Ophthal. Physiol. Opt.

2002 22: 565–571

Efficacy of treatment for convergence

insufficiency using vision therapy
Paul Adler
50 High Street, Stotfold, Herts SG5 4LL, UK

Abstract
Purpose: The purpose of this study was to determine if vision therapy (VT), as practised within the
constraints of UK optometric practice, employing graded routine eye exercises, is as an effective
method for treatment of convergence insufficiency (CI) as previously published data suggest. The
study also evaluates the associated symptoms before and after therapy.
Methods: As many optometrists diagnose CI solely on the basis of near point of convergence (NPC)
and treat only when symptoms are present (Letourneau et al., 1979; Rouse et al., 1997), in this study
CI was defined as NPC of 10 cm or greater (either with or without the presence of asthenopic
symptoms for near work) accompanied by exophoria greater at near than at distance. The effect of
treatment by optometric vision therapy (OVT) on the NPC and number of symptoms was investigated
for 92 patients by retrospectively reviewing the clinical records. Success was defined as the
restoration of NPC to normal values and significant reduction in the presenting symptoms.
Results: The effect of treatment on the NPC was shown to be highly significant (t ¼ 14.61,
p < 0.001). Although treatment times were slightly longer, the success rates were higher than
reported by other authors. Post-treatment values for NPC were: <10 cm (98.9%), <8.5 cm (95.7%)
and <6.5 cm (80.4%). Longer treatment times were noted for patients who complained that the text
appeared to move (v2, p ¼ 0.007).
Conclusion: Vision therapy is an effective method for treatment of CI.

Keywords: convergence insufficiency, treatment, vision therapy

the NPC to normal values and reports the associated

Introduction
symptoms.
Convergence insufficiency (CI) is characterised by some In optometric practice the diagnosis of CI is most
authors primarily by an extended near point of conver- often, but not universally, made on the basis of
gence (NPC) and is frequently associated with asthen- measured NPC using a push up technique, and the
opic symptoms for near work. The associated visual severity of the symptoms (Letourneau et al., 1979;
symptoms include headaches, intermittent crossed di- Rouse et al., 1997). Convergence insufficiency is most
plopia, blurred vision, eye strain, tired eyes, sleepiness often described as a syndrome that includes the follow-
and loss of concentration. Near point performance is ing signs: exophoria that is greater at near than at
reduced by an inability to make or comfortably sustain distance; remote NPC; decreased or absent fusional
the convergence demand that is required by the task convergence, especially at near; and normal prism
(Grisham, 1988). This study primarily examines the divergence (Rouse et al., 1997).
effect of optometric vision therapy (OVT) on restoring Convergence insufficiency can be found in patients
with orthophoria, or even esophoria, at near, although
this is less common (Griffin and Grisham, 1995). Other
Received: 20 October 2001 clinical findings associated with CI include low AC:A
Revised form: 28 May 2002 ratios and deficient accommodative responses, including
Accepted: 15 July 2002 disuse of accommodative convergence and accommo-
dative insufficiency (Evans, 2002).
Correspondence and reprint requests to: Paul Adler
Tel.: 01462 732393; fax: 01462 733881
The NPC is defined as the point in space located
E-mail address: info@[Link] directly in front of the patient’s face in the median plane

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566 Ophthal. Physiol. Opt. 2002 22: No. 6

