Effects of vision therapy on near exodeviation in children with convergence insufficiency treated during the convergence insufficiency treatment trials.

PURPOSE: To report the change in the magnitude of near exodeviation in children with symptomatic convergence insufficiency successfully treated with office-based vergence/accommodative therapy in the Convergence Insufficiency Treatment Trial-Attention and Reading Trial. METHODS: A total of 131 children 9-14 years of age with symptomatic convergence insufficiency classified as successfully treated with office-based vergence/accommodative therapy at the 16-week outcome visit were included. Masked examiners measured the near ocular deviation by the prism and alternate cover test at baseline, primary outcome and 1-year post-treatment. The mean change in near deviation was calculated from baseline to primary outcome, from primary outcome to 1-year post-treatment and from baseline to 1-year post-treatment. RESULTS: Of the 131 participants successfully treated with vergence/accommodative therapy, 120 completed the 1-year post-treatment visit. A significant change in near exodeviation was observed at baseline to primary outcome (2.6Δ less exo, p < 0.001, moderate effect size d = 0.61) and at baseline to 1-year post-treatment (2.0Δ less exo; p < 0.001, small effect size d = 0.45). The change from primary outcome to 1-year post-treatment (0.6Δ more exo; p = 0.06, small effect size d = 0.11) was not significant. Forty per cent (48/120) of participants had a decrease in near exodeviation >3.5∆ (expected test/retest variability) between baseline and the primary outcome examination. Of the 120 participants, one (1.0%) was esophoric at the primary outcome and was subsequently exophoric at 1-year post-treatment. Four participants (3.3%) who were orthophoric or exophoric at the primary outcome were esophoric (all ≤3∆) at the 1-year post-treatment visit. CONCLUSION: On average, the near exodeviation was smaller in size immediately after the discontinuation of vergence/accommodative therapy (2.6∆, moderate effect size) and 1 year post vergence/accommodative therapy (2.0∆, small effect size) in children with convergence insufficiency who were successfully treated; 40% had a clinically meaningful decrease in exophoria. The development of near esophoria was rare.

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.

Comparison of Visual Symptom Frequency and Occupational Issues Between Patients With and Without Concussion.

IMPORTANCE: Occupational therapy practitioners' knowledge of and advocacy for clients with visual symptoms postconcussion can have a considerable impact on recovery. OBJECTIVE: To compare the frequency of vision symptoms and occupational performance deficits in a sample of participants with and without concussion. DESIGN: Cross-sectional study. SETTING: Sports medicine clinic. PARTICIPANTS: Adolescents and adults with concussion (n = 20) and musculoskeletal injuries (n = 19). OUTCOMES AND MEASURES: Measures included monocular amplitude of accommodation, near point of convergence, Binocular Vision Assessment (BVA) computerized screening for phoria, BVA computerized screening for fusional vergence, the Developmental Eye Movement Test, the Canadian Occupational Performance Measure, and the Convergence Insufficiency Symptom Survey-Concussion Version (CISS-CON). RESULTS: We found significant differences between participants with and without concussion using the CISS-CON (p = .001), positive fusional vergence (p = .02), and near point of convergence (p = .02). Participants with concussion scoring above cutoffs on multiple measures reported poorer performance (p = .005) and satisfaction (p = .004) with valued occupations. CONCLUSIONS AND RELEVANCE: Concussion has a detrimental effect on vision and occupation, and occupational therapy practitioners are well-positioned to assess and address issues arising from this relationship. Plain-Language Summary: Vision symptoms commonly experienced after a concussion are associated with reduced occupational performance and satisfaction and can have a considerable impact on recovery. Occupational therapy assessment for clients with concussion should include screening for vision difficulties.

Comparing the directional effect of number calling on the developmental eye movement test results in Hebrew-speaking children.

