Medical Care

Convergence exercises (ie, orthoptics, vision therapy) and/or base-in prisms are the mainstays of treatment for convergence insufficiency.^[25]

Orthoptics and vision therapy

The most commonly prescribed treatment is home-based exercises, such as pencil push-ups, although specific methodologies vary among practitioners.^{[6, 26]}Pencil push-ups require fixation on a near target such as the number on a pencil and repeatedly bringing it from an arm’s length away toward the nose while maintaining fusion and focus until blur/diplopia is noted.

Home-based computer therapy involves specialized software to stimulate either convergence or convergence and accommodative responses. The putative benefits would include the opportunity for daily therapy while allowing for more structure than pencil push-ups, as well as the ability to monitor compliance. These have been shown to be beneficial in ameliorating both the signs and symptoms of convergence insufficiency.^[27]

Office-based therapy provides a more structured environment and does not preclude the use of additional home-based exercises. It allows for the use of additional specialized equipment, such as base-out prism reading and stereogram cards, under the supervision of an orthoptist or a vision therapist. Different techniques can selectively induce and train responses to accommodative or vergence stimuli. It has been demonstrated that these exercises can result in changes in the coupling between accommodation and vergence responses.^[28]No uniformly agreed upon standardized protocol for office-based therapy exists.^[29]

Base-in prisms for near correct for ocular misalignment and can reduce accommodative overaction. These prisms can be ground into a separate pair of reading glasses, or Fresnel prisms can be fitted over the reading segment of the patient's bifocals.

A 2011 Cochrane review concluded that office-based therapy was more effective than home-based exercise or computer-based therapy in children. In adults, office-based therapy was more effective in treating clinical signs but not symptoms. In children, neither home-based approach was effective for symptoms, while computer therapy was superior with regards to clinical signs. This same review also assessed limited trials for base-in prisms and concluded that there may be a benefit in adults, although results were not superior to placebo in children.^[30]

Refractive correction to monovision may also be helpful in treating the symptoms of convergence insufficiency.

Surgical Care

Numerous surgical techniques are available to patients in whom conservative treatment fails, including various forms of bilateral lateral rectus recession, bilateral medial rectus resection, and lateral rectus recession with medial rectus resection. However, given the efficacy of conservative treatment and the invasive nature of surgical intervention, conservative measures should be fully explored.^[31]It should also be noted that, postoperatively, prisms may yet be required for overcorrection esotropia or residual or recurrent exodeviation.^{[32, 33, 34]}

Activity

Patient activities are not restricted.

Prevention

Since the underlying etiology of convergence insufficiency is unclear, no specific recommendations can be given to prevent it. Avoidance of near work is often both undesirable and impractical.

Long-Term Monitoring

A combination of in-office and at-home orthoptics and vision therapy probably represents the best therapeutic approach for convergence insufficiency.^{[30, 35]}Follow-up depends on the severity of symptoms and the treatment modality or modalities pursued.

Medication

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Author

Eric R Eggenberger, DO, MS, FAAN Neurologist, Departments of Neurology and Ophthalmology, Mayo Clinic

Eric R Eggenberger, DO, MS, FAAN is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Osteopathic Association, North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Coauthor(s)

Anthony J Brune, III, DO Vestibular Neurologist and Neuro-ophthalmologist, Memorial Healthcare

Anthony J Brune, III, DO is a member of the following medical societies: American Academy of Neurology, American Osteopathic Association, North American Neuro-Ophthalmology Society, Sigma Sigma Phi Osteopathic Honor Society

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, The Scientific Research Honor Society, 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

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.

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.