and defined by the intersection of the lines of sight when Furthermore, no studies base success rates on the new
maximal convergence is used (Millodot, 2000). It is an norms established by Hayes et al. (1998). They reported
important clinical measurement and is included rou- NPC break values (mean ± S.D.) were 3.3 ± 2.4 cm
tinely in optometric eye examinations. The point at for kindergartners, 4.1 ± 2.4 cm for third graders and
which the patient reports that the target has become 4.3 ± 3.4 cm for sixth grades and they recommended a
double or the examiner observes one eye to lose fixation clinical cut-off value of 6 cm be used for patients of
and turn outward, whichever occurs first, is taken as the elementary school age.
NPC. The numerical value attributed to the NPC is Reported success rates of CI treatment vary from 9
obtained by measuring the distance from this point to (Norn, 1966) to 96% (Cohen and Soden, 1984). In a
the plane of the centre of rotation of the two eyes using a review of the literature, Grisham (1988) found an
ruler (von Noorden, 1996). In practice, however, the average cure rate, using VT for CI, of 72%. The
measurement is made to the point on the subject’s head differences in cure rates can be explained, at least in
midway between the two eyes. Duane (1895) described part, by the different treatment regimens used and the
extended NPC as the most consistent finding in CI. different criteria employed. Some studies reported only
Rouse et al. (1997) found that NPC was used in making on subjective results whilst others included quantitative
the diagnosis by 93.8% of optometrists surveyed and measures in defining success. These included long-term
often the diagnosis of CI was made solely on the basis of effects of treatment on the NPC, near heterophoria,
NPC (Letourneau et al., 1979; Rouse et al., 1997). positive fusional reserves at near, and symptoms
Normal values for NPC are widely considered to be (Grisham, 1988). Improvement in symptoms and NPC
between 8 and 10 cm (Hodkoda, 1984; Letourneau and were usually maintained if initial treatment restored
Ducic, 1988; Dwyer, 1991; Scheiman and Wick, 1994; normal NPCs (Grisham, 1988). Grisham (1988) also
Griffin and Grisham, 1995; von Noorden, 1996; Rouse states that the effect of in-office training is independent
et al., 1997). Several recent studies have shown that of age until the late presbyopic years.
NPC in children up to sixth grade is in general less than The present study examines the efficacy of weekly
6 cm (Hayes et al., 1998; Hong Chen et al., 2000). office-based OVT supplemented by daily home practice
The prevalence of CI has been estimated as between sessions of between 15 and 20 min per day, using a
2.2 and 13% depending on the number of clinical retrospective cohort study, and includes all patients
criteria used in order to diagnose the condition treated by VT with a diagnosis of CI in a UK general
(Letourneau et al., 1979; Letourneau and Ducic, 1988; optometric practice.
Porcar and Martinez-Palomera, 1992; Rouse et al.,
1998; Lara et al., 2001). Rouse et al. (1998) suggested
Methods
that amongst child patients aged 8–12 years, the rate of
CI in the highly suspect, or definite categories, was as Clinical records were reviewed of all patients who had
high as 17.6%. They also found the percentage of been treated by weekly office-based VT supplemented by
children rated as symptomatic increased with the num- daily home practice sessions of between 15 and 20 min
ber of CI-related clinical signs present. per day for CI, between February 1993 and May 1999.
In UK hospital ophthalmology departments, the A total of 110 patients received VT for CI. Sixteen cases
conventional treatment is by orthoptic intervention were excluded because of incomplete data (four records
using simple convergence exercises or more often failed to record initial or final NPCs), or because
physiological diplopia exercises employing chiastoscopic treatment was declined (12 cases). A further two cases
flat fusion stereograms. In UK optometric practice, mild were excluded because they were too young to be treated
cases are often treated using simple pencil to nose in the same way as the others included in the study. Data
exercises with physiological diplopia controls performed from 92 patients were included in the study. The
at home supervised by a family member. More severe age ranged from 6 to 35 years (mean ± S.D, 10.2 ±
cases are often referred to hospital ophthalmology 3.55 years).
departments for orthoptic intervention. In these cases, All the patients were assessed before treatment, and
treatment is by home exercises. on completion of the treatment, by the author. All of the
There has recently been an increase in optometric patients completed the treatment as requested.
treatment by vision therapy (VT), which entails a graded Data were collected on the NPC and symptoms
exercise regimen with more frequent visits to the practice before and after treatment. The clinic routinely uses a
for therapy (hereinafter described as office visits) with questionnaire to record symptoms at the initial evalu-
shorter intervals between office visits. Vision therapy has ation and on discharge (Figure 1). The questionnaire
been shown to be effective in CI (Daum, 1986) and is was completed in advance of the first appointment
well established in the USA and some other countries by the patient, with the help of parents and verified
but has not previously been evaluated in the UK. by the author during the examination. An identical

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 Convergence insufficiency: P. Adler 567

Figure 1. The questionnaire administered to all patients routinely.

