7. Convergence Insufficiency - Clinical Binocular Vision Fall 2026

What is the incidence of convergence insufficiency in the population?

5%

What are the 3 classic signs of convergence insufficiency?

-Exophoria greater at near

-Reduced NPC

-Insufficient PFV

____% of exodeviations have convergence insufficiency

62

True or False:

Convergence insufficiency is common among university students

True

Only 2% of CI's have a _____

constant strabismus

_____% of convergence insufficiency patients are symptomatic

75-85

Some patients may not report symptoms of convergence insufficiency d/t ______

avoidance

When are symptoms of convergence insufficiency common?

With near work

If a significant phoria is also present in a patient with convergence insufficiency, symptoms may be present at _____ as well

distance

True or False:

convergence insufficiency is an acute disorder

False -- typically long standing or chronic

Symptoms of convergence insufficiency will be worse at the (beginning/end) of the day

end

Symptoms of convergence insufficiency (increase/decrease) with increased work or fatigue

increase

Patients with convergence insufficiency score (high/low) on the CISS symptom survey

high

What does the CISS help differentiate convergence insufficiency from?

Patients with normal BV

Is the CISS symptom survey reliable?

Yes

Patients with more signs of CI will score (higher/lower) on the CISS symptom survey

higher

What are the symptom associations of convergence insufficiency that will cause a patient to score higher on the CISS symptom survey?

-Exo deviation

-Reduced PFV

-Reduced NPC

Is the CISS symptom survey solely diagnostic for convergence insufficiency?

No -- many other BV disorders will have similar symptoms and thus score similarly on the survey

What are the common symptoms of convergence insufficiency in children?

-Lose place when reading

-Lose concentration

-Have to re-read

-Read slowly

-Trouble remembering

-Get sleepy with near work

-Words blur

-Have double vision

-Get headaches

You should watch for ______ when assessing a child for convergence insufficiency

unusual head posture or covering an eye when reading

With convergence insufficiency, there will tend to be a greater exo deviation at (distance/near)

near

Can an exo deviation be present at distance in a patient with convergence insufficiency?

Yes

A patient with convergence insufficiency will have decreased (positive/negative) fusional vergences at near

positive

A patient with convergence insufficiency will have decreased (BI/BO) ranges at near

BO -- inadequate positive fusional vergence

True or False:

Patients with convergence insufficiency will have below normal BO values or not meet Sheard's criterion

true

True or False:

Patients with CI can have reduced binocular accommodative facility

true

Patients with convergence insufficiency will have difficulty clearing (plus/minus) lenses on facility testing

plus

Patients with convergence insufficiency will have a (high/low) AC/A

low

Patients with convergence insufficiency generally have a receded NPC. Will it ALWAYS be receded?

No

What is another way to check NPC without using an accommodative target with PD sticks?

Penlight with R/G gls

Will there likely be a significant difference in accommodative target v penlight w R/G gls when doing NPC testing on a patient with convergence insufficiency?

Yes -- ~5.5cm difference in break and recovery with penlight (shows patient has worse values with the penlight)

True or False:

You may see greater recession with repeated NPC testing

true

Describe a convergence deficit and how it is different than convergence insufficiency?

-Orthophoria or small phoria is present at near

-Decreased PFV

-Receded NPC

What is the definition of convergence insufficiency according to recent clinical trials?

->4pd more exo at near than at distance

-Receded NPC (>6cm)

-Insufficient positive fusional vergence

How to confirm that a patient has INSUFFICIENT positive fusional vergence ranges?

-Fails Sheards

-Insufficienct minimum positive fusional vergence with BO blur and break

Can accommodative ability be reduced in patients with convergence insufficiency?

Yes

Can a patient with convergence insufficiency suppress?

Yes -- but they do not have to

A patient with convergence insufficiency will have (good/bad) stereo

good

A patient with convergence insufficiency will have a (high/low) AC/A

low

What is pseduoconvergence insufficiency?

-Reduced ability to accommodate leading to reduced AA and difficulty with minus on accommodative facility testing

-Patient will have a reduced PRA

-High LAG of accommodation

-Secondary "false exo" deviation at near

-Inadequate positive fusional vergence ranges

How to improve pseudoconvergence insufficiency?

With treatment of accommodative dysfunction (therapy and/or lenses)

What are the possible DDX for convergence insufficiency?

-Functional disorders (basic Exo and divergence excess)

-Underlying pathology

What is the management plan for a patient with convergence insufficiency?

-correct refractive error

-BI prism

-orthoptics

-vision therapy (home based or office based)

-vergence accommodative therapy (home based or office based)

What did the BICITT (Base In Convergence Insufficiency Treatment Trial) test?

-Children ages 8-19 with symptomatic CI

-Used distance Rx w/ BI prism vs placebo glasses (dist Rx only)

-6 weeks of full time reading glasses wear

What did the BICITT (Base In Convergence Insufficiency Treatment Trial) show?

-Significant decrease in symptoms in BOTH GROUPS

-No significant difference between groups in ability to converge

-No significant difference between groups in symptoms

What did the CITT (Convergence Insufficiency Treatment Trial) test?

-Patients aged 9-18 with symptomatic CI

-Vision therapy/orthoptics vs pencil push ups vs placebo

-12 weeks of treatment

What did the CITT (Convergence Insufficiency Treatment Trial) show?

-Office Based vision therapy was the most effective after 12 weeks in reducing NPC and increasing positive fusional vergence ranges

-Pencil Push ups were the same effectiveness as the placebo.

What were the results of the CITT (Convergence Insufficiency Treatment Trial) related to CISS scores?

-There were significantly lower CISS scores in the office based vision therapy group compared with the other 3 groups

-No difference between the home based therapies and office based placebo groups

What were the results of the CITT (Convergence Insufficiency Treatment Trial) related to NPC?

