Here is a quote that should stop you dead in your tracks: “Furthermore, pediatricians should know that convergence insufficiency is frequently over diagnosed”. This quote comes from a publication titled Contemporary Pediatrics: Expert Advice for Today’s Pediatrician. It’s contained on the third page of a column on Dyslexia dated August 1, 2016, authored by Sheryl M. Handler, MD – a pediatric ophthalmologist. Naturally Dr. Handler presents no evidence that convergence insufficiency is frequently over diagnosed, because it is opinion masquerading as fact.
Dr. Handler is not new to this subject, being lead author of a Joint Technical Report on Learning Disabilities, Dyslexia, and Vision published in the journal Pediatrics in 2011. These joint reports have been issued by organized ophthalmology and pediatrics each decade since the 1970s in an effort to minimize the role of vision in general, and vision therapy in particular as related to learning and reading difficulties. The thinly veiled agenda of these policy statements has been exposed numerous times, well summarized in papers published in Optometry (the journal of the American Optometric Association) in 2002 and in 2010, as well as in the AOA News.
Here is the summary paragraph regarding vision from the Joint Technical Report published in 2011 from which Dr. Handler appears to have extrapolated her claim that CI is frequently over diagnosed:
“In summary, vision problems can interfere with the process of reading; however, vision problems are not the cause of dyslexia. Significant refractive errors can make reading more difficult. Convergence insufficiency and poor accommodation, both of which are uncommon in children, can interfere with the physical act of reading but not with decoding and word recognition. Thus, treatment of these disorders can make reading more comfortable and may allow reading for longer periods of time but does not directly improve decoding or comprehension. If reading impairment is attributable solely to a visual problem, improvement in school performance should be observed once the problem is corrected.”
This straw man assertion is reminiscent of the undocumented claim that most children who complain of blur or diplopia at near are merely confused by physiological diplopia and have no real accommodative or binocular problems. Whimsical claims of this nature are addressed in an article by Cooper and Jamal published in 2012 in which they write:
“Many older studies imply that CI is not common in children, because symptoms are not commonly reported until the second or third decade of life. Recently,Wright and Boger suggested that symptoms of blur and diplopia found in children are a result of interpretation of normal physiologic phenomena. However, they provide no documentation to support this position. In addition, if the symptoms were a consequence of normal physiologic phenomena, one would not expect to find a difference between active vision therapy versus placebo.18 It had been assumed that young adults spend more time performing near point work than children, thus, young adults are more likely to complain of symptoms. Recent studies by members of the CITT Study Group have found a higher prevalence of CI in children than had been previously assumed.”
In addition to the alleged over diagnosis of CI being undocumented, the column contains frank misinformation regarding the appropriate treatment of the condition. It states:
“Children diagnosed with symptomatic convergence insufficiency are usually prescribed convergence eye exercises to be performed at home. These exercises usually result in improved reading comfort within a few weeks. In-office exercises with at-home reinforcement are considered if a child continues to show signs and symptoms of convergence insufficiency.”
There is no scientific evidence to support that convergence exercises done only at home are adequate enough to be offered as front-line therapy for CI. In fact evidence-based medicine derived from the landmark CITT study published in Archives of Ophthalmology in 2008 shows that this approach results in a 40% rate of improvement that is tantamount to placebo therapy.
Many authorities believe that reading disabilities are a continuum, with dyslexia residing at the far end of reading disability but lacking any definitive test for its identification. Other authorities posit that dyslexia is a gift that should be celebrated for its advantages rather than dwelling on associated disabilities. At the very least, as noted by Vidyasagar and Pammer in Trends in Cognitive Sciences, it is premature to dismiss the role of vision and visual attention dyslexia, and to attribute dyslexia entirely to phonological problems. Certainly phonological approaches to reading have their place, but families struggling with the burden of reading disability whose children do not respond adequately to these interventions should encouraged rather than discouraged from pursuing other treatment approaches. The notion that every child diagnosed with CI, and for whom optometric therapy has been prescribed should be routed to a pediatric ophthalmologist for a second opinion (as advised in the Contemporary Pediatrics column) is unfounded if not ill-advised.
To be clear, my purpose here is not an ad hominem attack on Dr. Handler, but setting the record straight on dogma and misinformation so that pediatricians, parents, and other child advocates can help these children achieve to their full potential. Something good may actually come of this article if readers make it down the Comments section. An anonymous poster wrote:
“The author mentions convergence insufficiency. There is currently a multi-center randomized clinical trial sponsored by the National Institutes of Health/National Eye Institute for 9-14 year old children with symptomatic convergence insufficiency. Reading and attention are tested before and after treatment. The study is in the last year of recruitment. This study may be of interest to medical professionals who have patients with convergence insufficiency.”