Creating consistency in the diagnosis of convergence insufficiency: screening methods.

PURPOSE: To determine the sensitivity of various clinical tests in the diagnosis of convergence insufficiency. METHODS: A total of 254 patients were recruited with complaints consistent with convergence problems but no prior history of strabismus surgery, eye exercises, prism use, recent concussion, or other ocular or neurological diseases. Each patient completed the convergence insufficiency symptom survey (CISS), and the following data were collected: ocular alignment at distance and near, convergence and divergence fusional amplitudes at distance and near, near-point of convergence (NPC) using an accommodative target and red lens, and assessment of quality of convergence movement (QoCM) and quality of fusional movements (QoFM). The sensitivity of each clinical test was calculated. RESULTS: Measurement of NPC using red lens and subjective assessment of the QoCM and QoFM were the most sensitive diagnostic tools for near symptoms consistent with convergence insufficiency: 93.3%, 98.4%, and 94.5% respectively. CISS score, convergence fusional amplitude at near, and exophoria at near had lower sensitivities: 62.9%, 46.0%, and 72.0%, respectively. Although the majority of our patients had a heterophoria or heterotropia at distance (96.8%) and/or near (98.8%), most presented with only small phorias. Furthermore, of those who had a deviation at near, only 22% had the near exophoria exceeding the distance exophoria by 10Δ. CONCLUSIONS: In our study cohort, NPC with red lens and subjective assessment of QoCM and QoFM proved to be the most sensitive screening tools for near symptoms consistent with convergence insufficiency.

The visual consequences of virtual school: acute eye symptoms in healthy children.

PURPOSE: To investigate acute eye symptoms in healthy children after a typical day of virtual school during the COVID-19 pandemic. METHODS: The study population included 110 healthy children 10-17 years of age who were enrolled in full-time or hybrid virtual school. Children with a history of central nervous system or ocular pathology, recent concussions, reported poor vision, convergence insufficiency, history of orthoptic therapy, strabismus, amblyopia, or learning disorders were excluded. Background information was collected, including demographics, family and personal ocular history, and virtual school specifications. Eligible children completed a modified convergence insufficiency symptom survey (CISS) and an asthenopia survey before and after a virtual school session. CISS and asthenopia survey symptoms were scored, and the differences in symptomatology before and after school were calculated. RESULTS: The average sum of the CISS scores increased from 5.17 before school to 9.82 after (P < 0.001), with 61% of children recording an increase in convergence insufficiency symptoms and 17% experiencing severe convergence insufficiency symptoms after school. Average asthenopia symptom scores increased from 1.58 to 2.74 (P < 0.001), with 53% of children recording an increase in asthenopia symptoms. Significant increases were seen in 12 of 15 CISS questions and in 4 of 5 asthenopia questions. CONCLUSIONS: In this study cohort, otherwise healthy children experienced acute ocular symptoms following virtual school.

Inconsistent diagnostic criteria for convergence insufficiency.

BACKGROUND: Convergence insufficiency (CI) is a common entity but seems to be an ill-defined diagnosis that incorporates many near-vision symptoms. The current literature often varies in its criteria for diagnosis. Without a clear definition and standardization of the clinical examination, there is the potential for misdiagnosis and/or the inclusion of other diagnoses as CI. The purpose of this study was to assess the uniformity of diagnostic criteria in a well-defined practice environment. METHODS: The medical records of individuals diagnosed with CI between June 2007 and November 2014 who were patients of 6 fellowship-trained strabismologists in private practices and at Wills Eye Hospital clinics were reviewed retrospectively. Exclusion criteria included any previous treatments for CI, prior strabismus surgery, or other causes for strabismus, including cranial nerve palsies. The following data were collected: age, sex, race, age at diagnosis, past medical and family history, relevant symptoms, visual acuity, near point of convergence (NPC), strabismus measurements, and fusional amplitudes at distance with base-out and base-in prisms. RESULTS: A total of 387 patients fit our inclusion criteria and were analyzed in our study. There was no uniformity across clinicians in the clinical evaluation and diagnosis of patients with CI. The amplitude of the NPC was highly variable, and most clinicians did not assess the quality of the convergence movement or perform convergence fusional amplitude testing in making the diagnosis of CI. CONCLUSIONS: Our review has demonstrated the range of criteria within one group of practitioners to diagnose CI. This may reflect our current understanding and the need for an evidence-based definition of the disease and its diagnosis.

Pediatric optic neuritis.

