Comparing clinical measures of near point of convergence and accommodation from the lateral canthus and browline in a paediatric and adolescent population.

PURPOSE: Clinicians measure the near point of convergence (NPC) and the amplitude of accommodation (AA) from the spectacle plane, the bridge of the nose or the lateral canthus when assessing visual function. These values are compared to standard clinical criteria to diagnose vergence and accommodation deficits, despite varying reference points. This prospective study explored measuring relative to the spectacle plane and from the lateral canthus for NPC and monocular AA, and the resulting clinical implications of diagnosing visual deficits. METHODS: Participants were seen by a single clinician for an eye examination. NPC was measured from the forehead and the lateral canthus of the right eye. Monocular AA was measured from the brow and the lateral canthus. Differences between measurements were analysed using non-parametric statistical tests including Wilcoxon Signed Rank, as well as linear regression and a linear mixed effects model to adjust for inter-eye correlation and repeated measures. Chi-square tests were used to assess differences in rates of abnormal findings. RESULTS: Data were collected from 70 participants (53% female, median age 13 [11-15] years). On average, measuring NPC from the lateral canthus yielded a value 1.8 cm higher than measuring from the forehead. Measuring AA from the lateral canthus resulted in an average difference of 1.5 cm compared to measuring from the brow. A total of 39% and 76% of subjects failed NPC compared to clinical norms when measured from the forehead or the lateral canthus, respectively, while 7% and 40% failed AA when measured from the brow or the lateral canthus, respectively. CONCLUSION: With the variable anatomy of the eye, it is imperative to account for the measurement point when assessing visual function. Measuring from the lateral canthus greatly increased the failure rates for NPC and AA compared with measuring from the forehead and brow, respectively.

The Impact of the Test Dissociation on the Binocular Balance of Children.

PURPOSE: this research compared the dissociated phoria at near and distance fixation in free space using the Howell test, alternate Cover test, and Thorington test. METHODS: 220 healthy Mexican children (mean age 8.3±2.5 years) participated in this study. Phorias were quantified at both distances using each test, from the least to the most disruptive. The stereopsis degree and near point of convergence (break/recovery) were analyzed to understand their role in the visual system's sensorimotor balance. RESULTS: statistically significant differences were found among techniques, with a higher congruence for the EF. However, only the Howell and Thorington tests can be interchanged. The break value and near exophoria relate to each other and affect the stereopsis degree, whereas age is associated with the stereopsis degree and break value. CONCLUSIONS: the three techniques cannot be interchanged except for the Howell and Thorington test for the EF at far. The differences in the mode of dissociation could relate to the results.

Receded near point of convergence as a predictor of mild cognitive impairment in the general geriatric population: results from a population-based study.

AIM: To investigate the relationship between near point of convergence (NPC) and mild cognitive impairment (MCI) in the general elderly population. METHODS: The present report is a part of the Tehran Geriatric Eye Study (TGES): a population-based cross-sectional study conducted on individuals 60 years of age and above living in Tehran, Iran using the multi-stage stratified random cluster sampling method. Cognitive status was assessed using the Persian version of the Mini-Mental State Examination (MMSE). All study participants underwent complete ocular examination including measurement of uncorrected and best-corrected visual acuity, objective and subjective refraction, cover testing, NPC measurement, and slit-lamp biomicroscopy. RESULTS: The data of 1190 individuals were analyzed for this report. The mean age of the participants analyzed was 66.82±5.42 (60-92y) and 728 (61.2%) of them were female. Patients with MCI had a significantly more receded NPC compared to subjects with normal cognitive status (10.89±3.58 vs 7.76±2.71 cm, P<0.001). In the multivariable logistic regression model and in the presence of confounding variables, a receded NPC was statistically significantly associated with an increased risk of MCI (odds ratio: 1.334, 95% confidence interval: 1.263 to 1.410, P<0.001). According to receiver operating characteristic (ROC) analysis, a cut point NPC> 8.5 cm (area under the curve: 0.764, P<0.001) could predict the presence of MCI with a sensitivity and specificity of 70.9% and 69.5%, respectively. CONCLUSION: A receded NPC can be clinically proposed as a predictor of MCI in older adults. It is recommended that elderly with a receded NPC>8.50 cm undergo detailed cognitive screening for a definite diagnosis of MCI. In this case, the necessary interventions can be carried out to slow down MCI progression to dementia.