-Mean NPC significantly improved in the office based vision therapy group when compared with the other 3 groups

-Mean NPC of home based groups better than office based placebo

-No significant difference between the 2 home-based groups

What were the results of the CITT (Convergence Insufficiency Treatment Trial) related to PFV?

-Mean PFV for in office based therapy significantly greater than other groups

-Mean PFV in home based computer therapy significantly better than home based pencil push ups and in office placebo groups

-No significant difference between pencil pushup and placebo groups

With CI, (signs/symptoms) will improve before (signs/symptoms)

signs, symptoms

We could see improvements in NPC and PFV within ____ weeks with office based therapy in patients with convergence insufficiency

4

For patients with both convergence insufficiency and accommodative dysfunction, improvements to AF and AA were seen in ___ weeks

4

True or False:

Presence of a co-existing accommodative dysfunction will significantly change response to convergence insufficiency treatment

false -- it will not

How to translate the results of CITT studies to clinical practice?

-Children should be routinely tested for CI

-12 weeks of office-based VT significantly more effective than HB pencil push ups and HB computer vergence accommodative therapy w/ pencil push ups in improving symptoms and clinical measures of convergence

____% of patients with convergence insufficiency achieved normalization of or improvement in symptoms/clinical measures of convergence after 12 weeks of therapy

75

What is the 1st line treatment for the treatment of symptomatic CI in children?

OBVAT

What if OBVAT is not possible for children with CI?

Consider HBCVAT

What was shown in the Convergence Insufficiency Treatment Study (CITS-PEDIG)?

-Neither HB computer of PPUs were successful treatment when prescribed for 12 weeks

-Some children who were assigned to the placebo improved (16%)

-Limited ability to directly compare the groups d/t insufficient recruitment and differential loss to F/U

What is the CISS?

subjective survey

True or False:

Comorbid (dry eye, allergies) or normal ocular conditions could elicit positive response on the CISS

true

What are the conclusions of the CITT-ART study?

-Consistent with previous studies, OBVAT statistically significant and clinically relevant differential effect on clinical measures

-In contrast, self-reported symptom severity measured with CISS did not correspond with NPC and PFV results

-CISS may no longer adequately quantify symptoms attributable to changes in visual function

Is more therapy better?

12wks vs 16 wks

Similar results found. In patients who did not improve in 12 wks, more of them were shown to improve within 16wks

With convergence insufficiency VT, do the results "stick"?

-87% of patients in the OBVAT group remained successful or improved at 1 year

-HBPP = 66%

-HBCVAT = 80%

-OB placebo = 69%

VT for CI is associated with what?

clinical and cortical activity changes

What is the proper management of CI in children?

-OBVAT most effective

-Home based computer therapy possible

-Pencil push up not effective

-BI prism not effective

What is the proper management for CI in a presbyope?

PAL w/ BI prism at near only

CI results in what symptoms when reading?

-Visual discomfort

-Diplopia

-Tired eyes

-HAs

-Loss of place

-Frequent re-reading

-Loss of concentration

-Reading slowly

-Problems remembering

What is a successful therapy for patients with problems reading d/t CI?

OBVAT

Does there seem to be an effect on academic behaviors in patients who perform OBVAT for CI?

Yes

What was the 16wk outcome of the CITT-ART (Convergence Insufficiency Attention and Reading Trial) Study?

-Mean adjusted improvement in the Reading Comprehension subtest scores were not significantly different between the groups (Control vs treatment)

-16 weeks of OBVAT therapy no more effective than placebo therapy for improving standardized reading performance or attention in children with symptomatic CI

-Improvements in clinical measures did not correlate to significantly greater improvement in standardized measures of reading and attention after 16 weeks of OBVAT compared to placebo group

Describe the placebo group in the CITT-ART (Convergence Insufficiency Attention and Reading Trial) Study?

-DID NOT include procedures specifically directed at improving convergence, reading eye movements, or visual attention

-Instructed to keep targets clear and single

-Most procedures required visual attention

According to the CITT-ART (Convergence Insufficiency Attention and Reading Trial) Study, what patients have the greatest potential for reading improvement?

-younger children

-mild to moderate reading problems

True or False:

There is evidence suggesting that combining literacy instruction with treatments that address underlying conditions related to reading difficulties can enhance reading outcomes

true

OVERVIEW:

Is CI common?

Yes

OVERVIEW:

Exo greater at near is associated with what other findings?

-reduced NPC

-insufficient PFV (below Sheards/normative values)

OVERVIEW:

Are CI patients often symptomatic?

Yes

OVERVIEW:

Differentiate CI from convergence deficit

Convergence deficit = deficits in convergence without exo at near

CI MANAGEMENT OVERVIEW

What are the most effective strategies?

-BI prism NOT effective in children

-OBVAT significantly more effective than HB computer therapy or pencil push ups

CI MANAGEMENT OVERVIEW

Clinical measures will improve (before/after) symptoms

before

CI MANAGEMENT OVERVIEW

After 12 weeks of OBVAT ____% of individuals with CI have normal or improved clinical measured of convergence

75

CI MANAGEMENT OVERVIEW

Effects of CI OBVAT are maintained for how long?

1 year

CI MANAGEMENT OVERVIEW

Changes/improvements are observed on what other devices after OBVAT?

Eye tracking and fMRI

CI MANAGEMENT OVERVIEW

If OBVAT not available, are there other helpful strategies?

HB computer therapy shows some improvement in clinical measures

CI MANAGEMENT OVERVIEW

CI therapy (does/does not) improve reading or attention

No

CI MANAGEMENT OVERVIEW

Limitations of the CISS

may not quantify changes in symptoms attributable to change in visual function with therapy