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Convergence Insufficiency

Convergence Insufficiency
Articles and National Institute of Health Research
In an ABC Health Beat report titled "Eyeing a Problem," we learned about young patients Clark Walcott and Kaylan Holmes.  They were part of the approximately 60% of students identified as "problem learners" that actually have undetected vision problems.

Eye condition may seem like a learning problem
By Sylvia Perez

It's a vision disorder that could affect a child's ability to read and learn, and it's something many parents have never heard of.

According to the American Optometric Association, 60 percent of students identified as "problem learners" may actually have undetected vision problems. One of those problems could be something called convergence insufficiency.

"They said, 'Oh he does have this convergence insufficiency in his eyes,' and I thought, 'Oh that's a big name for something, what is it?" recalled mother Patty Walcott.

Walcott was surprised to learn that despite having 20/20 vision, her son, Clark, has C.I.

Convergence insufficiency is an eye movement disorder where the eyes don't turn inward when focusing on a nearby object. For example, when you read or look at something up close you may not realize it, but your eyes should naturally turn inward. People with c-i have have to work harder to do this...

"I was getting a lot of headaches," said Clark.

Headaches are one symptom, while others include difficulty concentrating, squinting or closing one eye, blurred vision, double vision and difficulty reading. For students, that can translate into a short attention span, fatigue and a tough time maintaining good grades.

Clark's parents didn't make a connection right away. They didn't think his complaints matched what you would think to be an eye condition.

Pediatric specialists at the Wheaton Eye Clinic in Naperville help diagnose and treat C.I.

"A lot of people have it and don't necessarily know they have it," said Michael Kipp, pediatric ophthalmologist at the clinic.

It's estimated that anywhere from 5-12 percent of U.S. children may have the condition. But there may be many more that go undiagnosed because it can only be found with special eye-focusing tests. C.I. usually isn't caught with standard eye chart tests.

Nadene Holmes, another mother, said her daughter Kaylan was initially misdiagnosed.

"They said there was nothing wrong with her eyes and don't worry about it, and we'll see her back in three to four years," Holmes said.

But Kaylan was still getting headaches. A second opinion revealed the muscle deficiency. The good news is that C.I., in most cases, can be corrected with eye-focusing exercises.

"The exercises we do are very, very simple," said Susan Stepleton, O.D., pediatric optometrist. "Just taking the time to do them, most kids get better in two to three months."

The specialists say it's like going to the gym and working your muscles to get them in better tone.

After a couple of months of hard work, the exercises seem to be paying off for Clark. His parents said they saw an improvement in his ability to read for longer periods and that his grades rebounded. They also said his headaches lessened as well.

C.I. is most often detected in adolescence, but adults can have it too. Doctors stress that C.I. may contribute to reading difficulties, but in most cases, is not the sole cause.

If you're concerned about your child's eyesight, be sure to ask that their eye screening include a check for muscle imbalance.

Convergence Insufficiency Treatment Trial
Sponsored by the National Institutes of Health

Researchers have concluded that the most effective form of treatment for Convergence Insufficiency (CI) in children is office based vision therapy with a trained therapist combined with home reinforcement.

The Convergence Insufficiency Treatment Trial was a collaborative study with optometrists and opthalmologists, funded by the National Eye Institute, and conducted at nine sites throughout the United States to include the Mayo Clinic ….The study was published in the Archives of Ophthalmology. Dr. Scheiman said. “This study is the first large-scale, high-quality study that’s been produced, and it’s a major breakthrough.”

