunctions were more prevalent than accommodative dysfunctions or accommodative and binocular dysfunctions together in a randomised population of university students.
... ,17,21,30,31,36,38---40,50,52---54,57,58,60---65 analysed symptoms using patients' descriptions of their case histories or on the basis of questions posed by the person conducting the examination. Of the 11 questionnaires used, the CI-specific CISS V-15 questionnaire was the most frequently employed, having been used in 21 studies 8,13---16,19,20,23,25---27,29,32---35,43---46,48 , followed by the 19item College of Optometrists in Vision Development Quality of Life (QOVD-QOL) questionnaire18,22,42,47 (developed for visual abnormalities in general) and the Conlon survey28,32,37 developed for visual disorders in general and the Academic Behaviour Survey 13,24,35 (for CI). The remaining questionnaires were used once only.9,41,49,51,55,56,59 ...
Purpose:
To determine the symptoms associated with accommodative and non-strabismic binocular dysfunctions and to assess the methods used to obtain the subjects' symptoms.
Methods:
We conducted a scoping review of articles published between 1988 and 2012 that analysed any aspect of the symptomatology associated with accommodative and non-strabismic binocular dysfunctions. The literature search was performed in Medline (PubMed), CINAHL, PsycINFO and FRANCIS. A total of 657 articles were identified, and 56 met the inclusion criteria.
Results:
We found 267 different ways of naming the symptoms related to these anomalies, which we grouped into 34 symptom categories. Of the 56 studies, 35 employed questionnaires and 21 obtained the symptoms from clinical histories. We found 11 questionnaires, of which only 3 had been validated: the convergence insufficiency symptom survey (CISS V-15) and CIRS parent version, both specific for convergence insufficiency, and the Conlon survey, developed for visual anomalies in general. The most widely used questionnaire (21 studies) was the CISS V-15. Of the 34 categories of symptoms, the most frequently mentioned were: headache, blurred vision, diplopia, visual fatigue, and movement or flicker of words at near vision, which were fundamentally related to near vision and binocular anomalies.
Conclusions:
There is a wide disparity of symptoms related to accommodative and binocular dysfunctions in the scientific literature, most of which are associated with near vision and binocular dysfunctions. The only psychometrically validated questionnaires that we found (n=3) were related to convergence insufficiency and to visual dysfunctions in general and there no specific questionnaires for other anomalies.
... Convergence insufficiency is associated with near visual symptoms, including eyestrain, headaches, blurred vision, diplopia, difficulty concentrating, and loss of comprehension after brief short periods of reading or performing near work activities [21][22][23]. The convergence insufficiency symptom survey (CISS) rating scale, a valid and reliable survey instrument for children [22], allows a two-factor analysis of the visual symptoms; firstly, whether or not the symptom is present, and secondly, how frequently the symptom occurs. ...
... Convergence insufficiency is associated with near visual symptoms, including eyestrain, headaches, blurred vision, diplopia, difficulty concentrating, and loss of comprehension after brief short periods of reading or performing near work activities [21][22][23]. The convergence insufficiency symptom survey (CISS) rating scale, a valid and reliable survey instrument for children [22], allows a two-factor analysis of the visual symptoms; firstly, whether or not the symptom is present, and secondly, how frequently the symptom occurs. ...
Traditional Chinese eye exercises of acupoints involve acupoint self-massage. These have been advocated as a compulsory measure to reduce ocular fatigue, as well as to retard the development of myopia, among Chinese school children. This study evaluated the impact of these eye exercises among Chinese urban children.
409 children (195 males, 47.7%), aged 11.1 +/- 3.2 (range 6--17) years, from the Beijing Myopia Progression Study (BMPS) were recruited. All had completed the eye exercise questionnaire, the convergence insufficiency symptom survey (CISS), and a cycloplegic autorefraction. Among these, 395 (96.6%) performed the eye exercises of acupoints. Multiple logistic regressions for myopia and multiple linear regressions for the CISS score (after adjusting for age, gender, average parental refractive error, and time spent doing near work and outdoor activity) for the different items of the eye exercises questionnaire were performed.
Only the univariate odds ratio (95% confidence interval) for "seriousness of attitude" towards performing the eye exercises of acupoints (0.51, 0.33-0.78) showed a protective effect towards myopia. However, none of the odds ratios were significant after adjusting for the confounding factors. The univariate and multiple beta coefficients for the CISS score were -2.47 (p = 0.002) and -1.65 (p = 0.039), -3.57 (p = 0.002) and -2.35 (p = 0.042), and -2.40 (p = 0.003) and -2.29 (p = 0.004), for attitude, speed of exercise, and acquaintance with acupoints, respectively, which were all significant.
