Home vision therapy and prism prescription in presbyopic persons with convergence insufficiency: study protocol for a randomized controlled trial

BACKGROUND

Convergence insufficiency is a common issue in the field of binocular vision. Various treatment options have been suggested for managing this condition, but their efficacy in individuals with presbyopia remains unclear. The objective of this study is to compare the effectiveness of home-based vision therapy and prism prescription, in presbyopic patients with convergence insufficiency.

METHODS/DESIGN

It is a randomized, prospective, double-blind clinical trial, with total of 150 participants randomly assigned to the three groups. The Control Group will receive a new near glasses as a conventional prescription, along with aimless and random eye movement exercises that do not have any convergence or accommodation effects. The Home Vision Therapy Group will receive new near glasses with accommodative and convergence eye exercises. The Prism Group will receive a near prismatic glasses prescribed using the Sheard's criterion. All treatments will be administered for a period of 2 months, and measurements of the modified convergence insufficiency symptoms survey (CISS), near point convergence, near phoria, and positive fusional vergence will be taken at baseline, one month later, and at the end of the treatment.

DISCUSSION

We aim to identify which component - either the prism prescription or the home vision therapy - is more effective in improving binocular abilities and reducing patients' symptom scores.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05311917 with last update on 04/22/2023.

Office-based vergence and anti-suppression therapy for the treatment of small-to-moderate angle intermittent exotropia: A randomised clinical trial

PURPOSE

To evaluate the short-term (1 week after completion of treatment) effect of office-based vergence and anti-suppression therapy (OBVAT) on the Office Control Score when compared to observation alone in children with small-to-moderate angle intermittent exotropia (IXT).

METHODS

In this single-masked (examiner masked), two-arm, single-centre randomised clinical trial, 40 participants, 6 to <18 years of age with untreated IXT, were randomly assigned to OBVAT or observation alone. Participants assigned to therapy received 60 min of OBVAT with home reinforcement once per week for 16 weeks. Therapy included vergence, accommodation and anti-suppression techniques. The primary outcome measure was the comparison of the distance Office Control Score between the two groups at the primary outcome visit (i.e., 17-week follow-up visit).

RESULTS

At the primary outcome visit, the OBVAT group (n = 20) had a significantly better distance Office Control Score (adjusted mean difference: -0.9; 95% CI: -0.2 to -1.5; p = 0.008; partial eta squared: 0.19) than the observation group (n = 16). Participants from the OBVAT group were more likely than those from the observation group to have ≥1 point of improvement at the 17-week visit (OBVAT group: 75%; Observation group: 25%; p = 0.006).

CONCLUSIONS

In this randomised clinical trial of participants aged 6 to <18 years with IXT, we found that the OBVAT group had a significantly better distance Office Control Score than the observation group at the 17-week visit. This study provides the first data from a randomised clinical trial demonstrating the effectiveness of OBVAT for improving the control of IXT. Eye care practitioners should consider OBVAT as a viable, non-surgical treatment option for IXT. A full-scale randomised clinical trial investigating the long-term effectiveness of OBVAT in treating IXT is warranted.

Does coexisting accommodative dysfunction impact clinical convergence measures, symptoms and treatment success for symptomatic convergence insufficiency in children?

PURPOSE

To determine whether coexisting accommodative dysfunction in children with symptomatic convergence insufficiency (CI) impacts presenting clinical convergence measures, symptoms and treatment success for CI.

METHODS

Secondary data analyses of monocular accommodative amplitude (AA; push-up method), monocular accommodative facility (AF; ±2.00 D lens flippers) and symptoms (CI Symptom Survey [CISS]) in children with symptomatic CI from the Convergence Insufficiency Treatment Trial (N = 218) and CITT-Attention and Reading Trial (N = 302) were conducted. Decreased AA was defined as more than 2D below the minimum expected amplitude for age (15 - ¼ age); those with AA < 5 D were excluded. Decreased AF was defined as <6 cycles per minute. Mean near point of convergence (NPC), near positive fusional vergence (PFV) and symptoms (CISS) were compared between those with and without accommodative dysfunction using analysis of variance and independent samples t-testing. Logistic regression was used to compare the effect of baseline accommodative function on treatment success [defined using a composite of improvements in: (1) clinical convergence measures and symptoms (NPC, PFV and CISS scores) or (2) solely convergence measures (NPC and PFV)].

RESULTS

Accommodative dysfunction was common in children with symptomatic CI (55% had decreased AA; 34% had decreased AF). NPC was significantly worse in those with decreased AA (mean difference = 6.1 cm; p < 0.001). Mean baseline CISS scores were slightly worse in children with coexisting accommodative dysfunction (decreased AA or AF) (30.2 points) than those with normal accommodation (26.9 points) (mean difference = 3.3 points; p < 0.001). Neither baseline accommodative function (p ≥ 0.12 for all) nor interaction of baseline accommodative function and treatment (p ≥ 0.50) were related to treatment success based on the two composite outcomes.

CONCLUSIONS

A coexisting accommodative dysfunction in children with symptomatic CI is associated with worse NPC, but it does not impact the severity of symptoms in a clinically meaningful way. Concurrent accommodative dysfunction does not impact treatment response for CI.

Home- and Office-Based Vergence and Accommodative Therapies for Treatment of Convergence Insufficiency in Children and Young Adults: A Report by the American Academy of Ophthalmology

PURPOSE

To review home- and office-based vergence and accommodative therapies for treatment of convergence insufficiency (CI) in children and young adults up to 35 years of age.

METHODS

Literature searches were conducted through October 2020 in the PubMed database for English-language studies. The combined searches yielded 359 abstracts, of which 37 were reviewed in full text. Twelve of these were considered appropriate for inclusion in this assessment and assigned a level of evidence rating by the panel methodologist.

RESULTS

Of the 12 studies included in this assessment, 8 were graded as level I evidence, 2 were graded as level II evidence, and 2 were graded as level III evidence. Two of the level I studies included older teenagers and young adults; the remainder of the studies exclusively evaluated children. Two randomized controlled trials found that office-based vergence and accommodative therapies were effective in improving motor outcomes in children with symptomatic CI. However, the studies reported conflicting results on the efficacy of office-based therapy for treating symptoms of CI. Data were inconclusive regarding the effectiveness of home-based therapies (including pencil push-ups and home computer therapy) compared with home placebo. In young adults, office-based vergence and accommodative therapies were not superior to placebo in relieving symptoms of CI.

CONCLUSIONS

Level I evidence suggests that office-based vergence and accommodative therapies improve motor outcomes in children with symptomatic CI, although data are inconsistent regarding symptomatic relief. Evidence is insufficient to determine whether home-based therapies are effective.

Effect of Vergence/Accommodative Therapy on Attention in Children with Convergence Insufficiency: A Randomized Clinical Trial

SIGNIFICANCE

The results of this study suggest that clinicians providing vergence/accommodative therapy for convergence insufficiency in children should not suggest that such treatment will lead to improvements in attention when compared with placebo treatment.

PURPOSE

This study aimed to compare the effects of 16 weeks of vergence/accommodative therapy and placebo therapy on changes in attention for children in the Convergence Insufficiency Treatment Trial-Attention and Reading Trial.

METHODS

Three hundred ten children 9 to 14 years old with convergence insufficiency were assigned to receive treatment with office-based vergence/accommodative therapy or placebo therapy. Attention tests were administered at baseline and after 16 weeks of treatment. The primary measure of attention was the Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior (SWAN) scale. Other measures included the Swanson, Nolan, and Pelham checklist; the Homework Problems Checklist; and the d2 Test of Attention. Within and between-group differences are reported using Cohen d effect sizes.