CI is a common childhood eye-muscle coordination problem. (The following symptoms usually appear after 3rd grade when students start reading chapter books and they go from learning to read to reading to learn)

Symptoms include Loss of place while reading Loss of comprehension after short periods of reading (reading all the words yet not remembering what was read) Headaches Eyestrain (not necessarily corrected with glasses) Sleepiness (Homework that should take 20 – 30 minutes takes hours and creates lots of family stress) (Two or more semesters of Tutoring with more expected in the future)

The U.S. Chamber of Commerce—the world's largest business federation representing more than 3 million businesses and organizations of every size, sector, and region—believes that improving the performance of the K-12 education system in the United States is necessary to provide a strong foundation for both U.S. competitiveness and for individuals to succeed in our rapidly changing world. (overview - http://www.uschamber.com/icw/reportcard/default) is reporting: Despite decades of reform efforts and many trillions of dollars in public investment, U.S. schools are not equipping our children with the skills and knowledge they-and the nation-so badly need….education spending has steadily increased and rafts of well-intentioned school reforms have come and gone. But student achievement has remained stagnant, and our K-12 schools have stayed remarkably unchanged-preserving, as if in amber, the routines, culture, and operations of an obsolete 1930s manufacturing plant.

The measures of our educational shortcomings are stark indeed; most 4th and 8th graders are not proficient in either reading or mathematics. Only about two-thirds of all 9th graders graduate from high school within four years. And those students who do receive diplomas are too often unprepared for college or the modern workplace. Despite such grim data, for too long the business community has been willing to leave education to the politicians and the educators-standing aside and contenting itself with offers of money, support, and goodwill. But each passing year makes it clear that more, much more, is needed.

Good grades take work. Don’t be fooled with the statement 20/20 is perfect vision. 20/20 is only the clarity of seeing and is the first part of the visual perceptual / processing system. When the eyes don’t work together the information going to the brain is convoluted and the brain will produce poor results / grades. Use your commonsense why is poor performance in school happening? You know your child is smart when you verbally question them. How come when it comes time to read the paragraph (they skip words / lines) / take a written test (they have below average results – although orally quizzing they ‘know it cold’) / simple homework takes longer than normal, etc.? It is not because they like conflict or getting yelled at THEIR VISUAL SYSTEM NEEDS VISION THERAPY. As the parent these symptoms don‘t go away the symptoms are telling you something so use your commonsense and get your child’s eye evaluated by a Fellow in the College of Optometrists in Vision Development www.covd.org any other evaluation will not find these deficiencies. Most eye doctors are not trained in this area so they don’t test for eye alignment or muscle imbalance issues or blow off the symptoms therefore it must not be there. Who is the loser? Your family and your struggling child. All it take is one child to unknowingly stress the rest of the family with undetected eye muscle problems the key is homework issues (especially homework that takes hours and hours). CALL OUR OFFICE AND TELL US YOU WANT THE $10 STUDENT VISION SCREENING – a $75.00 value (if you don’t tell us you want the free screening and we do a full evaluation – pull out your checkbook it is only $160 or more)

Lets get educated you about different fellowships in the eye profession. Medical doctors went to medical school to treat diseases with prescription drugs and perform surgery. Medical doctors don’t do physical, occupational, or other types of therapy because of the time requirements and that is why they hire professional physical or occupational therapists. The time commitment to learn the therapies would take to much time from their life’s training of being a surgeon. Muscle surgery only takes hours it is the therapy that takes months done by a professional therapist to get the muscles working together properly.

Our training in becoming ‘Board Certified in Vision Development and Therapy’ required three years in a vision therapy office after optometry school, case studies in vision therapy, research questions about vision therapy, visiting with a mentor (mine was located in D.C.), three hour vision therapy examination, and finally an oral examination by the International Certifying Board. To keep our certification it requires 24 hours of continuing education specifically for vision therapy. The Virginia Board of Optometry only requires 14 hours of continuing education and that can be in contact lenses, glaucoma, eye disease, retina, and numerous other areas.

