Randomized Clinical Trial of Treatments for Symptomatic Convergence Insufficiency in Children

Dr Scheiman (study chair); Karen Pollack (study coordinator); Dr Cotter (vice chair); Dr Hertle (vice chair); and Dr Rouse.

CONVERGENCE INSUFFICIENCY (CI) is a common binocular vision disorder1-4 that is often associated with a variety of symptoms, including eyestrain, headaches, blurred vision, diplopia, sleepiness, difficulty concentrating, movement of print while reading, and loss of comprehension after short periods of reading or performing close activities.5-13 Various treatments10,14- 23 are commonly prescribed, including passive treatment with base-in prism reading glasses and active treatment, such as home-based therapy using pencil pushups (HBPP) alone, home-based therapy using pencil push-ups plus other therapy techniques, office-based vision therapy, and orthoptics. Consensus regarding the most effective treatment is lacking and there are considerable differences among treatments in time and cost. Recent studies that surveyed the ophthalmic community suggest that HBPP is the most commonly prescribed treatment by both ophthalmologists and optometrists for young patients with symptomatic CI.

Objective: To compare home-based pencil push-ups (HBPP), home-based computer vergence/accommodative therapy and pencil push-ups (HBCVAT_), officebased 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 group’s 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_.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

Arch Ophthalmol. 2008;126(10):1336-1349

Full trial: http://archopht.ama-assn.org/cgi/reprint/126/10/1336