Convergence Insufficiency: Part 2

Do you get headaches when you read or use the computer? Does your child cover or close an eye while they read? Do your eyes hurt at the end of the work day? Is homework time with your child a constant battle against avoidance behaviors? Do words move on the page when you are trying to read? These are all symptoms of convergence insufficiency – a very common, and very treatable, vision condition that affects people of all ages.

In Convergence Insufficiency: Part 1 we discussed the signs and symptoms of convergence insufficiency, a common eye teaming deficit. During this blog we will discuss the good stuff; diagnosis and treatment of convergence insufficiency. It may seem like an exaggeration but having convergence insufficiency can influence life's path and treating it can be truly life-altering. For the past 30 years we have treated patients with convergence insufficiency and their stories are inspiring.

We see the child who went from hating and failing school to getting good grades and being accepted into college. We also see the adult who changed careers because of constant headaches, eyestrain and double vision. Convergence may not threaten your ability to read the 20/20 row once a year at the eye doctor's office, but it definitely threatens your ability to use your vision 365 days a year.


How is convergence insufficiency diagnosed?

Convergence insufficiency is a vision condition which is diagnosed by an eye doctor; optometrist or ophthalmologist. Even though eye doctors diagnose the condition, many professions see the signs of convergence insufficiency and are able to refer patients for evaluation. Teachers, reading specialists, therapists (physical, speech, occupational), pediatricians and teachers may see signs of convergence insufficiency, however the connection to a vision condition is not always made. While some may refer the patient for a Binocular Vision Assessment, others may mistake convergence insufficiency for dyslexia, ADHD, or poor motor skills. It is important to remember that, like any condition, convergence insufficiency cannot be diagnosed based on symptoms. Standardized, age-appropriate vision testing can differentiate convergence insufficiency from other vision conditions with similar symptoms.

It is not uncommon for parents to rely on pediatricians, school nurses or the Lion's Club to perform vision screenings for their children. Unfortunately, in many instances parents assume this type of screening replaces an eye exam performed by a trained eye care professional; an optometrist or an ophthalmologist. These screenings often test the vision to the same extent as the vision test at the DMV – also not an eye exam. A comprehensive eye examination is necessary to accurately assess a person's prescription, eye health and rule out a wide variety of vision conditions – including convergence insufficiency.

So convergence insufficiency is first detected during a comprehensive eye examination with an optometrist or an ophthalmologist. Ready for the tricky part? Not all eyecare providers perform the testing to diagnose convergence insufficiency (and even fewer treat the condition). So how do you choose an eye doctor to best-serve your visual needs? You look for training and expertise.
 

• Residency-Trained Pediatric Optometrist: Only pediatric optometrists and pediatric ophthalmologists have the specialized training and equipment necessary to provide a comprehensive and age-appropriate pediatric eye examination. A pediatric eye doctor must dilate a child's eyes in order to perform a thorough examination. A thorough examination is necessary to accurately diagnose vision conditions, including binocular vision dysfunction (including convergence insufficiency).

  NOTE: Not all doctors who see children have advanced training in pediatric eyecare

  Many eye doctors will see children. Some, shockingly, will say they specialize in children's eyecare even though they lack a residency, or other advanced training, in pediatric eyecare. All children, regardless if convergence insufficiency is suspected, should see a residency-trained pediatric optometrist. This ensures that your doctor has the training and knowledge to effectively diagnose and treat the vision conditions affecting the pediatric population.

• Residency-Trained Neuro-Optometrist: An optometrist who is residency-trained in binocular vision, neuro-optometry or vision therapy can diagnose and treat convergence insufficiency in patients of all ages. So yes, if you are an adult who does not want to see a pediatric eye doctor, there is a doctor for you as well. An optometrist who has completed advanced residency-training in the area of binocular vision has the advanced training necessary to treat complex binocular vision problems, including convergence insufficiency. An optometrist with this level of training can perform a Binocular Vision Assessment and prescribe Vision Therapy.

  NOTE: Many doctors will say they see patients who have convergence insufficiency, but this does not mean they have the knowledge and skill to effectively treat the condition.