RESULTS

For the SWAN, there was no significant difference between the groups for the inattention scale parental report (d = 0.036; 95% confidence interval, -0.21 to 0.28) or for the hyperactivity impulsivity scale parental report (d = -0.003; 95% confidence interval, -0.24 to 0.24). Similar results were found for teacher reports and the secondary measures (d estimates from -0.97 to +0.10). There were, however, large within-group changes with d ≥ 1 in both treatment groups for the SWAN, the Homework Problems Checklist, and the d2 Test of Attention.

CONCLUSIONS

These results suggest that vergence/accommodative therapy is no better than placebo therapy in improving attention. Large improvements in inattention, completing homework, and selective and sustained attention were found in each group. However, these improvements cannot be attributed to improvements in vergence and accommodation and are likely due to nonspecific effects of an intensive therapy regimen.

Effectiveness of vergence/accommodative therapy for accommodative dysfunction in children with convergence insufficiency

PURPOSE

To determine the effectiveness of office-based vergence/accommodative therapy for improving accommodative amplitude and accommodative facility in children with symptomatic convergence insufficiency and accommodative dysfunction.

METHODS

We report changes in accommodative function following therapy among participants in the Convergence Insufficiency Treatment Trial - Attention and Reading Trial with decreased accommodative amplitude (115 participants in vergence/accommodative therapy; 65 in placebo therapy) or decreased accommodative facility (71 participants in vergence/accommodative therapy; 37 in placebo therapy) at baseline. The primary analysis compared mean change in amplitude and facility between the vergence/accommodative and placebo therapy groups using analyses of variance models after 4, 8, 12 and 16 weeks of treatment. The proportions of participants with normal amplitude and facility at each time point were calculated. The average rate of change in amplitude and facility from baseline to week 4, and from weeks 4 to 16, were determined in the vergence/accommodative therapy group.

RESULTS

From baseline to 16 weeks, the mean improvement in amplitude was 8.6 dioptres (D) and 5.2 D in the vergence/accommodative and placebo therapy groups, respectively (mean difference = 3.5 D, 95% confidence interval (CI): 1.5 to 5.5 D; p = 0.01). The mean improvement in facility was 13.5 cycles per minute (cpm) and 7.6 cpm in the vergence/accommodative and placebo therapy groups, respectively (mean difference = 5.8 cpm, 95% CI: 3.8 to 7.9 cpm; p < 0.0001). Significantly greater proportions of participants treated with vergence/accommodative therapy achieved a normal amplitude (69% vs. 32%, difference = 37%, 95% CI: 22 to 51%; p < 0.0001) and facility (85% vs. 49%, difference = 36%, 95% CI: 18 to 55%; p < 0.0001) than those who received placebo therapy. In the vergence/accommodative therapy group, amplitude increased at an average rate of 1.5 D per week during the first 4 weeks (p < 0.0001), then slowed to 0.2 D per week (p = 0.002) from weeks 4 to 16. Similarly, facility increased at an average rate of 1.5 cpm per week during the first 4 weeks (p < 0.0001), then slowed to 0.6 cpm per week from weeks 4 to 16 (p < 0.0001).

CONCLUSION

Office-based vergence/accommodative therapy is effective for improving accommodative function in children with symptomatic convergence insufficiency and coexisting accommodative dysfunction.

Interventions for convergence insufficiency: a network meta-analysis

BACKGROUND

Convergence insufficiency is a common binocular vision disorder in which the eyes have a strong tendency to drift outward (exophoria) with difficulty turning the eyes inward when reading or doing close work.

OBJECTIVES

To assess the comparative effectiveness and relative ranking of non-surgical interventions for convergence insufficiency through a systematic review and network meta-analysis (NMA).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PubMed and three trials registers up to 20 September 2019.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) examining any form of non-surgical intervention versus placebo, no treatment, sham treatment, or other non-surgical interventions. Participants were children and adults with symptomatic convergence insufficiency.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. We performed NMAs separately for children and adults.

MAIN RESULTS

We included 12 trials (six in children and six in adults) with a total of 1289 participants. Trials evaluated seven interventions: 1) office-based vergence/accommodative therapy with home reinforcement; 2) home-based pencil/target push-ups; 3) home-based computer vergence/accommodative therapy; 4) office-based vergence/accommodative therapy alone; 5) placebo vergence/accommodative therapy or other placebo intervention; 6) prism reading glasses; and 7) placebo reading glasses. Six RCTs in the pediatric population randomized 968 participants. Of these, the Convergence Insufficiency Treatment Trial (CITT) Investigator Group completed four RCTs with 737 participants. All four CITT RCTs were rated at low risk of bias. Diagnostic criteria and outcome measures were identical or similar among these trials. The four CITT RCTs contributed data to the pediatric NMA, incorporating interventions 1, 2, 3 and 5. When treatment success was defined by a composite outcome requiring both clinical measures of convergence to be normal, and also show a pre-specified magnitude of improvement, we found high-certainty evidence that office-based vergence/accommodative therapy with home reinforcement increases the chance of a successful outcome, compared with home-based computer vergence/accommodative therapy (risk ratio (RR) 1.96, 95% confidence interval (CI) 1.32 to 2.94), home-based pencil/target push-ups (RR 2.86, 95% CI 1.82 to 4.35); and placebo (RR 3.04, 95% CI 2.32 to 3.98). However, there may be no evidence of any treatment difference between home-based computer vergence/accommodative therapy and home-based pencil/target push-ups (RR 1.44, 95% CI 0.93 to 2.24; low-certainty evidence), or between either of the two home-based therapies and placebo therapy, for the outcome of treatment success. When treatment success was defined as the composite convergence and symptom success outcome, we found moderate-certainty evidence that participants who received office-based vergence/accommodative therapy with home reinforcement were 5.12 (95% CI 2.01 to 13.07) times more likely to achieve treatment success than those who received placebo therapy. We found low-certainty evidence that participants who received office-based vergence/accommodative therapy with home reinforcement might be 4.41 (95% CI 1.26 to 15.38) times more likely to achieve treatment success than those who received home-based pencil push-ups, and 4.65 (95% CI 1.23 to 17.54) times more likely than those who received home-based computer vergence/accommodative therapy. There was no evidence of any treatment difference between home-based pencil push-ups and home-based computer vergence/accommodative therapy, or between either of the two home-based therapies and placebo therapy. One RCT evaluated the effectiveness of base-in prism reading glasses in children. When base-in prism reading glasses were compared with placebo reading glasses, investigators found no evidence of a difference in the three outcome measures of near point convergence (NPC), positive fusional vergence (PFV), or symptom scores measured by the Convergence Insufficiency Symptom Survey (CISS). Six RCTs in the adult population randomized 321 participants. We rated only one RCT at low risk of bias. Because not all studies of adults included composite success data, we could not conduct NMAs for treatment success. We thus were limited to comparing the mean difference (MD) between interventions for improving NPC, PFV, and CISS scores individually using data from three RCTs (107 participants; interventions 1, 2, 4 and 5). Compared with placebo treatment, office-based vergence accommodative therapy was relatively more effective in improving PFV (MD 16.73, 95% CI 6.96 to 26.60), but there was no evidence of a difference for NPC or the CISS score. There was no evidence of difference for any other comparisons for any outcomes. One trial evaluated base-in prism glasses prescribed for near-work activities and found that the prism glasses group had fewer symptoms compared with the placebo glasses group at three months (MD -8.9, 95% CI -11.6 to -6.3). The trial found no evidence of a difference with this intervention in NPC or PFV. No adverse effects related to study treatments were reported for any of the included studies. Excellent adherence was reported for office-based vergence/accommodative therapy (96.6% or higher) in two trials. Reported adherence with home-based therapy was less consistent, with one study reporting decreasing adherence over time (weeks 7 to 12) and lower completion rates with home-based pencil/target push-ups.

AUTHORS' CONCLUSIONS

Current research suggests 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.