The Function of the Proprioceptive, Vestibular and Visual Systems Following Fatigue in Individuals With and Without Chronic Ankle Instability.

To maintain postural balance, the proprioceptive, vestibular, and visual systems continuously provide body position and movement data to the central nervous system. In this study, our main aim was to examine, for the first time, the influence of anaerobically or aerobically induced fatigue on these separate functions in persons with and without chronic ankle instability (CAI). We obtained assessments pre- and post-fatigue protocols from 60 physical education students (Mage = 24.3, SD = 3.4) Twenty-seven students had CAI, and 33 students did not have CAI). To measure proprioception, we used the AMEDA device; for vision, we used near point of convergence (NPC); and, for vestibular function, we used subjective visual vertical (SVV). We found a pre-post proprioception (AMEDA) effect in the aerobic group (p < .001), and a visual (NPC) effect in both anaerobic and aerobic participant groups (both p < .001). There were no visual system (NPC) fatigue effect differences among aerobic or anerobic participants who had or did not have CAI (p = .047); there was a significant aerobic fatigue effect on proprioception (AMEDA) (p = .010) that favored participants without CAI. There was a significant interaction effect between time of testing and CAI for visual (NPC) (p = .003) in the aerobic group only. In both the anaerobic and aerobic groups, post-fatigue vestibular function (AMEDA) was significantly lower for those with than those without CAI (anaerobic: p = .030; and aerobic: p =.016). Thus, post-fatigue, participants with CAI showed worse proprioceptive, visual, and vestibular function than those without CAI. Future investigators should further examine each movement sense system in individuals with CAI.

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.

Are binocular alignment and convergence amplitude different between phakic and pseudophakic older patients?

PURPOSE: To compare the binocular alignment status and convergence amplitude between phakic and pseudophakic older adults. METHODS: The present report is a part of the Tehran Geriatric Eye Study (TGES), a population-based study performed on the elderly population above 60 years of age in Tehran, Iran. All study participants were transferred to the examination site and underwent complete ocular examinations including the measurement of uncorrected and best-corrected visual acuity, objective and subjective refraction, unilateral and alternating cover tests, and slit-lamp biomicroscopy. RESULTS: Of 3791 invitees, 3310 participated in the TGES (response rate: 87.3%). After applying the exclusion criteria, the data of 1969 individuals were analyzed for this report. The mean of far exophoria, far esophoria, near exophoria, and near esophoria was 5.09 ± 3.66, 8.20 ± 9.60, 6.94 ± 3.69, 7.00 ± 5.83 prism diopter in phakic and 5.15 ± 2.43, 6.50 ± 5.80, 7.77 ± 4.00, 4.75 ± 1.50 prism diopter in pseudophakic individuals, respectively. The mean of far exotropia, far esotropia, near exotropia, and near esotropia was 14.92 ± 9.49, 22.00 ± 13.86, 15.09 ± 7.20, 21.33 ± 14.47 prism diopter in phakic and 19.67 ± 22.5, 8.00 ± 0, 17.36 ± 7.55, 17.36 ± 7.55, 0 prism diopter in pseudophakic individuals, respectively. Near exophoria (P = .003) was significantly higher in pseudophakic than in phakic participants after controlling the effects of age, sex, body mass index, diabetes, and hypertension. The mean near point of convergence was 7.94 ± 3.27 cm in phakic and 7.99 ± 3.3 cm in pseudophakic participants. CONCLUSION: Near exophoria was significantly higher in pseudophakic compared to phakic individuals while other deviations and near point of convergence were not significantly different between phakic and pseudophakic groups.