The traditional Chinese eye exercises of acupoints appeared to have a modest effect on relieving near vision symptoms among Chinese urban children aged 6 to 17 years. However, no remarkable effect on reducing myopia was observed.
... Shin et al. 148 evaluated 57 children ages 9 to 13 years who initially had symptomatic CI (N = 27) or symptomatic CI with an AI (N = 30). They were divided into 2 groups: a treatment and a control group. ...
Convergence insufficiency is a common binocular vision disorder affecting approximately 5% of the population in the United States. It is often associated with a host of symptoms that occur when doing near work, such as reading and computer viewing. This article reviews the existing literature on convergence insufficiency including etiology, diagnosis, sensorimotor findings, and management.
Purpose:
To determine whether coexisting accommodative dysfunction in children with symptomatic convergence insufficiency (CI) impacts presenting clinical convergence measures, symptoms and treatment success for CI.
Methods:
Secondary data analyses of monocular accommodative amplitude (AA; push-up method), monocular accommodative facility (AF; ±2.00 D lens flippers) and symptoms (CI Symptom Survey [CISS]) in children with symptomatic CI from the Convergence Insufficiency Treatment Trial (N = 218) and CITT-Attention and Reading Trial (N = 302) were conducted. Decreased AA was defined as more than 2D below the minimum expected amplitude for age (15 - ¼ age); those with AA < 5 D were excluded. Decreased AF was defined as <6 cycles per minute. Mean near point of convergence (NPC), near positive fusional vergence (PFV) and symptoms (CISS) were compared between those with and without accommodative dysfunction using analysis of variance and independent samples t-testing. Logistic regression was used to compare the effect of baseline accommodative function on treatment success [defined using a composite of improvements in: (1) clinical convergence measures and symptoms (NPC, PFV and CISS scores) or (2) solely convergence measures (NPC and PFV)].
Results:
Accommodative dysfunction was common in children with symptomatic CI (55% had decreased AA; 34% had decreased AF). NPC was significantly worse in those with decreased AA (mean difference = 6.1 cm; p < 0.001). Mean baseline CISS scores were slightly worse in children with coexisting accommodative dysfunction (decreased AA or AF) (30.2 points) than those with normal accommodation (26.9 points) (mean difference = 3.3 points; p < 0.001). Neither baseline accommodative function (p ≥ 0.12 for all) nor interaction of baseline accommodative function and treatment (p ≥ 0.50) were related to treatment success based on the two composite outcomes.
Conclusions:
A coexisting accommodative dysfunction in children with symptomatic CI is associated with worse NPC, but it does not impact the severity of symptoms in a clinically meaningful way. Concurrent accommodative dysfunction does not impact treatment response for CI.
Background/Purpose
To assess the prevalence of nonstrabismic accommodative and vergence dysfunctions among primary schoolchildren in Hampyeong, a rural area of South Korea.
Methods
Five hundred and eighty-nine primary schoolchildren, 8–13 years old, were each given a thorough eye examination, including binocular-vision testing, near point of convergence, horizontal phoria measurement by von Graefe, and negative and positive vergence amplitudes with prism bar, to determine any form of accommodative or vergence dysfunctions.
Results
Of the 589 participants examined, 168 (28.5%) primary schoolchildren presented some form of nonstrabismic accommodative or vergence dysfunctions. The prevalence of accommodative dysfunctions and vergence dysfunctions was 13.2% and 9%, respectively. Convergence insufficiency (10.3%) was more prevalent than convergence excess (1.9%), and accommodative insufficiency (5.3%) was more prevalent than accommodative excess (1.2%).
Conclusion
This study suggests that nonstrabismic accommodative and vergence dysfunctions are prevalent in the rural area of South Korean primary schoolchildren, and convergence insufficiency was the most prevalent.
To investigate and report the clinical characteristics at initial presentation in patients who had Duane Syndrome, especially binocular vision and functional amblyopia.
The medical files of patients with Duane's syndrome were reviewed. The main outcome measures of the study were the initial clinical characteristics including amblyopia and associated risk factors including deficiences of binocular vision.
The review identified 99 patients with Duane Syndrome. The median age of patients was 6 years. The frequency of amblyopia at initial presentation was 23 percent. Forty-five patients had measurable stereopsis and 58 patients had binocular vision fusion.
Amblyopia and altered binocular function are important among the clinical features of Duane Syndrome which should be highlighted at initial examination.
To evaluate two cases of intermittent exotropia treated by vision therapy the efficacy of the treatment by complementing the clinical examination with a 3D videooculography to register and to evidence the potential applicability of this technology for such purpose.
We report the binocular alignment changes occurring after vision therapy in a woman of 36 years with an intermittent exotropia of 25 prism diopters at far and 18 PD at near and a child of 10 years with 8 PD of intermittent exotropia in primary position associated to 6 PD of left eye hypotropia. Both patients presented good visual acuity with correction in both eyes. Instability of ocular deviation was evident by VOG analysis, revealing also the presence of vertical and torsional components. Binocular vision therapy was prescribed and performed including different types of vergence, accommodation, and consciousness of diplopia training.
