Convergence insufficiency in a young child
October 24, 2016 7:26 AM   Subscribe

Based on the results of my near-6-year-old's kindergarten eye exam, and watching the followup, I expect he may be diagnosed with convergence insufficiency and we may be recommended to do vision therapy. I'm interested in hearing about people's experiences, and in any information that may help me evaluate whatever I'm told at the upcoming meeting to discuss the results of the exams.

I haven't been told the results of the in-depth convergence evaluation yet, but my (granted, only partially informed) suspicion from watching the evaluation is that he didn't pass several subtests. For now, I want to be as prepared as possible for when we discuss results and treatment options at the meeting, so let's assume I don't get told that everything's actually fine.

I read the AAP statement that was linked in the previous thread. While it goes to great pains to emphasize that dyslexia is not a vision problem and should not be treated by vision therapy, it does say that Symptomatic convergence insufficiency is a treatable condition. To improve reading comfort, it can be treated with near-point exercises, prism convergence exercises, or computer-based convergence exercises. Micropanda does fit a number of the traits described in convergence insufficiency checklists I've read (coordination, ball skills, is a fluent reader and writer but with very limited stamina) so there are reasons to want to treat it if the optometrist tells us there's a problem.

So, I kind of feel like vision therapy is woo in certain cases but maybe not in this type of case? The optometrist we saw is FCOVD certified, and thus far hasn't set off any creepy/woo alarm bells. (No heavy metal detox or previous normal eye exams here.) That said, should we get a second opinion from a pediatric ophthalmologist right away? At a later date? What will be the difference between the ophthalmic exam and the optometric exam? (At the first exam, we opted not to dilate Micropanda's eyes, but we did do the retinal photo.)

Long story short, I feel uncomfortable because it seems like opthalmologists and optometrists are not entirely in agreement about vision therapy. There are some recent published clinical trials that suggest vision therapy helps, but there are also plenty of essays by optometrists and ophthalmologists talking smack about each other. On the one hand I feel like the MD carries some weight, on the other hand, our occupational therapist has been more helpful than our developmental pediatrician. I don't want to go in with a chip on my shoulder but I also don't want to be sold a bill of goods.

A few more specific questions: If you did vision therapy with your kid, did it help? What kind of symptoms improved, and how much? Were you able to get insurance coverage? If no, how much did it cost? How did you handle optometrist vs opthalmologist? Did you get multiple opinions, were they conflicting, and how did you handle that?
posted by telepanda to Health & Fitness (11 answers total) 1 user marked this as a favorite
My brother had this problem as a kid. The doctors realized around the time he turned 5 that when he looked at a line of text on a page, he saw double. My parents decided to delay him going to kindergarten by a year and so he stayed home and did eye exercises regularly at home and had a bunch of check-ins with the eye doctor (I think it was our family optometrist, but I'm not 100% sure). By the end of the year, he could focus just fine on a page, so they sent him off to school. He still had to do eye exercises periodically for another year or two, but he learned how to read very quickly and had no problem with learning disabilities in school. He wore glasses all the time as a kid and he still has to wear reading glasses as an adult. From our family's perspective though, the eye exercises--what you're calling vision therapy--worked great.

If your kid does turn out to have a convergence insufficiency, I would also think about signing him up in a year or two for some kind of martial art or dance or swimming or some other activity where he can work on his coordination without the extra distraction of dealing with a ball--like you have to in baseball or basketball. My brother was a bit uncoordinated for most of his childhood, and he never got much of a chance to work on it, because baseball was basically the only sport for boys in our town and that was too hard for him. But he really thrived when he got to high school and got into cross-country running and Tae Kwon Do.
posted by colfax at 7:57 AM on October 24, 2016

My two cents (I work with children with developmental disabilities and many of my patients have been through vision therapy):

1. As you note, there are children with legitimate convergence insufficiency and this can be absolutely diagnosed by an ophthalmologist. Getting a second opinion would be worth it.
2. The issues you raise are unlikely to be caused by a vision issue alone. More likely a more complex presentation that affects integration of complex behaviors like directing and sustaining attention, coordination of complex movements, etc. Treating the vision issue does not address the overarching issue.
4. Ask how the optometrist would assess progress. In many cases, children perform the same activity after each session to track progress. Doing the same measure repeatedly provides you practice, and you typically get better at any activity you practice.