Corrección refractiva en pacientes con heteroforia. Informe de casos / Refractive correction in patients with heterophoria. Case reports

Introducción: La heteroforia es la mala alineación de los ejes oculares, que es compensada durante la fijación binocular, al utilizar el mecanismo de fusión. Tiene una alta prevalencia en la población. Objetivo: Evidenciar la importancia de una corrección óptica personalizada en pacientes con heteroforias. Presentación de casos: Se presentan cuatro pacientes que acudieron a consulta de oftalmología, para refracción por presentar síntomas astenópicos. Después de una evaluación completa de cada uno, se constató en todos, la presencia de heteroforia. Se determinó la existencia de exoforia, en tres de ellos, fundamentalmente asociada a insuficiencia de convergencia y esoforia en uno, con exceso de convergencia. Se indicó en todos los casos la corrección óptica personalizada, teniendo en cuenta los resultados de exámenes y se logró la eliminación de las molestias en los pacientes. Conclusiones: Las heteroforias son una causa frecuente de síntomas astenópicos. Es necesario realizar un adecuado estudio, antes de indicar una corrección refractiva, teniendo en cuenta la identificación y cuantificación de la foria, evaluación de las vergencias fusionales, así como estudio del punto próximo de convergencia y la relación convergencia acomodación(AU)

Introduction: Heterophoria is the misalignment of the ocular axes, which is compensated during binocular fixation using the fusion mechanism. It has a high prevalence in the population. Objective: To demonstrate the importance of a personalized optical correction in patients with heterophorias. Cases report: Four cases who attended an ophthalmology consultation for refraction due to asthenopic symptoms are presented. After a complete evaluation of every one of the cases, the presence of heterophoria was found in all of them. The existence of exophoria, mainly associated with insufficient convergence, was determined in three of them; and convergence excess esophoria was identified in one case. Personalized optical correction was indicated in all cases, taking into account the results of the examinations; also, the discomfort in the patients was eliminated. Conclusions: Heterophorias are a frequent cause of asthenopic symptoms. It is necessary to carry out an adequate study before indicating a refractive correction, considering the identification and quantification of phoria, evaluation of fusional vergences, the study of the near point of convergence, and the accommodation-convergence relationship(AU)

Evaluating the extent of change in near point of convergence in traumatic brain injury: a systematic review and meta-analysis.

OBJECTIVE: Traumatic brain injury (TBI) causes significant impact on visual system. This study reports the impact of TBI on the near point of convergence (NPC) measure in individuals with mild TBI. METHODS: A systematic review and meta-analysis were conducted for studies that quantified NPC changes in mild TBI. The relevant studies were searched using search engines such as PubMed, EMBASE, Medline and Google Scholar. Thirty studies fulfilled the criteria for systematic review while twelve studies were included in the meta-analysis from 444 patients with mild TBI and 881 controls. RESULTS: This study showed a large and significant impact of head injury on the clinical measure of NPC in patients with mild TBI with a combined effect size of 0.98(95% CI: 0.67-1.29) and significantly moderate heterogeneity (Q(18) = 60.84,P = .001,I2 = 72.06%). Moderator analysis and subgroup analysis showed no difference in effect size with age and post-injury period. CONCLUSIONS: This study demonstrated that NPC is largely affected by the impact of TBI. Given the ease with which it can be measured and without the need of specialists and dedicated equipment, NPC measure might provide a supplementary measure of oculomotor function in addition to less sensitive and more subjective questionnaires and personal reports.

Convergence insufficiency: Review of clinical diagnostic signs.

Convergence insufficiency (CI) is a common binocular vision (BV) disorder characterized by difficulty in maintaining motor fusion at near, which affects approximately 7.5 percent of the population. Diagnostic criteria for the disorder are inconsistent, ranging from one to many clinical signs. Methodology for clinical tests is inconsistent in measurement technique, visual targets, required repetitions, and normative values. This manuscript demonstrates the inconsistencies amongst published studies, and highlights the importance of consistent clinical diagnostic signs, measurement techniques, visual targets, and cut-off criteria. For each clinical sign, the recommended methodology for the procedure is described. Several studies do not take age into account when diagnosing CI in their cohorts. As such, the review emphasizes changes in diagnostic signs with age. This manuscript highlights the need for consistent and clear procedures and diagnostic criteria amongst clinicians and provides the basis for future studies in terms of diagnostic testing required for CI of varying age groups.