After therapy, excellent ranges of fusional vergence and a to-the-nose near point of convergence were obtained.The 3D VOG examination confirmed the compensation of the deviation with a high level of stability of binocular alignment. Significant improvement could be observed after therapy in the vertical and torsional components that were found to become more stable. Patients were very satisfied with the outcome obtained by vision therapy.
3D-VOG is a useful technique for providing an objective register of the compensation of the ocular deviation and the stability of the binocular alignment achieved after vision therapy in cases of intermittent exotropia, providing a detailed analysis of vertical and torsional improvements.
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 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 push-ups therapy.
Main Outcome Measures
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
Symptoms, which were similar in all groups at baseline, were significantly reduced in the vision therapy/orthoptics group (mean symptom score decreased from 32.1 to 9.5) but not in the pencil push-ups (mean symptom score decreased from 29.3 to 25.9) or placebo vision therapy/orthoptics groups (mean symptom score decreased from 30.7 to 24.2). Only patients in the vision therapy/orthoptics group demonstrated both statistically and clinically significant changes in the clinical measures of near point of convergence (from 13.7 cm to 4.5 cm; P < .001) and positive fusional vergence at near (from 12.5 prism diopters to 31.8 prism diopters; P < .001).
Conclusions
In this pilot study, vision therapy/orthoptics was more effective than pencil push-ups or placebo vision therapy/orthoptics in reducing symptoms and improving signs of convergence insufficiency in children 9 to 18 years of age. Neither pencil push-ups nor placebo vision therapy/orthoptics was effective in improving either symptoms or signs associated with convergence insufficiency.
The purpose of this study was to fill a significant void in the ophthalmic literature by performing a large scale, comprehensive, prospective study of the prevalence of vision disorders and ocular pathology in a clinical pediatric population using well-defined diagnostic criteria.
A prospective study was performed on 2,023 consecutive patients between the ages of 6 months and 18 years presenting for an initial comprehensive examination at the Eye Institute of The Pennsylvania College of Optometry. There were 373 subjects between 6 months and 5 years, 11 months of age, and 1,650 subjects between 6 years and 18 years of age.
The most important finding from this study is that other than refractive anomalies, the most common conditions optometrists are likely to encounter in a pediatric population are binocular vision and accommodative disorders. The prevalence of accommodative and binocular (strabismic and non-strabismic) vision disorders is 9.7 times greater than the prevalence of ocular disease in children 6 months to 5 years of age, and 8.5 times greater than the prevalence of ocular disease in children 6 to 18 years of age.
The data from this study has great significance for clinicians, optometric educational institutions, health care planners, and administrators. This data suggests that other than refractive anomalies, the most prevalent conditions in the clinical pediatric population are binocular and accommodative disorders. Clinicians should use a minimum data base that includes assessments of accommodation and binocular vision that will allow them to detect conditions with the highest prevalence.
To estimate the frequency of convergence insufficiency (CI) and its related clinical characteristics among 9- to 13-year-old children.
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 Hofstetter's minimum amplitude formula or had greater than a + 1.00 D lag on Monocular Estimate Method retinoscopy.
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.
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.
A wide range of visual parameters used to evaluate binocular function were evaluated in a paediatric population (1056 subjects aged 6-12 years). Mean values are provided for these ages in optometric tests that directly assess the vergence system, horizontal phorias for near and far vision (measured by a modified version of the Thorington method), negative and positive vergence amplitude for near and far vision (step vergence testing), vergence facility (flippers 8 Delta BI/8 Delta BO), and near-point of convergence (penlight push-up technique and red-lens push-up technique), as well as stimulus accommodative convergence/accommodation ratio and stereoacuity (Randot test) which provide an overall evaluation of the vergence, accommodative and oculomotor systems. A statistical comparison (anova and Bonferroni post hoc test) of these values between ages was performed. The differences, although statistically significant, were not clinically meaningful, and therefore we identified two trends in the behaviour of these parameters. For all parameters, except for vergence facility, we established a single mean reference value for the age range studied. The difference between the means for vergence facility indicated the need to divide the population into two age ranges (6-8 and 8-12 years). This study establishes statistical normal values for these parameters in a paediatric population and their means are a valuable instrument for separating children with binocular anomalies from those with normal binocular vision.
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 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 push-ups therapy.
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.