A supervisor of mine once said that the intervention you choose is expected to address the specific concern it treats. So physical therapy to a leg will help build strength in that leg. We do not expect it to have an impact on cognition, for example. Similarly here, there is no evidence that exercises to improve muscle coordination in the eyes would necessarily address the broad range of concerns vision therapy is purported to. In my experience, kids with a whole host of developmental issues from autism spectrum to dyslexia to emotional regulation concerns have been prescribed the exact same intervention by optometrists. The start is usually 12-16 sessions of vision therapy, with additional sessions added at times. The children I see have continued to have the same broader concerns after vision therapy.

So can it work? Yes, for some children. Buyer be very aware, however.
posted by goggie at 8:05 AM on October 24, 2016

It's not exactly what you're looking for, but as a data point, I've had vision therapy myself as an adult (ability to compensate for convergence problems decreased with age, and I started having the usual symptoms -- sight bouncing around on the page, losing focus, closing one eye to read, a little bit of balance stuff). Eventually I was diagnosed by an ophthalmologist and given prism lenses. When I told her they hadn't helped very much, she told me about vision therapy but didn't give me a referral. I got the therapy ultimately from an optometrist who specialized in it.

My focus was tested before, during, and after and it was much stronger after. Anecdotally, my reading improved. It didn't snap right back to normal, because my issues were exacerbated by anxiety (all my jobs and hobbies are reading-heavy, and I don't have good insurance and rarely get an eye exam, so it was a long period of wondering what was wrong). With time, the anxiety has declined and reading normalized.

My sense is that vision therapy isn't inherently woo. It's been around for a long time and can absolutely help with convergence problems. But a certain wooishness has started to cling to it because of overdiagnosis and attempts to use it to explain all the complexities of reading and balance issues. I think it's very much worth investigating, especially if you get a couple of opinions, but keep your eyes open.

As for the practical questions: the opinions didn't conflict, but I had a strong sense that the two types of doctors didn't get along even before I started reading up on it. My insurance accepted it, but at a very high copay, so I paid out of pocket ($90 a session; for financial reasons, the optometrist was willing to let me work semi-independently with exercises and computer stuff and check in every few weeks, so I only came in a handful of times).
posted by thesmallmachine at 8:34 AM on October 24, 2016

I did vision therapy for strabismus when I was about 8 (early 80s).

I did prism exercises (reading with a prism taped to my glasses) as well as something that would probably be done by computer now: my parents would set our tv to black and white and tape red cellophane over half the screen and green over the other half. If I didn’t keep my eyes aligned, the two halves would appear to me to overlap and half the screen would go dark for me. It was good incentive for kid who didn’t get a lot of screen time to really work at keeping her eyes in alignment.

It worked. I can “let” my eyes go unaligned, but it doesn’t happen involuntarily. No woo. Vision therapy saved me from surgery, which would have been the next step.

I don’t know anything about convergence insufficiency, but the description makes it sound like a similar condition that only happens when you’re doing close work, so I would totally believe that vision therapy could fix it. As for diagnosis, I’m sure a second opinion never hurts, but if you trust the optometrist I don’t think there’s any reason to be suspicious of it, especially since you feel like your son has symptoms that could be consistent.
posted by Kriesa at 10:02 AM on October 24, 2016

I can confirm that they do that by computer now, Kriesa, though the TV version sounds a lot more fun than the red-green stuff I did (which mostly involved training myself to pick 3D images out of computer-generated noise).
posted by thesmallmachine at 10:14 AM on October 24, 2016 [1 favorite]

I have convergence insufficiency and my divorced parents disagreed on whether it was a real thing or something I would grow out of. I wasn't diagnosed until I was an adult who finally went to an optometrist as an adult with the vague complaint of "I don't read well."

