A solution to convergence insufficiency

Combining physician supervision with home treatment bests other strategies

The best way to treat convergence insufficiency may involve both an in-office and at home regimen, according to Rachel A. Coulter, O.D., associate professor, College of Optometry, Nova Southeastern University, Ft. Lauderdale, Fla. Close to three quarters of patients improved with the combined approach compared with less than half of those who used the traditional method, investigators reported in the October 2008 issue of Archives of Ophthalmology.
Convergence insufficiency is a reasonably common disorder. For school age children, Dr. Coulter estimates that the prevalence is about 5%. Hallmarks of the condition center on the individual’s ability to perform tasks at near. “When these kids try to do near work they experience symptoms that include double vision, blurred vision, headaches, eye strain, and certain performance problems like losing their place while reading, difficulty concentrating, and reading inefficiently,” Dr. Coulter said.
Traditionally this has been treated with a technique dubbed “pencil pushups,” done by patients at home. “You would go into the doctor, who would send you home with some instructions to do some exercises just using a pencil, and the doctor would follow you and see if your symptoms improved,” Dr. Coulter said. “Over the last decade doctors have done some vision therapy as well, but that was probably done by the minority of practitioners.” In addition, the latest development has been using computers to do treatment either in the doctor’s office or at home.

Four-armed trial

To try to determine what would be the most effective way to treat this disorder investigators here set up the trial. “This study grew out of a long sequence of studies looking at convergence insufficiency treatment,” Dr. Coulter said. Nova Southeastern University served as one of the nine clinical centers that enrolled 221 children in the study.
The 221 children ages 9 to 17 included were randomized into one of four treatment arms. In one group patients performed traditional at home pencil pushups, an exercise in which a patient follows the end of a pencil as it comes closer to the bridge of the nose. In a second group patients did the traditional pencil pushups plus were told to perform exercises using an in-home software program. The third group involved a combination of in-office vision therapy and home computer work, and the fourth, a group of control subjects, performed a placebo treatment.
After 12 weeks of treatment, one group fared markedly better than the rest. “The results showed that the group that combined in-office with home treatment showed a significant reduction in symptoms that was the greatest compared to the other three groups,” Dr. Coulter said. Investigators found that 73% of those in the combined home/office-based visual therapy group were successful or improved, as were 42% of those doing pencil pushups and 35% of those using the in-home software program together with the pencil pushups. Those receiving the placebo treatment fared nearly as well as those using the combination approach, with 33% showing improvement after using the approach.
Dr. Coulter was surprised by how closely the placebo results measured up to some of the bonafide treatments. “One would think that there would be certainly more of a difference between the home-based computer group and the placebo group because the treatments were completely different and that was well-reviewed and studied,” Dr. Coulter said. It also gave her a little pause to see how much better the in-office group fared compared with the rest. “I think 73% to 42% is a fairly marked difference,” she said.

Professional oversight needed

Some of the success with the in-office approach is likely owed to professional oversight. “We always wonder about patients’ adherence to protocols,” Dr. Coulter said. “There were logs in this study, we had regular contact, and we tried to equalize the attention factor in terms of those coming in for treatment versus those working on it at home. But then you have to consider how much having someone oversee what a patient is doing influences results.”
In this particular study, investigators tried to determine how patients would fare under typical conditions. “We wanted to look at how things are in the real world,” Dr. Coulter said. “In the real world if a doctor gives you a home-based software program, the doctor doesn’t call you up to check to see if you’re using your program. If anything this study had more oversight [then would normally be seen].”
In gauging effectiveness of the different approaches, another factor to consider is cost. “Obviously it is a lot more expensive for patients to come in the real world and do their therapy once a week than it is to take a computer program home,” Dr. Coulter said. As a result, while critics acknowledge that 73% versus 42% is a substantial difference, they note that the in-office approach has a much higher price tag and question whether this is warranted.
Dr. Coulter sees the study as offering patients valuable information. “Being able to tell patients who have the condition what the projected outcomes will be and then being able to provide them with cost information and letting them make a decision, I think that there’s a real value in that,” she said.
In the future, Dr. Coulter hopes to continue doing research in this area. “We’re actually working on a pilot study that will probably be a continuation of looking at convergence insufficiency in reading performance,” she said. “So it’s not like we’re done. We do need to go forward.”

Editors’ note: Dr. Coulter has no financial interests related to her comments.

Contact information

Coulter: 954-262-1438, staceyco@nova.edu