Symptoms, which were similar in all groups at baseline, were significantly reduced in the vision therapy/orthoptics group (mean symptom score decreased from 32.1 to 9.5) but not in the pencil push-ups (mean symptom score decreased from 29.3 to 25.9) or placebo vision therapy/orthoptics groups (mean symptom score decreased from 30.7 to 24.2). Only patients in the vision therapy/orthoptics group demonstrated both statistically and clinically significant changes in the clinical measures of near point of convergence (from 13.7 cm to 4.5 cm; P < .001) and positive fusional vergence at near (from 12.5 prism diopters to 31.8 prism diopters; P < .001).
In this pilot study, vision therapy/orthoptics was more effective than pencil push-ups or placebo vision therapy/orthoptics in reducing symptoms and improving signs of convergence insufficiency in children 9 to 18 years of age. Neither pencil push-ups nor placebo vision therapy/orthoptics was effective in improving either symptoms or signs associated with convergence insufficiency.
One theory of the etiology of convergence insufficiency is the presence of an underlying low AC/A ratio. In this study there were 207 patients with varying degrees of exophoria, but all with typical signs and symptoms of convergence insufficiency. It was clinically demonstrated that their asthenopia was caused by using excessive accommodative rather than fusional convergence. They were treated with home stereograms and followed for a two year period after treatment had been discontinued. Only those patients who progressed to the point of developing both fusional and voluntary convergence, indicated by their performance on the stereograms, maintained their increased convergence amplitude and remained asymptomatic for at least two years after treatment. These results indicate that a permanent alteration of the AC/A ratio had taken place.
Purpose: To estimate the frequency of convergence insufficiency (Cl) 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 Cl. These children were classified according to the presence and number of the following clinical signs: (1) exophoria at near S4A than far, (2) insufficient fusional convergence, and (3) receded nearpoint of convergence. Also, children were classified as accommodative insufficient (AI) if they failed Hofstetter's 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 Cl measurements and were classified as: no Cl (nonexophoric at near or exophoric at near and<4A difference between near and far) (78.6%); low suspect Cl (exophoric at near and one clinical sign: exophoria at near >4A than far) (8.4%); high suspect Cl (exophoric at near and two clinical signs) (8.8%); and definite Cl (exophoric at near and three clinical signs) (4.2%). Cl status varied according to ethnicity and study site (p<0.0005), but not gender. The frequency of AI increased with the number of Cl-related signs. For Cl children with three signs, 78.9% were classified as also having AI.
Conclusions: These findings suggest that Cl (defined as high suspect and definite) is frequent (13%) among fifth and sixth grade children. In addition, there is a high percentage of Cl children with an associated AI
(C) 1999 American Academy of Optometry
The purpose of this study was to investigate the prevalence and types of non-strabismic accommodative and/or vergence dysfunctions in primary school children, and to determine the relationship of these dysfunctions to academic achievement. A total of 1031 parents and their children aged 9-13 years responded to the College of Optometrists in Vision Development Quality of Life (COVD-QOL) questionnaire. Of these, 258 children whose visual symptom scores were > or =20 were identified for further evaluation. Comprehensive eye and vision examinations were provided to the children who met the eligibility criteria (114 of 258): eligible symptomatic children were those without amblyopia, strabismus, ocular and systemic pathology, and contact lens wear. Children were also excluded if they had visual acuity poorer than 20/25 in either eye or vertical phoria >1 prism diopter. The results showed that 82 of 114 (71.9%) of criteria-eligible symptomatic primary school children had non-strabismic accommodative and/or vergence dysfunctions. In addition, a significant relationship was found between these dysfunctions and academic scores in every academic area (reading, mathematics, social science and science) in the total sample. Therefore, accommodative and vergence functions should be tested for all school children who have visual symptoms and/or academic difficulties. Additional study is needed to determine if improvements of accommodative and vergence functions also improve academic achievement.
Purpose:
To assess the long-term stability of improvements in symptoms and signs in 9- to 17-year-old children enrolled in the Convergence Insufficiency Treatment Trial who were asymptomatic after treatment for convergence insufficiency.
Methods:
Seventy-nine patients who were asymptomatic after a 12-week therapy program for convergence insufficiency were followed for 1 year [33/60 in office-based vergence/accommodative therapy (OBVAT), 18/54 in home-based pencil push-ups (HBPP), 12/57 in home-based computer vergence/accommodative therapy and pencil push-ups (HBCVAT+), and 16/54 in office-based placebo therapy (OBPT)]. Symptoms and clinical signs were measured 6 months and 1 year after completion of the 12-week therapy program. The primary outcome measure was the mean change on the Convergence Insufficiency Symptom Survey (CISS). Secondary outcome measures were near point of convergence, positive fusional vergence at near, and proportions of patients who remained asymptomatic or who were classified as successful or improved based on a composite measure of CISS, near point of convergence, and positive fusional vergence.