PURPOSE: To evaluate the directional effect of number calling on the developmental eye movement (DEM) test in Hebrew-speaking children who read from right (R) to left (L). Previously, the DEM has been studied in nine languages, all read from L to R and has never been tested on Hebrew speakers. METHODS: Healthy Hebrew-speaking children, aged 6-13 years were divided into two age groups (6-9, 10-13 years). Children had near visual acuity of 0.00 logMAR or better, no strabismus, stereoacuity ≤100 s of arc and near point of convergence ≤6 cm. The DEM test was performed twice, from R to L and L to R, randomly. Comparisons between age groups for horizontal and vertical reading speed and ratio between reading directions were analysed, as well as the correlation between age and directionality. RESULTS: A total of 92 children were included; 48 and 44 in the 6-9 and 10-13 year age groups, respectively. The mean vertical and horizontal time for both directions (R to L and L to R) in the younger group was significantly slower than the older group (p < 0.001). The older children showed no significant difference in the horizontal time reading from L to R and R to L. However, the younger children read more quickly in their native direction (R-L; 71.5 ± 25.9 s) compared with L-R (76.0 ± 31.4 s, p = 0.01). In both directions, the ratio was significantly higher in the younger age group. A negative correlation was demonstrated between age and reading ratio (p = 0.001). CONCLUSIONS: A clear directional preference of R to L was found in children under 10 years of age. We suggest administering the test from R to L in young Hebrew-speaking children. These results may also apply to young Arab- and Persian-speaking children who also read from R to L.

Vergence/accommodative therapy for symptomatic convergence insufficiency in children: Time course of improvements in convergence function.

PURPOSE: To evaluate the time course of improvements in clinical convergence measures for children with symptomatic convergence insufficiency treated with office-based vergence/accommodative therapy. METHODS: We evaluated convergence measures from 205, 9- to 14-year-old children with symptomatic convergence insufficiency randomised to office-based vergence/accommodative therapy in the Convergence Insufficiency Treatment Trial - Attention and Reading Trial (CITT-ART). Near-point of convergence (NPC) and near-positive fusional vergence (PFV) were measured at baseline and after 4, 8, 12 and 16 weeks of therapy; mean change in NPC and PFV between these time points were compared using repeated measures analysis of variance. Rates of change in NPC and PFV from: (1) baseline to 4 weeks and (2) 4-16 weeks were calculated. For each time point, the proportion of participants to first meet the normal criterion for NPC (<6 cm), PFV blur (break if no blur; >15Δ and >2 times the exodeviation) and convergence composite (NPC and PFV both normal) were calculated. RESULTS: The greatest change in NPC and PFV (7.6 cm and 12.7 Δ) and the fastest rate of improvement in NPC and PFV (1.9 cm/week and 3.2 Δ/week, respectively) were both found during the first 4 weeks of therapy, with both slowing over the subsequent 12 weeks. After 12 weeks of therapy, the NPC, PFV and convergence composite were normal in 93.2%, 91.7% and 87.8% of participants, respectively, and normalised with another 4 weeks of therapy in 4.4%, 2.0% and 4.4% of participants, respectively. CONCLUSION: Although the greatest improvements in NPC and PFV occurred in the first 4 weeks of therapy, most participants had weekly improvements over the subsequent 12 weeks of treatment. While most children with convergence insufficiency obtained normal convergence following 12 weeks of therapy, an additional 4 weeks of vergence/accommodative therapy may be beneficial for some participants.

Preoperative binocular vision characteristics in the age-related cataract population.

BACKGROUND: This study is the first part of the "Binocular Vision Anomalies after Cataract Surgery" study that aimed to investigate the impact of cataract surgery on binocular vision status in adults with age-related cataract. This study aimed to investigate the preoperative binocular vision status of participants with age-related cataract. METHODS: Patients who elected to undergo bilateral cataract surgery (≥50 years of age) were recruited. Clinical measures of binocular vision including stereopsis, ocular alignment, fusional vergence, vergence facility, convergence amplitude and a symptom survey related to binocular vision anomalies were administered. A detailed classification protocol was established to identify the presence of binocular vision anomalies. The frequency of specific binocular vision anomalies and normative data of binocular vision measures were reported. RESULTS: A total of 73 subjects were evaluated. No strabismus was detected in the cohort. Non-strabismic binocular vision anomalies were detected in 24 subjects (32.9%), of whom 18 (24.7%) had convergence insufficiency, 3 (4.1%) had basic exophoria, 2 (2.7%) had convergence excess, and 1 (1.4%) had fusional vergence dysfunction. Decreased vergence facility and convergence amplitude were more common compared to the pre-presbyopes (P < 0.01). CONCLUSION: Binocular vision problems, especially convergence insufficiency, are common in the adults with age-related cataract. The study results demonstrate that the lack of normative binocular vision data for the presbyopic population is a significant gap in the literature and suggest the need for a study of normative data for this population. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (NCT03592615, USA).

