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Convergence Insufficiency Treatment & Management

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

Medical Care

Convergence exercises (ie, orthoptics, vision therapy) and/or base-in prisms are the mainstays of treatment of convergence insufficiency.[8]

Orthoptics and vision therapy

Near point of convergence exercises: An accommodative target, such as a column of telephone numbers taped to a tongue depressor or piece of cardboard, is placed remote to the patient's near point of convergence and gradually brought toward the tip of the nose with the patient converging to avoid diplopia. Just before there is a break in fusion, the patient holds fixation on the target for 10 seconds. This so-called push-up is repeated 10 times, 2-4 times a day, until the patient is able to hold fixation to approximately 6-8 cm from the nose. The exercises can be tapered and then used on an as-needed basis when the patient notices a recurrence of symptoms.

Other forms of convergence training: Base-out prism reading and stereogram cards may be used by an orthoptist or a vision therapist to improve fusional convergence. New, affordable computerized fusional vergence training programs (eg, Computer Orthoptics) are also available. These self-paced programs can be used on a personal computer in the patient's home.

Base-in prisms for near only: These prisms can be ground into a separate pair of reading glasses, or Fresnel membrane prisms can be fitted over the reading segment of the patient's bifocals.

A paper by Scheiman et al[9] in a review of 3 multicenter randomized clinical trials, while recognizing some limitations of the summarized studies, reported that office-based vision therapy provides superior results as a treatment modality versus specific home-based therapies (pencil push-up and some computer-based therapy) or placebo.

A study is currently underway through the Pediatric Eye Disease Investigator Group (PEDIG) regarding the treatment of symptomatic convergence insufficiency. The purpose of this study is as follows:[10]

  • To determine the effectiveness of active home-based computer vergence/accommodative therapy versus placebo home-based computer vergence/accommodative therapy for the treatment of symptomatic convergence insufficiency in children aged 9-18 years.
  • To determine the effectiveness of home-based computer vergence/accommodative therapy compared with home-based near target push-ups for the treatment of symptomatic convergence insufficiency in children aged 9-18 years.
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Surgical Care

The decision to proceed with surgery should be made with caution and only after all orthoptic efforts have failed.[11]

Bilateral medial rectus resection is usually the most effective operation for convergence insufficiency.[12] However, the patient should be warned about the possibility of uncrossed diplopia at distance fixation after surgery. This typically resolves within 1-3 months postoperatively. The exophoria at near often recurs after several years, although most patients remain asymptomatic.

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Activity

Patient activities are not restricted.

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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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