Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury.

PURPOSE: This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI, the prevalence of concurrent visual dysfunctions with CI in TBI is unknown. METHODS: A retrospective analysis of 557 medical records from TBI civilian patients was conducted. Patients were all evaluated by a single optometrist. Visual acuity, oculomotor function, binocular vision function, accommodation, visual fields, ocular health, and vestibular function were assessed. Statistical comparisons between the CI and non-CI, as well as inpatient and outpatient subgroups, were conducted using χ and Z tests. RESULTS: Approximately 9% of the TBI sample had CI without the following simultaneous diagnoses: saccade or pursuit dysfunction; third, fourth, or sixth cranial nerve palsy; visual field deficit; visual spatial inattention/neglect; vestibular dysfunction; or nystagmus. Photophobia with CI was observed in 16.3% (21 of 130), and vestibular dysfunction with CI was observed in 18.5% (24 of 130) of the CI subgroup. Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 23.3% (130 of 557) and 26.9% (150 of 557), respectively, within the TBI sample. Accommodative dysfunction was common within the nonpresbyopic TBI sample, with a prevalence of 24.4% (76 of 314). Visual field deficits or unilateral visual spatial inattention/neglect was observed within 29.6% (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p < 0.001). Most TBI patients had visual acuities of 20/60 or better in the TBI sample (85%; 473 of 557). CONCLUSIONS: Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9% of the visually symptomatic TBI civilian population studied. A thorough visual and vestibular examination is recommended for all TBI patients.

Short-term adaptations of the dynamic disparity vergence and phoria systems.

The ability to adapt is critical to survival and varies between individuals. Adaptation of one motor system may be related to the ability to adapt another. This study sought to determine whether phoria adaptation was correlated with the ability to modify the dynamics of disparity vergence. Eye movements from ten subjects were recorded during dynamic disparity vergence modification and phoria adaptation experiments. Two different convergent stimuli were presented during the dynamic vergence modification experiment: a test stimulus (4° step) and a conditioning stimulus (4° double step). Dynamic disparity vergence responses were quantified by measuring the peak velocity (°/s). Phoria adaptation experiments measured the changes in phoria over a 5-min period of sustained fixation. The maximum velocity of phoria adaptation was determined from an exponential fit of the phoria data points. Phoria and dynamic disparity vergence peak velocity were both significantly modified (P < 0.001). The maximum velocity of phoria adaptation was significantly correlated with the changes in convergence peak velocity (r > 0.89; P < 0.001). There was a strong correlation between the ability to adaptively adjust two different oculomotor parameters: a tonic and dynamic component. Future studies should investigate additional interactions between these parameters, and the ability to adaptively change other oculomotor systems such as the saccadic or smooth pursuit system. Understanding the ability to modify phoria, dynamic disparity vergence, and other oculomotor parameters can yield insights into the plasticity of short-term adaptation mechanisms.

Vision therapy in adults with convergence insufficiency: clinical and functional magnetic resonance imaging measures.

PURPOSE: This research quantified clinical measurements and functional neural changes associated with vision therapy in subjects with convergence insufficiency (CI). METHODS: Convergence and divergence 4° step responses were compared between 13 control adult subjects with normal binocular vision and four CI adult subjects. All CI subjects participated in 18 h of vision therapy. Clinical parameters quantified throughout the therapy included: nearpoint of convergence, recovery point of convergence, positive fusional vergence at near, near dissociated phoria, and eye movements that were quantified using peak velocity. Neural correlates of the CI subjects were quantified with functional magnetic resonance imaging scans comparing random vs. predictable vergence movements using a block design before and after vision therapy. Images were quantified by measuring the spatial extent of activation and the average correlation within five regions of interests (ROI). The ROIs were the dorsolateral prefrontal cortex, a portion of the frontal lobe, part of the parietal lobe, the cerebellum, and the brain stem. All measurements were repeated 4 months to 1 year post-therapy in three of the CI subjects. RESULTS: Convergence average peak velocities to step stimuli were significantly slower (p = 0.016) in CI subjects compared with controls; however, significant differences in average peak velocities were not observed for divergence step responses (p = 0.30). The investigation of CI subjects participating in vision therapy showed that the nearpoint of convergence, recovery point of convergence, and near dissociated phoria significantly decreased. Furthermore, the positive fusional vergence, average peak velocity from 4° convergence steps, and the amount of functional activity within the frontal areas, cerebellum, and brain stem significantly increased. Several clinical and cortical parameters were significantly correlated. CONCLUSIONS: Convergence peak velocity was significantly slower in CI subjects compared with controls, which may result in asthenopic complaints reported by the CI subjects. Vision therapy was associated with and may have evoked clinical and cortical activity changes.

