| Convergence Insufficiency | |
|---|---|
| Other names | Convergence disorder |
| Specialty | Ophthalmology, optometry  |
Convergence insufficiency is a sensory and neuromuscular anomaly of the binocular vision system, characterized by a reduced ability of the eyes to turn towards each other, or sustain convergence.
The symptoms and signs associated with convergence insufficiency are related to prolonged, visually demanding, near-centered tasks. They may include, but are not limited to, diplopia (double vision), asthenopia (eye strain), transient blurred vision, difficulty sustaining near-visual function, abnormal fatigue, headache, and abnormal postural adaptation, among others. In some cases, difficulty with making eye contact have been noted as a complaint amongst those affected.[ citation needed ] Note that some Internet resources confuse convergence and divergence dysfunction, reversing them.[ citation needed ]
Diagnosis of convergence insufficiency is made by an eye care professional skilled in binocular vision dysfunctions, such as an optometrist, ophthalmologist, or orthoptist to rule out any organic disease. Convergence insufficiency is characterized by one or more of the following diagnostic findings: patient symptoms, high exophoria at near, reduced accommodative convergence/accommodation ratio, receded near point of convergence, and low fusional vergence ranges and/or facility. Some patients with convergence insufficiency have concurrent accommodative insufficiency—accommodative amplitudes should therefore also be measured in symptomatic patients.
Convergence insufficiency can cause difficulty learning to read. [1] [2] [3]
Convergence insufficiency may be treated with convergence exercises prescribed by an eyecare specialist trained in orthoptics or binocular vision anomalies (see: vision therapy). Some cases of convergence insufficiency are successfully managed by prescription of eyeglasses, sometimes with therapeutic prisms.
Pencil push-ups therapy is performed at home. The patient brings a pencil slowly to within 2–3 cm (0.79–1.18 in) of the eye just above the nose about fifteen minutes per day five times per week. Patients should record the closest distance that they could maintain fusion (keep the pencil from going double as long as possible) after each five minutes of therapy. Computer software may be used at home or in an orthoptist's/vision therapist's office to treat convergence insufficiency. A weekly 60-minute in-office therapy visit may be prescribed. This is generally accompanied with additional in-home therapy. [4]
In 2005, the Convergence Insufficiency Treatment Trial (CITT) published two randomized clinical studies. The first, published in Archives of Ophthalmology , demonstrated that computer exercises when combined with office/based vision therapy/orthoptics were more effective than "pencil pushups" or computer exercises alone for convergency insufficiency in nine- to eighteen-year-old children. [5] The second found similar results for adults 19 to 30 years of age. [6] In a bibliographic review of 2010, the CITT confirmed their view that office-based accommodative/vergence therapy is the most effective treatment of convergence insufficiency, and that substituting it in entirety or in part with other eye training approaches such as home-based therapy may offer advantages in cost but not in outcome. [7] A later study of 2012 confirmed that orthoptic exercises led to longstanding improvements of the asthenopic symptoms of convergence sufficiency both in adults and in children. [8] A 2020 Cochrane Review concludes that office-based vergence/accommodative therapy with home reinforcement is more effective than home-based pencil/target push-ups or home-based computer vergence/accommodative therapy for children. In adults, evidence of the effectiveness of various non-surgical interventions is less clear. [9]
Both positive fusional vergence (PFV) [10] and negative fusional vergence (NFV) [11] can be trained, and vergence training should normally include both. [12] [13] Surgical correction options are also available, but the decision to proceed with surgery should be made with caution as convergence insufficiency generally does not improve with surgery. Bilateral medial rectus resection is the preferred type of surgery. However, the patient should be warned about the possibility of uncrossed diplopia at distance fixation after surgery. This typically resolves within one to three months postoperatively. The exophoria at near often recurs after several years, although most patients remain asymptomatic.
In some cases, convergence insufficiency can be the underlying cause of difficulty learning to read. As a result of the eyes not converging on the same point for sustained periods of time when reading, words can appear blurry or double because the brain is receiving two different images. Convergence insufficiency is not a learning disability. However, some children with the condition who are struggling to learn to read can be confused for having dyslexia due to difficulty learning to read. Children struggling with symptoms such as letters appearing blurry or double and experience tiredness or headaches when reading should consult an optometrist. [1] [3] [2]
Among fifth and sixth grade children convergence insufficiency is 13%. [14] In studies that used standardized definitions of convergence insufficiency, investigators have reported a prevalence of 4.2–6% in school and clinic settings. The standard definition of convergence insufficiency is exophoria greater at near than at distance, a receded near point of convergence, and reduced convergence amplitudes at near. [4]
Esotropia is a form of strabismus in which one or both eyes turn inward. The condition can be constantly present, or occur intermittently, and can give the affected individual a "cross-eyed" appearance. It is the opposite of exotropia and usually involves more severe axis deviation than esophoria. Esotropia is sometimes erroneously called "lazy eye", which describes the condition of amblyopia; a reduction in vision of one or both eyes that is not the result of any pathology of the eye and cannot be resolved by the use of corrective lenses. Amblyopia can, however, arise as a result of esotropia occurring in childhood: In order to relieve symptoms of diplopia or double vision, the child's brain will ignore or "suppress" the image from the esotropic eye, which when allowed to continue untreated will lead to the development of amblyopia. Treatment options for esotropia include glasses to correct refractive errors, the use of prisms, orthoptic exercises, or eye muscle surgery.