Results:
One-year follow-up visit completion rate was 89% with no significant differences between groups (p = 0.26). There were no significant changes in the CISS in any treatment group during the 1-year follow-up. The percentage who remained asymptomatic in each group was 84.4% (27/32) for OBVAT, 66.7% (10/15) for HBPP, 80% (8/10) for HBCVAT+, and 76.9% (10/13) for OBPT. The percentage who remained either successful or improved 1-year posttreatment was 87.5% (28/32) for OBVAT, 66.6% (10/15) for HBPP, 80% (8/10) for HBCVAT+, and 69.3% (9/13) for OBPT.
Conclusions:
Most children aged 9 to 17 years who were asymptomatic after a 12-week treatment program of OBVAT for convergence insufficiency maintained their improvements in symptoms and signs for at least 1 year after discontinuing treatment. Although the sample sizes for the home-based and placebo groups were small, our data suggest that a similar outcome can be expected for children who were asymptomatic after treatment with HBPP or HBCVAT+.
In 2000, the UK's College of Optometrists commissioned a report to critically evaluate the theory and practice of behavioural optometry. The report which followed Jennings (2000; Behavioural optometry--a critical review. Optom. Pract. 1: 67) concluded that there was a lack of controlled clinical trials to support behavioural management strategies. The purpose of this report was to evaluate the evidence in support of behavioural approaches as it stands in 2008. The available evidence was reviewed under 10 headings, selected because they represent patient groups/conditions that behavioural optometrists are treating, or because they represent approaches to treatment that have been advocated in the behavioural literature. The headings selected were: (1) vision therapy for accommodation/vergence disorders; (2) the underachieving child; (3) prisms for near binocular disorders and for producing postural change; (4) near point stress and low-plus prescriptions; (5) use of low-plus lenses at near to slow the progression of myopia; (6) therapy to reduce myopia; (7) behavioural approaches to the treatment of strabismus and amblyopia; (8) training central and peripheral awareness and syntonics; (9) sports vision therapy; (10) neurological disorders and neuro-rehabilitation after trauma/stroke. There is a continued paucity of controlled trials in the literature to support behavioural optometry approaches. Although there are areas where the available evidence is consistent with claims made by behavioural optometrists (most notably in relation to the treatment of convergence insufficiency, the use of yoked prisms in neurological patients, and in vision rehabilitation after brain disease/injury), a large majority of behavioural management approaches are not evidence-based, and thus cannot be advocated.
To determine the variation of visual discomfort symptom reporting in a group of college students over a 1 year period.
Subjects were screened for visual acuity and uncorrected refractive error before participating in the study. A survey of visual discomfort developed by Conlon et al., Vis Cogn 1999;6:637-666, and the Convergence Insufficiency Symptom Survey (CISS) were administered to a group of 23 college students twice with approximately 1 year between administrations. All subjects also completed two clinical assessments of accommodation and vergence.
The mean time between administrations of the symptom surveys was 13 months. There was no clinically significant mean difference between the first and second administration of both visual discomfort surveys. The intraclass correlation coefficient was 0.82 for the Conlon et al., Vis Cogn 1999;6:637-666 survey and 0.85 for the CISS. The 95% limits of agreement for the Conlon et al., Vis Cogn 1999;6:637-666 survey was -18.44, 17.92 and for the CISS was -14.36, 13.36. The intraclass correlation coefficient values for the optometric tests ranged from 0.38 to 0.83.
Visual discomfort symptoms were found to be stable in the majority of young college students over a 1 year period. However, a minority of students showed large variability between the two administrations of the surveys.
A follow-up over a period of 1-4.7 years was done on nine patients between the ages of 9-16 years, who had a combination of accommodation and convergence insufficiency without any known history of head trauma, febrile illness or drug use. The initial examinations disclosed exophoria and/or exotropia in near fixation, markedly low amplitudes of accommodation in both eyes, and remote near points of convergence in all patients. There was no correlation between the severity of convergence insufficiency and that of accommodative insufficiency. The extent of convergence insufficiency remained unchanged except for one patient who had a gradual and complete recovery and two other patients who underwent resection of both medial rectus muscles. The amplitude of accommodation recovered in varying degrees in six patients, while it decreased further in two other patients during the follow-up period. On initial examination, these two patients had the most remote near point of convergence (20 cm) and the lowest accommodative amplitude (less than 2 D) in common.
The validity and permanence of orthoptic treatment for vergence deficiencies requires investigation due to the subjective nature of determining success in most clinical cases, i.e., the amelioration of symptoms and increases in vergence ranges. The relation between Risley prism vergences, a subjective measure, and vergence tracking rate, an objective index, is investigated. The course of orthoptics progress is compared in cases of clinical vergence dysfunction. Vergence-deficient control subjects showed no significant change in either index. However, trained subjects demonstrated rapid increases in both indices. The persistence of the training effect was monitored for up to 9 months. No regression was observed in subjects who met all release criteria, but one subject who chose to terminate therapy early showed a slow regression in tracking rate and recurrence of symptoms. These data support the validity of vergence training and increase the plausibility of previous clinical reports of orthoptics success.