Traumatic Brain Injury in Children: Do the Eyes Have It? The Orthoptic Evaluation of Traumatic Brain Injury

Because the neuropathological changes caused by mild traumatic brain injury (mTBI) more often manifest as functional impairments than structural abnormalities, the clinical diagnosis of mTBI may rely too heavily on a combination of history and self-reported symptoms. The mechanism of injury in mild traumatic brain injury (mTBI) predicts that supranuclear pathways controlling eye movement systems would be vulnerable to damage, and diagnostic tests of these systems would be high-yield. In fact, tests of oculomotor function have proven to be highly sensitive in detecting neurological soft signs, but may require expensive, specialized equipment. Fortunately, Certified Orthoptists (COs) are skilled at the evaluation of accommodative dysfunction, abnormalities of saccades, smooth pursuit, and vestibular eye movements, and vergence errors using standard ophthalmic equipment. Because COs are accustomed to adapting the sensorimotor exam to infants and pre-verbal children, they are able to modify or design objective methods, the results of which may be difficult for the patient with a functional overlay to decipher and deceive. When the patient with a history of mTBI presents to the ophthalmologist with visual symptoms and a normal routine eye exam, it is important to order a sensorimotor examination by a CO to confirm the diagnosis.

The Convergence Insufficiency Neuro-mechanism in Adult Population Study (CINAPS) Randomized Clinical Trial: Design, Methods, and Clinical Data

Purpose: To describe the design and methodology of the Convergence Insufficiency Neuro-mechanism in Adult Population Study (CINAPS), the first randomized clinical trial (RCT) studying young adults with symptomatic convergence insufficiency (CI) using a combination of traditional clinical tests, objective eye movement recordings, and functional brain activities as outcome measures.Methods: In this double-masked RCT, binocularly normal controls (BNC) (N = 50) and CI patients (N = 50) are randomized into office-based vergence/accommodative therapy (OBVAT) or office-based placebo therapy (OBPT). Outcome measures included clinical signs and symptoms, phoria adaptation, forced fixation disparity curves, binocular rivalry, vergence and saccadic objective eye movements, and task-induced functional brain activities. This study is registered on ClinicalTrials.gov NCT03593031.Results: No significant baseline differences are observed between the BNC (p > .4) or CI (p > .3) participants assigned to OBVAT or OBPT for age, near point of convergence (NPC), positive fusional vergence (PFV), phoria at distance and near, amplitude of accommodation, or the Convergence Insufficiency Symptom Survey (CISS). Significant differences are observed between the CI and BNC cohorts at baseline measurements for NPC, PFV, difference in phoria from far to near, amplitude of accommodation, and CISS (p < .001). For the CI patients, 26% had a comorbidity of accommodation insufficiency, and 16% self-reported ADHD.Conclusion: Features of the study design include the following: standardized diagnostic and office-based therapeutic intervention, placebo treatment arm, masked clinical outcome examinations, objective eye movement recordings, functional imaging, phoria adaptation, fixation disparity curves and binocular rivalry measurements.

Effect of Vergence/Accommodative Therapy on Reading in Children with Convergence Insufficiency: A Randomized Clinical Trial

SIGNIFICANCE

The results of this study suggest that clinicians providing vergence/accommodative therapy for the treatment of childhood convergence insufficiency should not suggest that such treatment, on average, will lead to improvements on standardized assessments of reading performance after 16 weeks of treatment.

PURPOSE

The purpose of this study was to determine the effect of office-based vergence/accommodative therapy on reading performance in 9- to 14-year-old children with symptomatic convergence insufficiency.

METHODS

In a multicenter clinical trial, 310 children 9 to 14 years old with symptomatic convergence insufficiency were randomized in a 2:1 ratio to 16 weeks of office-based vergence/accommodative therapy or office-based placebo therapy, respectively. The primary outcome was change in reading comprehension as measured by the reading comprehension subtest of the Wechsler Individual Achievement Test, Third Edition (WIAT-III) at the 16-week outcome. Secondary reading outcomes of word identification, reading fluency, listening comprehension, comprehension of extended text, and reading comprehension were also evaluated.

RESULTS

The adjusted mean improvement in WIAT-III reading comprehension was 3.7 (95% confidence interval [CI], 2.6 to 4.7) standard score points in the vergence/accommodative therapy group and 3.8 (95% CI, 2.4 to 5.2) points in the placebo therapy group, with an adjusted mean group difference of -0.12 (95% CI, -1.89 to 1.66) points that was not statistically significant. No statistically significant treatment group differences were found for any of the secondary reading outcome measures.

CONCLUSIONS

For children aged 9 to 14 years with symptomatic convergence insufficiency, office-based vergence/accommodative therapy was no more effective than office-based placebo therapy for improving reading performance on standardized reading tests after 16 weeks of treatment.

A Randomized Trial to Increase the Assessment Accuracy of Glaucoma and Optic Disc Characteristics by Orthoptists

INTRODUCTION

The aim of this study was to determine the accuracy of orthoptists when examining the optic disc for signs of glaucoma, and to explore the impact of targeted clinical education on accuracy.

METHODS

In this randomized controlled trial, 42 monoscopic color optic disc images were presented to 46 orthoptists who assessed the likelihood of glaucoma as well as optic disc size, shape, tilting, vertical cup-to-disc ratio, cup shape, depth, presence of hemorrhage, peripapillary atrophy, and retinal nerve fiber layer. The level of agreement with specialist ophthalmologists was assessed. Participants were then randomly assigned to an experimental group (targeted postgraduate education on optic disc assessment) or to no intervention. The educational program was designed to increase knowledge of the characteristic features associated with glaucomatous optic neuropathy. All participants re-examined the included optic disc images after a period of 6 to 8 weeks. The primary outcome measure was a change in agreement between attempts.

RESULTS

The education group showed significant improvements between attempts for identifying hemorrhages (P = .013), retinal nerve fiber layer defects (0.035), disc size (P = .001), peripapillary atrophy (P = .030), and glaucoma likelihood (P = .023). The control group did not show any statistically significant improvement. The intervention group showed significantly more improvement when identifying hemorrhages (P = .013), disc size (P = .001), disc shape (P = .033), and cup shape (P = .020) compared with the control group.

DISCUSSION

Orthoptists who received additional postgraduate online education based on principles of adult learning were more accurate at assessing the optic disc for glaucoma. These results highlight the value of continuing education to optimize clinical practice in allied health professionals.

2016 International Orthoptic Congress Burian Lecture: Folklore or Evidence?

The theme of the 2016 Burian Lecture is how our understanding of strabismus has been changed by the research carried out in our laboratory in Reading over the years. Accommodation and convergence are fundamental to orthoptics, but actual responses have often been very different compared to what we had expected. This paper outlines how our laboratory's understanding of common issues such as normal development of accommodation and convergence, their linkage, intermittent strabismus, anisometropia, orthoptic exercises, and risk factors for strabismus have changed. A new model of thinking about convergence and accommodation may help us to better understand and predict responses in our patients.

Modification of the titmus fly test to improve accuracy

INTRODUCTION

In spite of its well-known flaws, the Titmus test is still the most commonly available and frequently utilized stereotest worldwide. Detecting stereopsis in the patient with small-angle strabismus is an important part of the sensorimotor exam. Because these patients often have only gross stereopsis, stereoacuity may have to be evaluated with the House Fly plate alone. This study evaluates an alternative method of presentation designed to decrease the false positive rate of the Titmus Fly test.

METHODS

A group of orthotropic volunteers with normal binocular vision, a group of patients with small angle strabismus, and a group of patients whose angle of strabismus was large enough to preclude stereopsis were tested with the Titmus Fly using two different presentations and compared.

RESULTS

The sensitivity of the Titmus Fly test was 79%, but specificity was only 26% due to the large number of false positive responses detected with the modified presentation. Patients with childhood-onset strabismus who have been repeatedly exposed to this test over many visits were particularly vulnerable to overestimation of stereoacuity.