In biology, binocular vision is a type of vision in which an animal has two eyes capable of facing the same direction to perceive a single three-dimensional image of its surroundings. Binocular vision does not typically refer to vision where an animal has eyes on opposite sides of its head and shares no field of view between them, like in some animals.
Orthoptics is a profession allied to the eye care profession. Orthoptists are the experts in diagnosing and treating defects in eye movements and problems with how the eyes work together, called binocular vision. These can be caused by issues with the muscles around the eyes or defects in the nerves enabling the brain to communicate with the eyes. Orthoptists are responsible for the diagnosis and non-surgical management of strabismus (cross-eyed), amblyopia and eye movement disorders. The word orthoptics comes from the Greek words ὀρθός orthos, "straight" and ὀπτικός optikοs, "relating to sight" and much of the practice of orthoptists concerns disorders of binocular vision and defects of eye movement. Orthoptists are trained professionals who specialize in orthoptic treatment, such as eye patches, eye exercises, prisms or glasses. They commonly work with paediatric patients and also adult patients with neurological conditions such as stroke, brain tumours or multiple sclerosis. With specific training, in some countries orthoptists may be involved in monitoring of some forms of eye disease, such as glaucoma, cataract screening and diabetic retinopathy.
Diplopia is the simultaneous perception of two images of a single object that may be displaced horizontally or vertically in relation to each other. Also called double vision, it is a loss of visual focus under regular conditions, and is often voluntary. However, when occurring involuntarily, it results from impaired function of the extraocular muscles, where both eyes are still functional, but they cannot turn to target the desired object. Problems with these muscles may be due to mechanical problems, disorders of the neuromuscular junction, disorders of the cranial nerves that innervate the muscles, and occasionally disorders involving the supranuclear oculomotor pathways or ingestion of toxins.
Vision therapy (VT), or behavioral optometry, is an umbrella term for alternative medicine treatments using eye exercises, based around the pseudoscientific claim that vision problems are the true underlying cause of learning difficulties, particularly in children. Vision therapy has not been shown to be effective using scientific studies, except for helping with convergence insufficiency. Most claims—for example that the therapy can address neurological, educational, and spatial difficulties—lack supporting evidence. Neither the American Academy of Pediatrics nor the American Academy of Ophthalmology support the use of vision therapy.
A vergence is the simultaneous movement of both eyes in opposite directions to obtain or maintain single binocular vision.
Exotropia is a form of strabismus where the eyes are deviated outward. It is the opposite of esotropia and usually involves more severe axis deviation than exophoria. People with exotropia often experience crossed diplopia. Intermittent exotropia is a fairly common condition. "Sensory exotropia" occurs in the presence of poor vision in one eye. Infantile exotropia is seen during the first year of life, and is less common than "essential exotropia" which usually becomes apparent several years later.
The Optometric Extension Program Foundation (OEPF) is an international, non-profit organization dedicated to the advancement of the discipline of optometry, with recent emphasis on behavioral optometry and vision therapy.
An optometrist is an individual who provides a service related to the eyes or vision. It is any healthcare worker involved in eye care, from one with a small amount of post-secondary training to practitioners with a doctoral level of education.
Positive relative accommodation (PRA) in biology, is a measure of the maximum ability to stimulate eye accommodation while maintaining clear, single binocular vision. This measurement is typically obtained by an orthoptist, ophthalmologist or optometrist during an eye examination using a phoropter. After the patient's distance correction is established, she or he is instructed to view small letters on a card 40 cm from the eyes. The examiner adds lenses in −0.25 diopter increments until the patient first reports that they become blurry. The total value of the lenses added to reach this point is the PRA value.
Fixation disparity is a tendency of the eyes to drift in the direction of the heterophoria. While the heterophoria refers to a fusion-free vergence state, the fixation disparity refers to a small misalignment of the visual axes when both eyes are open in an observer with normal fusion and binocular vision. The misalignment may be vertical, horizontal or both. The misalignment is much smaller than that of strabismus. While strabismus prevents binocular vision, fixation disparity keeps binocular vision, however it may reduce a patient's level of stereopsis. A patient may have a different fixation disparity at distance than near. Observers with a fixation disparity are more likely to report eye strain in demanding visual tasks; therefore, tests of fixation disparity belong to the diagnostic tools used by eye care professionals: remediation includes vision therapy, prism eye glasses, or visual ergonomics at the workplace.