A list of Fellowships in the eye care profession follow: American Academy of Ophthalmology American Assoc. of Pediatric Ophthalmology and Strabismus American Society of Cataracts and Refractive Surgeons American College of Surgeons Corneal Society Contact lenses Low Vision Neuro-ophthalmology and orbital disease Ophthalmic Plastic and Reconstructive Surgery Public Health Retinal and Vitreous disease


Vision Development and Therapy (Dr. Toler)

Not Autistic or Hyperactive. Just Seeing Double at Times
By LAURA NOVAK

As an infant, Raea Gragg was withdrawn and could not make eye contact. By preschool she needed to smell and squeeze every object she saw.

Raea Gragg, 9, needed therapy to help her eyes work together.

“She touched faces and would bring everything to mouth,” said her mother, Kara Gragg, of Lafayette, Calif. “She would go up to people, sniff them and touch their cheeks.”

Specialists conducted a battery of tests. The possible diagnoses mounted: autism spectrum disorder, neurofibromatosis, attention-deficit hyperactivity disorder, anxiety disorder.

A behavioral pediatrician prescribed three drugs for attention deficit and depression. The only constant was that Raea, now 9, did anything she could to avoid reading and writing.

Though she had already had two eye exams, finding her vision was 20/20, this year a school reading specialist suggested another. And this time the ophthalmologist did what no one else had: he put his finger on Raea’s nose and moved it in and out. Her eyes jumped all over the place.

Within minutes he had the diagnosis: convergence insufficiency, in which the patient sees double because the eyes cannot work together at close range.

Experts estimate that 5 percent of school-age children have convergence insufficiency. They can suffer headaches, dizziness and nausea, which can lead to irritability, low self-esteem and inability to concentrate.

Doctors and teachers often attribute the behavior to attention disorders or seek other medical explanations.

Mrs. Gragg said her pediatrician had never heard of convergence insufficiency.

Dr. David Granet, a professor of ophthalmology and pediatrics at the University of California, San Diego, said: “Everyone is familiar with A.D.H.D. and A.D.D., but not with eye problems, especially not with convergence insufficiency. But we don’t want to send kids for remedial reading and education efforts if they have an eye problem. This should be part of the protocol for eye doctors.”

In 2005, Dr. Granet studied 266 patients with convergence insufficiency. Nearly 10 percent also had diagnoses of attention deficit or hyperactivity — three times that of the general population. The reverse also proved true: examining the hospital records of 1,700 children with A.D.H.D., Dr. Granet and colleagues found that 16 percent also had convergence insufficiency, three times the normal rate.

“When five of the symptoms of A.D.H.D. overlap with C.I.,” he said, “how can you not step back and say, Wait a minute?”

Dr. Eric Borsting, an optometrist and professor at the Southern California College of Optometry who has also studied the links between vision and attention problems, agreed. “We know that kids with C.I. are more likely to have problems like loss of concentration when reading and trouble remembering what they read,” he said.
“Doctors should look at it when there’s a history of poor school performance.”

Dr. Stuart Dankner, a pediatric ophthalmologist in Baltimore and an assistant clinical professor at Johns Hopkins, said that children should be tested for convergence difficulty, but cautioned that it was not the cause of most attention and reading problems.

Dr. Dankner recommended an overall assessment by a psychologist or education specialist. “An eye exam should be done as an adjunct,” he said, “because even if the child has convergence difficulty, they will usually also have other problems that need to be addressed.”

Doctors recommend a dilated eye exam and a check of eye teaming and focusing skills. Testing includes using a pen or finger to test for the “near point of convergence,” as well as a phoropter, which uses lenses and prisms to test the eyes’ ability to work together.

There is no consensus on how to treat convergence insufficiency. Next spring, the National Eye Institute will announce the results of a $6 million randomized clinical trial measuring the benefits of vision therapy in a doctor’s office versus home-based therapy.

For Raea Gragg, the treatment was relatively simple. For nine months she wore special glasses that use prisms to help the eyes converge inward. She then had three months of vision therapy. She has just entered fourth grade and is reading at grade level.

“Raea didn’t know how to describe it because that’s all she’s ever known,” her mother said. “She felt like she had been telling us all along that she couldn’t see, but nobody listened.”