Agreement between three methods for measuring near point of convergence among patients with different refractive errors.

PURPOSE: To describe the agreement of three methods of Near Point of Convergence (NPC) measurement among patients with different refractive errors. METHODS: 60 asymptomatic subjects, 18 - 25 yrs old, were included in 3 groups: emmetropes, myopes and hypermetropes. All subjects underwent NPC break point and recovery point measurement by Royal Air Force (RAF) rule, Pencil Rule (PR) and penlight with red green glasses (RG) using standard techniques. The values obtained were compared within each group by Friedman test. Bland Altman plots were constructed and Limits of Agreement calculated. RESULTS: Hypermetropes performed poorly in RG test with significantly receded break point and recovery point values (10.30 ± 1.45cm, 13.13± 1.20cm) compared to RAF test (7.18 ± 1.86 cm, 10.15 ± 2.11cm ) and PR test (7.78 ± 1.75 cm, 10.75 ± 1.44cm). The recovery point values of the emmetropes with RG test (10.15 ± 2.32cm) was significantly receded compared to PR (9.30 ± 1.72 cm) and RAF test (Emm: 9.08 ± 2.30cm). The myopes performed better with PR test with significantly better recovery point values with PR test (8.70 ± 1.97 cm) compared to RAF (9.68 ± 2.08) and RG (9.45 ± 1.73) tests. The limits of agreement were wide suggesting disagreement between the tests. CONCLUSION: The RG test yields more receded results in hypermetropes compared to the RAF and PR tests, and the PR test yields better results than the RAF test in myopes. Thus, the results obtained by these different methods show a lack of agreement. The variability is not uniform in patients with different refractive errors.

Characteristics of saccades during the near point of convergence test.

The near point of convergence test is widely used to evaluate binocular vision. It assesses the ability of the eyes to converge at short distances. Although the test consists of a pure symmetrical vergence task, small involuntary saccades occur concurrently. The main goal of this study was to analyze saccadic characteristics as a function of vergence demand when testing the near point of convergence. To this purpose, the eye movements of 11 participants were registered with an eye-tracker while they performed the near point of convergence test by following a target that traveled forward and backward on a motorized bench. Saccade amplitude increased and, on average, saccade rate decreased with vergence demand. In general, the direction of the concurrent vergence movement had no significant effect on saccade characteristics. However, each individual subject showed idiosyncratic behavior. Most saccades tended to be corrective in terms of both binocular disparity and individual fixation position errors. In particular, most participants tended to correct the fixation position error of the dominant eye.

Distribution of near Point of Convergence, near Point of Accommodation, Accommodative Facility and Refractive Errors in a Rural Population Living in Northern Iran.

Purpose: To evaluate near point of convergence (NPC), near point of accommodation (NPA), and accommodative facility (AF) in order to determine their normative data in a rural population.Methods: The target population for this population-based, cross-sectional study was people living in rural areas. Each subject underwent extensive optometric and ophthalmic examinations, including the measurement of visual acuity, refraction, NPA, NPC, and AF.Results: The data of 1113 individuals was analyzed of whom 58.8% (n = 576) were women. The mean age of the participants was 15.26 ± 7.38 years (range: 6-30 years). The mean spherical equivalent of the subjects was 0.16 ± 0.63 D. The prevalence of myopia, hyperopia and astigmatism was 16.28% (13.97-18.58), 5.97% (4.49-7.44), 11.93% (9.91-13.95) in this study, respectively The mean and 95% confidence interval of NPC, NPA, and binocular accommodative facility (BAF) was 6.99 cm (6.84-7.15), 9.91 cm (9.71-10.11), and 9.84 cpm (9.63-10.06), respectively. A significant correlation was found between age and the parameters such that all evaluated parameters worsened significantly with age (P < .001).Conclusion: The results of the present study showed the normal ranges of NPA, NPC, and BAF in a 6-30 year-old population living in rural areas of northern Iran. These parameters changed significantly with age.

