Share this article on:

Home-Based Therapy for Symptomatic Convergence Insufficiency in Children: A Randomized Clinical Trial

Pediatric Eye Disease Investigator Group

doi: 10.1097/OPX.0000000000000975
Feature Article - Public Access

Purpose: To compare the effectiveness of home-based (HB) computer vergence/accommodative therapy (HB-C) to HB near target push-up therapy (HB-PU) and to HB placebo treatment (HB-P) among children aged 9 to <18 years with symptomatic convergence insufficiency (CI).

Methods: In this multicenter randomized clinical trial, participants were randomly assigned to computer therapy, near target push-ups, or placebo. All therapy was prescribed for 5 days per week at home. A successful outcome at 12 weeks was based on meeting predetermined composite criteria for the CI Symptom Survey, near point of convergence, and positive fusional vergence at near.

Results: A total of 204 participants were randomly assigned to HB-C (n = 75), HB-PU (n = 85), or HB-P (n = 44). At 12 weeks, 16 of 69 (23%, 95% CI: 14–35%) in the HB-C group, 15 of 69 (22%, 95% CI: 13–33%) in the HB-PU group, and 5 of 31 (16%, 95% CI: 5–34%) in the HB-P group were classified as having a successful outcome. The difference in the percentage of participants with a successful outcome in the HB-C group compared with the HB-PU group was −4% (two-sided 97.5% CI: −19 to +11%; p = 0.56) and with the HB-P group was +5% (two-sided 97.5% CI: −12 to +22%; p = 0.52), adjusted for baseline levels of the composite outcome components.

Conclusions: The majority of participants with symptomatic CI did not have a successful outcome at 12 weeks. Some participants treated with placebo were successful. With recruitment reaching only 34% of that originally planned and differential loss to follow-up among groups, estimates of success are not precise and comparisons across groups are difficult to interpret.

The Writing Committee and a list of the members of the Pediatric Eye Disease Investigator Group appear in the Acknowledgments.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.optvissci.com).

Mitchell M. Scheiman, Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647. e-mail: pedig@jaeb.org

Convergence insufficiency (CI) is a binocular vision disorder that has been reported to affect approximately 4% of school-age children in the United States.1–4 Symptoms occur while reading or doing close work and include loss of place, having to re-read a word or phrase, reading slowly, poor comprehension, sleepiness, blurred vision, diplopia, headaches, and eye strain.5–14 Treatment strategies include nonsurgical treatments, such as base-in prism or pencil push-ups, and variations of office-based and home-based vision therapy. Recent randomized clinical trials have shown office-based vergence/accommodative therapy with home reinforcement to be more effective than office-based placebo therapy,14–16 home-based pencil push-ups alone,14–16 and home-based computer vergence/accommodative therapy plus pencil push-ups14 in treating children with symptomatic CI.

Home-based treatments require fewer office visits and less patient-doctor contact time and may be less costly than office-based therapy, although formal cost-effectiveness studies have not been done. However, home-based computer vergence/accommodative therapy and home-based pencil push-up treatments have not been compared with placebo controls, raising questions about their clinical effectiveness.14,15 Another unknown is whether strategies to improve treatment compliance may increase success rates for children treated by home-based computer vergence/accommodative therapy and other home-based therapies.

The study reported herein was a multicenter randomized clinical trial designed to compare the effectiveness of home-based computer vergence/accommodative therapy (HB-C) with home-based near target push-up therapy (HB-PU; commonly referred to as pencil push-ups) and to compare HB-C to home-based placebo therapy (HB-P) in children 9 to <18 years of age with symptomatic CI.

Back to Top | Article Outline

METHODS

The study was supported through a cooperative agreement with the National Eye Institute of the National Institutes of Health, Department of Health and Human Services and was conducted according to the tenets of the Declaration of Helsinki by the Pediatric Eye Disease Investigator Group (PEDIG) at 30 clinical sites (private practices or academic institutions). The protocol and Health Insurance Portability and Accountability Act (HIPAA)–compliant informed consent forms were approved by the institutional review boards (IRB). A parent or guardian (referred to subsequently as “parent”) of each study participant gave written informed consent, and each participant assented to participation if required by site IRBs. Study oversight was provided by an independent data and safety monitoring committee. The study is listed on www.clinicaltrials.gov, under identifier NCT01515943, accessed April 23, 2015. The complete study protocol is available on the PEDIG website (www.pedig.net, accessed April 23, 2015).