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568 Ophthal. Physiol. Opt. 2002 22: No. 6

questionnaire was administered at the review when the plane also provides kinaesthetic feedback by small
decision to cease treatment was made. amounts (P. Harris, personal communication, 1997).
Convergence insufficiency was diagnosed in this Where the patient was able to perform any procedure
study as NPC of 10 cm or greater, either with or to the degree of competency expected for their age, the
without the presence of asthenopic symptoms for near activity was not given as an exercise. Accommodative
work, accompanied by exophoria greater at near than skills were included because accommodative dysfunction
at distance. Measurements of NPC were made by is often associated with CI and will, when deficient,
asking the patient to fixate an N5 (or larger if result in fatigue and blurred vision. Convergence exer-
appropriate) letter printed on a ruler. The rule was cises utilising physiological diplopia suppression con-
brought towards the patient on the mid-line, and the trols and multisensory input were given to all patients.
patient asked to report any blur or diplopia immedi- This was considered important as central foveal sup-
ately. The NPC was recorded either from the point at pression causes confusion (Griffin and Grisham, 1995).
which diplopia was first noted by the patient, or, from Furthermore, giving binocular exercises in the presence
the point that the examiner observed one eye to of central foveal suppression may result in the exercising
deviate, as suggested by Hayes et al. (1998). Each of monocular skills or reinforcing the suppression.
measurement of the NPC was taken three times and an Additional base-in and base-out fusional range work
average measurement was recorded on the clinical using both in office and home exercises, either with
notes. Measurements were made to the nearest centi- stereoscopes or with chiastoscopic fusion training meth-
metre using the centimetre scale on the rule or a ods, were given. Chiastoscopic fusion is the crossing of
retractable tape if the distances were large. the visual axes relative to the plane of the paper on
All patients were required to undergo various exerci- which is printed a standard stereogram. This requires an
ses as part of their treatment to ensure adequate visual understanding of voluntary convergence in order to
skills in convergence and accommodative function. The ÔfuseÕ the two images whilst maintaining accommodation
activities were performed in a sequential order and are at the plane of the card and is described in more detail
shown in Table 1. All exercises have been described by elsewhere (Griffin and Grisham, 1995).
Griffin and Grisham (1995) (see Table 1) except for ÔEye An optometric assistant, trained to deliver VT saw
ControlÕ. This exercise required the patients to look at a patients weekly in the clinic for training. The optomet-
vertical line, made by touching together their own first rist reviewed progress at least after every six office visits.
fingers held vertically, by the finger tips, and held on the Where the therapist felt the patient had completed the
mid-line at arm’s length. The fingers are then brought treatment, earlier review was arranged. Modifications to
closer, a centimetre at a time, ensuring the vertical line the exercises were made to make the task easier or more
made by the patient’s own first fingers remains single difficult depending on the ability of each patient. Thus,
and an awareness of physiological diplopia is main- the precise therapy offered varied depending on the age
tained for all distant objects. Tactile feedback from the and need and was not identical in each case. Patients
point at which the two fingers are in apposition and were given new activities to undertake as soon as they
proprioceptive feedback of the arms help to ensure the had succeeded with the present ones to ensure that there
patient’s full attention is directed at the task of was as little boredom as possible. Often a similar
converging. The movement of the fingers in the vertical exercise at a slightly more difficult level was given so
that a graded approach was taken and each patient
could progress at their own pace. This ensured that
Table 1. General sequence of activities and location of VT. The all exercises were selected to be appropriate for the
sequence of OVT activities used as described by Griffin and Grisham skill level of each patient, so that there was a high
(1995). Eye Control was described by P. Harris (personal commu- probability that the patient would succeed and to
nication, 1997) increase motivation.
Activity Office or home Several activities were prescribed for practice at home
so that patients increased their skill levels in conver-
Monocular accommodative rocka Office and home
gence, accommodation and fusional range at the same
Monocular trombone reading Office and home
Eye control Office and home
time.
Beads on a string Office and home A home exercise programme was provided to practice
Chiastoscopic fusion exercises Office and home the skills learned in the clinic. Patients were asked to
Aperture rule Office only practice three or four activities every day at home
Stereoscopes Office only between office visits. Each activity was prescribed for
Tranyglyphs Office only around 5 min a day. Patients were thus expected to
Vectograms Office only
complete between 15 and 20 min of training activities
a
Normative values were used as described by Zellers et al. (1984). per day. A family member was trained as a helper, to