Suppression of an eye is a subconscious adaptation by a person's brain to eliminate the symptoms of disorders of binocular vision such as strabismus, convergence insufficiency and aniseikonia. The brain can eliminate double vision by ignoring all or part of the image of one of the eyes. The area of a person's visual field that is suppressed is called the suppression scotoma. Suppression can lead to amblyopia.
Heterophoria is an eye condition in which the directions that the eyes are pointing at rest position, when not performing binocular fusion, are not the same as each other, or, "not straight". This condition can be esophoria, where the eyes tend to cross inward in the absence of fusion; exophoria, in which they diverge; hyperphoria, in which one eye points up or down relative to the other; or cyclophoria, in which one eye is rotated differently around its line of sight from that of the other. Phorias are known as 'latent squint' because the tendency of the eyes to deviate is kept latent (hidden) by fusion. A person with two normal eyes has single vision (usually) because of the combined use of the sensory and motor systems. The motor system acts to point both eyes at the target of interest; any offset is detected visually. Heterophoria occurs only during dissociation of the left eye and right eye, when fusion of the eyes is absent. If you cover one eye you remove the sensory information about the eye's position in the orbit. Without this, there is no stimulus to binocular fusion, and the eye will move to a position of "rest". The difference between this position, and where it would be were the eye uncovered, is the heterophoria. The opposite of heterophoria, where the eyes are straight when relaxed and not fusing, is called orthophoria.
Stereopsis recovery, also recovery from stereoblindness, is the phenomenon of a stereoblind person gaining partial or full ability of stereo vision (stereopsis).
Accommodative infacility also known as accommodative inertia is the inability to change the accommodation of the eye with enough speed and accuracy to achieve normal function. This can result in visual fatigue, headaches, and difficulty reading. The delay in accurate accommodation also makes vision blurry for a moment when switching between distant and near objects. The duration and extent of this blurriness depends on the extent of the deficit.
Susan A. Cotter is a professor of optometry at the Southern California College of Optometry (SCCO) at Marshall B. Ketchum University where she teaches in the classroom and clinic, works with the residents, and conducts clinical researches. Her scientific work is related to related to clinical management strategies for strabismus, amblyopia, non-strabismic binocular vision disorders, and childhood refractive error.
Botulinum toxin therapy of strabismus is a medical technique used sometimes in the management of strabismus, in which botulinum toxin is injected into selected extraocular muscles in order to reduce the misalignment of the eyes. The injection of the toxin to treat strabismus, reported upon in 1981, is considered to be the first ever use of botulinum toxin for therapeutic purposes. Today, the injection of botulinum toxin into the muscles that surround the eyes is one of the available options in the management of strabismus. Other options for strabismus management are vision therapy and occlusion therapy, corrective glasses and prism glasses, and strabismus surgery.
In ophthalmology, horror fusionis is a condition in which the eyes have an unsteady deviation, with the extraocular muscles performing spasm-like movements that continuously shift the eyes away from the position in which they would be directed to the same point in space, giving rise to diplopia. Even when the double vision images are made to nearly overlap using optical means such as prisms, the irregular movements prevent binocular fusion. The name horror fusionis arises from the notion that the brain is, or at least appears to be, actively preventing binocular fusion.
The prism fusion range (PFR) or fusional vergence amplitude is a clinical eye test performed by orthoptists, optometrists, and ophthalmologists to assess motor fusion, specifically the extent to which a patient can maintain binocular single vision (BSV) in the presence of increasing vergence demands. Motor fusion is largely accounted to amplitudes of fusional vergences and relative fusional vergences. Fusional vergence is the maximum vergence movement enabling BSV and the limit is at the point of diplopia. Relative fusional vergence is the maximum vergence movement enabling a patient to see a comfortable clear image and the limit is represented by the first point of blur. These motor fusion functions should fall within average values so that BSV can be comfortably achieved. Excessive stress on the vergence system or inability to converge or diverge adequately can lead to asthenopic symptoms, which generally result from decompensation of latent deviations (heterophoria) or loss of control of ocular misalignments. Motor anomalies can be managed in various ways, however, in order to commence treatment, motor fusion testing such as the PFR is required.
In ophthalmology, accommodative excess occurs when an individual uses more than normal accommodation for performing certain near work. Accommodative excess has traditionally been defined as accommodation that is persistently higher than expected for the patient's age. Modern definitions simply regard it as an inability to relax accommodation readily. Excessive accommodation is seen in association with excessive convergence also.
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