Back to Top | Article Outline

Patient Selection

All participants presented to a PEDIG pediatric ophthalmologist or optometrist either seeking treatment or for routine care. Data were not collected to document which of the two reasons applied. Major eligibility included (1) age 9 to <18 years; (2) near exophoria ≥4 prism diopters (PD) greater than at distance; (3) reduced positive fusional vergence at near (PFV), defined as <20 PD mean PFV blur or failing Sheards’ criterion (mean PFV measured less than twice the near phoria magnitude); (4) mean near point of convergence (NPC) of ≥6 cm break; (5) symptomatic CI, defined as a Convergence Insufficiency Symptom Survey (CISS) (see SDC Fig. 1, available at http://links.lww.com/OPX/A259)8,17 score of ≥16 points; (6) best-corrected visual acuity of 20/25 or better in each eye at distance and near; and (7) near random dot stereoacuity of at least 400 seconds of arc. Additional eligibility criteria were applied to maintain masking of participants to their randomized treatments. A complete listing of inclusion and exclusion criteria can be found in Appendix Table 1, available at http://links.lww.com/OPX/A260.

Back to Top | Article Outline

Randomization and Treatment

Data were entered on the PEDIG website, and participants were randomly assigned (using a permutated block design stratified by site) to one of three HB treatment groups (HB-C group, HB-PU group, and HB-P group) in a 2:2:1 ratio with a 1-in-5 chance of being randomized to the HB-P group.

All therapies were prescribed 5 days per week for 12 weeks to be performed at home and are described in the CITS Procedures Manual (http://publicfiles.jaeb.org/pedig/protocol/CITS_Procedures_Manual_v_5_0_03_04_14.pdf). The HB-C group was prescribed 15 minutes of active computer vergence/accommodative therapy (CVAT) and 5 minutes of placebo flipper exercises. The HB-PU group was prescribed 15 minutes (in full or split into three 5-minute intervals) of a well-defined near target push-up (NTP) procedure and 5 minutes of placebo CVAT. The HB-P group was prescribed 15 minutes of placebo CVAT and 5 minutes of placebo flipper exercises.

All therapies were performed using (or in conjunction with) customized versions of the Home Therapy System (HTS; Home Vision Therapy, Inc., Gold Canyon, AZ) computer software that included a series of timed procedures within each therapy session. This software tracked the amount of time spent on each activity within each therapy session. The active CVAT consisted of fusional vergence procedures (base-in, base-out, autoslide, jump ductions) and an accommodative facility program. Placebo CVAT was similar to the active version except there was no specific accommodation program and the procedures were designed not to stimulate or exert any extra demand on the vergence system.

At enrollment, participants demonstrated their ability to perform the therapies for their assigned treatment group after instruction from study-certified personnel regarding program installation and completion of therapy procedures. Participants were to remain masked to their treatment group until they completed the study.

Back to Top | Article Outline

Testing Procedures

At each visit, the CISS was administered first, followed by clinical testing performed without cycloplegia in participants’ optimal refractive correction at enrollment (if required) by a study-certified examiner. Eligibility testing consisted of the CISS; ocular alignment (cover/uncover testing, prism and alternative cover test); three repeated trials of NPC (break, recovery), PFV (blur, break, recovery), and near point of accommodation (NPA) in the right eye; stereoacuity using the Randot Preschool Stereotest at near (Stereo Optical Co., Chicago, IL); and a cycloplegic refraction performed within 6 months before enrollment. For eligibility and follow-up examinations, the mean of the three repeated trials was computed for the NPA, NPC break, and PFV blur (the break point was used if no blur was reported for that trial) assessments. A full description of the test procedures are provided in the aforementioned CITTS Procedures Manual.

With the exception of the cycloplegic refraction and stereoacuity testing, the CISS and clinical testing were repeated at each follow-up examination by an examiner who was masked to participants’ treatment group. Ocular alignment, NPC, PFV, and NPA were required to be performed by a pediatric optometrist, pediatric ophthalmologist, or certified orthoptist.

Back to Top | Article Outline

Follow-Up Visits and Primary Outcome

Unmasked site personnel prescribed treatment for a 12-week period, consisting of a 1-week phone call to inquire about installation of the computer programs, and two visits 6 and 12 weeks after randomization. The primary outcome was “a successful outcome” based on meeting predefined composite criteria at 12 weeks. Participants were classified as achieving a successful outcome if they met “success” criteria at 12 weeks for all three measures as follows: (1) CISS score of <16 points and improvement of ≥9 points since baseline, (2) mean NPC break of <6 cm and a 12-week to baseline ratio of <0.763 for mean NPC break, and (3) mean PFV blur of >15 PD and a 12-week to baseline ratio of >1.419 for mean PFV blur. Previously reported repeatability data were used to define the improvement criterion for a single CISS score and for the mean of three repeated NPC break and PFV blur trials.14

Back to Top | Article Outline

Treatment Compliance

Compliance, defined as completion of the prescribed therapy session for ≥5 days per week, was actively monitored for all treatment groups each week using electronic data transferred from participants’ computer programs to a secure server via the internet. Although study personnel were able to electronically view treatment usage data for each of the therapies, performance data were only available for the active CVAT. Unmasked site personnel contacted participants who were noncompliant with one or both of their therapy procedures. In addition, performance checks (only available for the HB-C group) were conducted within the first 3 weeks of treatment to verify proper setup and use of the therapy.