PURPOSE OF REVIEW: Pediatric optic neuritis may be challenging to diagnose and treat. Significant clinical investigation of optic neuritis occurring in adults guides current clinical practices. Differences in presentation and prognosis exist for pediatric patients with optic neuritis when compared with adults including the risk of developing multiple sclerosis. The aim of this review is to provide an update on latest advances in the diagnosis, treatment and current research concerning pediatric optic neuritis. RECENT FINDINGS: Limited case series and retrospective reviews constitute much of the data we know about patients with pediatric optic neuritis. Pediatric optic neuritis is included in the spectrum of neuroinflammatory diseases. Testing modalities (ocular coherence tomography and visual evoked potentials) and serologic testing (antibodies against aquaporin-4 and myelin oligodendrocyte glycoprotein) are being investigated for diagnostic and prognostic value. The low incidence of pediatric optic neuritis results in small sample sizes may contribute to conflicting results of different studies. SUMMARY: Recent advances in diagnostic and serologic testing in pediatric neuritis may offer better diagnosis, treatment and prediction of prognosis. Validation requires well designed prospective research.

Current concepts in convergence insufficiency.

PURPOSE OF REVIEW: As the majority of our patients are spending significant time using computers and reading, it is important to understand any disease process that can affect one's near vision. Convergence insufficiency, not an uncommon condition, is still not screened for by most eyecare professionals. This review aims to report the current screening methods and diagnostic criteria, and to summarize the current treatment of convergence insufficiency. RECENT FINDINGS: The current literature shows that convergence insufficiency has a prevalence of 2-17% in the general population and an even higher rate, up to 49%, in patients who have suffered a traumatic brain injury. Although the measurement is still not standardized, near point of convergence and patient symptomatology appear to be an appropriate screen for convergence insufficiency. Further study is needed to establish standardization of diagnostic criteria. It is now well recognized that orthoptic/vergence therapy provides excellent improvement in the clinical measurements and symptoms associated with convergence insufficiency. SUMMARY: Convergence insufficiency is a condition that causes a significant impact on near vision. Treatment with orthoptic/vergence therapy can reduce symptomatology and greatly improve one's quality of life. Further study is needed to provide an evidence-based definition that encompasses all cases of convergence insufficiency, research possible subtypes of the disease and establish the efficacy of home-based computer therapy as compared to office-based orthoptic/vergence therapy.

Intermittent exotropia: continued controversies and current management.

PURPOSE OF REVIEW: Continued controversy exists regarding intermittent exotropia and its management. Although it has been studied extensively, the indication for and timing of intervention and what therapy is most efficacious remains unclear. This article reviews the most recent research and the controversies surrounding the disease classification and treatment options in the management of intermittent exotropia. RECENT FINDINGS: Current studies are underway to uncover the natural history of the intermittent exotropia. Patching and observation are reasonable treatment options in the first 6 months of the disease presentation. As the disease progresses and nonsurgical management fails, botulinum toxin may play a role or be an alternative option in the early treatment of intermittent exotropia. Surgical treatment with orthoptic therapy may result in improved postoperative outcomes. SUMMARY: Although significant investigations have been performed on this entity, there remains poor cohesiveness between clinical trials resulting in lack of clarity regarding when and how to treat intermittent exotropia. As the natural history of the disease is elucidated and researchers standardize their assessment of the control of the strabismus and what constitutes a successful treatment outcome, better understanding may occur to develop more efficacious remedies. Despite being less known and utilized, botulinum toxin and orthoptic therapy are options for treatment for intermittent exotropia and should be considered for appropriate patient's treatment protocol.

Convergence insufficiency and its current treatment.

PURPOSE OF REVIEW: Considerable uncertainty and controversy has existed concerning the management of convergence insufficiency. Only recently there have been significant scientific studies published that compare the effectiveness of the commonly prescribed treatments. This paper reviews the most recent research and literature on convergence insufficiency and its treatment. RECENT FINDINGS: The first large-scale placebo-controlled, randomized clinical trials to study the various treatments of convergence insufficiency have recently been published. Current research compares the effectiveness of base-in prism glasses, pencil push-ups, and vision therapy in reducing the signs and symptoms of convergence insufficiency and suggests that orthoptic therapy is the most efficacious treatment for convergence insufficiency. SUMMARY: Intensive orthoptic therapy is the treatment of choice for convergence insufficiency. Pencil push-ups and use of accommodative targets have a role in the treatment of convergence insufficiency when used as part of a more intensive orthoptic program. Base-in prism glasses should be reserved for reduction of symptoms in the presbyopic population.