In the late 1800s and early 1900s, some ophthalmologists considered very seriously different elements of visual function (control of the movement of the eyes) insofar as it contributes to significant dysfunction and interferes with reading. At times, the concepts of visual dynamics and dysfunction were valid in the view of the American ophthalmological community, however they were nearly never considered in other specialties, such as pediatrics. At the same time, pioneers in behavioural vision science (mostly American behavioural optometrists) were studying very closely the myriad components and subtleties human visual behaviour as it relates to daily life and function. The idea of neuromuscular visual dysfunction of any significance seemed to completely fall off the pediatric ophthalmology radar in the first half of the 20th century and was routinely rebuked as a sham and waste of time.
Most recently however, especially since the first Iraq war in the early 1990s, there has evolved a renewed interest in the greater neural and vision science communities as injured soldiers exhibit debilitating visual and spatial dysfunction. Where medications and surgery are not efficacious, assisting in recalibrating visual-spatial mapping and reasoning can be highly effective in provide relief and restoring function. This, in addition to many other conditions such as strabismus, amblyopia, and Convergence Insufficiency, is the chosen domain of behavioural optometrists. Still to this day, detailed assessment of visual function is not a requirement of pediatric ophthalmology or pediatrics in diagnosing (ruling out) organic (DSM-IV) learning disorders.
There is one hold out to this story, that of CI (that is, Convergence Insufficiency). It has been in discussion in a number of scientific and medical journals for well over a century, and this largely because, in my opinion, it is easy to spot and impossible to deny: The CI patient will have perfectly normal and highly functioning eyes but will still complain of tremendous discomfort when doing any sort of near work, be it a jeweler, accountant, writer, so long as it is sustained work requiring some concentration. In severe cases, even looking at a smart phone to make a phone call is uncomfortable. People will have trouble focusing, or maintaining focus, and will frequently suffer diplopia and headache. Imagine then, a child who has CI, struggling simply to see a consistent single image on a page – might this not look even a little like a reading disorder? Why would we not check for this before administering other invasive and potentially harmful treatments?
Even while the larger field of visual efficiency is ignored by ophthalmology, CI remains current, again, because it won’t go away. Behavioural optometry has been effectively treating convergence insufficiency for 100 years, that is, in addition to a great many other conditions that are still of no consequence to ophthalmology, but have significant impact on daily living and functioning for many thousands of people in every town and city in every state, province, and country around the world. That is, everywhere where people read, write or work at computer. Lasers, injections, or scalpels do little to help problems of visual dynamics. Furthermore, when applied in the wrong conditions, they will almost always make a relatively simple problem worse and lead to much greater suffering and expense to the patient.
The following article supports the use of vision therapy, in particular at home vision therapy, in the treatment of CI. Slowly, American ophthalmology is waking up (opening its eyes) to what a large part of the world vision science community has known for some time: There’s more to vision than eye disease, and so a perspective broader than what medicine provides is needed.
If you detect some degree of frustration here, you’re not mistaken. Every now and then, there is a concerted effort on the part of some medical subspecialties in the US to condemn vision therapy and behavioural optometry by releasing another joint statement on the value of VT; very predictably, these statements soon need revision or further comment when another aspect of VT is widely accepted as effective clinically and in the accounting office. The frustration comes in when, in spite of the volumes of evidence and treatment protocols present in vision science and optometric writing, this century of wisdom and clinical experience is denied to those who would otherwise benefit from it – This because decidedly unbalanced and sometimes unfounded literature research which is then subsequently referenced by those who know no different. It would appear this is a matter of professional hubris and market share, plain and simple. Less and less frequently is this due to ignorance of visual dynamics and visual processing as newer graduates of ophthalmology and pediatrics recognize the fundamental role of vision and vision dysfunction in children’s learning.
Articles such as the following slowly shines the light on behavioural optometry has known for a hundred years, but is only now starting to emerge as something to pay attention to in the medical sciences. It’s noteworthy that optometry has determined that while the conclusion below (“the computer orthoptic program is an effective option for treating symptomatic convergence insufficiency”) is true, what is the MOST effective is optometric vision therapy, not just video games.
From the Journal of the AAPOS (Association of American Pediatric Ophthalmology and Strabismus), April 2011.
Treatment of symptomatic convergence insufficiency with a home-based computer orthoptic exercise program
Angela Serna BAppSc(Orthoptics), MPH, David L. Rogers MD, Mary Lou McGregor MD, Richard P. Golden MD, Don L. Bremer MD and Gary L. Rogers MD. Nationwide Children’s Hospital, Department of Ophthalmology, Columbus, Ohio
To determine the efficacy of a home-based computer orthoptic program to treat symptomatic convergence insufficiency.
A retrospective review of consecutive patients with symptomatic convergence insufficiency treated with a home-based computer orthoptic program was performed. Symptomatic convergence insufficiency was defined as: near point of convergence (NPC) >6 cm, decreased positive fusional vergence, exophoria at near at least 4pd greater than at far, and documented complaints of asthenopia, diplopia, or headaches with reading or near work. The Computer Orthoptics CVS program was used for this study. Before beginning the computer orthoptic program, patients with an NPC >50 cm were given 4 base-in prisms and push-up exercises (NPC exercises with an accommodative target) for 2 weeks.
A total of 42 patients were included. Mean treatment duration was 12.6 weeks; mean follow-up, 8.5 months. Of the 42 patients, 35 were treated with the home-based computer orthoptic program and push-up exercises; the remaining 7 only used the computer orthoptic program. Because of a remote NPC, 5 patients were given base-in Fresnel prism before starting treatment. Baseline mean NPC was 24.2 cm; posttreatment mean NPC improved to 5.6 cm: 39 patients (92.8%) achieved an NPC of 6 cm (p < 0.001). Positive fusional vergence improved in 39 patients (92.8%). Fourteen patients reduced their near exophoria by 5pd. A total of 27 patients (64.2%) reported resolution of symptoms after treatment.
In our study, home-based computer orthoptic exercises reduced symptoms and improved NPC and fusional amplitudes. The computer orthoptic program is an effective option for treating symptomatic convergence insufficiency.
A response to the above study was presented by some researchers in optometry. The author points out that the above research is flawed, but offers alternate evidence that home therapy can be effective, if not completely so: