Convergence Insufficiency is Frequently Overdiagnosed (?)


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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.”

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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.”

10 thoughts on “Convergence Insufficiency is Frequently Overdiagnosed (?)

  1. Dear Lenny,

    THANK YOU for sharing this misinformation regarding convergence insufficiency and reading. It is obvious that medicine is still over focused on their ill advised campaign to discredit optometric vision therapy. The comments and conclusions are based on evidence BIASED opinions and not evidence based data. The CITT study, which included both ophthalmologists and optometrists, has concluded that vision therapy is effective in the treatment of convergence insufficiency. It is not the only treatment available but it is the most effective. Ironically, most ophthalmologists still recommend pencil push-ups despite its ineffectiveness. According to the CITT study, placebo therapy was more effective than pencil push-ups but many ophthalmologists are blinded to this finding.

    On the other hand, we need to move beyond a one to one relationship between convergence insufficiency and reading or any learning problems. As eye care practitioners, we need to address the vision problem and allow the educators or other appropriate professionals to address the learning problems. The latter problems are rarely in my opinion simply visual in nature. We need to understand that complex problems are not black and white but many shades of gray (more than 50). The continuing bashing of vision therapy is another example of medicines perverse tendency to BULLY all non medical practitioners. Their use of drugs for learning problems or surgery for strabismus is often based on personal and biased opinions regarding treatments without any research.

    It is time to put the patient/child FIRST. For a profession that has been listed as the third leading cause of death within our health system, they should be focused on dealing with their own problems instead of attempting to discredit optometric vision therapy. I am not aware of any patients, who have died during an in office based vision therapy program. It is time to mover into the next century.

    AND finally for those individuals, who still down play the significance of vision in the act of reading or life. Please close your eyes and read a chapter in a book and send me the results of this non visual experience. THANK YOU AGAIN for your continued attempt to clarify the issues related to vison and learning and vision and life.

    Richard

  2. Handler needs to be called out to write only post documentation. Otherwise time will show she needs to go back to school. Just saw a 6 year old girl who had exotropia at age two with s/p now microstrabismus; esotropia.
    With prism and Tetris VT I am going to get her steropsis back. She already has stereo at 6 inches.
    Just received a letter from a peds ophthalmology who saw one of my patients referred by a pediatrician. These md’s
    belong to the same club house. The letter confirmed intermittent exotropia with surgery needed if patching did not work. The ped doc is respondible if the patents sue as he referred for the wrong result. There u have it. We got past the readers digest article, and past
    Bobby Hope and others. We will make it so that ophthalmology does surgery and we do everything else since we know more about everything else. August

  3. OMD’s don’t have time for office based VT so their profession is a pill or a shot or surgery.
    Patient this week; watering eyes and filmy vision. Ophthalmology told her did not know why. No pill or shot or surgery needed.
    Patient had plugged meibomian glands. RX. Bruder gel pack and tea tree shampoo scrubs and MGD drops. Saved another patient like all us grass roots Optometrists.

  4. The problem that I am having here is that dyslexia is being used for ANY problem involving reading. We know that visual stress makes it difficult for a person to get the words into the brain for processing. Is there no way that we can create a paradigm shift in parents and society by using the word dyslexia (problems reading) but adding visual? I really like Lenny’s words of “Visual Attentional Dyslexia”. I just got back from a seminar on Learning Disabilities that spent over half of the time discussing Dyslexia. Not once did the word vision appear in the lecture. We keep pussy-footing around agreeing with medicine that we do not treat dyslexia. Why can we not stand up proudly and say that we treat “Visual Attentional Dyslexia” but not “(insert words for “the dyslexia that we do not treat” here)”? Until we do, general medicine will continue to make us sound like snake oil even when we do a bang-up job of treating this stuff.

  5. Amy, so long as we insist that a) all dyslexia is visually-based, and b) we can treat dyslexia through OVT, there will be those who justifiably apply the snake-oil label to what we do. Let’s bear in mind that there are forms of reading disability that are not primarily vision-based, and where OVT will have little to no effect.

    • But we don’t say that we treat dyslexia – as we define dyslexia (a problem connecting symbols to word sounds). The rest of the world does not define dyslexia as we do. Can we not change our definition to be in line with the rest of the world (dyslexia = problems reading) but say that we treat visual dyslexia and not auditory dyslexia?

  6. Amy, either we treat dyslexia or we don’t. You say ‘we treat visual dyslexia and not auditory dyslexia’, and then say ‘we don’t say that we treat dyslexia’. Fundamentally, if we can help a child through OVT, it’s not dyslexia we’re treating. It is quite valid to say that we treat dyslexia-mimicking disorders, and that these are often misdiagnosed as dyslexia. As for following a world standard in nomenclature, yes please, let’s speak the same language as the rest of the world.

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