LOGO

Lecture VI
CONVERGENCE INSUFFICIENCY(CI)

Natnael L.
May -2017

1
 Out line
Definition
Symptoms of CI
Diagnosis
Management

2
 Objectives
At of this session, you will be able to:
 Define what convergence insufficiency is
 Describe the etiology of CI
 Explain the symptoms of CI
 Describe the diagnosis and management options
of CI

3
 Definition
 Refers to an inability to obtain or to maintain adequate
convergence for comfortable binocular vision at near
 Or poorly controlled convergence at near

4
 Definition-----cont
 When the patient is tired or his/her binocular vision is under
stress:
The condition can be conceptualized as permanently
decompensated exophoria at usually close working
distance which can result in a transient
decompensation at the normal working distance
 Characterized by a remote near point of convergence,
usually it is more remote than 8-10 cm

5
 ETIOLOGY OF CI
1. Disuse of accommodative convergence
 Because of accommodation convergence r/ship;
 Uncorrected myopes, presbyopes wearing their
reading glasses and absolute hyperopes may
all make reduced accommodative effort
2. Anatomical factors
 Such as large pd or divergent position of
anatomical rest

6
 ETIOLOGY OF CI-----Cont
3. Developmental factors
 Convergence is broken under stress conditions
4. Strabismus
 Convergence insufficiency was presented in both
convergent and divergent
5. Disuse of eyes
 Disuse of eyes for long periods of time
 Amblyopia in one eye or
 Blurred image in one eye
7
 ETIOLOGY OF CI---Cont
6. Vertical heterophoria
 Comitant or incomitant and break down into strabismus in
some direction of gaze, or adverse visual conditions
 During this time, surgery is suggested before treatment of
convergence inadequacy
7. General debility
 Poor general health, aging, urban life, metabolic disorders,
toxic conditions and local infections or endocrine disorder
are important factors
 The effect of any medication that the patient is taking
should also be considered 8
 ETIOLOGY OF CI---Cont
8. Paralysis of convergence
 Conditions affecting the brain stem
 Disseminated sclerosis
 Tabes dorsallis
 Traumatic conditions may have a sudden onset
of diplopia

9
 SYMPTOMS OF CI
 Usually associated with near vision and consists of:
Tired eyes
Intermittent blurring and double vision
Headache
Visual fatigue
Drowsiness
Sleepiness
Difficulty concentrating
Movement of print while reading and loss of
comprehension 10
 SYMPTOMS OF CI------cont
• Patient often report symptoms are relieved if one eye is
closed
• Become worse if the patient is suffering from:
• Tirednes
• Over work
• Ill health
• Anxiety associated with other heterophoric conditions

11
 Diagnosis of primary CI
A. Near point of convergence(NPC)
 Subjective NPC-the point at which the patient reports a
doubling of the target as it approaches the eye
 Objective NPC-the patient, sometimes, may not report
doubling, but the practitioner must observe the distance
at which one eye ceases to converge
 Normal values is taken as being less than 8 cm
 Thus, patients with NPC between 8-20 cm, may have
convergence difficulties

12
 Diagnosis of primary CI----
B. Jump convergence
 We direct a patient to look at distance object and then to
change fixation to one held at about arm’s length or less
than this from the eyes and on the median line
 The practitioner should observe to see if the change of
convergence is performed satisfactorily.
 Normally, a prompt and smooth convergence movement
from distance fixation to near vision

13
 B. Jump convergence ---- Cont
Abnormal response
• Over convergence
• Versional movement
• Slow or hesitant movement
• No movement of either eye or movement of one
eye

14
 Cont----------------
The above responses indicate a failure of normal
convergence
Failure of jump convergence test occurs more often
than a poor NPC, and appears to be associated with
symptoms more frequently.
Jump convergence test seems more useful clinical
tests, but both NPC and JC should included in
routine examination

15
 Diagnosis of primary CI----
C. HETROPHORIA TESTS
o For near vision, usually show compensated
exophoria
o About one-third of patients with convergence
insufficiency, there is decompensated exophoria
for near vision, more likely occurs in elderly
patients

16
 Diagnosis of primary CI----
D. Fixation disparity tests
 For near vision, these tests show suppression of one of
the monocular markers in about one-fifth of the
convergence insufficiency cases
 In the absence of strabismus, this suppression for near
vision can be taken as a possible indication of the
presence of convergence inadequacy
 Reading at 20 cm usually results in an increased exo-slip
and this effect is likely greater in convergence
insufficiency
17
 Diagnosis of primary CI----

E. Age
 As age increases esophoria will change into exo-
deviation at distance which results difficulty to
converge
 Elderly patients are mainly affected than young
patients

18
 Diagnosis of primary CI----
F. Amplitude of accommodation
 Convergence and accommodation insufficiency
are distinguished from ophthalmoplegia, because
accommodation insufficiency has a sudden onset
of symptoms
 Convergence insufficiency with accommodation
insufficiency usually show trouble in the teenagers
and sometimes improves after several years
 AC/A ratio is very low
19
 Diagnosis of Secondary CI