CONCLUSION

If the Titmus fly test is the only stereoacuity measure that can be used due to the presence of manifest strabismus, modifying the presentation of the test plate with this method will improve accuracy and precision of results.

Change in convergence and accommodation after two weeks of eye exercises in typical young adults

BACKGROUND

Although eye exercises appear to help heterophoria, convergence insufficiency, and intermittent strabismus, results can be confounded by placebo, practice, and encouragement effects. This study assessed objective changes in vergence and accommodation responses in naive young adults after a 2-week period of eye exercises under controlled conditions to determine the extent to which treatment effects occur over other factors.

METHODS

Asymptomatic young adults were randomly assigned to one of two no-treatment (control) groups or to one of six eye exercise groups: accommodation, vergence, both, convergence in excess of accommodation, accommodation in excess of convergence, and placebo. Subjects were tested and retested under identical conditions, except for the second control group, who were additionally encouraged. Objective accommodation and vergence were assessed to a range of targets moving in depth containing combinations of blur, disparity, and proximity/looming cues.

RESULTS

A total of 156 subjects were included. Response gain improved more for less naturalistic targets where more improvement was possible. Convergence exercises improved vergence for near across all targets (P = 0.035). Mean accommodation changed similarly but nonsignificantly. No other treatment group differed significantly from the nonencouraged control group, whereas encouraging effort produced significantly increased vergence (P = 0.004) and accommodation (P = 0.005) gains in the second control group.

CONCLUSIONS

True treatment effects were small, significantly better only after vergence exercises to a nonaccommodative target, and rarely related to the response they were designed to improve. Exercising accommodation without convergence made no difference to accommodation to cues containing detail. Additional effort improved objective responses the most.

The orthoptics of Down syndrome

Patients with Down syndrome have many ocular anomalies. Most of them are treatable conditions that can strongly affect their quality of life if not addressed at an early age. It is important for clinicians to be aware of improvements in both the medical field and the educational systems in the assessment of these patients and in their treatment.

Acquired nonparalytic causes of superior oblique dysfunction

BACKGROUND AND PURPOSE

To conduct a retrospective study to investigate the causes of acquired superior oblique dysfunction, excluding paralysis, in a consecutive series of adult patients and to compare presenting symptoms and clinical findings.

METHODS

A retrospective review of all adult patients with superior oblique dysfunction between the ages of 18 and 80 who met the study profile was conducted at Saint Louis University Medical Center between January 2000 and April 2012. The presenting symptoms, clinical findings, and treatment course for each patient was recorded. The study was approved by the Institutional Review Board of our institution.

RESULTS

Acquired forms of nonparalytic superior oblique dysfunction were identified in forty-eight patients. These included superior oblique myokymia (twenty-three patients), superior oblique click syndrome or variable Brown syndrome (nine), canine tooth syndrome (five), spontaneous acquired Brown syndrome (four), iatrogenic or traumatic Brown syndrome (four), and ocular neuromyotonia affecting the superior oblique (three).

CONCLUSIONS

Several nonparalytic entities were identified that caused superior oblique dysfunction. Clinical findings may be similar despite entirely different mechanisms. Subjective symptoms may be difficult for the patient to describe or for the examiner to elicit on the day of the examination. Specific techniques can be used in eliciting, differentiating, and documenting the conditions. These included trochlear palpation, modified head tilt technique, interpretation of torsion, and Hess charts.

Vision therapy: are you kidding me? Problems with current studies

BACKGROUND AND PURPOSE

Orthoptic exercises are routinely prescribed to treat symptoms of convergence insufficiency (CI). The type and duration of treatment tends to vary among providers as until recently, few strong randomized control studies have addressed the efficacy of convergence insufficiency management. The aim of this paper is to address these studies and discuss their limitations.

METHODS

A review of the literature pertaining to convergence insufficiency was conducted. Articles relevant to the treatment of this disorder were analyzed, and those with adequate studies pertaining to CI treatment methods were included.

RESULTS

There are limited randomized control trials evaluating the effectiveness of vision therapy, and those that do exist have limitations: small patient populations, differing outcome measures, treatment length and intensity, and placebo effects, which are all confounding factors when assessing the validity of the current studies.

CONCLUSION

Despite the prevalence of convergence insufficiency, the known efficacy of vision therapy remains somewhat questionable. There is evidence to suggest that some form of therapy is effective in reducing symptoms and clinical findings of convergence insufficiency, but there is a lack of equal comparison in order to conclude which forms of treatment are best.

Feedback of personal retinal images appears to have a motivational impact in people with non-proliferative diabetic retinopathy and suboptimal HbA1c: findings of a pilot study

AIM

To conduct a pilot study to explore the potential impact of visual feedback of personal retinal images on diabetes outcomes.

METHODS

Twenty-five participants with non-proliferative diabetic retinopathy and suboptimal HbA(1c) (> 53 mmol/mol; > 7%) were randomized to receive visual feedback of their own retinal images or to a control group. At baseline and 3-month follow-up, HbA(1c), standard measures of beliefs, diabetes-related distress and self-care activities were assessed.

RESULTS

In unadjusted models, relative to controls, the intervention group showed significantly greater improvement in HbA(1c) at 3-month follow-up (-0.6% vs. +0.3%, P < 0.01), as well as enhanced motivation to improve blood glucose management (P < 0.05).

CONCLUSIONS

This small pilot study provides preliminary evidence that visual feedback of personal retinal images may offer a practical educational strategy for clinicians in eye care services to improve diabetes outcomes in non-target compliant patients. A fully powered randomized controlled trial is required to confirm these findings and determine the optimal use of feedback to produce sustained effects.

Binocular coordination of saccades during reading in children with clinically assessed poor vergence capabilities

Prior studies have pointed toward a link between the saccadic and vergence systems, coordinating binocular saccadic movements. Recent studies have shown that vergence deficits in children induce poor binocular coordination during saccades, but none of them have studied ocular motility in children during a daily task such as reading. The present study tests whether vergence deficits in children perturb binocular coordination of saccades and fixation during reading. Our second objective was to explore whether vergence training could improve the quality of binocular coordination. Twelve patients (from 7.3 to 13.4 years old) complaining from vertigo but without vestibular and neurological pathology underwent orthoptic tests and were selected for our study when they presented vergence deficits. Eye movements were recorded during a reading task with a Mobile EyeBrain® Tracker video-oculography system. Data were compared to twelve age-matched controls with normal orthoptic values. While there was no statistically significant difference in saccade amplitudes between the two groups (p=0.29), patients showed higher disconjugacy during and after the saccades compared to controls (p<0.001). After orthoptic training, six patients out of the first 12 examined came back for a second oculomotor test. All showed a significant improvement of their binocular saccade coordination. We suggest that the larger disconjugacy during reading observed in patients before training could be due to poor vergence as initially assessed by orthoptic examination. Such findings support the hypothesis of a tight relationship between the saccadic and vergence systems for controlling the binocular coordination of saccades. The improvement reported after orthoptic training is in line with the hypothesis of an adaptative interaction on a premotor level between the saccadic and vergence system.

Vision therapy and computer orthoptics: evidence-based approach to use in your practice

Convergence insufficiency is a commonly seen disorder of the vergence system. Its clinical characteristics and symptoms have been well described by Duane and von Graefe. Laboratory studies have clarified the vergence pathway, which includes a bi-phasic response. Several recent randomized controlled trials show the effectiveness of common treatment modalities, including pencil pushups, computer orthoptics, and office-based therapy. More studies are needed to investigate the possibility that other treatments may treat convergence insufficiency in a more profound way by acting on other parts of the vergence system.