Disparity vergence differences between typically occurring and concussion-related convergence insufficiency pediatric patients.

This study sought to test the hypothesis that significant differences would be observed in clinical measures, symptoms, and objective assessments of vergence eye movements between children with typically developing convergence insufficiency (TYP-CI) and children with persistent post-concussion symptoms with convergence insufficiency (PPCS-CI). Data from age-matched binocularly normal controls (BNC) were used for comparison. Data from three groups of children 11 to 17 years of age are presented: BNC (N = 11), TYP-CI (N = 10), and PPCS-CI (N = 15). Clinical measures of vergence, accommodation, and symptom severity were collected. Symmetrical 4° disparity vergence eye movements were quantified with an eye tracker integrated into a head-mounted display (Oculus DK2). Peak velocity and final response amplitude of convergence and divergence eye movement responses were assessed. The mean near point of convergence (break) was more receded (worse), the amplitude of accommodation more deficient, and convergent and divergent peak velocities slower in the PPCS-CI group compared with the TYP-CI and BNC groups. These results suggest that PPCS-CI may be a different clinical entity than TYP-CI. Hence, more research is warranted to determine whether the therapeutic interventions that are effective for TYP-CI can also be used for PPCS-CI populations.

Binocular Vision in Patients with Multiple Sclerosis.

PURPOSE: Oculomotor disorders have been reported in multiple sclerosis (MS) in up to 80% of cases. There have been studies evaluating binocular vision in several neurological diseases, but not in MS. Considering that a high percentage of eye-movement anomalies have been reported, the aim of this study was to analyze binocular vision in these subjects. METHODS: A total of 59 participants with MS - 21 with monocular optic neuritis, eleven with binocular optic neuritis, and 27 without optic neuritis - and 26 age-matched controls were enrolled. Binocular vision was analyzed using near point of convergence (NPC), positive and negative fusional vergence for far and near distance, measurement of heterophoria at both distances with cover and modified Thorington tests, and random-dot stereoscopy. RESULTS: The percentage of subjects with abnormal NPC values was highest in the MS group, followed by the MSONm (MS with optic neuritis in one eye), MSONb (MS with optic neuritis in both eyes), and control groups. MS patients showed an esophoric trend at near distance. Positive fusional vergence showed no significant differences between control and MS groups, but higher variability in recovery was found in MS groups. Negative fusional vergence at near distance showed significant differences between the control group and the two MS groups, with optic neuritis for both break-point and recovery values. A high percentage of patients with MS had alterations on stereopsis. CONCLUSION: Alterations in binocular vision were present in MS, with divergence at near distance and stereopsis the most affected parameters. Likewise, MS patients with optic neuritis showed worse binocular vision.

The impact of high- and moderate-intensity exercise on near-point of convergence metrics.

Background: Near point of convergence (NPC) assesses the vergence ability of the visuo-oculomotor system; however, little is known regarding: the extent and duration exercise impacts NPC and the between- and within-day reliability of NPC metrics.Methods: An accommodative ruler with a miniature Snellen chart was placed upon the philtrum (upper lip). Participants (n=9) focused upon a 'V' sized 20/20, while the chart was moved at ~1-2 cm/s toward and away from the eyes (twice in each direction). Testing commenced at 8:00am with NPC measures being collected at baseline before three randomized conditions with serial follow-ups occurring at six post-condition timepoints (0-8 hours following). The conditions consisted of 25-minutes high-intensity intervals (10, one-minute intervals at ~85-90% heart-rate reserve), 45-minutes of moderate-intensity exercise (at ~50-60% heart-rate reserve), and a control condition (30-minutes quiet rest).Results: NPC was not impacted across any of the three conditions (all p > .59). Additionally, NPC measures between baseline conditions and across the control condition displayed very high levels of within-day and between-day reliability (coefficient of variation <3.8%).Conclusions: Future NPC measures using an accommodative ruler can be taken immediately following exercise and may be pertinent as a complementary tool in the future sideline screening of concussion.

Near Points of Convergence and Accommodation in a Population of University Students in Iran.