Many people ask the question - 'Aren't all eye doctors the same?' They assume that all doctors will equally diagnose and treat convergence insufficiency. Fortunately, eyecare has several sub-specialty providers. This means that there is an expert in the area of your visual needs – pediatrics, binocular vision, low vision, specialty contact lenses, ocular disease. While this means that you can get an extremely high level of care, it also means that you may end up seeing a doctor who is not the best match for you. This is why it is important for children to see a residency-trained pediatric optometrist and individuals who suspect convergence insufficiency to see a residency-trained pediatric optometrist or a residency-trained neuro-optometrist.

You may wonder why an optometrist, rather than an ophthalmologist, would see patients with convergence insufficiency. Ophthalmologists can also diagnose convergence insufficiency, however the vast majority of treatment for convergence insufficiency is performed by optometrists. Surgery does not fix convergence insufficiency, which is why an eye surgeon (ophthalmologist) may not be the best fit.

The best way to evaluate convergence insufficiency and develop an effective treatment plan is to have a Binocular Vision Assessment with an optometrist who is residency-trained in binocular vision, neuro-optometry or vision therapy.

What are the treatment options for Convergence Insufficiency?

So now the million dollar question... How do you treat convergence insufficiency? The answer is simple, however the varied treatments that are prescribed makes it complicated for patients and parents. We see patients who have been told to do several things to treat their convergence insufficiency and have had variable results.

So is convergence insufficiency treatable? The answer is undoubtedly 'Yes!'

Is treatment effective? The answer again is 'YES'. The catch... the right treatment is effective, the wrong treatment is not.

While there may be many options available, the effectiveness is drastically different. Let's talk about the various methods used to treat (or pacify the patient without truly treating) convergence insufficiency in the context of evidence-based medicine.
 

• PENCIL PUSHUPS: We start with this option not because it is the most effective, but because it is the most commonly prescribed treatment in both optometry and ophthalmology. Convergence insufficiency is a very complex visual process but it is often simplified and explained as 'you cannot cross your eyes'. Some doctors take this over-simplification and prescribe an over-simplified treatment – pencil pushups. Despite its popularity there is not really any research to back it up. In fact, the research comparing pencil pushups to a placebo (fake) treatment found pencil pushups to be no more effective than the fake treatment in treating convergence insufficiency.

  So why do some people respond to pencil pushups? 1) Most conditions have a placebo effect. 2) If the only test the doctor uses to test for the presence of convergence insufficiency is an in-office pencil pushup then you are teaching the patient a trick to pass the test 3) The goal of the exercise is to see one pencil. You can mistakenly train a patient to ignore one eye (suppress) and they will see 1 pencil all of the time. Try it, cover one eye and bring the pencil all the way to your nose, you will only see one. So while does not effectively treat convergence insufficiency it can trick patients, parents and some doctors into thinking that it has worked.

• PRISM: Prism is a component that can be incorporated into somebody's glasses to optically shift images. Prism is often used to manage double vision or certain cases of strabismus (eye turn). Similarly, doctors use prism in an attempt to treat convergence insufficiency. Unfortunately, prism is unable to make the necessary modifications to the visual system necessary to effectively treat convergence insufficiency. It is effective in managing double vision, which is why it often serves as a 'crutch' for patients looking for immediate relief of double vision.

• COMPUTER THERAPY / HOME THERAPY: Based on the success of in-office vision therapy (discussed below), various computer or home-based programs for eye exercises have been developed. Sounds great right? Buy a computer program, sit your kid down for their eye exercises and watch the success. Well unfortunately, home-based computer vergence programs are not very effective. In fact, during the Convergence Insufficiency Treatment Trials, the computer treatment was the LEAST effective treatment option. So you could actually say that doing nothing is more effective than computer programs.
  
  NOTE: Computer programs are no more effective if you do them at a doctor's office. You are paying someone to watch your child perform an ineffective treatment for convergence insufficiency.
  