Eye Tracking Metrics Differences among Uninjured Adolescents and Those with Acute or Persistent Post-Concussion Symptoms.

SIGNIFICANCE: Eye tracking assessments that include pupil metrics can supplement current clinical assessments of vision and autonomic dysfunction in concussed adolescents. PURPOSE: This study aimed to explore the utility of a 220-second eye tracking assessment in distinguishing eye position, saccadic movement, and pupillary dynamics among uninjured adolescents, those with acute post-concussion symptoms (≤28 days since concussion), or those with persistent post-concussion symptoms (>28 days since concussion). METHODS: Two hundred fifty-six eye tracking metrics across a prospective observational cohort of 180 uninjured adolescents recruited from a private suburban high school and 224 concussed adolescents, with acute or persistent symptoms, recruited from a tertiary care subspecialty concussion care program, 13 to 17 years old, from August 2017 to June 2021 were compared. Kruskal-Wallis tests were used, and Bonferroni corrections were applied to account for multiple comparisons and constructed receiver operating characteristic curves. Principal components analysis and regression models were applied to determine whether eye tracking metrics can augment clinical and demographic information in differentiating uninjured controls from concussed adolescents. RESULTS: Two metrics of eye position were worse in those with concussion than uninjured adolescents, and only one metric was significantly different between acute cases and persistent cases. Concussed adolescents had larger left and right mean, median, minimum, and maximum pupil size than uninjured controls. Concussed adolescents had greater differences in mean, median, and variance of left and right pupil size. Twelve metrics distinguished female concussed participants from uninjured; only four were associated with concussion status in males. A logistic regression model including clinical and demographics data and transformed eye tracking metrics performed better in predicting concussion status than clinical and demographics data alone. CONCLUSIONS: Objective eye tracking technology is capable of quickly identifying vision and pupillary disturbances after concussion, augmenting traditional clinical concussion assessments. These metrics may add to existing clinical practice for monitoring recovery in a heterogeneous adolescent concussion population.

Reliability of step vergence method for assessing fusional vergence in intermittent exotropia.

PURPOSE: To evaluate the reliability of the step vergence method in measuring fusional vergence in subjects with intermittent exotropia. METHODS: Thirty-two Chinese participants aged 7-20 years with intermittent exotropia (excluding the convergence insufficiency type) were enrolled in this prospective study. At the eligibility screening, visual acuity, cover test and the Office Control Score were performed. For eligible participants at study visit 1, negative and positive fusional vergence at distance and near, eye dominance and the fusion maintenance test were performed. All eligible participants returned for study visit 2 on the same day (2-4 h later), and the testing was repeated. The primary outcome measures were the intra-class correlation coefficient, coefficient of repeatability and smallest detectable change in the break and recovery points of negative and positive fusional vergence between the two study visits. RESULTS: The intra-class correlation coefficient for different vergence parameters ranged from 0.64 to 0.87. The coefficient of repeatability and the smallest detectable change for the distance positive fusional vergence break point were ±20.5 and 13.1 ∆, respectively. There was no significant difference in any vergence parameter between the first and second visits. The coefficient of repeatability and the smallest detectable change in all distance vergence parameters were high when compared to the mean value. The association between distance vergence parameters and the Office Control Score was significant only when including subjects who failed to fuse at the beginning of the test. CONCLUSION: The data demonstrate that measurement of fusional vergence with a prism bar has low repeatability in subjects with intermittent exotropia. In these individuals, convergence ability at distance is compromised, whereas other vergence parameters are not adversely affected. While the step vergence method is a valuable test in daily practice, caution is warranted when using it in clinical research.

