Friday, April 03, 2009

convergence insufficiency-things you should know

convergence insufficiency, a new term in our little world. I took Ciarra in for some testing recently for school, in effect it is "IQ testing". The Dr that tested her noticed some very odd things in the results, and once she showed me, I saw clearly what she meant. In some parts of the testing, Ciarra got the answers wrong, one test that comes to mind was a keyed box thing where you had to put the coded answer according to the key above into a little box, there were 15 or so little boxes under the key code. Ciarra got them all wrong...sort of. When we looked closer, she had most of them correct, but diagonally wrong by one box, she put them in the box under and to the left of the correct box. But they were for the most part correct, of course she was scored as missing them.

It was a clear indication to the Dr that something was going on with her eyes. Test after test came back as showing visual problems, of course there was plenty she got wrong just because she didnt get the question, etc, but clearly something was up with her eyes.

We had Ciarra tested a year or so ago by an eye doctor who prescribed glasses, and sent us on our way. I have had a strong feeling something more was going on, she just seemed to struggle with reading...not how to read, but the mechanics of how she held her body. It is a bit hard to explain. She always tilted her head while reading, and I have come to recognize that I do the same thing, although I know I am having terrible trouble seeing these days, I thought it was just me.

Turns out, Ciarra and I both have something called convergence insufficiency, also known as exophoria. In all my reading and trying to stay on top of medical issues with DS, I have never heard of this one. Luckily, the doc that did her IQ testing knew of a "developmental eye doc" that does very specific testing. I was honestly stunned to see the difference between regular eye exams and this one. In depth is an understatement. wow.

A few things I learned about CI:

During the act of reading, the demand is for the two eyes to turn inward so that they are aimed at the reading task. If the eyes have a tendency to deviate outward, the child must use excess effort and energy to maintain fixation on the reading task. Most studies have shown that the greater the amount of effort involved in reading, the lower will be the comprehension and the lower will be the performance. When reading, the eyes do not move smoothly over a line of print. Rather, they make a series of fixations looking from word to word. When an exophoria exists, each time fixation is broken and moved to the next word, the eyes will tend to deviate outwards and they must be brought back in to regain fixation. Human nature being what it is, the child generally has an avoidance reaction to the reading task. This is compounded by the fact that anything the child doesn't do well, he would rather not do. This is the child who looks out the window rather than paying visual attention. He is commonly given labels. He is often accused of having a short attention span and not trying. He is told that he would do better if he tried harder, but he has tried harder to no avail. He is often labeled as having dyslexia, minimal brain dysfunction, learning disability, etc. Commonly, he loses his place while reading and/or uses his finger or a marker to maintain his place. While making the eye movements during the act of reading, he might not land on the next word, but rather land a few words further on. Consequently, he commonly omits small words or confuses small words. Often, he just adds a word or two to make the sentence make sense. If the two eyes are pointing at the same point in space, a person will see the fixated object as being single. Double vision or overlapping vision (Figure #3) results if the two eyes are not exactly pointing at the same point. Don't expect a child to tell you that his vision isn't clear. He has no yardstick of comparison to inform him that his vision differs from the vision of anyone else.

A Parent's Checklist
Look for these signs and symptoms.

If you check off several items on the following checklist, consider taking your child for a vision exam.

You observe the following behavior in your child:

one eye drifts or aims in a different direction than the other (look carefully -- this can be subtle). This is significant even if it only occurs when the child is tired or stressed.

turns or tilts head to see

head is frequently tilted to one side or one shoulder is noticeably higher

squinting or closing or covering of one eye

excessive blinking or squinting
short attention span
daydreaming in class
poor handwriting
poor visual/motor skills (often called "hand-eye coordination")

problems moving in space, frequently bumps into things or drops things
clumsiness on playground or at home

While reading or doing close work your child:

holds the book or object unusually close

closes one eye or covers eye with hand

twists or tilts head toward book or object so as to favor one eye

frequently loses place and fatigues easily

uses finger to read

rubs eyes during or after short periods of reading
reversals when reading (i.e., "was" for "saw", "on" for "no", etc.)
reversals when writing (b for d, p for q, etc.)
omitting small words
confusing small words
transposition of letters and numbers (12 for 21, etc.)
loss of place when reading, line to line and word to word.
child's ability to learn verbally surpasses his ability to learn visually.

Your child frequently complains of:

only being able to read for short periods of time
headaches or eyestrain
nausea or dizziness
motion sickness
Say no more. If your child reports seeing double, please take your child for a binocular vision evaluation immediately. You are invited to request a free referral at the Directory of Vision Care Providers.

Reading Skills and Binocular Visual Skills
One of the tests used in optometric offices is to have the child read words while looking into an instrument called a Telebinocular. The performance is compared between reading with either eye alone and with both eyes together. The difference in performance is often quite dramatic if there is an eye teaming problem. One eye performance might be quite satisfactory, but reading with both eyes together will be slower and many more errors will be made.

Every child with difficulty reading should be given the Convergence Insufficiency Symptom Survey pdf to see whether convengence insufficiency is contributing to the problem. The mean score for children wtih convergence insufficiency 30 vs. 8.4 (for more info, see here).