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 Convergence insufficiency: P. Adler 569

ensure that each patient was given proper feedback and there was no significant difference between males and
encouragement for the home therapy. Written instruc- females at the end of treatment (v2, p ¼ 0.26). There
tions of each activity were provided to the helper and, in were no statistical differences demonstrated between the
addition, a daily log was supplied and each patient was age at which treatment commenced and the NPC
asked to assess how well the session had gone. This achieved (v2, p ¼ 0.92).
enabled an assessment of how regularly the exercises Of the 92 patients, 90 patients (98.9%) achieved the
were undertaken. Understanding how easy the patient generous 10 cm point for NPC. Of the two who did not
found each exercise helped to decide on the degree of achieve this level, one commenced with an NPC of
difficulty of the next task that was given. 50 cm and only managed 28 cm at completion and the
Treatment was continued until the patient achieved other demonstrated very little improvement. Using
an NPC of at least 6 cm with ease. In cases where this values of 8 cm or less as the value for success, four
end point was not reached, treatment was continued patients did not meet the criteria for success (4.3%). The
until there was no further progress on two consecutive success rate for this group is thus 95.7%. Using the cut-
visits. Once the required end point had been reached, the off of normality recommended by Hayes et al. (1998)
patient was asked to practice one activity for 5 min once and Hong Chen et al. (2000) for younger children of
a week for a period of 2 months to reinforce the skills 6 cm as the criteria for success in this study, a rate of
they had learned. 80.4% is achieved, 18 subjects achieving NPCs more
remote than 6 cm. The number of patients achieving
each NPC, relative to their starting point is shown in
Results
Table 2.
The patient group consisted of 92 subjects of whom 67 The average improvement of the NPC was 18.3 cm
(73%) were male and 25 (27%) female. Age ranged from (S.D. ± 11.3; v2, p < 0.001). There was no statistical
5 to 35 years. The mean age was 10.18 years difference between boys and girls nor was there any
(S.D. ± 3.55). The mean age of the males was correlation between the starting point for NPC and the
11.72 years (S.D. ± 5.37) and 9.6 years (S.D. ± 2.38) end point either for the group as a whole or for either
for the females. The greater percentage of males could gender. Furthermore, the age at diagnosis does not
reflect the referral pattern to the practice, which receives affect the NPC at diagnosis or after treatment.
many recommendations from teachers, as the ratio of The number of visits for treatment ranged from 2 to
males to females is similar to the proportion of children 20 office visits. The mean was 7.4 (S.D. ± 4.63) visits
who underachieve at school (Warnock, 1978). The (Figure 3). There was no significant correlation between
patients’ ages at presentation are shown in Figure 2, the number of visits and the NPC before or after
with 76% presenting to our practice before the age of treatment (v2, p ¼ 0.958); nor does gender affect the
13 years. number of visits.
On initial diagnosis, the mean NPC was 23.17 cm Analysis of the visual symptoms demonstrated that
(S.D. ± 12.28), range 10–60 cm. After treatment, the there were multiple complaints before treatment. Many
mean NPC for the whole group was 4.88 cm patients complained of more than one visual symptom.
(S.D. ± 3.15) [boys 5.64 cm (S.D. ± 5.17) and girls Incomplete data excluded 13 cases. There were 445
4.6 cm (S.D. ± 1.92)]. The effect of treatment on the individual reports of symptoms. These included: dis-
NPC was highly significant (t ¼ 14.61, p < 0.001), but tance blur after close work, words appearing to jump