Cataract surgery is not associated with post-operative binocular vision anomalies in age-related cataract patients.

PURPOSE: To compare the binocular vision status of patients pre- and post-cataract surgery, and to investigate the risk factors for patients who develop binocular vision anomalies post-surgery. METHODS: A prospective study of patients (≥50 years) who elected to undergo bilateral cataract surgery was implemented. A comprehensive binocular vision test battery including stereopsis, ocular alignment, fusional vergence, vergence facility, near point of convergence and the Convergence Insufficiency Symptom Survey (CISS) was administered before the first surgery and at the third visit after surgery on the second eye. A detailed diagnostic classification protocol was applied to identify the presence of binocular vision anomalies pre- and post-surgery. RESULTS: Seventy-three participants were included at baseline, 24 (33%) of whom were diagnosed with non-strabismic binocular vision anomalies (NSBVA), mainly convergence insufficiency (18/73, 25%). Fifty-one participants completed the post-operative evaluation, 17 (33%) of whom had NSBVA pre-surgery and 13 (26%) post-surgery (p = 0.48). There were a number of conversions from NSBVA to normal binocular vision and vice versa. Logistic regression showed that the adjusted odds ratio of pre-existing NSBVA diagnosis for predicting the risk of post-operative NSBVA was 6.37 (p < 0.01). There were no significant changes in most binocular vision measures post-surgery, except for a significant improvement in the CISS score (p < 0.01, Cohen's d = 0.83). CONCLUSIONS: Binocular vision anomalies, especially convergence insufficiency, are prevalent in the age-related cataract population. Cataract surgery does not appear to be a significant risk factor for the development of new binocular vision anomalies. A pre-existing binocular vision anomaly is the main risk factor for predicting a post-operative binocular vision anomaly in this population.

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 - » 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.

Negative Fusional Vergence Is Abnormal in Children with Symptomatic Convergence Insufficiency.

SIGNIFICANCE: Deficits of disparity divergence found with objective eye movement recordings may not be apparent with standard clinical measures of negative fusional vergence (NFV) in children with symptomatic convergence insufficiency. PURPOSE: This study aimed to determine whether NFV is normal in untreated children with symptomatic convergence insufficiency and whether NFV improves after vergence/accommodative therapy. METHODS: This secondary analysis of NFV measures before and after office-based vergence/accommodative therapy reports changes in (1) objective eye movement recording responses to 4° disparity divergence step stimuli from 12 children with symptomatic convergence insufficiency compared with 10 children with normal binocular vision (NBV) and (2) clinical NFV measures in 580 children successfully treated in three Convergence Insufficiency Treatment Trial studies. RESULTS: At baseline, the Convergence Insufficiency Treatment Trial cohort's mean NFV break (14.6 ± 4.8Δ) and recovery (10.6 ± 4.2Δ) values were significantly greater (P < .001) than normative values. The post-therapy mean improvements for blur, break, and recovery of 5.2, 7.2, and 1.3Δ, respectively, were statistically significant (P < .0001). Mean pre-therapy responses to 4° disparity divergence step stimuli were worse in the convergence insufficiency group compared with the NBV group for peak velocity (P < .001), time to peak velocity (P = .01), and response amplitude (P < .001). After therapy, the convergence insufficiency group showed statistically significant improvements in mean peak velocity (11.63°/s; 95% confidence interval [CI], 6.6 to 16.62°/s), time to peak velocity (-0.12 seconds; 95% CI, -0.19 to -0.05 seconds), and response amplitude (1.47°; 95% CI, 0.83 to 2.11°), with measures no longer statistically different from the NBV cohort (P > .05). CONCLUSIONS: Despite clinical NFV measurements that seem greater than normal, children with symptomatic convergence insufficiency may have deficient NFV when measured with objective eye movement recordings. Both objective and clinical measures of NFV can be improved with vergence/accommodative therapy.

Maintenance of normal fusion in intermittent exotropia.