[Screening for visual impairment in children: new tests and the place of the orthoptist]

The fragility and plasticity of visual function in children necessitates early detection and treatment of visual disorders. New approaches such as portable automatic refraction, tonometry and digital fundus examination have improved the quality of screening The problem now is a lack of ophthalmologists. One possible solution is to redefine the role of orthoptists. The waiting time for an ophthalmologist appointment is very long in some parts of France (up to a year), because of a training quota established in the 1980s, as well as retirements (average age 52 years), and a concentration of specialists in the south of France and around medical schools. Today, France trains only 80 specialists per year, whereas twice as many are needed Anglo-Saxon countries (US, Canada, United Kingdom) have created a profession--the optometrist--that is intermediate between the optician and the ophthalmologist. This profession is not recognized in France, yet optometrists are capable of detecting many anomalies and quickly referring a child to a specialist.

Non-surgical interventions for convergence insufficiency

BACKGROUND

Convergence insufficiency is a common eye muscle co-ordination problem in which the eyes have a strong tendency to drift outward (exophoria) when reading or doing close work. Symptoms may include eye strain, headaches, double vision, print moving on the page, frequent loss of place when reading, inability to concentrate, and short attention span.

OBJECTIVES

To systematically assess and synthesize evidence from randomized controlled trials (RCTs) on the effectiveness of non-surgical interventions for convergence insufficiency.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, Science Citation Index, the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov ) on 7 October 2010. We manually searched reference lists and optometric journals.

SELECTION CRITERIA

We included RCTs examining any form of non-surgical intervention against placebo, no treatment, sham treatment, or each other.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed eligibility, risk of bias, and extracted data. We performed meta-analyses when appropriate.

MAIN RESULTS

We included six trials (three in children, three in adults) with a total of 475 participants. We graded four trials at low risk of bias.Evidence from one trial (graded at low risk of bias) suggests that base-in prism reading glasses was no more effective than placebo reading glasses in improving clinical signs or symptoms in children.Evidence from one trial (graded at high risk of bias) suggests that base-in prism glasses using a progressive addition lens design was more effective than progressive addition lens alone in decreasing symptoms in adults. At three weeks of therapy, the mean difference in Convergence Insufficiency Symptoms Survey (CISS) score was -10.24 points (95% confidence interval (CI) -15.45 to -5.03).Evidence from two trials (graded at low risk of bias) suggests that outpatient (or office-based as used in the US) vision therapy/orthoptics was more effective than home-based convergence exercises (or pencil push-ups as used in the US) in children. At 12 weeks of therapy, the mean difference in change in near point of convergence, positive fusional vergence, and CISS score from baseline was 3.99 cm (95% CI 2.11 to 5.86), 13.13 diopters (95% CI 9.91 to 16.35), and 9.86 points (95% CI 6.70 to 13.02), respectively.In a young adult population, evidence from one trial (graded at low risk of bias) suggests outpatient vision therapy/orthoptics was more effective than home-based convergence exercises in improving positive fusional vergence at near (7.7 diopters, 95% CI 0.82 to 14.58), but not the other outcomes.Evidence from one trial (graded at low risk of bias) comparing four interventions, also suggests that outpatient vision therapy/orthoptics was more effective than home-based computer vision therapy/orthoptics in children. At 12 weeks, the mean difference in change in near point of convergence, positive fusional vergence, and CISS score from baseline was 2.90 cm (95% CI 0.96 to 4.84), 7.70 diopters (95% CI 3.94 to 11.46), and 8.80 points (95% CI 5.26 to 12.34), respectively. Evidence was less consistent for other pair-wise comparisons.

AUTHORS' CONCLUSIONS

Current research suggests that outpatient vision therapy/orthoptics is more effective than home-based convergence exercises or home-based computer vision therapy/orthoptics for children. In adult population, evidence of the effectiveness of various non-surgical interventions is less consistent.

[Treatment of non accomodated concomitant strabismus]

The aim of the study was comparative evaluation of surgical treatment and complex pre and postoperative pleoptic, orthoptic, diploptic treatment of non accommodated concomitant strabismus and identification of the optimum age for surgical treatment of strabismus. The 75 patients (from 2 to 10 years old) with manifested concomitant convergent strabismus were divided into two groups: patients operated at the age from 2 to 4 years old; patients operated at the age of 4-10 years). The 75 of patients operated at the age from 2 to 4 years old, which underwent orthoptic-diploptic treatment pre- and postoperatively got binocular vision showed the full recovery in only 40% of cases of the same age-group undergone the surgical treatment in combination with the direct occlusion. Binocular vision was achieved in 68% of patients operated at the age of 4-10 years with complex treatment, and in 25% in patients of the same age group with surgical treatment plus occlusion. The findings showed the efficacy of complex treatment as well as pre and postoperative pleoptic-orthoptic-diploptic treatment of strabismus and direct occlusion. Thus, the results of this study suggest that the delay of surgical treatment limits the ability to obtain optimal results.

Evidenced-based medicine: treatment for amblyopia

Amblyopia is defined as reduced and uncorrectable vision in a structurally normal eye. Early detection of amblyopia is very important. This can be accomplished through screening programs designed to identify amblyopia risk factors. Testing can be performed by trained teachers, technicians, school nurses and pediatricians as well as by eye care professionals. Once a child is identified as having an amblyopia risk factor it is crucial that the parents follow up with a pediatric ophthalmologist for a comprehensive examination. Amblyopia is the leading cause of monocular vision loss in the United States for adults under the age of 40. Amblyopia is amenable to therapy and is cost effective to treat. It is believed that earlier therapy for amblyopia provides better outcomes, but treatment has been shown effective even in some older children. In this paper, studies are cited regarding treatment of amblyopia.

Functional benefits of sensory and motor evaluation before strabismus surgery

Evaluating the sensory and motor status of your strabismus patient is an important part of the preoperative examination. However, not all clinicians follow the same protocol for this assessment. Many rely on personal experience to determine what tests to do. Is this enough? Interpreting the evidence regarding the proper preoperative exam for strabismus patients and incorporating it into your practice can help to enhance your postoperative results.

ROP: A cautionary tale: what we know and what we think we know

Retinopathy of prematurity is a complex disease with many subtleties and considerable individual variation. In order to obtain highly reliable evidence as to the nature of ROP, rigorous, randomized, controlled, multicenter trials that enroll a large number of eligible subjects are required. Fortunately, such trials have been conducted and have yielded a wealth of information. It is essential to critically evaluate these trials as well as other levels of scientific evidence to determine what our current state of knowledge is. This review focuses on what we know as fact and what may be common practice or empirical knowledge not based on rigorous evidence.

[Refractive laser eye surgery and binocular vision disorders--case report]

Laser refractive surgery is a lively developing branch of ophthalmology. There are a numbers of contraindications for this type of surgery, but many of them are difficult to define, for example binocular vision impairment. Accurate analysis of orthoptic examination before refractive surgery, has forced us to dissuade our patient from refractive surgery, despite the fact that there were no other contraindications.

CASE STUDY

A 33 years old woman referred for refractive surgery because of bilateral myopia (right eye: -5.25 Dsph -0.75 Dcyl ax. 170; left eye: -5.0 Dsph). There was no strabismus or other binocular vision disorders in her history. Orthoptic examination revealed exophoria, slight hyperphoria and considerable bilateral convergence insufficiency, which would have contributed to future strabismic complications.

Nonsurgical treatment for esotropia secondary to Arnold-Chiari I malformation: A case report

A 14-year-old girl with diplopia and esotropia secondary to Arnold-Chiari I malformation was surgically treated with Arnold-Chiari I malformation decompression (suboccipital craniectomy), C1 and partial C2 laminectomy, and duraplasty. The residual esotropia was treated with compensatory prisms and vision therapy more than 1 year after Arnold-Chiari malformation surgery. The esotropia was resolved after approximately 3.5 months of treatment. Five years later, the patient continued to maintain fusion without compensatory prism.

Children with low literacy and poor stereoacuity: an evaluation of complex interventions in a community-based randomized trial

PURPOSE

To assess, among children with low literacy and poor stereoacuity, the efficacy of two intervention programs on child vision and education compared to a control program.