Quantification of heterophoria and phoria adaptation using an automated objective system compared to clinical methods.

PURPOSE: To develop a system with which to quantify objectively the heterophoria to be measured throughout eye movement experiments. This study compared precision, resolution and accuracy characteristics of a limbus eye movement tracking system to the alternate cover test and the Maddox rod. METHODS: Precision testing was performed using each technique with binocularly-normal subjects at different test sessions. Resolution was measured and compared between the three systems. The heterophoria or phoria was measured from 40 cm/16 inches objectively with the limbus eye movement system and the Maddox rod during a sustained convergence-induced phoria adaptation experiment using physical and haploscope visual targets to compare accuracy. RESULTS: Precision testing quantified that the responses objectively recorded using the limbus tracking system exhibited similar standard deviations to the Maddox rod and the alternate cover test techniques. The limbus tracking method has the ability to quantify the response decay to phoria and has better resolution when compared to the clinical methods. When physical targets were used to induce phoria adaptation, the correlation was significant between the limbus eye movement tracking system and the Maddox rod after near and far adaptation, where the Maddox rod measurements were slightly more esophoric compared to those measured with the limbus tracking system. CONCLUSION: This objective limbus tracking system offers a better means by which to study the phoria and its adaptation throughout an eye movement experiment. The broader aim of this research is to establish a tool that will further the basic science of oculomotor control and binocular dysfunctions.

Sustained fixation induced changes in phoria and convergence peak velocity.

PURPOSE: This study sought to investigate the influence of phoria adaptation on convergence peak velocity from responses located at different initial vergence positions. METHODS: Symmetrical 4° convergence step responses and near dissociated phoria (measured at 40 cm from the subject's midline) were recorded from six subjects with normal binocular vision using an infrared limbus tracking system with a haploscope. Two different sustained fixations (1° and 16° convergent rotation along the subject's midline) were used to study whether phoria had an influence on the peak velocity of convergence responses located at two initial vergence positions (1° or 'far' steps and 12° or 'near' steps). RESULTS: Phoria was significantly adapted after a sustained fixation task at near (16°) and far (1°) (p<0.002). A repeated measures ANOVA showed that convergence far steps were significantly faster than the near steps (p<0.03). When comparing convergence steps with the same initial vergence position, steps measured after near phoria adaptation were faster than responses after far adaptation (p<0.02). A regression analysis demonstrated that the change in phoria and the change in convergence peak velocity were significantly correlated for the far convergence steps (r = 0.97, p = 0.001). A weaker correlation was observed for the near convergence steps (r = 0.59, p = 0.20). CONCLUSION: As a result of sustained fixation, phoria was adapted and the peak velocity of the near and far convergence steps was modified. This study has clinical considerations since prisms, which evoke phoria adaptation, can be prescribed to help alleviate visual discomfort. Future investigations should include a systematic study of how prisms may influence convergence and divergence eye movements for those prescribed with prisms within their spectacles.

The relationship between phoria and the ratio of convergence peak velocity to divergence peak velocity.

PURPOSE: The purpose of this study was to investigate the relationship between phoria and the dynamics of vergence eye movements as described by the ratio of convergence average peak velocity to divergence average peak velocity, termed the vergence peak velocity ratio. METHODS: Phoria and vergence step responses were recorded. Three measures of phoria were assessed: baseline phoria, which is the initial phoria measurement; adapted phoria, which is the phoria measured after a visual task; and change in phoria, which is defined as adapted phoria minus baseline phoria. Phoria was modified in two experiments: vergence steps located at different initial positions and different sustained convergent fixations. Four linear regression analyses were conducted to study the interactions among baseline phoria and vergence peak velocity ratio, adapted phoria and vergence peak velocity ratio, baseline and adapted phoria, and baseline phoria and change in phoria. RESULTS: Baseline and adapted phoria were significantly correlated to vergence peak velocity ratio. Adapted phoria and baseline phoria were also significantly correlated. The change in phoria induced by the vergence steps or a sustained fixation task was independent of the baseline phoria. CONCLUSIONS: These data support that phoria is a factor in the asymmetry between peak velocity of convergence and divergence and that baseline phoria level is not a factor in the amount of change observed in phoria level (adapted phoria minus baseline phoria). Future oculomotor models of vergence should incorporate phoria within the design.