PURPOSE: To evaluate the reliability of the Bagolini filter bar and striated lenses for measuring the fusion maintenance score, which is the ability of participants with intermittent exotropia to maintain normal sensorimotor fusion. METHODS: Thirty-two Chinese participants aged 7-20 years with intermittent exotropia (excluding the convergence insufficiency type) were enrolled in this prospective study. At the eligibility screening, visual acuity, cover test and assessment of the office control score were performed. At study visit 1, eligible participants underwent negative and positive fusional vergence tests at far and near, eye dominance test and the fusion maintenance test. All eligible participants returned for study visit 2 on the same day (2-4 h later) and the testing was repeated. The primary outcome measure was the intra-class correlation coefficient of the fusion maintenance score between the two study visits. RESULTS: The intra-class correlation coefficient of the fusion maintenance score was 0.84, indicating good reliability. There was no significant difference (mean difference = 0.05, p = 0.95) between the fusion maintenance scores for the first (5.62) and second study visits (5.57). The coefficient of repeatability and the smallest detectable change for the fusion maintenance scores were 7.6 and 6.3, respectively. The fusion maintenance score was significantly associated with the distance (Spearman correlation -0.57, p < 0.001) and near (Spearman correlation -0.4, p = 0.02) office control scores. CONCLUSION: These data demonstrate that the fusion maintenance score is a reliable tool to evaluate sensorimotor fusion in intermittent exotropia. These results suggest that the fusion maintenance score may be a useful outcome measure in future clinical trials to evaluate the effectiveness of treatments for intermittent exotropia.

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.

A Normative Study of Objective Measures of Disparity Vergence and Saccades in Children 9 to 17 Years Old.

SIGNIFICANCE: This study establishes normative data for objective outcome measures of vergence and saccade eye movements for the pediatric population. These data should facilitate future clinical trial design. PURPOSE: This study was designed to establish normative data for objective measures of disparity vergence and saccades in children between the ages 9 and 17 years using an objective binocular eye movement tracking system. METHODS: Participants (aged 9 to 17 years) had a vision examination including refraction, accommodative, and binocular vision testing. Eligibility criteria included 20/25 visual acuity with best correction, normal accommodation, and binocular vision. The ISCAN RK-826PCI binocular tracking system (ISCAN, Woburn, MA) was used to objectively record horizontal, symmetrical disparity vergence, and saccadic eye movements. Parameters assessed included peak velocity, time to peak velocity, latency, and response amplitude for both disparity vergence and saccades. RESULTS: One hundred eighteen participants were recruited (54.94% female; mean age, 13.5 years), and 77.1% (91/118) of the participants completed the assessment with usable data. A sample of the normative data included peak velocity (°/s), which had a mean ± standard deviation of 25.4 ± 2.9, 22.0 ± 3.0, 225 ± 16.7, and 332.5 ± 20.5 for 4° convergence, 4° divergence, 5° saccades, and 10° saccades, respectively. The mean ± standard deviation for the latency (seconds) measures were 0.28 ± 0.1, 0.28 ± 0.16, 0.23 ± 0.05, and 0.23 ± 0.05 for 4° convergence, 4° divergence, 5° saccades, and 10° saccades, respectively. CONCLUSIONS: Normative data enable researchers to have benchmark results for comparison with patient populations with binocular dysfunction. These objective disparity vergence measures can serve as outcome measures in future clinical trials to assess the effectiveness of therapeutic interventions by determining whether post-treatment results are similar to normal data.

Convergence Insufficiency Neuro-mechanism in Adult Population Study Randomized Clinical Trial: Clinical Outcome Results.