For each treatment regimen, unmasked site personnel estimated the average frequency and duration of completed therapy per session from 0 to 6 weeks and from 6 to 12 weeks based on electronic data from the computer programs and interview with the participant and/or parent. The estimated percentage of prescribed therapy completed was categorized as 0 to 25%, >25 to 50%, >50 to 75%, >75%, or unknown (if unable to quantify the amount of treatment).

Back to Top | Article Outline

Statistical Analyses

The primary outcome was success at 12 weeks. The pre-planned sample size was 595 participants [238 participants in each of the two active treatment groups, 119 participants in the placebo (HB-P) group] to have 90% power to detect a treatment group difference for each of the two pairwise comparisons, HB-C versus HB-PU and HB-C versus placebo, assuming true population success percentages of 30%, 15%, and 10% for the HB-C group, HB-PU group, and HB-P group, respectively, with a type I error rate of 2.5% per comparison (5% overall) including adjustments for three planned interim analyses for futility and no more than 10% loss to follow-up. The assumed success percentages were determined based on the Convergence Insufficiency Treatment Trial (CITT)14 and clinical expertise. Due to sample size considerations, it was not feasible to compare the HB-PU group with the HB-P group as a primary outcome pairwise comparison based on the assumed successful outcome percentages of 15% vs. 10%.

After 27 months of recruitment, the study’s steering committee stopped enrollment into the trial due to insufficient recruitment. No interim monitoring was performed.

The primary analysis included two pairwise treatment group comparisons of the percentages of participants achieving a successful outcome using binomial regression adjusting for baseline covariates of CISS score (<28 points vs. ≥28 points), mean NPC break (<10 cm vs. ≥10 cm), and mean PFV blur (≥15 PD vs. <15 PD). The two pairwise treatment group comparisons were performed using linear contrasts with Bonferroni adjustment for multiple comparisons. The primary analysis included data from 12-week examinations completed between 10 and 18 weeks (inclusive), following a modified intent-to-treat principle that excluded participants with missing 12-week outcomes. Alternative analyses yielded similar results (data not shown) and included the following: exclusion of 12-week examinations completed outside of the protocol window (12–15 weeks, inclusive), imputation of 12-week outcomes for participants with a missing 12-week examination using two different multiple imputation strategies, and two post-hoc analyses that (1) included 12-week examinations completed outside of the analysis window and (2) assumed a “non-success” outcome for those with missing 12-week examinations.

Secondary outcomes included the percentage of participants who met success criteria for the individual components of the primary outcome composite measure and for both vergence measures (NPC and PFV), and percentage classified as improvers (12-week CISS score improvement of ≥9 points since baseline, 12-week to baseline ratio of <0.763 for mean NPC break, and 12-week to baseline ratio of >1.419 for mean PFV blur). For the HB-C group, the association between CVAT completion (defined as achieving ≥15 stars for the jump vergence exercise) and success at 12 weeks was evaluated using Bernard’s exact test. All analyses were conducted using SAS version 9.4 (SAS Inc., Cary, NC).

Back to Top | Article Outline

RESULTS

At 30 sites between June 2012 and August 2014, 204 participants were randomly assigned to the HB-C group (n = 75), HB-PU group (n = 85), or the HB-P group (n = 44). The mean age was 12.4 years at enrollment. The mean baseline CISS score was 29.9 points, and the mean NPC break and mean PFV blur were 14.0 cm and 12.1 PD, respectively. Table 1 shows that baseline characteristics were similar across the three treatment groups.

Back to Top | Article Outline

Visit Completion and Treatment Compliance

The 12-week primary outcome examination was completed within the analysis window by 69 (92%), 69 (81%), and 31 (70%) participants in the HB-C, HB-PU, and HB-P groups, respectively (Fig. 1). Examiners were masked to treatment group for all examinations.