Clinical care routinely includes prescription of lenses that compensate for the distance refractive error. Indeed, refractive correction is so commonly prescribed that we often neglect its potential effects on disorders of binocular vision. We report improvement of binocular function that resulted 1 or more months after prescription of an initial spectacle correction for 143 nonstrabismic patients who had a refractive error and either a vergence anomaly (28%), an accommodative anomaly (8%), or both (64%). Refractive correction was estimated objectively with an autorefractor and subjectively refined without cycloplegia. Most corrections were low to moderate in power, essentially following Orinda Study guidelines. Recovery of normal vergence and accommodative function varied according to refractive error type (79% of hyperopic astigmats recovered; 20% of myopes recovered), direction of astigmatic axes (67% recovered who had against-the-rule; 45% with with-the-rule recovered), age (63% below age 12 years recovered; 41% older than age 13 years recovered), and vergence anomaly (67% of patients with fusional vergence dysfunction recovered; 38% of those with basic exophoria recovered). These results suggest that improvement in acuity is not the only reason for prescription of a refractive correction--prescription of even small corrections should be considered as these can dramatically improve vergence and accommodative function for many patients.
Medical diagnoses such as headaches, diplopia, nausea, and asthenopia are conditions that are often treated with optometric vision therapy. Improvement of such subjective conditions after a regimen of therapy is often difficult to objectively quantify. The goal of this study was to verify the test-re-test reliability of a new clinical survey instrument, the College of Optometrists in Vision Development (COVD) Quality of Life Outcomes Assessment, which allows the analysis of symptoms data.
The first-year class of optometry students at the Oklahoma College of Optometry at Northeastern State University were administered the instrument in a group setting on two different occasions, two weeks apart. Nineteen students completed both test and re-test. Statistical analysis by the Wilcoxon Signed Rank Test and paired t test were performed.
Each subject reported some of the 30 symptoms on both test and re-test. The instrument was found to be reliable. Wilcoxon Signed Rank Analysis showed no significant differences in test-retest scores, either pooled or item-by-item. A paired t-test group and item analysis were insignificantly different between scores. Spearman's rho correlation for test-retest of each subject was 0.878. Eighty-nine percent (17 of 19) scored insignificantly different between administrations. Ninety percent of the items (27 of 30) were found to vary insignificantly between the two administrations.
The COVD Quality of Life Outcomes Assessment is a reliable tool to measure changes in symptoms on the basis of optometric intervention--specifically, vision therapy.
Optometry is very interested in demonstrating that the therapies it prescribes are efficacious. Vision therapy is one of the traditional therapies of optometry, but it has not been as well accepted as other therapies. One of the reasons for this lack of acceptance has been the lack of studies that demonstrate quality of life improvement in the patient who has undergone a course of optometric vision therapy. The College of Optometrists in Vision Development Quality of Life checklist (COVD-QOL) was designed as a tool to assist in the documentation of these improvements. The COVD-QOL has been demonstrated to have good test-retest reliability and has shown that ADD/ADHD children have significantly higher scores on this instrument than non-ADD/ADHD children. This pilot study was designed to study if vision therapy would have a significant positive impact on 7- to 18-year-old children.
A prospective, five-office study was designed. A total of 62 consecutive children (whose parents agreed to participation) completed a course of optometric in-office vision therapy. Pre- and post-COVD-QOL's were completed at the end of therapy or at the end of 20 hours of in-office optometric vision therapy, whichever was shorter. The pre- and post-symptoms data were analyzed, collectively and by individual symptoms.
The mean total scores, as well as each individual item score on the COVD-QOL, were significantly better on post-test than on pre-test.
The COVD-QOL can be used to measure changes in symptoms, and to objectively demonstrate quality of life changes that are achieved through optometric vision therapy.
For nearly 75 years, optometric vision therapy has been an important mode of therapy for both children and adults who manifested a range of nonstrabismic accommodative and vergence disorders.
In this article, the scientific basis for, and efficacy of, optometric vision therapy in such patients will be discussed. Using bio-engineering models of the oculomotor system as the conceptual framework, emphasis will be focused on studies that used objective recording techniques to directly assess therapeutically related changes in oculomotor responsivity.
The findings clearly support the validity of optometric vision therapy. Furthermore, the results are consistent with the tenets of general motor learning.
The purpose of this article was to investigate the association between convergence insufficiency (CI) and accommodative insufficiency (AI) and symptoms in a group of school-aged children.
