Recognizing convergence insufficiency…could a greater miracle take place?


“Could a greater miracle take place than for us to look through each other’s eyes only for an instant?”  Henry David Thoreau

This is a story of a healthy 20 year old college freshman. He was my “eye opening” patient this week. His case  is neither extreme nor unusual for those of us who work in the field of developmental vision and rehabilitation. But for this young man, the impact of his vision condition could very easily change the trajectory of his life.

He presented for a vision evaluation with me, not from a professional referral, but from a family recommendation. On the surface, he had no complaints of blurred vision and wore no glasses. In the past, his mother noted that  he started struggling in reading in mid elementary school. There was frustration and notably lowered self esteem.  His present “symptom profile” was also problematic in reading fluency as he is now trying to “make it” in college. He also had trouble with attention and concentration for reading and homework. But most notable, he mentioned that words have always doubled within a few minutes of reading. His previous eye exams were “normal”. Likewise, my testing found that he had 20/20 visual acuity, normal ocular health and refracted at +0.25 both eyes. But, during his binocular vision assessment he could only converge his eyes to 12-16 inches on the penlight red/green (PLRG) near point of convergence (NPC) test. Since 2-3 inches is the expected on the PLRG NPC test, it was no surprise that he was seeing words double when reading!

When asked why he had never told anyone he saw double when reading, his response to me was, “I thought that was just normal.” Yes, at age 20, he thought everyone saw that way!  What’s more, he was also “diagnosed” with ADHD when he was in 9th grade and on Adderall ever since. For his mother, this was one of her primary concerns…to get him off this medication!

For the optometric physicians reading this, of course, my patient  has a classic condition of Convergence Insufficiency.

So, why was this young man my “eye opener” this week when on the very same day we had three other incredibly complex patients who had just completed their vision therapy treatment plans, including a 58 year old man who suffered a visual field loss following a stroke, an 8 year old boy and a 6 year old girl with severe developmental delays and visual processing and visual motor deficits and now are all reading and doing well in their home life, school and and activities in daily living?

The answer is  because this young man’s vision problem didn’t jump out and smack his eye care providers in the face and say, “Here I am do something about this!” He had a binocular vision problem, that for years was unnecessarily overlooked yet impacted him academically, emotionally and even medically considering the potential negative side effects of 6 years of the psycho-stimulant, Dextroamphetamine (Adderall), on his life.

In the end, this is why this young man’s case was so meaningful to me.  Not because it was complex or difficult to treat. It was because in spite of being overlooked or ignored, at least now his condition (CI) was identified and with proper vision therapy treatment, his world could change for the better. He will be able to read without words doubling and have significantly improved attention and concentration and his confidence will emerge for his college studies. Plus, the need for ADHD medication will be drastically lessened or eliminated.

But, my question to the world is very simply this.  When will this binocular dysfunction, Convergence Insufficiency, that affects nearly 1 in 15 patients, ever be taken as the serious vision problem it is? All doctors, optometrists, ophthalmologists, pediatricians, family physicians, psychologists and neuropsychologists should be sensitive to this condition and do the necessary tests to make the diagnosis and manage. The PLRG NPC is an example of an easy test to do.

Here is the PDF to show how to perform the PLRG NPC test.

For more VisionHelp Blog posts on this topic Click here.

No one should have to struggle with Convergence Insufficiency. Now wouldn’t that be a miracle?

Dan L. Fortenbacher, O.D., FCOVD

3 thoughts on “Recognizing convergence insufficiency…could a greater miracle take place?

  1. What a timely entry. I had 3 elementary school referrals today to assess handwriting and all 3 had convergence insufficiency.

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