A. Systemic Diseases:
 Metabolic disorders
 Toxic conditions
 Local infections and endocrine disorders
 DM
 HTN
 Any medication
 Adverse of the medications
20
 Diagnosis of Secondary CI----cont
B. Vertical muscle defects:
 Any defect of the SO muscles, IR muscles
(which are a major eye depressors) results in
inadequacy to converge
 Mainly paralysis of trochlea nerve and
oculomotor nerve

21
 Management of CI
Treatment of convergence insufficiency is usually
by Orthoptic exercises and is nearly always
successful even if with older patients
Orthoptic exercises improve convergence fusional
reserve

22
 Management of CI
1. Removal of causes of decompensation:
• Factors that create decompensation
heterophoria may aggravate convergence
insufficiency
• So, thoughts should be given to the working
conditions, to the general health and to the
general well being of the patient

23
 Management of CI
2. Refractive correction
It is usually necessary to give a reading addition,
for young patients who have convergence
insufficiency combined with accommodative
convergence insufficiency
The reading glasses relieve the symptoms
Young myopes with previously uncorrected, may
find the refraction correction relieves the problems

24
 Management of CI
3. Orthoptic exercises
 Proven quite successful exercises if the patient is
motivated to do and for young patients, especially
designed to be used at home employing a parent
and child team.
 Have detailed instructions to make the
parent/older patients the vision therapist
 Most widely used eye exercises are the following:

25
 A. PUSH UP
 Can be done by using the RAF rule or a reading text
 Instructions:
• Hold the text at arm’s length and try to read it
• Then, bring the text towards your eye but be sure that
you can still read it
• Stop moving when you are not able to read
• Push the text back and again try to read it
• By repeatedly doing this exercises you can train
convergence
• The exercises can be done for about 10-20 minutes
twice a day for about 3-4 weeks 26
B. JUMP CONVERGENCE
 Patient is asked to fixate in turn on distance and
near targets and to report any diplopia activating
voluntary convergence
 Should show smooth and symmetrical movements
 Any abnormal responses can be relieved by
repeatedly doing the exercises as they are told to
the practitioner

27
C. Physiological diplopia
 When images fall outside panum’s area for the two foveas
will not fused as singe percept and perceived as double
 If objects fall on disparate points they will be seen as double
 It is present in normal functioning visual system
 Will not appreciated by patients with binocular vision
problems
 So, it used to check as both eyes are functioning correctly
I.e. no suppression present while carrying out exercises to
train fusional reserves
28
D. Bead on string exercises
Useful in improving positive fusional reserves
String appears as two strings attached at area of
the bead
Points in front of the bead appear in crossed
physiological diplopia and points behind the bead
appears in uncrossed diplopia
Bead serves as movable fixation target
29
INSTRUCTIONS
A bead is threaded onto a piece of string
The patient holds the piece of string on the bridge of their nose
The other end tied to an object directly in front of the patient
Bead is placed away from the patient than the NPC
The patient should see a single bead
The string should form an X, centered on the bead
Point out to the patient as awareness of physiological diplopia can be used to
check suppression
The bead is gradually moved towards the patient until diplopia or suppression
This procedure does not exercise relative convergence or accommodation, as
they change together
it may assist in heterophoria cases where patient has difficulty in appreciating
physiological diplopia correctly 30
4. Relieving prisms
 The last option of treatment if the above exercises are not
functional
 Are not appropriate to convergence insufficiency except
when it is combined with accommodative insufficiency or
decompensated exophoria which doesn’t respond to
exercises
 Base IN prism are incorporated to the Px's prescription
 Prism power determined by giving weakest prism which

31
 Allows patient to show prompt and smooth
convergence on jump convergence test
 Can be used to treat children and older patients
which have low motivation to perform the exercises
as well as busy individuals who have no time for
doing exercises

32
 RECALL AND FOLLOW UP
After 3-4 weeks the practitioner should ask about
 How easy or difficult the exercises have been
 How often they have done and for how long on
average each day
 The patient should be asked about any change in
their initial symptoms and asked whether new
symptoms has occurred

33
 RECALL AND FOLLOW UP
 Repeat relevant clinical tests and compared with
those obtained before giving the exercises.
 If the symptoms and clinical signs have improved
then the exercises can be stopped.
 If little or no improvement, the alternative
approaches need to be considered

34
 Indications of success of treatment
The symptoms associated with convergence
insufficiency may relieved after proper performance
The NPC of the patient will be improved usually<8 cm
The patient will not have difficulties in performing near
tasks efficiently and perfectly
The associated decompensated exophoria will show
some signs of compensation after the treatment

35
“An Orthoptic Exercise is possible for All ”
10Q!! 36