METHODS

Eighty-eight children aged 8 to 13 years who had reading problems, and demonstrated poor stereoacuity as measured by the Titmus stereocircle test (> 100 seconds arc) or computerized assessment were randomized to one of two intervention programs: Lawson vision or Phono-Graphix, or a control group: Parental Literacy Support. Vision (Lang test, visual acuity, convergence insufficiency symptom survey) and education assessments (Woodcock Reading Mastery Tests-Revised) were conducted at baseline, intervention end (10 weeks), and 36 weeks. Analysis used intention to treat multi-level models.

RESULTS

Compared to the parental literacy support group, convergence insufficiency symptoms were reduced 36 weeks post-randomization amongst those receiving the Lawson orthoptic intervention (mean difference -5.55; 95% confidence interval (CI): -11.1 to -0.05, P < 0.05). Stereoacuity, measured by the Lang test, improved for both the Lawson and Phono-Graphix interventions compared to the parental literacy support group (-1.01; 95% CI: -1.6 to -0.4, P = 0.001, and -0.77; 95% CI: -1.4 to -0.2, P = 0.01). At the 36 week follow-up assessment, word identification had also improved for the Lawson and Phono-Graphix groups but other educational outcomes did not improve.

CONCLUSION

A formal randomized control trial was feasible in this setting. Intervention among children with poor stereoacuity and low literacy produced small improvements in stereopsis and convergence insufficiency symptom scores. Further randomized control trials should be conducted to clarify the role of orthoptic intervention on literacy in selected child populations.

Are Orthoptic Exercises an Effective Treatment for Convergence and Fusion Deficiencies?

PURPOSE

To investigate whether orthoptic exercises are an effective way to influence the near point of convergence, fusion range and asthenopic symptoms.

METHODS

Seventy-eight patients met the inclusion criteria of visual acuity 6/9 or better, no history of orthoptic treatment, squint surgery or Meares Irlen syndrome/dyslexia. Information was collected from case records related to diagnosis, near point of convergence, fusion range, prism and cover test measurements and symptoms. Type, duration and frequency of exercises were also recorded. Non-parametric statistics were applied.

RESULTS

Patients ranged in age from 5 to 73 years (mean 11.9). Females outnumbered males (46:32). The diagnoses were: decompensating heterophoria (n = 50) or convergence insufficiency (n = 28: primary 27; secondary 1). Exophoria was more common (n = 65), than esophoria (n = 11) or orthophoria (n = 1). Treatments were aimed at improving near point of convergence and/or reduced fusional reserves. The mean treatment period was 8.2 months. Reduced near point of convergence normalized following treatment in 47/55 cases, and mean near point of convergence improved from 16.6 to 8.4 cm (p = 0.0001). Fusional reserves normalized in 29/50. Fusional convergence improved significantly for those with exodeviation (p > 0.0006). Asthenopic symptoms improved in 65 patients. A reduction in deviation of 5 pd or more occurred in 20 patients.

CONCLUSIONS

Orthoptic exercises are an effective means of reducing symptoms in patients with convergence insufficiency and decompensating exophoria, and appear to target the proximal and fusional components of convergence. Their role in esophoria is unclear and needs further study.

Improving visual skills: II-remote assessment via Internet

BACKGROUND

Even though poor readers often have poor visual skills, such as binocular coordination and oculomotor control, students' visual skills are rarely assessed. Computer assessments have the potential to assist in identifying students whose visual skills are deficient. This study compared assessments made by an Internet-based computer orthoptics program with those of an on-site vision therapist.

METHODS

Students (N = 41) in grades 1 through 8, reading at least 2 levels below grade, were assessed for visual skill dysfunction (including binocular fusion and tracking ability) by a vision therapist at their school in Wisconsin. The therapist determined whether the student had adequate visual skills based on clinical and behavioral observations. A "remote" investigator located in California determined the adequacy of accommodative facility, tracking, and vergence skills in the same students, based on quantitative progress through the modules of an Internet-based computer orthoptics training program during 3 assessment sessions.

RESULTS

The on-site therapist made 33 referrals for possible visual skills training (80%). The remote investigator made 25 referrals (61%), all of which were consistent with referrals made by the on-site therapist; thus, no false-positives occurred when using the remote assessment technique. The 8 additional referrals by the therapist were attributed to the ability to observe student behavior during assessment.

CONCLUSIONS

Remote assessment of visual skills via an Internet orthoptics program may provide a simple means to detect visual skill problems experienced by poor readers.

[Therapeutic schedule in ambliopia--experience of Eye Clinic Cluj]

THE PURPOSE

To establlsh a protocol for the treatment of amblyopia and the methods used to maintain the results (visual acuity).

MATERIAL AND METHODS

Fifty children with amblyopia were treated in the Pediatric Ophthalmology Department of the Ophthalmological Cllnic in Cluj. Full time occlusion was used in all children. Pleoptic methods (Haidinger procedure, anti crowding fenomenon exercices and visual attention exercices) were done in the amblyopic children. The study analyzed the correlation of the visual acuity and the type of amblyopia (strabismic, anysometropic), the age of the patients and the age at the initiation of the treatment, the compliance. The visual acuity was followed up by check outs every 4-6 months.

RESULTS AND CONCLUSION

The study concluded that the treatment of choice in amblyopia is the full time occlusion. The partial occlusion and the optical penalization is reserved for the maintenance of the result (visual acuity) until the children reach the age of 7-8, when the sensitive period of visual development ends. The compliance of the children and parents is important. The hospitalization and the pleoptics used in a amlyopic children collectivity improve the children cooperation and the therapeutical results.

The effect of testing distance on the bielschowsky head tilt test

AIMS

The Bielschowsky Head Tilt Test (BHTT) is a commonly used test in Orthoptic practice and is used mainly to differentiate between a long standing Superior Oblique and Superior Rectus palsy. No consistent test distance is recommended in the literature and therefore the aim of this study was to determine whether test distance had an effect upon the measurements obtained.

METHOD

Thirteen participants were recruited. Participants had either longstanding or recent onset unilateral Superior Oblique palsy. Prism Cover Test measurements of the vertical angle of deviation were taken whilst the participant tilted their head to either side whilst fixating on a target at 33 cm, 3 m and 6 m.

RESULTS

The test distance does have a significant effect on the change in vertical angle measured with head tilted to either side (x2+7.747,DoF 2, p=0.021). When the median values are considered it appears that the significant effect occurs due to a smaller change in angle between head tilt to the affected side when fixing at 3 metres. This was confirmed using the Wilcoxon signed rank test (33cmv3m p=0.039, 3m v 6m p=0.013 and 33cm v 6m p=0.67).

CONCLUSIONS

The testing distance at which the BHTT is performed appears to have an effect upon the measurements obtained. The clinical importance of the difference in the change of angle with head tilt to either side is debatable due to the fact that the difference in the median measurement value between the three test distances is a maximum of 3 prism dioptres.

Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children

OBJECTIVE

To compare home-based pencil push-ups (HBPP), home-based computer vergence/accommodative therapy and pencil push-ups (HBCVAT+), office-based vergence/accommodative therapy with home reinforcement (OBVAT), and office-based placebo therapy with home reinforcement (OBPT) as treatments for symptomatic convergence insufficiency.

METHODS

In a randomized clinical trial, 221 children aged 9 to 17 years with symptomatic convergence insufficiency were assigned to 1 of 4 treatments.

MAIN OUTCOME MEASURES

Convergence Insufficiency Symptom Survey score after 12 weeks of treatment. Secondary outcomes were near point of convergence and positive fusional vergence at near.

