Office-based vergence accommodative therapy is an effective treatment for children with symptomatic convergence insufficiency, according to the results of a randomized controlled trial reported in the October issue of Archives of Ophthalmology.
“Convergence insufficiency (CI) is a common binocular vision disorder that is often associated with a variety of symptoms, including eyestrain, headaches, blurred vision, diplopia, sleepiness, difficulty concentrating, movement of print while reading, and loss of comprehension after short periods of reading or performing close activities,” write Mitchell Scheiman, OD, from Pennsylvania College of Optometry in Philadelphia, and colleagues from the Convergence Insufficiency Treatment Trial Study Group. “Various treatments are commonly prescribed, including passive treatment with base-in prism reading glasses and active treatment, such as home-based therapy using pencil pushups (HBPP) alone, home-based therapy using pencil push-ups plus other therapy techniques, office-based vision therapy, and orthoptics. Consensus regarding the most effective treatment is lacking and there are considerable differences among treatments in time and cost.”
The goal of this study was to compare the efficacy of 4 different treatments of symptomatic convergence insufficiency in children: 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).
In this study, 221 children aged 9 to 17 years with symptomatic convergence insufficiency were randomly assigned to receive 1 of the 4 treatments. The primary endpoint was the Convergence Insufficiency Symptom Survey (CISS) score after 12 weeks of treatment, and secondary endpoints were near point of convergence and positive fusional vergence at near.
After 12 weeks of treatment, children in the OBVAT group fared significantly better vs children in the other 3 groups. Mean CISS score was 15.1 in the OBVAT group vs 21.3, 24.7, and 21.9 in the HBCVAT+, HBPP, and OBPT groups, respectively (P < .001). Near point of convergence and positive fusional vergence at near were also significantly improved in the OBVAT group vs the other groups (P < .005 for all comparisons).
In the OBVAT, HBPP, HBCVAT+, and OBPT groups, outcome was successful or improved in 73%, 43%, 33%, and 35% of patients, respectively.
"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," the study authors write. "Office-based vergence accommodative therapy is an effective treatment for children with symptomatic convergence insufficiency."
Limitations of this trial include study not designed to show the maximal possible improvement with treatment, possible placebo effect associated with office-based therapy, inability to determine which procedures were most effective or which factors within a particular group contributed to the outcome, slight differences in adherence among the groups, lack of generalizability beyond children with symptomatic convergence insufficiency who are aged 9 to 17 years, and therapy program designed with considerably closer follow-up than is typical in clinical practice.
In an accompanying editorial, David K. Wallace, MD, MPH, from Duke University Eye Center in Durham, North Carolina, notes that despite these limitations, this study offers valuable data on success rates of various treatments for patients with symptomatic convergence insufficiency. However, the study was not designed to measure the cost of different treatments.
"Uncertainty remains as to whether office-based treatment would be superior to equally intensive home-based therapy," Dr. Wallace writes. "Perhaps intensive home-based therapies are not feasible for many patients who need positive reinforcement to stick with their treatment routines. Additional studies that include more intensive and flexible home-based regimens and an evaluation of the cost-effectiveness of different treatment options are needed."
The National Eye Institute of the National Institutes of Health, Department of Health and Human Services, supported this study. One of the study authors has disclosed a financial relationship with Computer Orthoptics, the company that sells the program used for the HBCVAT+ group. Dr. Wallace has disclosed no relevant financial relationships.
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