SIGNIFICANCE: These data confirm the effectiveness of office-based vergence/accommodative therapy for improving the near point of convergence and positive fusional vergence in young adults with symptomatic convergence insufficiency within a double-masked longitudinal randomized clinical trial. PURPOSE: This study aimed to report changes in clinical signs and symptoms of convergence insufficiency from a randomized clinical trial evaluating the effectiveness of office-based vergence/accommodative therapy for young adults with symptomatic convergence insufficiency. METHODS: In this double-masked, randomized clinical trial, convergence insufficiency patients (n = 50; average age, 21 ± 3 years; range, 18 to 32 years) were randomized to either office-based vergence/accommodative therapy or office-based placebo therapy. Improvements in (1) near point of convergence, (2) positive fusional vergence, and (3) self-reported symptoms (Convergence Insufficiency Symptom Survey [CISS] score) were evaluated after twelve 1-hour sessions of treatment within the office comparing the results from the vergence/accommodative therapy and the placebo therapy groups. RESULTS: The mean near point of convergence improved by 6.0 and 3.1 cm in the vergence/accommodative and placebo therapy groups, respectively (mean difference of -2.9 cm; 95% confidence interval [CI], -4.6 to -1.0 cm; P < .01). The mean positive fusional vergence increased by 17.3 and 7.4Δ in the vergence/accommodative and placebo therapy groups, respectively (mean difference of 9.9Δ; 95% CI, 4.9 to 16.0Δ; P < .001). The mean CISS score improved by 12.4 and 10.1 points in the vergence/accommodative and placebo therapy groups, respectively (mean difference of 2.3 points; 95% CI, -8.3 to +4.6 points; P = .56). CONCLUSIONS: Our results demonstrate that office-based vergence/accommodative therapy is effective for improving the near point of convergence and positive fusional vergence in young adults with symptomatic convergence insufficiency. However, given that both treatment groups had a similar reduction in self-reported symptoms, we recommend that the CISS be revised if it is to be used as an outcome measure in future studies of convergence insufficiency.

Eye Tracking as a Biomarker for Concussion in Children.

OBJECTIVE: Concussion is the most common type of brain injury in both pediatric and adult populations and can potentially result in persistent postconcussion symptoms. Objective assessment of physiologic "mild" traumatic brain injury in concussion patients remains challenging. This study evaluates an automated eye-tracking algorithm as a biomarker for concussion as defined by its symptoms and the clinical signs of convergence insufficiency and accommodation dysfunction in a pediatric population. DESIGN: Cross-sectional case-control study. SETTING: Primary care. PATIENTS: Concussed children (N = 56; mean age = 13 years), evaluated at a mean of 22-week post-injury, compared with 83 uninjured controls. INDEPENDENT VARIABLES: Metrics comparing velocity and conjugacy of eye movements over time were obtained and were compared with the correlation between Acute Concussion Evaluation (ACE) scores, convergence, and accommodation dysfunction. MAIN OUTCOME MEASURES: Subjects' eye movements recorded with an automated eye tracker while they watched a 220-second cartoon film clip played continuously while moving within an aperture. RESULTS: Twelve eye-tracking metrics were significantly different between concussed and nonconcussed children. A model to classify concussion as diagnosed by its symptoms assessed using the ACE achieved an area under the curve (AUC) = 0.854 (71.9% sensitivity, 84.4% specificity, a cross-validated AUC = 0.789). An eye-tracking model built to identify near point of convergence (NPC) disability achieved 95.8% specificity and 57.1% sensitivity for an AUC = 0.810. Reduced binocular amplitude of accommodation had a Spearman correlation of 0.752(P value <0.001) with NPC. CONCLUSION: Eye tracking correlated with concussion symptoms and detected convergence and accommodative abnormalities associated with concussion in the pediatric population. It demonstrates utility as a rapid, objective, noninvasive aid in the diagnosis of concussion.

Test-retest of a phoria adaptation stimulus-induced functional MRI experiment.

This study was designed to identify the neural substrates activated during a phoria adaptation task using functional magnetic resonance imaging (MRI) in young adults with normal binocular vision and to test the repeatability of the fMRI measurements for this protocol. The phoria adaptation task consisted of a block protocol of 90 seconds of near visual crossed fixation followed by 90 seconds of far visual uncrossed fixation, repeated three times; the data were collected during two different experimental sessions. Results showed that the oculomotor vermis, cuneus, and primary visual cortex had the greatest functional activity within the regions of interest studied when stimulated by the phoria adaptation task. The oculomotor vermis functional activity had an intraclass correlation coefficient (ICC) of 0.3, whereas the bilateral cuneus and primary visual cortex had good ICC results of greater than 0.6. These results suggest that the sustained visual fixation task described within this study reliably activates the neural substrates of phoria adaptation. This protocol establishes a methodology that can be used in future longitudinal studies investigating therapeutic interventions that may modify phoria adaptation.