PURPOSE: To determine the distribution of the near point of convergence (NPC) and near point of accommodation (NPA) in a young student population in Iran. METHODS: The subjects were selected using a cluster sampling method. All students underwent optometry tests, including visual acuity measurement, refraction, and cover test, as well as ophthalmic examinations. The NPC and NPA were measured using an accommodative target (near Snellen chart). RESULTS: Of 1,595 students, the data of 1,357 were analyzed. The mean NPC and NPA in the total sample were 7.25 cm (95% confidence interval [CI], 7.02 to 7.48) and 9.99 cm (95% CI, 9.69 to 10.29), respectively. Older age was associated with an increase in the NPC, which increased from 6.98 cm in 18-20 years olds to 9.51 cm in those over 30 years. The NPA was significantly associated with age and refractive errors in the multiple linear regression model, increasing from 9.92 cm in 18-20 years olds to 11.44 cm in those over 30 years ( P = 0.003). Hyperopic eyes had lower NPA than myopic and emmetropic eyes ( P = 0.001). In younger age groups, the mean accommodation amplitude was lower than the mean Hofstetter value. Moreover, with age, especially after 30 years, the mean values surpassed those determined using the Hofstetter formula. CONCLUSION: The NPC values in this study were lower than those previously reported for identical age groups. The Hofstetter formula is not always an accurate predictor of the accommodation amplitude in the Iranian adult population.

The utility of the Convergence Insufficiency Symptom Survey (CISS) post-concussion.

Background: The Convergence Insufficiency Symptom Survey (CISS) is being utilized as an assessment measure following concussion despite minimal research. This study explored the sensitivity and specificity of the CISS in identifying receded near point of convergence (NPC) post-concussion. Methods: Prospective study of 130 patients post-concussion aged 11-25, classified into normal NPC (n = 94) and CI (n = 36) groups (i.e., NPC >5 cm), completed the CISS, VOMS, and PCSS. Sensitivity and specificity identifying receded NPC were explored with published CISS cutoff score (>16). ROC with AUC analysis was conducted to determine an alternate CISS cutoff score to yield optimal sensitivity and specificity in patients with concussion. Results: Utilizing the published cutoff score, the CISS demonstrated adequate sensitivity (.78 [95% CI = .60-.89]) but poor specificity (.35 [95%CI = .26-.46]). ROC curve demonstrated that CISS score was significant (P = .01) in predicting a positive test result (i.e., NPC >5) with AUC of .65 (95%CI .54-.76). An alternative cutoff score (CISS>23) maximized sensitivity (.70) and specificity (.53) for identifying receded NPC. Conclusions: Both the previously published CISS cutoff and our sample-based cutoff score yielded a high rate of false positives for receded NPC. CISS scores post-concussion may help the clinician understand difficulties with visual tasks but is not a suitable diagnostic tool in this patient population.

Clinical predictors of symptom resolution for children and adolescents with sport-related concussion.

OBJECTIVE: The goal of this study was to determine which variables assessed during an initial clinical evaluation for concussion are independently associated with time until symptom resolution among pediatric patients. METHODS: Data collected from a prospective clinical registry of pediatric patients with concussion were analyzed. The primary outcome variable was time from injury until symptom resolution. Predictor variables assessed within 10 days after injury included preinjury factors, Health and Behavior Inventory scores, headache severity, and balance, vestibular, and oculomotor test performances. The researchers used univariate Cox proportional models to identify potential predictors of symptom resolution time and constructed a multivariate Cox proportional hazards model in which total duration of concussion symptoms remained the outcome variable. RESULTS: The sample consisted of 351 patients (33% female, mean age 14.6 ± 2.2 years, evaluated 5.6 ± 2.6 days after concussion). Univariate Cox proportional hazards models indicated that several variables were associated with a longer duration of symptoms, including headache severity (hazard ratio [HR] 0.90 [95% CI 0.85-0.96]), headache frequency (HR 0.83 [95% CI 0.71-0.96]), confusion (HR 0.79 [95% CI 0.69-0.92]), forgetfulness (HR 0.79 [95% CI 0.68-0.92]), attention difficulties (HR 0.83 [95% CI 0.72-0.96]), trouble remembering (HR 0.84 [95% CI 0.72-0.98]), getting tired often (HR 0.86 [95% CI 0.76-0.97]), getting tired easily (HR 0.86 [95% CI 0.76-0.98]), dizziness (HR 0.86 [95% CI 0.75-0.99]), and abnormal performance on the Romberg test (HR 0.59 [95% CI 0.40-0.85]). A multivariate Cox proportional hazards model indicated that an abnormal performance on the Romberg test was independently associated with a longer duration of symptoms (HR 0.65 [95% CI 0.44-0.98]; p = 0.038). CONCLUSIONS: For children and adolescents evaluated within 10 days after receiving a concussion, abnormal performance on the Romberg test was independently associated with a longer duration of symptoms during recovery. In line with findings of other recent studies investigating predictors of symptom resolution, postural stability tests may provide useful prognostic information for sports medicine clinicians.