  Using a computer program to treat a condition that results in headaches and eyestrain at the computer takes a special sense of humor. Performing one type of activity at one distance is not going to be effective in treating a condition as complex as convergence insufficiency (similar to pencil pushups). Also, computer-based programs can embed poor visual habits or create an unbalanced visual system. This creates more work for a doctor to properly treat convergence insufficiency as they have to both treat the condition and undo the poor visual habits.

• SURGERY: When difficulties with eye teaming are present, some eyecare providers recommend surgery. Surgery is effective in improving certain types of strabismus (eye turn), however it is not appropriate for treating convergence insufficiency. The eyes are aligned (no eye turn) with convergence insufficiency and the dysfunction arises from the coordination of binocular vision skills rather than a misalignment of the eyes. For this reason, surgery should not be recommended to treat convergence insufficiency.

• IN-OFFICE VISION THERAPY: In many ways we have saved the best for last. Research has shown in-office vision therapy to be the most effective treatment for convergence insufficiency, and it wasn't even close. Working one-on-one with a trained vision therapist and under the supervision of a residency-trained optometrist, you can have great success with treating convergence insufficiency. The far greater success with in-office vision therapy is possible because you get constant feedback, varied activities to address various deficiencies and you effectively make neurological changes to the visual system.

  NOTE: Like any therapy, vision therapy will vary from one provider to the next. This occurs as training and personal philosophy influence a providers approach to treatment. This is why it is important to work with an optometrist who is residency-trained in binocular vision, neuro-optometry and vision therapy who uses an evidence-based approach to care. This ensures that you are working with a doctor who is trained to treat complex binocular vision conditions and is up-to-date with current research in binocular vision.

So, if you suspect convergence insufficiency what should you do?
 

• STEP 1: Schedule a comprehensive eye exam with a residency-trained pediatric optometrist or residency-trained neuro-optometrist. This visit will evaluate the need for a prescription, evaluate ocular health and evaluate for deficiencies in binocular vision that warrant further testing.

• STEP 2: Schedule a Binocular Vision Assessment with an optometrist who is residency-trained in binocular vision, neuro-optometry or vision therapy. This visit will evaluate the nature and severity of the convergence insufficiency and compare visual performance to age-based normative data. Based on the results of the Binocular Vision Assessment, the doctor will be able to prescribe a personalized in-office vision therapy program that is tailored to your visual needs.

• STEP 3: Enroll in an in-office vision therapy program performed under the direction of an optometrist who is residency-trained in binocular vision, neuro-optometry or vision therapy. When choosing a program make sure that: 1) The doctor has proper residency-training 2) All therapy sessions are performed by a trained vision therapist 3) All vision therapy sessions are one-on-one (no group or computer therapy sessions) 4) The program follows an evidence-based approach to care. This last one can be subjective. Working with a doctor who is a Fellow of the American Academy of Optometry demonstrates a commitment of evidence-based eyecare.

If you suspect either yourself or your child has Convergence Insufficiency it is important to seek the care of an eye doctor who is trained in binocular vision dysfunction and pediatric eyecare. Many eye doctors say they have an interest in children's vision or claim to specialize in pediatric vision care. As a healthcare consumer it can be difficult to determine a doctor's training and skill set. Do your research. After graduation did the doctor complete residency training in pediatrics, binocular vision, vision therapy or neuro-optometry? If an eye doctor claims to specialize in a particular area of care look for specific, university level training beyond optometry school.

When you call to schedule an appointment ask the following questions:
 

• Is the doctor a pediatric vision specialist?

• What type of training does the doctor have in pediatrics?

• Where did the doctor complete this training?

• Does the doctor dilate patients, including children, during the eye exam?

• Does the doctor provide vision care for children with special needs?

• Does the doctor diagnose and treat functional vision problems?

• Does the doctor diagnose and treat lazy eye (amblyopia)?

• Does the doctor diagnose and treat eye alignment problems?
   

These questions will give you an indication about the eye doctor's training in pediatrics and binocular vision dysfunction. This information allows you to make a more informed decision about care for yourself or your child.