The symptoms can include eyestrain, headaches, blurred vision, sleepiness and trouble retaining information when reading. Other symptoms associated with convergence insufficiency include a "pulling" sensation around the eyes, the rubbing or closing of one eye when reading, words seeming to "jump" or "float" across the page, needing to reread the same line of words, frequent loss of place, general inability to concentrate and short attention span.

Children with this condition will not benefit from tutoring, special education or extra help from teachers until the condition is diagnosed and treated. A child can have 20/20 vision and still have this disorder. It's not routinely checked with eye exams, and schools don't test for it.

I suspect that many children out there are undiagnosed or misdiagnosed and going untreated. The treatment for convergence insufficiency disorder is noninvasive, effective, and much of it can be done at home. It involves special vision therapy that can help retrain the eyes. Interestingly enough, as the Doc spoke yesterday, I "got it" so well because she was describing ME as well. Hopefully the therapy we do for Ciarra will benefit me as well. If not, there are special prisms we can get for my glasses that will help.

What is Vision Therapy or Visual Training?

Vision therapy (visual training, vision training) is an individualized supervised treatment program designed to correct visual-motor and/or perceptual-cognitive deficiencies which have various causes, such as:

inadequate sensorimotor development
trauma to the nervous system (i.e., birth injury, brain trauma, closed head trauma, etc.)
in some cases, contributing hereditary factors (i.e., crossed-eyes, wandering eyes)
Vision therapy trains the entire visual system which includes eyes, brain and body. However, it is important to understand that vision therapy is a form of neurological training or rehabilitation (it can be compared to some forms of occupational therapy or physical therapy). The goal of vision therapy is to train the patient's brain to use the eyes to receive information effectively, comprehend it quickly and react appropriately.

Vision therapy sessions include procedures designed to enhance the brain's ability to control eye alignment, eye movements, focusing abilities, and eye teamwork (binocular vision). Visual-motor skills and endurance are developed through the use of specialized computer and optical devices, including therapeutic lenses, prisms and filters. During the final stages of therapy, the patient's newly acquired visual skills are reinforced and made automatic through repetition and by integration with motor and cognitive skills.

Can vision therapy help children with learning problems?

Yes! Vision therapy can be an important part of the overall treatment of a child's learning problem. Vision and sensorimotor deficits can cause eyestrain, headaches, blurred or double vision, loss of place while reading, and difficulty maintaining attention on close work. Even intelligent, highly motivated children can be severely handicapped by these problems in the academic environment.

Correcting these deficits allows affected children to benefit from academic remediation and to achieve their full potential in the classroom.

Approximately 20% of school-aged children may be affected to some degree by learning related vision disorders. This percentage dramatically increases within the special education, learning disabled and remedial reading populations, where as many as 70% of the students have a significant visual component to their learning problems.

I have high hopes that Ciarra and I both can get our eyes working better. And I thought you might be interested in knowing about this hidden condition that just might be masking some of those awesome abilities our kids have. If your child fits the description, start asking questions!!

Here's looking at you, beautiful girl.


My name is Sarah said...

This is Joyce. Very interesting information. I personally have never heard of this either. What an observant Dr. that took the time to analyze the results and just report the results.

datri said...

Thanks so much for this. Kayla has a LOT of those symptoms. She does have intermittent estropia in her left eye (it turns in on occasion, usually when tired) and we've seen three pediatric ophthalmologist, none who seem to know what to do. Well, one wanted to do surgery, but I thought that was a bit extreme for a condition that only happens on occasion. But I will definitely mention this at our next appointment!

RML said...

That was fascinating! I will certainly keep an eye out for it with my kids just in case.

K said...

Your blog is gorgeous
Just discovered this through Kara

Dominick M Maino, OD, MEd, FAAO, FCOVD-A said...

I saw your comments regarding convergence insufficiency...and being one of those "developmental docs" I thought I'd comment. Individuals with Down syndrome may have many problems including eye teaming, focusing, eye movement and high refractive error (nearsightedness, farsightedness, and astigmatism). Just about all of the children I see receive glasses with multifocal lenses (one power for distance another for near to help with focusing) and even prism (prisms help with eye coordination). I would like to suggest that your readers go to the College of Optometrists in Vision
Development at to find a developmental optometrist in their area. I also have a special interest in children and adults with disability and post the latest research in this area on my blog at

If your readers have any questions I can be reached at .

Dominick M. Maino, OD, MEd, FAAO, FCOVD-A; Professor of Pediatrics/Binocular Vision; Illinois Eye Institute

Jennifer said...

Your information is very concise and well presented. I am 35 years old, and was recently diagnosed with ci. I was involved in a terrible motor vehicle accident as a teenager. I sustained a head injury. This condition has plagued my attention span for years. I could never figure out why I was never the Same after my accident. My grade fell severly in college. I could just never prove I understood the information because my tests never reflected my intelligence. As a result has affected my self esteem and motivation for years. All parents should request to see a behavioral optometrist if your child is having problems with school grades. As well as have them tested as teenager to make sure it is not developmental. I wish no childthe suffering I went as a young adult.