Premorbid migraine history as a risk factor for vestibular and oculomotor baseline concussion assessment in pediatric athletes.

OBJECTIVEMigraine history has recently been identified as a risk factor for concussion and recovery. The authors performed a cross-sectional study examining baseline outcome measures on newly developed and implemented concussion assessment tools in pediatrics. The purpose of this study was to examine the effects of premorbid, diagnosed migraine headaches as a risk factor on vestibular and oculomotor baseline assessment in pediatric athletes.METHODSPediatric athletes between the ages of 8 and 14 years with a diagnosed history of migraine headache (n = 28) and matched controls without a history of diagnosed migraine headache (n = 28) were administered a baseline concussion assessment battery, consisting of the Vestibular/Ocular Motor Screening (VOMS), near point of convergence (NPC), and the King-Devick (K-D) tests. Between-groups comparisons were performed for vestibular symptoms and provocation scores on the VOMS (smooth pursuit, saccades, convergence, vestibular/ocular reflex, visual motion sensitivity), NPC (average distance), and K-D (time).RESULTSIndividuals diagnosed with migraine headaches reported greater VOMS smooth pursuit scores (p = 0.02), convergence scores (p = 0.04), vestibular ocular reflex scores (p value range 0.002-0.04), and visual motion sensitivity scores (p = 0.009). Differences were also observed on K-D oculomotor performance with worse times in those diagnosed with migraine headache (p = 0.02). No differences were reported on NPC distance (p = 0.06) or headache symptom reporting (p = 0.07) prior to the VOMS assessment.CONCLUSIONSPediatric athletes diagnosed with migraine headaches reported higher baseline symptom provocation scores on the VOMS. Athletes with migraine headaches also performed worse on the K-D test, further illustrating the influence of premorbid migraine headaches as a risk factor for elevated concussion assessment outcomes at baseline. Special consideration may be warranted for post-concussion assessment in athletes with migraine headaches.

Changes in the Disparity Vergence Main Sequence after Treatment of Symptomatic Convergence Insufficiency in Children.

This study investigates the underlying physiological mechanisms that may lead to improved outcomes for symptomatic convergence insufficiency (Cl) patients after 12 weeks of office-based vergence/accommodation therapy (OBVAT) by evaluating the change in the main sequence of vergence and saccadic eye movements. In this prospective trial, 12 participants with symptomatic Cl were recruited and treated with 12 weeks of OBVAT. Outcome measures included the objective assessment of the following: peak velocity, time to peak velocity, latency, response amplitude, and clinical changes in the near point of convergence (NPC), positive fusional vergence (PFV) and symptoms via the Convergence Insufficiency Symptom Survey (CISS). Ten of the twelve participants (83%) were categorized as "successful" and two were "improved" based on pre-determined published criteria (CISS, NPC, PFV). There were statistically significant changes in peak velocity, time to peak velocity, and response amplitude for both 4° and 6° symmetrical convergence and divergence eye movements. There was a significant change in the main sequence ratio for convergence post-OBVAT compared to baseline measurements (P=0.007) but not for divergence or saccadic responses. Phasic/step vergence movements adjust the underlying neural control of convergence and are critical within a vision therapy program for Cl patients.