Table 2. NPC at presentation compared with NPC post-treatment

(in cm)
NPC post-treatment
NPC at Total number
presentation 0–6 7–8 9–10 26–30 of patients

9–10 5 1 2 8
11–15 17 4 1 22
16–20 22 1 23
21–25 11 2 13
26–30 6 3 9
31–40 4 2 6
41–50 8 1 1 10
51+ 1 1
Figure 2. Age (years) at which treatment for CI was commenced in
Total 74 14 3 1 92
years against number of patients.

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570 Ophthal. Physiol. Opt. 2002 22: No. 6

p ¼ 0.047) and having to hold text further away

(v2 ¼ 51.797, d.f. ¼ 36, p ¼ 0.043).

Discussion
The results clearly indicate that when CI is defined by
NPC alone, VT is an effective form of therapy. Even
when the normative NPC findings of Hayes et al. (1998)
and Hong Chen et al. (2000) are taken as the goal for
treatment, VT can be considered as successful.
Our results appear to be rather better than in many
previously reported studies, although a cure rate of 96%
Figure 3. The number of patients plotted against the number of
weekly visits during treatment.
was reported by Cohen and Soden (1984), who treated
28 patients with convergence of greater than 10 cm or a
recovery of 7.5 cm beyond the break point. This high
around, text appearing to change size, fade, have success rate may be due to the frequency and number of
colours around it, gaps between words disappearing, sessions and graded therapy activities designed to
text appearing to be hidden by the apparent whiteness of promote motivation. Training family helpers to ensure
the page, diplopia, needing to hold near work further that the activities were properly performed and practised
away, rubbing the eyes frequently during close work and may have helped to enhance the compliance, which is
screwing the eyes up during near tasks, tilting the book, always a problem in this type of treatment. The majority
excessive blinking, moving the book around and head- of the patients were self-financing and this could have a
aches. large positive effect on the motivation of the patient,
The results are reported in Table 3, which shows each and thus the success.
symptom or sign along with the frequency with which it The number of visits in our study is rather more than
was reported, and the significance of the effect of many researchers have found. Daum (1984) suggested
treatment on each symptom. All symptoms except that 4.3 (S.D. 4.1 weeks) visits were required using a
seeing colours around text and eye rubbing during close regimen of home therapy. The longer treatment times in
tasks show significant improvements after OVT our study group could be related to the young age of the
(p £ 0.01). subjects. A further consideration was the philosophy of
More sessions to reach acceptable NPCs were re- ensuring the lowest possible NPC before discharge. This
quired for those patients complaining of words that was an important consideration during treatment as this
appeared to move on the page (v2 ¼ 52.495, d.f. ¼ 36, has been shown to ensure that there is less chance of

Table 3. Reported symptoms before and after treatment

Percentage Percentage of Percentage of
Cases of responses cases before VT cases after VT v2, p

DV blur 40 8.99 43.5 1.1 0.001

Jump 30 6.74 32.6 2.2 0.001
Size change 28 6.29 30.4 2.2 0.005
Fade 19 4.27 20.7 1.1 0.001
Colours 27 6.07 29.3 2.2 0.04
Appear to move 31 6.97 33.7 2.2 0.001
Text hidden 29 6.52 31.5 2.2 0.001
Diplopia 42 9.44 45.7 2.2 0.001
Holding at arms length 13 2.52 14.1 3.3 0.01
Eye rubbing 44 9.89 47.8 3.3 0.02
Screwing eyes up 29 6.52 31.5 2.2 0.001
Tilting book 31 6.97 33.7 2.2 0.001
Excessive blinking 24 5.39 26.1 1.1 0.002
Moves book 30 6.74 32.6 3.3 0.006
Headaches 28 6.29 30.4 1.1 0.001
100

Responses to the symptom questionnaire before and after OVT described as a percentage of all symptoms reported, percentage of cases before
OVT, percentage of cases after OVT and the significance of the intervention (v2) on each symptom.