RESULTS

After 12 weeks of treatment, the OBVAT group's mean Convergence Insufficiency Symptom Survey score (15.1) was statistically significantly lower than those of 21.3, 24.7, and 21.9 in the HBCVAT+, HBPP, and OBPT groups, respectively (P < .001). The OBVAT group also demonstrated a significantly improved near point of convergence and positive fusional vergence at near compared with the other groups (P

CONCLUSIONS

Twelve weeks of OBVAT results in a significantly greater improvement in symptoms and clinical measures of near point of convergence and positive fusional vergence and a greater percentage of patients reaching the predetermined criteria of success compared with HBPP, HBCVAT+, and OBPT. Application to Clinical Practice Office-based vergence accommodative therapy is an effective treatment for children with symptomatic convergence insufficiency.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00338611.

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Key Words

• convergence insufficiency
• asthenopia
• vision therapy
• orthoptics
• vergence/accommodative therapy
• pencil push-ups
• computer vergence/accommodative therapy
• placebo therapy
• exophoria
• eyestrain
• symptom survey

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MESH Headings

• Adolescent
• Child
• Confidence Intervals
• Convergence, Ocular
• Female
• Home Nursing
• Humans
• Male
• Multivariate Analysis
• Ocular Motility Disorders/diagnosis
• Ocular Motility Disorders/therapy
• Office Visits
• Ophthalmology/methods
• Orthoptics/methods
• Patient Compliance
• Probability
• Recovery of Function
• Reference Values
• Sensitivity and Specificity
• Severity of Illness Index
• Strabismus/diagnosis
• Strabismus/therapy
• Treatment Outcome
• Vision, Binocular
• Visual Acuity

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Grants

• U10 EY014712 NEI NIH HHS
• U10 EY014676-02 NEI NIH HHS
• U10 EY014712-04 NEI NIH HHS
• U10 EY014659-03 NEI NIH HHS
• U10 EY014676-01A1 NEI NIH HHS
• U10 EY014713-01A2 NEI NIH HHS
• U10 EY014713-02 NEI NIH HHS
• U10 EY014715-01A1S1 NEI NIH HHS
• U10 EY014716-04 NEI NIH HHS
• U10 EY014710-04 NEI NIH HHS
• U10 EY014676 NEI NIH HHS
• U10 EY014706-01A1S1 NEI NIH HHS
• U10 EY014713 NEI NIH HHS
• U10 EY014709 NEI NIH HHS
• U10 EY014659-01A2 NEI NIH HHS
• U10 EY014715-04 NEI NIH HHS
• U10 EY014712-01A1 NEI NIH HHS
• U10 EY014713-03 NEI NIH HHS
• U10 EY014706-01A1 NEI NIH HHS
• U10 EY014715-02 NEI NIH HHS
• U10 EY014709-03 NEI NIH HHS
• U10 EY014715-03 NEI NIH HHS
• U10 EY014676-04 NEI NIH HHS
• U10 EY014715 NEI NIH HHS
• U10 EY014716-03 NEI NIH HHS
• U10 EY014710-02 NEI NIH HHS
• U10 EY014709-04 NEI NIH HHS
• U10 EY014716-02 NEI NIH HHS
• U10 EY014716-02S1 NEI NIH HHS
• U10 EY014706-02 NEI NIH HHS
• U10 EY014713-04 NEI NIH HHS
• U10 EY014709-02 NEI NIH HHS
• U10 EY014712-03 NEI NIH HHS
• U10 EY014706-04 NEI NIH HHS
• U10 EY014710-01A1S1 NEI NIH HHS
• U10 EY014710-01A1 NEI NIH HHS
• U10 EY014659-04 NEI NIH HHS
• U10 EY014676-03 NEI NIH HHS
• U10 EY014712-01A1S1 NEI NIH HHS
• U10 EY014659-02 NEI NIH HHS
• U10 EY014676-01A1S1 NEI NIH HHS
• U10 EY014716-01A1 NEI NIH HHS
• U10 EY014709-01A1 NEI NIH HHS
• U10 EY014706-03 NEI NIH HHS
• U10 EY014716-01A1S1 NEI NIH HHS
• U10 EY014716 NEI NIH HHS
• U10 EY014715-01A1 NEI NIH HHS
• U10 EY014709-01A1S1 NEI NIH HHS
• U10 EY014712-02 NEI NIH HHS
• U10 EY014710-03 NEI NIH HHS
• U10 EY014659 NEI NIH HHS

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Affiliation(s) Collapse

Convergence Insufficiency Treatment Trial (CITT) Study Group. The convergence insufficiency treatment trial: design, methods, and baseline data

OBJECTIVE

This report describes the design and methodology of the Convergence Insufficiency Treatment Trial (CITT), the first large-scale, placebo-controlled, randomized clinical trial evaluating treatments for convergence insufficiency (CI) in children. We also report the clinical and demographic characteristics of patients.

METHODS

We prospectively randomized children 9 to 17 years of age to one of four treatment groups: 1) home-based pencil push-ups, 2) home-based computer vergence/accommodative therapy and pencil push-ups, 3) office-based vergence/accommodative therapy with home reinforcement, 4) office-based placebo therapy. Outcome data on the Convergence Insufficiency Symptom Survey (CISS) score (primary outcome), near point of convergence (NPC), and positive fusional vergence were collected after 12 weeks of active treatment and again at 6 and 12 months posttreatment.

RESULTS

The CITT enrolled 221 children with symptomatic CI with a mean age of 12.0 years (SD = +2.3). The clinical profile of the cohort at baseline was 9Delta exophoria at near (+/- 4.4) and 2Delta exophoria (+/-2.8) at distance, CISS score = 30 (+/-9.0), NPC = 14 cm (+/- 7.5), and near positive fusional vergence break = 13 Delta (+/- 4.6). There were no statistically significant nor clinically relevant differences between treatment groups with respect to baseline characteristics (p > 0.05).

CONCLUSION

Hallmark features of the study design include formal definitions of conditions and outcomes, standardized diagnostic and treatment protocols, a placebo treatment arm, masked outcome examinations, and the CISS score outcome measure. The baseline data reported herein define the clinical profile of those enrolled into the CITT.

Amblyopia and Strabismus Questionnaire (A&SQ): clinical validation in a historic cohort

BACKGROUND

We recently developed the Amblyopia & Strabismus Questionnaire (A&SQ) to assess the quality of life in amblyopia and/or strabismus patients, and evaluated its content and criterion validity. The A&SQ was now validated clinically by correlating its outcome with past and current orthoptic parameters in a historic cohort of amblyopia and/or strabismus patients.

METHODS

The cohort was derived from all 471 patients who were treated by occlusion therapy in the Waterland Hospital in Purmerend between 1968 and 1974 and born between 1962 and 1972. All children with insufficient visual acuity from the Waterland area had been referred to a single ophthalmologist and orthoptist. Of these, 203 were traced, and 174 filled out the A&SQ. In 137 of these, binocular vision, visual acuity, and angle of strabismus were reassessed 30-35 years after occlusion therapy. These clinical parameters were correlated with the five A&SQ domains: "distance estimation", "visual disorientation", "fear of losing the better eye", "diplopia", and "social contact and cosmetic problems".

RESULTS

The current acuity at distance of the amblyopic eye and reading acuity of the amblyopic eye correlated significantly with all five A&SQ domains (significance level P = 0.01-P = 0.05). Weaker correlations were found for binocularity. In spite of the expectation that stereopsis should strongly correlate with the domain "distance estimation", and angle of strabismus with the domain "social contact and cosmetic problems", the acuity of the amblyopic eye was the overall dominant parameter.

CONCLUSIONS

The adult acuity of the amblyopic eye seems the most important clinical determinant for quality of life in amblyopia and/or strabismus patients, even in domains of distance estimation, visual disorientation, and social contact and cosmetic problems, although intermediate determinants cannot be excluded.

Contrast sensitivity function and ocular higher-order aberrations following overnight orthokeratology

PURPOSE

To evaluate relationships among contrast sensitivity function, ocular higher-order aberration, and myopic correction in eyes undergoing overnight orthokeratology for myopia.