Objective Assessment of Disparity Vergence after Treatment of Symptomatic Convergence Insufficiency in Children.

SIGNIFICANCE: This first report of the use of objective measures of disparity vergence as outcome measures for symptomatic convergence insufficiency in children provides additional information that is not accessible with clinical tests. The study results also demonstrate that objective measures of vergence could be used in future randomized clinical trials of binocular vision disorders with children. PURPOSE: This study was designed to evaluate changes in objective measures of disparity vergence after office-based vergence/accommodative therapy (OBVAT) for convergence insufficiency in children 12 to 17 years old. METHODS: In this prospective trial, we recruited 10 participants with normal binocular vision and 12 with convergence insufficiency. All participants with convergence insufficiency were treated with 12 weeks of OBVAT. The primary outcome measure was average peak velocity for 4° symmetrical convergence steps. Other objective outcome measures of disparity vergence included time to peak velocity, latency, and accuracy. Changes in clinical measures (near point of convergence, positive fusional vergence at near) and symptoms were evaluated. RESULTS: There was a statistically significant increase in peak velocity and more accurate response amplitude to 4° symmetrical convergence step stimuli after OBVAT compared with baseline measurements. Near point of convergence, positive fusional vergence, and symptoms also statistically significantly improved after OBVAT. Ten of the 12 participants met clinical success criteria. CONCLUSIONS: In this prospective study on the treatment of symptomatic convergence insufficiency in children in which both clinical and objective eye movement measurements were used to evaluate the results of treatment, significant changes were found in symptoms and both clinical and objective measures of disparity vergence after completion of OBVAT in children with symptomatic convergence insufficiency.

Office-based Vergence and Accommodative Therapy for the Treatment of Intermittent Exotropia: A Pilot Study.

SIGNIFICANCE: This study will help to demonstrate the potential value of office-based vergence/accommodative therapy for the treatment of intermittent exotropia and provide data that can be used for planning future clinical trials. PURPOSE: This study was designed to evaluate changes in the office control score after office-based vergence/accommodative therapy for intermittent exotropia. METHODS: This was a prospective, unmasked pilot study. Fourteen Chinese participants aged 6 to 18 years with intermittent exotropia (excluding the convergence insufficiency type) were enrolled. All participants received 60 minutes of office-based vergence/accommodative therapy with home reinforcement once per week for 12 weeks. Therapy included vergence, accommodation, saccades and pursuits, antisuppression, and monocular fixation in binocular field techniques. The primary outcome measure was the change in the office control score from the baseline visit to the 13-week outcome visit. RESULTS: All participants completed the study. The office control score at distance changed by -1.0 (95% confidence interval [CI] = -1.6 to -0.4; P = .005; Cohen's d effect size, 0.93). The distant Look And Cover, then Ten seconds Observation Scale for Exotropia score and distant Newcastle control score total score changed by -0.7 (95% CI, -1.2 to -0.2; P = .02; Cohen's d effect size, 0.55) and -1.9 (95% CI, -2.8 to -1.0; P < .001; Cohen's d effect size, 1.37), respectively. Although there was no significant change in the angle of distance exodeviation (-1.8 prism diopter [Δ] less exodeviation; 95% CI, -3.74 to 0.14Δ; P = .11), a significant change was observed in the near angle (-4.4Δ less exodeviation; 95% CI, -7.3 to -1.5Δ; P = .01; Cohen's d effect size, 0.79). There was no significant change in stereopsis or the Chinese Intermittent Exotropia Questionnaire score. CONCLUSIONS: In this select group of children with intermittent exotropia, 12 weeks of office-based vergence/accommodative therapy with home reinforcement resulted in a statistically and clinically significant improvement in the distance control of exodeviation and the near exodeviation magnitude. These results suggest that there is a need for a randomized clinical trial designed to determine the effectiveness of vision therapy as a treatment modality for intermittent exotropia.