Averaging over the 12 weeks of treatment, completion of >75% of prescribed treatment for the primary (15-minute) therapy was reported by 47 of 69 participants (68%) in the HB-C group, 34 of 69 participants (49%) in the HB-PU group, and 17 of 31 participants (55%) in the HB-P group (Table 2). For the secondary (5-minute) therapy, completion of >75% of prescribed treatment was reported by 45 of 69 participants (65%) in the HB-C group, 44 of 69 participants (64%) in the HB-PU group, and 19 of 31 participants (61%) in the HB-P group.

Back to Top | Article Outline

Primary Analysis: Successful Outcome after 12 Weeks of Treatment

At the 12-week primary outcome examination, 16 of 69 participants (23%, 95% CI: 14–35%) in the HB-C group, 15 of 69 participants (22%, 95% CI: 13–33%) in the HB-PU group, and 5 of 31 participants (16%, 95% CI: 5–34%) in the HB-P group achieved a successful outcome (Table 3). The difference in the percentage of participants with a successful outcome between the HB-C and HB-PU (reference) groups was −4% (two-sided 97.5% CI: −19 to +11%; p = 0.56), after adjustment for baseline covariates. The difference between the HB-C and the HB-P (reference) groups was +5% (two-sided 97.5% CI: −12 to +22%; p = 0.52).

The percentage of participants classified as improvers and those who met the success criteria for the individual components of the composite measure and for both vergence measures are reported in Table 3. In the HB-C group, 18% of participants who completed the CVAT (n = 22) and 26% of participants who did not complete the CVAT (n = 47) met success criteria at the 12-week examination (difference: −7%, 95% CI: −27 to +17%).

Back to Top | Article Outline

DISCUSSION

We sought to evaluate the effectiveness of home-based therapy regimens for children 9 to <18 years of age with symptomatic CI, specifically comparing the percentage of participants with a successful outcome who were prescribed 12 weeks of HB-C to those prescribed 12 weeks of HB-PU, or placebo therapy. The majority of participants in the HB-C and HB-PU groups did not achieve a successful outcome at 12 weeks, and some children treated with placebo therapy were successful. Approximately one-third of the preplanned sample size was recruited, which resulted in insufficient power to compare treatment groups. In addition, differential loss to follow-up (HB-C 8%, HB-PU 19%, and HB-P 30%) introduced the potential for bias. Thus, we are unable to reach any conclusions regarding the effectiveness of HB-C compared with HB-PU and with placebo.

Our composite primary outcome criteria for success were stringent. Across treatment groups, less than 25% of participants were classified as having a successful outcome after 12 weeks of therapy. Although a higher percentage of participants improved between the 6- and 12-week visits in each treatment group, these results need to be viewed cautiously due to the large number of missing 12-week outcomes, particularly in the HB-PU and HB-P groups.

Reported estimates of compliance were reasonably good for the primary treatment procedure for the first 6 weeks of treatment, but a substantial decrease occurred in the subsequent 6 weeks, particularly in the HB-PU and HB-P groups (Table 2). These compliance data suggest that active CVAT may have been more engaging than placebo CVAT and participants were more likely to comply with this therapy through 12 weeks. Poorer compliance between 6 and 12 weeks may be one reason why participants in the HB-PU and HB-P groups were less likely to complete the 12-week primary outcome examination [HB-PU (81%) and HB-P (70%)] than participants in the HB-C group (92%).

Within the HB-C group, completion of the jump vergence component of the active CVAT program may be a surrogate for compliance. If the active CVAT program was effective, we might expect that participants who completed the program may have been more likely to achieve a successful outcome compared with those who did not complete the program. Our data did not find such a relationship; rather, only 18% of participants who completed the active CVAT program met achieved a successful outcome versus the 26% of participants who failed to complete the active CVAT program.

There is limited information in the literature about the rate of improvement in CI symptoms and clinical signs with HB treatments, and how many weeks of HB therapy is required to achieve a successful outcome. In our study, the majority of improvement occurred between 6 and 12 weeks, suggesting that 6 weeks of treatment with either HB-C or HB-PU is not sufficient (Table 4). At the 6-week visit, only 8% in the HB-C group and 3% in both the HB-PU and HB-P groups achieved a successful outcome. It is also important to note that the clinical findings (NPC and PFV) improved more rapidly than symptoms, as measured by the CISS, during the first 6 weeks (Table 3). This phenomenon has been reported previously in the CITT study in which symptoms improved more slowly than clinical signs.18 Thus, even if the symptoms do not improve during the first 6 weeks of HB therapy in a child with symptomatic CI, it may be reasonable to continue therapy for at least 6 additional weeks, as long as the clinical findings have improved.