METHODS

A prospective study was conducted in 46 eyes of 23 patients undergoing orthokeratology. Inclusion criteria were spherical equivalent refraction between -1.00 and -4.00 diopters (D), refractive astigmatism up to 1.00 D, and best-corrected visual acuity of 20/20 or better. Ocular higher-order aberrations and contrast sensitivity function were determined before and 3 months after initiation of the procedure. We measured three indices of contrast sensitivity function: contrast sensitivity, low-contrast visual acuity, and letter contrast sensitivity with the CSV-1000 charts (Vector Vision Co., Greenville, OH). Area under the log contrast sensitivity function (AULCSF) was calculated from the contrast sensitivity data.

RESULTS

Orthokeratology significantly improved logMAR uncorrected visual acuity (P < 0.0001; paired t-test) but significantly increased ocular higher-order aberrations (P < 0.0001) and decreased contrast sensitivity function, including AULCSF (P < 0.0001), low-contrast visual acuity (P = 0.0025), and letter contrast sensitivity (P < 0.0001; Wilcoxon signed-rank test). The induced changes in AULCSF, low-contrast visual acuity, and letter contrast sensitivity by orthokeratology showed significant correlation with changes in third-order (Pearson r = -0.430, P = 0.0026; r = 0.423, P = 0.0031; and Spearman r(s) = -0.351, P = 0.0186, respectively), fourth-order (r = -0.418, P = 0.0035; r = 0.425, P = 0.0029; and r(s) = -0.566, P = 0.0001, respectively), and total higher-order (r = -0.460, P = 0.0011; r = 0.471, P = 0.0008; and r(s) = -0.434, P = 0.0036, respectively) aberrations. The induced changes in contrast sensitivity function and higher-order aberrations significantly correlated with the amount of myopic correction (P < 0.01).

CONCLUSIONS

Orthokeratology significantly increases ocular higher-order aberrations and compromises contrast sensitivity function, depending on the amount of myopic correction.

Optical Quality of the Cornea After Overnight Orthokeratology

PURPOSE

To review changes in the optical quality of the cornea induced by overnight orthokeratology for myopia.

METHODS

Sixty-four eyes of 39 patients who underwent overnight orthokeratology for myopia were prospectively examined. Inclusion criteria were uncorrected visual acuity of 20/20 or better after treatment and a minimum follow-up of 3 months. To quantitatively assess changes in corneal regular and irregular astigmatism, videokeratography data were decomposed into spherical component, regular astigmatism, asymmetry, and higher-order irregularity using Fourier analysis. In addition, corneal wavefront aberrations were calculated by expanding anterior corneal height data from videokeratography into a set of orthogonal Zernike polynomials.

RESULTS

Although orthokeratology significantly reduced manifest refraction and improved uncorrected visual acuity, the asymmetry component, which is one of the features of irregular astigmatism, increased significantly from 0.35 +/- 0.22 to 0.64 +/- 0.40 D after treatment (P < 0.0001, paired t test). The increases in the asymmetry component significantly correlated with the amount of myopic correction (Pearson correlation coefficient, R = 0.40, P = 0.0009). Furthermore, the root-mean-square of third-order (coma-like) and fourth-order (spherical-like) aberrations significantly increased after orthokeratology (P < 0.0001, paired t test), and these increases showed significant positive correlations with the amount of myopic correction (Pearson correlation coefficient, R = 0.452, P = 0.0001 and R = 0.381, P = 0.0017, respectively).

CONCLUSION

Corneal irregular astigmatism and higher-order aberrations significantly increased even in clinically successful orthokeratology, and the increases correlated with the magnitude of myopic correction. A large myopic correction by orthokeratology should be avoided to not decrease corneal optical quality.

Predictors and a remedy for noncompliance with amblyopia therapy in children measured with the occlusion dose monitor

PURPOSE

Noncompliance is one of the limiting factors in the success of occlusion therapy for amblyopia. Electronic monitoring was used to investigate predictors of noncompliance, and, in a prospective randomized clinical trial, determined the effectiveness of an educational program.

METHODS

Compliance was measured electronically during 1 week every 3 months in 310 newly diagnosed amblyopic children. The family's demographic parameters and the child's clinical parameters were assessed for their influence on the level of compliance. In addition to standard orthoptic care, children were randomized to receive an educational cartoon story, reward stickers, and an information sheet for the parents (intervention group), or a picture to color (reference group). These and the electronic device were distributed during home visits by researchers. The primary outcome measure was the percentage of compliance (actual/prescribed occlusion time) in the two groups. The secondary outcome measure was the influence of demographic and clinical factors on compliance.

RESULTS

Compliance was associated with parental fluency in the national language, country of origin, level of education, and initial visual acuity of the child. During the first 1-week measurement period children in the intervention group had better compliance than the reference group had (78% +/- 32% vs. 57% +/- 40%; P < 0.0001), and fewer children were not occluded at all (3 vs. 23 in the reference group; P < 0.0001). This difference remained throughout the study period.

CONCLUSIONS

Poor parental fluency in the national language, a low level of education, and poor acuity at the start of treatment were predictors of low compliance. An educational program primarily aimed at the child improved compliance and reduced the number of children who did not comply with occlusion at all.

Effects of orthoptic treatment on the CA/C and AC/A ratios in convergence insufficiency

PURPOSE

To evaluate the effect of orthoptic treatment on the AC/A (A, accommodation; C, convergence) and CA/C ratios in subjects with convergence insufficiency (CI).

METHODS

The change in AC/A and CA/C ratios after a 12-week period of home-based orthoptic treatment was examined in 10 subjects (mean age, 25.4+/-4.1 years [SD]). Both the AC/A and CA/C ratios were measured by using gradient response methods. For the AC/A ratio, the gradient phoria method was used, and for the CA/C ratio the prism-induced change in accommodation was measured with a refractometer.

RESULTS

No change in the AC/A and CA/C ratios (P>0.05) were found after orthoptic treatment. However, improvements were found (P<0.05) in the fast and slow vergence mechanisms.

CONCLUSIONS

Despite improvements in the fast and slow vergence mechanisms no change was found in the AC/A and CA/C ratios after orthoptic treatment in CI subjects. This finding is unexpected in light of the present understanding of CI, and an alternative theory is proposed.

Intermittent exotropia: comparison of treatments

PURPOSE

To identify the best treatment option for intermittent exotropia.

METHODS

A retrospective analysis of the progress of 150 treated intermittent exotropia patients was performed. Treatment forms considered are: (i) surgery combined with orthoptic/occlusion therapy; (ii) surgery; (iii) orthoptic/occlusion therapy; and (iv) observation. Pearson's chi(2)-analysis of association of therapy form with success was performed. Reduction of exodeviation in prism dioptres between groups and subgroups were compared at 6 months, 1, 2 and 5 years follow up and the "within group" variations were compared. Exodeviation reduction in prism dioptres per millimetre of horizontal rectus surgery performed in the "surgery with orthoptic/occlusion therapy" and "surgery only" groups were compared.

RESULTS

Chi(2)-analysis revealed a significantly highest (P < 0.001) association with success in the "surgery with orthoptic/occlusion therapy" group at follow up. ANOVA analysis revealed that surgery with orthoptic/occlusion therapy resulted significantly (P < 0.001) in the highest reduction of exodeviation as compared with the other three treatment modalities at each follow up. Reduction of exodeviation in prism dioptres per millimetre of horizontal rectus surgery performed was significantly higher (P < 0.05) in the surgery with orthoptic/occlusion therapy group as compared with surgery only at all follow ups. Chi(2)-test revealed no significant association of success with the magnitude of initial exodeviation (P > 0.05).

CONCLUSION

Surgery with preoperative orthoptic/occlusion therapy had the highest success rates. Surgery with orthoptic/occlusion therapy was more effective in reducing exodeviation (prism dioptres per millimetre of horizontal rectus surgery), compared with surgery only.