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A Patient Health Concern
This presentation was originated by Dr. Dan L. Fortenbacher in January 2011 as part of an ongoing educational series for Family Physicians regarding one of the most important, yet often misunderstood and overlooked vision problems in patient health care today...
Convergence Insufficiency
Convergence Insufficiency A Patient Health Concern
Dan L. Fortenbacher, O.D., FCOVD
Convergence Insufficiency
A Patient Quality of Life Concern
Why?
Vision conditions that catch the public eye
Central vision based› Refractive conditions› Cataracts › Macular Degeneration› Amblyopia
Peripheral vision based› Glaucoma› Visual Field Loss after stroke (CVA)
Anterior segment› Acute Conjunctivitis › Dry Eyes› Allergies
Binocular Vision
Strabismus
Why it is important for Family Physicians to know about CI?
A disease that affects over 21 million in the United States
Massive research effort over 10 years by the CITT Group
Latest study (2008) NEI funded $6.1 M. multicenter including: The Mayo Clinic, Bascom Palmer and 6 Colleges of Optometry around the US.
Can cause behaviors that appear to be ADD/ADHD, reading and learning problems
There is a cure!
Convergence Insufficiency A Patient Health Concern
What are the key points to know about CI?
What is convergence insufficiency (CI)?› Clinical presentation
What to look for in the patient exam?› Symptom profile› Easy screening test
What you can do to help
What is Convergence Insufficiency (CI) ?
Wikipedia: Convergence insufficiency is a sensory and neuromuscular anomaly of the binocular vision system, characterized by an inability of the eyes to approach each other, or sustain convergence
Convergence insufficiency is a binocular vision problem…but it is NOT strabismus
Why Convergence Insufficiency?
Consider this -Even though CI…
Affects people of all ages Impact on lives can be significant It has had extensive research The correct treatment is efficacious and
permanent
Convergence Insufficiency is routinely…
Missed in vision screenings
Why is CI often missed in routine vision screenings
CI patients routinely have 20/20
Children with CI may not complain about their eyes to their parents or tell the family physician
Most CI patients have “quality of life” symptoms which are over looked in routine screenings
CI Symptoms
Avoids near centered visual tasks like reading
Eyes hurt or strain with sustained reading Headaches associated with sustained
reading Words have illusory movement or overlap
(double) when reading
CI symptoms masquerade as…
A patient who is a slow reader A patient who is thought to have attention
deficit disorder A patient who is not trying or is just “lazy”
when it comes to school work
CI Behavioral symptoms
Attention deficit for reading Frustration with emotional overload Reduced self esteem Avoidance of academic work Anxiety Depression Reduced social and physical involvement
How would you feel…
…if your reading did this?
How common is CI in children?
What is the chance that a school-age child will have convergence insufficiency?
A. <1% B. 2-4% C. 5-13% D. 20-25%
How common is CI in children?
What is the chance that a school-age child will have convergence insufficiency?
A. <1% B. 2-4% C. 5-13% D. 20-25%
Epidemiology Study - ChildrenScheiman M, et al. JAOA April 1996
1:12 children will have CI
How can you recognize the patient with CI?
Ask a few basic questions
Run a basic, yet important screening test
For parents of school age children…ask a few questions and listen
Does your child have trouble staying on task during a reading activity?
Do they have headaches with reading?
Turn to the child and ask, “Do you ever see words do this?”
For adults…ask a few questions and listen
Do you ever see words overlap when reading? (Double vision demo)
Do you have trouble staying on task during a reading activity?
Do you experience headaches or eye fatigue/strain with reading?
What to test?Near Point of Convergence (NPC)
The (NPC) is measured by bringing the test target to the nose and observing when the patient sees double, or one eye deviates out.
NPC ( receded 5cm or recovery greater than 7cm)
How to test NPC
Penlight Red/Green- Near Point of Convergence Test (PLRG NPC)
WHERE IS THE RESEARCH?
ArchOphthalmol. 2008;126(10):1336-1349 › Scheiman, et al. Randomized Clinical Trial of
Treatments for Symptomatic Convergence Insufficiency in Children
› $6.1million NEI funded› Multi-center study
Mayo Clinic, Bascom Palmer, University of California, OSU, SUNY, NOVA, PCO, UAB, SCCO,
› Masked, Prospective, Placebo Controlled
Treatment methods for CI
Pencil push-up “eye exercises” Home-based activities on computer
programs Office-based professionally guided vision
therapy with home reinforcement
CITTS Results
› Home-Based Pencil Push-ups (HBPP) no better than placebo therapy. Neither (HBPP) or placebo effective in reducing signs/symptoms of CI
› Pencil push-ups and home-based computer vision therapy (HBCVAT+) no better than placebo therapy
› Office-based vision therapy(OBVT) IS effective in treating CI in children
Modalities of TreatmentResults
Office-based, doctor supervised Optometric Vision Therapy Effective!
What can you do?
Screen Recognize Inform
Screen
PLRG NPC
Symptom Checklist
Recognize
Recognize the symptoms› Avoids near centered visual tasks like reading› Eyes hurt or strain with sustained reading › Headaches associated with sustained reading› Words have illusory movement or overlap (double) when reading
Diagnose receded NPC
Inform
Provide CI literature Advise further diagnostic evaluation Prescribe treatment
What is Vision Therapy?
Optometric Vision Therapy IS NOT eye exercises!!Vision Therapy is rehabilitation treatment of the visual brain with proven applications in neuroscience
Office-based vision therapy utilizes principles of neuroscience research…
1. Visual awareness
2. Feedback
3. Loading -Action, movement and relevance
Office-based optometric vision therapy in action!
More information
CITT Study – Archives of Ophthalmology Near point of Convergence Normative Data Research –
Journal of Vision Science Scheiman –CI Website VisionHelp Blog- http://visionhelp.wordpress.com
› CI: The Private Eye Goes Public – Part 1› CI:The
Private Eye Goes Public -Part 3…who’s looking out for the kids?
› All Topics on VisionHelp Blog on CI› Applying Neuroplasticity to Optometric Care
College of Optometrists in Vision Development www.covd.org
Contact Information for Dr. Fortenbacher wow@wowvision.net www.wowvision.com www.visionhelp.com Facebook: Wow Vision Therapy www.sovoto.com 2909 Division Street, Saint Joseph, MI 49085
269-983-3309 http://visionhelp.wordpress.com/author/dfortenbacher
THANK YOU!
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