It is unknown whether extending the duration of therapy beyond 12 weeks may lead to additional improvement. This study was not designed to determine the maximum treatment effect for any of the three treatments. Rather, we selected 12 weeks of treatment based on previous literature,14–16 consensus opinion of our planning committee, and a reluctance to keep participants on placebo therapy for longer than 3 months. Our data suggest additional improvement is unlikely given there was a decline in compliance between 6 and 12 weeks, and participants in the HB-C group who completed therapy were not more likely to be classified as a success than those who did not.

A significant limitation of the study was the differential loss to follow-up (HB-C 8%, HB-PU 19%, and HB-P 30%), which introduced the potential for bias. The successful outcome rate of 23% for HB-C may be the least subject to bias given the HB-C group had a 12-week visit completion rate of 92% (compared with 81% for HB-PU and 70% for HB-P). The upper 95% confidence limit for the proportion of participants with a successful outcome in the HB-C group is 35%, so it is unlikely there is a large treatment effect from HB-C therapy. If the success rate at outcome in the HB-PU group is unbiased, it is also unlikely there is a large treatment effect from HB-PU therapy (upper 95% confidence limit = 33%). Other potential limitations were that we did not formally assess whether participants remained masked to their treatment group during the study and the assessment of compliance was not completely objective because it was partially based on interview with the participant and/or parent in addition to electronic data from the computer programs.

During the planning stages of this study, there seemed to be sufficient enthusiasm among PEDIG investigators to proceed with the study despite the required sample size of 595 participants. However, once the study launched, it became clear that many investigators were not seeing as many eligible children in their practices, leading to insufficient recruitment and early termination of the study.

It is not clear why these active therapies were not successful in treating most of the participants with symptomatic CI. Inadequate compliance with treatment and poor effectiveness of home-based therapy for improving clinical signs and symptoms associated with CI are possibilities. However, the parents and participants were sufficiently motivated to enroll in the study, the participants were symptomatic based on their enrollment CISS scores, and compliance was reasonably good across all three treatments. In addition, there was no difference in the successful outcome rates of those in the HB-C group who successfully completed the program compared with those who did not compete all phases of the program. The treatment compliance data suggest that some participants, particularly in the HB-P and HB-PU groups, may have lost motivation as the study progressed, perhaps because their symptoms were not improving, they found the treatment to be boring, or due to some other unknown reason.

Neither HB-C nor HB-PU when prescribed for 12 weeks were successful in treating the majority of children with symptomatic CI, and some children treated with placebo achieved a successful outcome. Direct comparison of the treatment groups was limited by insufficient recruitment and differential loss to follow-up.

Mitchell M. Scheiman

Jaeb Center for Health Research

15310 Amberly Drive, Suite 350

Tampa, FL 33647

e-mail: pedig@jaeb.org

Back to Top | Article Outline

ACKNOWLEDGMENTS

This study was supported by the National Eye Institute of National Institutes of Health, Department of Health and Human Services EY011751, EY023198, and EY018810. The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. E.L.L. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Clinical Trial Registration: The study is listed on www.clinicaltrials.gov, under identifier NCT01515943.

No conflicting relationships exist for any author.

Content from this manuscript was presented at the annual American Academy of Optometry meeting, October 2015, New Orleans, LA.

Received December 22, 2015; accepted May 18, 2016.

Pediatric Eye Disease Investigator Group

Writing Committee

Lead authors: Mitchell M. Scheiman, Darren L. Hoover, Elizabeth L. Lazar, Susan A. Cotter, Raymond T. Kraker, Marjean T. Kulp, David K. Wallace, Erin C. Jenewein, Michael F. Gallaway, Indre M. Rudaitis, Ingryd J. Lorenzana.

Clinical Sites

Sites are listed in order by number of participants enrolled. Personnel are listed as (I) for Investigator, (C) for Coordinator, or (E) for Masked Examiner.

Philadelphia, PA: Salus University/Pennsylvania College of Optometry (31): Mitchell M. Scheiman, (I); Michael F. Gallaway, (I); Jenny Myung, (I); Ruth Y. Shoge, (I); Lynn H. Trieu, (I); Karen E. Pollack, (C).

Cranberry TWP, PA: Everett and Hurite Ophthalmic Association (25): Darren L. Hoover, (I); Pamela A. Huston, (C); Christine J. Deifel, (C); Kari E. Soros, (C).

Schaumburg, IL: Advanced Vision Center (23): Ingryd J. Lorenzana, (I); Beata Wajs, (C); Angelyque Lorenzana, (E); Yesenia Meza, (E); Marie Schirmer, (E).

Columbus, OH: The Ohio State University (15): Marjean T. Kulp, (I); Freda D. Dallas, (C); Nancy E. Stevens, (C); Michelle J. Buckland, (E); Tamara S. Oechslin, (E); Andrew J. Toole, (E).