Children ages 8 to 15 years were recruited from two public and 2 private elementary schools in Southern California. The CI Symptom Survey (CISS) was administered to all children before a Modified Clinical Technique vision screening. Children with normal visual acuity, minimal uncorrected refractive error, and no strabismus were tested for CI and Al.
Four hundred sixty nine children were initially screened and 392 participated in testing for CI and AI. Fifty-five percent of the children (218) were classified as having normal binocular vision (NBV), 4.6% (18) had three signs of CI, 12.7% (50) had two signs of CI, 10.5% (41) were classified as AI (with no signs of CI), and 16.6% (65) were classified as other. The symptom score was 3.78 for the NBV group, 4.6 for the two-sign CI group, 6.67 for the three-sign CI group, and 6.37 for the Al group. The three-sign CI and the Al groups scored significantly higher than the NBV group on the CISS (p < or = 0.001).
CI and AI are common conditions in school-age children and are associated with increased symptoms.
To examine the current scientific evidence base regarding the efficacy of eye exercises as used in optometric vision therapy.
A search was performed of the following databases: Allied and Complementary Medicine Database, Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, EMBASE, and MEDLINE. Relevant articles were reviewed and analyzed for strengths and weaknesses. Pertinent sections of classic texts were studied to provide a historical basis and to serve as a source for additional early references.
Forty-three refereed studies were obtained. Of these, 14 were clinical trials (10 controlled studies), 18 review articles, 2 historical articles, 1 case report, 6 editorials or letters, and 2 position statements from professional colleges. Many of the references listed by the larger reviews were unpublished or published in obscure or nonrefereed sources and therefore were not accessible.
Eye exercises have been purported to improve a wide range of conditions including vergence problems, ocular motility disorders, accommodative dysfunction, amblyopia, learning disabilities, dyslexia, asthenopia, myopia, motion sickness, sports performance, stereopsis, visual field defects, visual acuity, and general well-being. Small controlled trials and a large number of cases support the treatment of convergence insufficiency. Less robust, but believable, evidence indicates visual training may be useful in developing fine stereoscopic skills and improving visual field remnants after brain damage. As yet there is no clear scientific evidence published in the mainstream literature supporting the use of eye exercises in the remainder of the areas reviewed, and their use therefore remains controversial.
To inform ophthalmologists of the current status of visual training.
Personal perspective.
A perspective and analysis of current practices that include a review of the literature and personal experiences of the author.
Visual training of some sort has been used for centuries. In the first half of the twentieth century, in cooperation with ophthalmologists, orthoptists introduced a wide variety of training techniques that were designed primarily to improve binocular function. In the second half of the twentieth century, visual training activities were taken up by optometrists and paramedical personnel to treat conditions that ranged from uncomfortable vision to poor reading or academic performance. Other visual training has been aimed at the elimination of a wide variety of systemic symptoms and for the specific improvement of sight and even for the improvement of athletic performance. At present, ophthalmologists and orthoptists use visual training to a very limited degree. Most visual training is now done by optometrists and others who say it works. Based on an assessment of claims and a study of published data, the consensus of ophthalmologists regarding visual training is that, except for near point of convergence exercises, visual training lacks documented evidence of effectiveness.
Although visual training has been used for several centuries, it plays a minor and actually decreasing role in eye therapy used by the ophthalmologist. At the beginning of the twenty-first century, most visual training is carried out by non-ophthalmologists and is neither practiced nor endorsed in its broadest sense by ophthalmology.
Background:
Undetected visual problems are one of the causes of academic difficulties in the classroom. An easily administered screening device that identifies children who are likely to do poorly in school because of vision problems would be a valuable tool. The screening should be able to be performed by a classroom teacher or aide. The objective of this study was to determine if there was an association between vision-related quality-of-life factors (19-item College of Optometrists in Vision Development Quality of Life [COVD-QOL] questionnaire checklist) and academic performance. A secondary objective was to determine whether student and parent responses to the questionnaire would be similar.
Methods:
Ninety-one parents or guardians and their children, attending the third, fifth, and seventh grades in a public school participated in this study. Both the parent or guardian and student independently completed the checklist. The scores of both groups were compared with the Stanford IX test scores for total reading, total math, total spelling, and total battery scores of the Stanford IX. The parent or guardian and student scores were compared to evaluate the agreement (intergroup reliability).
Results:
Parent or guardian and student checklist scores were compared. The Wilcoxon Signed Rank test showed that the mean scores for the parent or guardian were significantly lower than for third grade students and also for the total sample. Visual symptoms were found to be inversely correlated to academic performance; the lower the academic score, the more symptoms were reported. Symptoms reported by third grade students and their parents tended to be more highly correlated with academic scores. In general, symptoms reported by the parent were more highly correlated with academic score than the symptoms reported by the student.
