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Convergence Insufficiency

  • Author: Michael J Bartiss, OD, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Oct 14, 2015
 

Background

Convergence insufficiency is a common condition that is characterized by a patient 's inability to maintain proper binocular eye alignment on objects as they approach from distance to near.[1, 2] There is typically an exophoria or intermittent exotropia at near, a receded near point of convergence, reduced positive fusional convergence amplitudes, and a low accommodation convergence/accommodation (AC/A) ratio. The symptoms associated with convergence insufficiency vary from mild to severe, but they are often extremely troublesome for patients with this condition, especially when associated with a small angle exotropia at the near working distance causing binocular diplopia.[3]

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Pathophysiology

The underlying etiology for convergence insufficiency is probably innervational.[1] The dramatic reduction of symptoms demonstrated by patients after undergoing appropriate therapy, which is accompanied by objective clinical findings of improved near point of convergence and fusional convergence amplitudes, strongly supports this hypothesis.

Some cases of convergence insufficiency also appear to have an etiologic connection to accommodative dysfunction.[4]

Convergence insufficiency is associated most commonly with an exophoric binocular posture at near, but patients with this disorder may demonstrate orthophoria or even mild esophoria at the time of their examination. The reasons for this variability are described within this article.

In the past, many ophthalmologists considered convergence insufficiency and its associated symptoms to be a neurotic manifestation of nonrelated psychological problems best dealt with by a psychiatrist.[5] However, it is now clear that convergence insufficiency is a legitimate, problematic binocular dysfunction. The clinician must consider whether the behavioral manifestations displayed by patients really result from the frustration caused by their inability to perform desired near vision tasks.

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Epidemiology

Frequency

United States

The prevalence of convergence insufficiency has been reported to be approximately 3-5% of the population. Incidence increases with additional near work demand. The disorder is reported to be rare in children younger than 10 years of age. However, the increased visual demands of schoolwork and prolonged periods of reading exacerbate symptoms in older children.[6] Indeed, many patients with this disorder have vocational and/or avocational visual demands that require prolonged close work. The most common presentation encountered by the clinician is that of a high school or college student who develops symptoms when excessive demands are placed on the visual system during extended periods of studying. Lack of sleep, illness, and anxiety are known to aggravate the problem.

International

The prevalence of this condition is the same in all industrial societies.

Mortality/Morbidity

The morbidity of convergence insufficiency relates to the near point visual demands of the patient's activities. Headaches, fatigue, frequent loss of place when reading, as well as frank binocular diplopia associated with near point tasks are among the symptoms associated with this condition.

Race

No racial predilection exists for convergence insufficiency.

Sex

No sexual predilection exists.

Age

The frequency of symptoms may increase with age as patients' ability to compensate for their relative divergent binocular alignment decreases with time.

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Contributor Information and Disclosures
Author

Michael J Bartiss, OD, MD Medical Director, Ophthalmology, Family Eye Care of the Carolinas and Surgery Center of Pinehurst

Michael J Bartiss, OD, MD is a member of the following medical societies: American Academy of Ophthalmology, North Carolina Medical Society, American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Sigma Xi, Southern Medical Association, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Richard W Allinson, MD Associate Professor, Department of Ophthalmology, Texas A&M University Health Science Center; Senior Staff Ophthalmologist, Scott and White Clinic

Richard W Allinson, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

References
  1. Von Noorden GK. Binocular Vision & Ocular Motility: Theory & Management of Strabismus. 5th ed. Mosby-Year Book; 1995. 468-476.

  2. Khawam E, Abiad B, Boughannam A, Saade J, Alameddine R. Convergence Insufficiency/Divergence Insufficiency Convergence Excess/Divergence Excess: Some Facts and Fictions. Case Rep Ophthalmol Med. 2015. 2015:680474. [Medline].

  3. Danchaivijitr C, Kennard C. Diplopia and eye movement disorders. J Neurol Neurosurg Psychiatry. 2004 Dec. 75 Suppl 4:iv24-31. [Medline].

  4. Harrison RL. Loss of fusional vergence with partial loss of accommodative convergence and accommodation following head injury. Binoc Vis. 1987. 2:93.

  5. Brown B. The convergence insufficiency masquerade. Am Orthoptic J. 1990. 40:94-7.

  6. Clark TY, Clark RA. Convergence Insufficiency Symptom Survey Scores for Reading Versus Other Near Visual Activities in School-Age Children. Am J Ophthalmol. 2015 Aug 12. [Medline].

  7. Master CL, Scheiman M, Gallaway M, Goodman A, Robinson RL, Master SR, et al. Vision Diagnoses Are Common After Concussion in Adolescents. Clin Pediatr (Phila). 2015 Jul 7. [Medline].

  8. Sreenivasan V, Bobier WR. Increased onset of vergence adaptation reduces excessive accommodation during the orthoptic treatment of convergence insufficiency. Vision Res. 2015 Jun. 111 (Pt A):105-13. [Medline].

  9. Scheiman M, Rouse M, Kulp MT, Cotter S, Hertle R, Mitchell GL. Treatment of convergence insufficiency in childhood: a current perspective. Optom Vis Sci. 2009 May. 86(5):420-8. [Medline]. [Full Text].

  10. Pediatric Eye Disease Investigator Group. Effectiveness of Home-Based Therapy for Symptomatic Convergence Insufficiency. pedig.jaeb.org. Available at http://pedig.jaeb.org/Studies.aspx?RecID=205. Accessed: April 18, 2013.

  11. Hermann JS. Surgical therapy of convergence insufficiency. J Pediatr Ophthalmol Strabismus. 1981 Jan-Feb. 18(1):28-31. [Medline].

  12. Nemet P, Stolovitch C. Biased Resection of the Medial Recti: A New Surgical Approach to Convergence Insufficiency. 1990. Vol 5: 213.

  13. Alvarez TL. A pilot study of disparity vergence and near dissociated phoria in convergence insufficiency patients before vs. after vergence therapy. Front Hum Neurosci. 2015. 9:419. [Medline].

  14. Wallace DK. Treatment options for symptomatic convergence insufficiency. Arch Ophthalmol. 2008 Oct. 126(10):1455-6. [Medline].

  15. Borsting EJ, Rouse MW, Mitchell GL, Scheiman M, Cotter SA, Cooper J, et al. Validity and reliability of the revised convergence insufficiency symptom survey in children aged 9 to 18 years. Optom Vis Sci. 2003 Dec. 80(12):832-8. [Medline].

 
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