Birmingham, AL: University of Alabama at Birmingham School of Optometry (14): Marcela Frazier, (I); Oakley W. Hayes, (I); Sarah D. Lee, (I); Wendy L. Marsh-Tootle, (I); Robert P. Rutstein, (I); Katherine K. Weise, (I); Michelle B. Bowen, (C); Michael P. Hill, (C); Ross B. Roegner, (C).

Fullerton, CA: Southern California College of Optometry, Marshall B. Ketchum University (12): Susan A. Cotter, (I); Carmen N. Barnhardt, (I); Angela M. Chen, (I); Raymond H. Chu, (I); Paula Handford, (I); Catherine L. Heyman, (I); Kristine Huang, (I); Lynn A. Lowell, (I); Lernik Mesropian Torossian, (I); Aman Sunner Basi, (I); Reena A. Patel, (I); Sue M. Parker, (C).

Miami, FL: Bascom Palmer Eye Institute (9): Susanna M. Tamkins, (I); Carolina Manchola-Orozco, (C); Eva M. Olivares, (C); Erin Yanowitch, (C); Kara M. Cavuoto, (E).

Chicago, IL: Illinois College of Optometry (ICO) (7): Yi Pang, (I); Megan Allen, (I); Christine L. Allison, (I); Brian W. Caden, (I); Elyse Nylin, (C).

Lisle, IL: Progressive Eye Care (7): Patricia L. Davis, (I); Indre M. Rudaitis, (I); Kathy A. Anderson, (E).

New York, NY: State University of New York College of Optometry (7): Marilyn Vricella, (I); Ida Chung, (I); Robert H. Duckman, (I); Hadassa L. Rutman, (I); Erica L. Schulman-Ellis, (I); Sara Meeder, (C).

Houston, TX: University of Houston College of Optometry (7): Ruth E. Manny, (I); Heather A. Anderson, (I); Debra C. Currie, (I); Karen D. Fern, (I); Janice M. Wensveen, (I); Sylvia Landa, (C); Fawn M. Candelari, (C); Joan Do, (C); Dashaini V. Retnasothie, (E).

Marlton, NJ: Michael F. Gallaway, O.D., P.C. (6): Michael F. Gallaway, (I); Debbie L. Killion, (C).

Ft. Lauderdale, FL: Nova Southeastern University College of Optometry, The Eye Institute (5): Erin C. Jenewein, (I); Jacqueline Rodena, (I); Yin C. Tea, (I); Nadine M. Girgis, (I); Julie Tyler, (I); Surbhi Bansal, (C); Annette Bade, (C).

Bloomington, IN: Indiana University School of Optometry (4): Don W. Lyon, (I); Vivian M. Wong, (I); Kristy M. Dunlap, (C).

Silverdale, WA: Jason C. Cheung, M.D., PS (4): Jason C. Cheung, (I); Melissa L. Rice, (I); Tiffany M. Parypa, (C); Andria E. Goddard, (C); Katrina A. Tally, (C).

Memphis, TN: Southern College of Optometry (4): Janette D. Dumas, (I); Pamela H. Schnell, (I); Marc B. Taub, (I); Kelly D. Dasinger, (C).

Lancaster, PA: Family Eye Group (3): David I. Silbert, (I); Noelle S. Matta, (C); Prucilla R. Shady, (E).

Rochester, MN: Mayo Clinica (3): Jonathan M. Holmes, (I); Tomohiko Yamada, (I); David A. Leske, (C); Rebecca A. Nielsen, (C); Sarah R. Hatt, (E); Laura Liebermann, (E).

Portland, OR: Pacific University College of Optometry (3): Richard London, (I); Ryan C. Bulson, (I); James J. Kundart, (I); Jayne L. Silver, (C).

Rio Rancho, NM: City of Vision Eye Care (2): Lisa M. Edwards, (I); Jessica N. Marquez, (C); Carolyn S. Marquez, (C).

Norfolk, VA: Eastern Virginia Medical School (2): Earl R. Crouch, Jr. (I); Earl R. Crouch III, (I); Gaylord G. Ventura, (C).

Durham, NC: North Carolina Eye Ear & Throat (2): Joan T. Roberts, (I); Heather M. Klem, (C); Lynelle G. Perez, (C);Marguerite J. Sullivan, (C).

Wheaton, IL: Wheaton Eye Clinic (2): Noha S. Ekdawi, (I); Darin L. Strako, (I).