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 Convergence insufficiency: P. Adler 571

regression in later years (Pantano, 1982). Most patients Evans, B. J. W. (2002) Pickwell’s Binocular Vision Anomalies,
achieve success in six sessions, however, there are some 4th edn. Butterworth-Heinemann, London.
who require much more. The data suggest that it may be Griffin, J. R. and Grisham, J. D. (1995) Binocular Anomalies:
worthwhile persevering in treatment for patients who do Diagnosis and Vision Therapy, Butterworth-Heinemann,
Boston.
not appear to respond quickly.
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Longer treatment times were noted for patients who
insufficiency: a literature review. Am. J. Optom. Physiol.
complained of words that appeared to move on the page Opt. 65, 448–454.
(v2, p ¼ 0.047) or where the text needed to be held Hayes, G. J., Cohen, B. E., Rouse, M. W. and De Land, P. N.
further away (v2, p ¼ 0.043). Both of these symptoms (1998) Normative values for the near point of convergence
suggest that there is a degree of binocular instability of elementary schoolchildren. Optom. Vis. Sci. 75, 506–512.
present resulting in an apparent shift of the position of Hodkoda, S. C. (1984) General binocular dysfunctions in an
the text, in the case of words appearing to move on the urban optometry clinic. J. Am. Optometric Assoc. 55, 491–
page, or causing the patient to avoid convergence in the 494.
case of holding the text far away. It may prove useful Hong Chen, A., O’leary, D. J. and Howell, E. R. (2000) Near
when developing treatment plans, to be aware that visual function in children. Ophthalmic Physiol. Opt. 20,
185–198.
patients complaining of these symptoms may take
Lara, F., Cacho, P., Garcı́a, A. and Megı́as, R. (2001) General
longer to treat.
binocular disorders: prevalence in a clinic population.
These findings confirm that treatment of CI by OVT is Ophthalmic Physiol. Opt. 21, 70–74.
an extremely effective treatment modality. The relatively Letourneau, J. E. and Ducic, S. (1988) Prevalence of conver-
simple and inexpensive treatment procedures, short gence insufficiency among elementary school children. Can.
treatment times and reduction of symptoms should re- J. Optom. 50, 194–197.
assure practitioners that OVT is an effective tool and Letourneau, J. E., Lapierre, N. and Lamont, A. (1979) The
that referral to ophthalmologist-led centres is not likely relationship between convergence in sufficiency and school
to lead to better results. Nevertheless, there is still a need achievement. Am. J. Optom. Physiol. Opt. 56, 18–22.
for a multicentre prospective study using a placebo Millodot, M. (2000) Dictionary of Optometry and Visual
control of exercises resembling VT. It should also be Science. Butterworth-Heinemann, Boston.
von Noorden, G. K. (1996) Binocular Vision Motility and
noted that, in this study, there was no masking for the
Ocular Motility. C. V. Mosby, St Louis.
pre- and post-treatment assessments. This is a possible
Norn, M. S. (1966) Convergence insufficiency: incidence in
source of bias which could affect the data. ophthalmic practice. Results of orthoptic treatment. Acta
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project grant from the College of Optometrists is Porcar, E. and Martinez-Palomera, A. (1992) Prevalence of
gratefully acknowledged as is the help received from binocular dysfunctions in a population of University
Dr Karen Windle, methodologist for HertsNet, and students. Graefes Arch. Clin. Exp Ophthalmology. 230,
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ª 2002 The College of Optometrists