Conclusion:
The COVD-QOL questionnaire is a cost-effective, quick, and easy tool that may be used in school screening to identify possible visual symptoms that are correlated to academic performance.
Accommodative insufficiency (AI) and convergence insufficiency (CI) have been associated with similar symptomology and frequently present at the same time. The severity of symptomology in CI has been linked to the severity of the CI, suggesting a dose-dependent relationship. However, with increasing severity of CI also comes increased comorbidity of AI. AI alone has been shown to cause significant symptomology. We hypothesize that AI drives the symptoms in CI with a comorbid AI condition (CIwAI) and that it is the increased coincidence of AI, rather than increased severity of CI, which causes additional symptomology.
Elementary school children (n = 299) participated in a vision screening that included tests for CI and AI and the CISS-V15 symptom survey. They were categorized into four groups:1) normal binocular vision (NBV); 2) AI-only; 3) CI-only; and 4) CIwAI. One hundred seventy elementary school children fell into the categories of interest.
Pairwise comparison of the group means on the symptom survey showed: 1) children with AI-only (mean = 19.7, p = 0.006) and children with CIwAI (mean = 22.8, p = 0.001) had significantly higher symptom scores than children with NBV (mean = 10.3); and 2) children with CI-only (mean = 12.9, p = 0.54) had a similar symptom score to children with NBV. Using a two-factor analysis of variance (AI and CI), the AI effect was significant (AI mean = 21.56; no AI mean = 11.56, p < 0.001), whereas neither the CI effect (p = 0.16) nor the CI by AI interaction effect (p = 0.66) were significant.
CI is a separate and unique clinical condition and can occur without a comorbid AI condition, our CI-only group. Past reports of high symptom scores for children with CI are the result of the presence of AI, a common comorbid condition. When AI is factored out, and children with CI only are evaluated, they are not significantly more symptomatic than children with NBV.
Fuse all cards (12 cards) on the single aperture settings and to card 6 on the double aperture setting (Phases 2 to 3) HTS Autoslide Vergence: Automatic demand of different BI
- Aperture
Aperture Rule: Fuse all cards (12 cards) on the single aperture settings and to card 6 on the double aperture setting (Phases 2 to 3). HTS Autoslide Vergence: Automatic demand of different BI/BO vergences at the computer (Phase 2).
Ability to clear 20 cpm of the 20/30 Accommodative Rock Card with monocular condition (Phase 1 and 2) and binocular condition
- Lens Flipper
Lens Flipper: Ability to clear 20 cpm of the 20/30 Accommodative Rock Card with monocular condition (Phase 1 and 2) and binocular condition (Phase 3).
Phase 1) Increase ranges of BI/BO vergence and develop immediate facility of BI
- Vectograms
Vectograms: Develop a vergence range of 15 D BI/30 D BO (Phase 1). Increase ranges of BI/BO vergence and develop immediate facility of BI/BO jump duction, SILO (Phase 2).
The placebo effect and other confounders
- Abelson
Abelson R, Abelson MB & Dewey-Mattia D. The placebo effect and other confounders. Rev Ophthalmol 2010; 17: 88–90.
Optometric Clinical Practice Guideline (CPG 20): Care of the Patient with Learning Related Vision Problems
- American Optometric
American Optometric Association. Optometric Clinical Practice Guideline (CPG 20): Care of the Patient with Learning Related Vision Problems. American Optometric Association: St. Louis, MO, 2000.
Optometric Clinical Practice Guideline (CPG 18): Care of the Patient with Accommodative and Vergence Dysfunction
- American Optometric
American Optometric Association. Optometric Clinical Practice Guideline (CPG 18): Care of the Patient with Accommodative and Vergence Dysfunction. American Optometric Association: St. Louis, MO, 1998.
Vision therapy for convergence dysfunctions
- Hs
- Shin
HS Shin et al. Vision therapy for convergence dysfunctions Ophthalmic & Physiological Optics 31 (2011) 180–189 ª 2011 The College of Optometrists
Automatic demand of both Base In and Out vergences at the computer (Phase 1) HTS Accommodative Rock: Automatic demand of different level of ± power lenses at the computer (Phase 1–3) Prism Flippers: Develop vergence facility
- Base Hts
- In
- Out
HTS Both Base In and Out: Automatic demand of both Base In and Out vergences at the computer (Phase 1). HTS Accommodative Rock: Automatic demand of different level of ± power lenses at the computer (Phase 1–3). Prism Flippers: Develop vergence facility with 8 D BI/8 D BO lenses (Gross target and Fine target being used at Phase 2 and Phase 3 respectively).
Guide to Vision Therapy
- Richman
Richman JE & Cron MT. Guide to Vision Therapy. Bernell Corp.: South Bend, 1989.
Changes in scores on the COVD quality of life assessment before and after vision therapy
- Harris