Chicago, IL: Ann & Robert H. Lurie Children’s Hospital of Chicago (1): Bahram Rahmani, (I); Sudhi P. Kurup, (I); Hantamalala Ralay Ranaivo, (C); Aaliyah Hamidullah, (C); Lisa M. Hartemayer, (C); Kristyn M. Magwire, (E); Vivian Tzanetakos, (E).

Poland, OH: Eye Care Associates, Inc. (1): Sergul A. Erzurum, (I); Diana McOwen, (C); Beth J. Colon, (C); Zainab Dinani, (E).

Waterbury, CT: Eye Care Group, P.C. (1): Andrew J. Levada, (I); Tara H. Cronin, (I); Susan H. Heaton, (C); Cheryl Capobianco, (C); Nathalie M. Gintowt, (C); Lindsay Gill, (E).

Big Rapids, MI: Michigan College of Optometry at Ferris State University (1): Paula S. McDowell, (I); Kerrie R. Currie, (C); RaeAnn M. Nordwall, (C).

Columbus, OH: Pediatric Ophthalmology Associates (1): Mary L. McGregor, (I); Meghan C. McMillin, (C); Kelsey A. Black, (C); Rae R. Fellows, (C); Michelle L. Hurst, (C).

Chicago Ridge, IL: The Eye Specialists Center, L.L.C. (1): Benjamin H. Ticho, (I); Megan Allen, (I); Deborah A. Clausius, (C); Sharon L. Giers, (C); Birva K. Shah, (E).

West Des Moines, IA: Wolfe Clinic (1): Myra N. Mendoza, (I); Donny W. Suh, (I); Jill J. Frohwein, (C); Jody L. Jackson, (C); Lisa M. Fergus, (E).

Resource Centers

PEDIG Coordinating Center: Raymond T. Kraker, Roy W. Beck, Nicole M. Boyle, Christina M. Cagnina-Morales, Courtney L. Conner, Danielle L. Chandler, Trevano W. Dean, Quayleen Donahue, Brooke P. Fimbel, James E. Hoepner, Joseph D. Kaplon, Elizabeth L. Lazar, B. Michele Melia, Rachel V. Orlowski, Diana E. Rojas, Jennifer A. Shah.

National Eye Institute—Bethesda, MD: Donald F. Everett.

Committees

CITS Planning Committee: Mitchell M. Scheiman (co-chair), Darren L. Hoover (co-chair), Roy W. Beck, Eileen E. Birch, Angela M. Chen, Alexander Christoff, Susan A. Cotter, Deborah R. Fishman, Marcela Frazier, Jonathan M. Holmes, Pamela A. Huston, Raymond T. Kraker, Marjean T. Kulp, Elizabeth L. Lazar, David A. Leske, Michele Melia, Michael X. Repka, David L. Rogers, Gary L. Rogers, Benjamin H. Ticho, Diane L. Tucker.

Strabismus Steering Committee: Eileen E. Birch, Danielle L. Chandler, Stephen P. Christiansen (2013–2014), Susan A. Cotter, Sean P. Donahue, Caroline C. Fang (2011–2012), Sarah R. Hatt, Jonathan M. Holmes, Darren L. Hoover (2010–2014), Lingkun Kong (2012–2014), Raymond T. Kraker, Elizabeth L. Lazar, Ingryd J. Lorenzana (2014-present), J. Ryan McMurtrey (2011–2012), Michele Melia, Brian G. Mohney, Karen Pollack (2014–present), Michael X. Repka, Mitchell M. Scheiman (2010–2014), Rosanne Superstein (2013–2014), Susanna M. Tamkins (2009–2014), David K. Wallace, Tomohiko Yamada (2014–present).

PEDIG Executive Committee: David K. Wallace (chair), William F. Astle (2013–present), Darron A. Bacal (2009–2010), Roy W. Beck, Eileen E. Birch, Angela M. Chen (2012–2014), Melanie L. Christian (2012–2014), Stephen P. Christiansen (2009–2010), Susan A. Cotter (2009–2014), Earl R. Crouch Jr. (2012–2014), Eric R. Crouch III (2010–2011, 2014–present), Sean P. Donahue (2012–2014), Laura B. Enyedi (2011–2013, 2014–present), Donald F. Everett, Jonathan M. Holmes, Darren L. Hoover (2008, 2011–2013), Pamela A. Huston (2009–2010), Jorie L. Jackson (2011–2012), Raymond T. Kraker, Marjean T. Kulp (2010–2012), Scott R. Lambert (2013–present), Katherine A. Lee (2014–present), Ruth E. Manny (2013–present), Aaron M. Miller (2011–2012), David B. Petersen (2011–2013), Michael X. Repka, David L. Rogers (2011–2013), Jayne L. Silver (2014–present), Benjamin H. Ticho (2010–2011), Katherine K. Weise (2014–present).

PEDIG Data and Safety Monitoring Committee: Marie Diener-West (chair), John D. Baker, Barry Davis, Donald F. Everett, Dale L. Phelps, Stephen W. Poff, Richard A. Saunders, Lawrence Tychsen.

Back to Top | Article Outline

REFERENCES

1. Rouse MW, Borsting E, Hyman L, Hussein M, Cotter SA, Flynn M, Scheiman M, Gallaway M, De Land PN. Frequency of convergence insufficiency among fifth and sixth graders. The Convergence Insufficiency and Reading Study (CIRS) group. Optom Vis Sci 1999;76:643–9.
2. Létourneau JE, Lapierre N, Lamont A. The relationship between convergence insufficiency and school achievement. Am J Optom Physiol Opt 1979;56:18–22.
3. Letourneau JE, Ducic S. Prevalence of convergence insufficiency among elementary school children. Can J Optom 1988;50:194–7.
4. Rouse MW, Hyman L, Hussein M, Solan H. Frequency of convergence insufficiency in optometry clinic settings. Convergence Insufficiency and Reading Study (CIRS) Group. Optom Vis Sci 1998;75:88–96.
5. Cooper J, Duckman R. Convergence insufficiency: incidence, diagnosis, and treatment. J Am Optom Assoc 1978;49:673–80.
6. Daum KM. Convergence insufficiency. Am J Optom Physiol Opt 1984;61:16–22.
7. Borsting E, Rouse MW, Deland PN, Hovett S, Kimura D, Park M, Stephens B. Association of symptoms and convergence and accommodative insufficiency in school-age children. Optometry 2003;74:25–34.
8. Borsting EJ, Rouse MW, Mitchell GL, Scheiman M, Cotter SA, Cooper J, Kulp MT, London R, Convergence Insufficiency Treatment Trial Group. Validity and reliability of the revised convergence insufficiency symptom survey in children aged 9 to 18 years. Optom Vis Sci 2003;80:832–8.
9. Kent PR, Steeve JH. Convergence insufficiency, incidence among military personnel and relief by orthoptic methods. Mil Surg 1953;112:202–5.
10. Poynter HL, Schor C, Haynes HM, Hirsch J. Oculomotor functions in reading disability. Am J Optom Physiol Opt 1982;59:116–27.
11. Mazow ML. The convergence insufficiency syndrome. J Ped Ophthalmol 1971;8:243–4.
12. Duke-Elder S, Wybar K. Ocular motility and strabismus. In: Duke-Elder S, ed. System of Ophthalmology. St Louis: Mosby; 1973;547–51.
13. Pickwell LD, Hampshire R. The significance of inadequate convergence. Ophthalmic Physiol Opt 1981;1:13–8.
14. Convergence Insufficiency Treatment Trial (CITT) Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol 2008;126:1336–49.
15. Scheiman M, Mitchell GL, Cotter S, Cooper J, Kulp M, Rouse M, Borsting E, London R, Wensveen J, Convergence Insufficiency Treatment Trial (CITT) Study Group. A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmol 2005;123:14–24.
16. Scheiman M, Mitchell GL, Cotter S, Kulp MT, Cooper J, Rouse M, Borsting E, London R, Wensveen J. A randomized clinical trial of vision therapy/orthoptics versus pencil pushups for the treatment of convergence insufficiency in young adults. Optom Vis Sci 2005;82:583–95.
17. Rouse M, Borsting E, Mitchell GL, Cotter SA, Kulp M, Scheiman M, Barnhardt C, Bade A, Yamada T, Convergence Insufficiency Treatment Trial (CITT) Investigator Group. Validity of the convergence insufficiency symptom survey: a confirmatory study. Optom Vis Sci 2009;86:357–63.
18. Scheiman M, Kulp MT, Cotter S, Mitchell GL, Gallaway M, Boas M, Coulter R, Hopkins K, Tamkins S, Convergence Insufficiency Treatment Trial (CITT) Study Group. Vision therapy/orthoptics for symptomatic convergence insufficiency in children: treatment kinetics. Optom Vis Sci 2010;87:593–603.

aCenter received support utilized for this project from an unrestricted grant from Research to Prevent Blindness Inc., New York, New York. Cited Here...

Keywords:

convergence insufficiency; home-based; home-based computer vergence/accommodative therapy; home-based near target push-up therapy; home-based placebo therapy; vision therapy; orthoptics; near point of convergence

Supplemental Digital Content

Back to Top | Article Outline
© 2016 American Academy of Optometry