The doctor did a litany of tests and concluded that I had a moderate case of CI. The way she framed treatment was that children can help correct this with exercises (like focusing on a pencil at various distances) and prism glasses but at my age glasses were the only thing that could help. The doctor also explained that my brain learned to work with the input it was receiving from my eyes which meant glasses wouldn't be instantly helpful like ones for near or far sighted correction.

I wore the glasses off and on but didn't stick to wearing them (new habits are hard to make). The main issues I have from this are bad depth perception and that most of my field of vision comes from one eye. The second one is difficult to explain but when I close the less dominant eye my field of vision is only slightly reduced (by 1/4). I think normal would be closing one eye should reduce your field of vision by 1/2.

The reading difficulty I have is that I miss bits of text when I read. In school our in class discussions highlighted this when we were talking about reading assignments and I would have missed some key detail. I have a difficult time with written directions too (which has led to hilarious mistakes baking). With this, I still preformed well in school but perhaps not as well as my potential.

I don't have opinions on the treatments but I wish I had gone through therapy for this while it was still correctable. I'm fine with it and have a full and happy life but this was a definite stumbling block that my brain had to work out.
posted by toomanycurls at 12:15 PM on October 24, 2016

We do almost exactly what Kriesa describes with our 4 year old. He wears red/green glasses and watches youtube videos with red cellophane partially occluding the screen. He loves doing his homework, and his strabismus is a lot better now. Surgery is on the list if he gets worse, but so far the therapy is helping (or he's just getting older and it's going away -- hard to say).

Another optometrist wanted to charge a lot more to do in-office therapy which would have been more involved. Our insurance didn't cover it, so we opted to try this first as the pediatric ophthalmologist recommended the optometrist we are using.
posted by freezer cake at 12:23 PM on October 24, 2016

Anecdata: Our was son diagnosed with convergence insufficiency when he was 12 (he is now 15), and frankly we weren't too surprised as we had suspected something wasn't right in that area. Although his grades have always been pretty good, by the time he reached middle school he had become a somewhat reluctant reader, and his typical evening homework was extending right up to his bedtime. Reading for him was becoming a struggle, and it only got much worse as he became more tired. It probably didn't help that he was also studying for his bar mitzvah at that time, which meant learning to read Hebrew, a language that reads from right to left.

The kicker for him (and the thing that actually won him over to doing the therapy) was that he was trying to improve his baseball skills for Little League and was having EXTREME difficulties hitting the ball -- like, his swings were a good 12" away from where the ball was crossing the plate, which is a huge discrepancy. His eyes/brain just could not pick up the ball and adjust in time to allow him to hit it. His swings were off to such a degree that even his coaches were suggesting that we should get his vision checked out.

So we had him tested and his results indicated that although his vision was "fine", his convergence and tracking were poor. His optometrist (who is also licensed as a vision therapist) felt that he could improve his convergence with vision therapy. She was not claiming that it would work as a panacea, but given the spectrum of issues we were facing (reading for school, reading Hebrew for his bar mitzvah, playing baseball) she felt therapy would be worthwhile.

We still vacillated a bit before committing to the therapy. Therapy was going to be expensive for us (~$10k), and it wasn't covered by our insurance, though IIRC we were able to put away some pre-tax dollars into our HSA account and pay from that.

Once we began the therapy, our son met with the therapist for about 10 months in total. The sessions began once each week for an hour until we were up to speed with the program, and then the frequency of the in-office sessions decreased to once or twice per month after the initial evaluation and ramp-up period. The therapy was both done in-session with a therapist and also with nightly homework assignments consisting of tactical hand/eye coordination exercises (there were a number of these) and computer-aided games/therapies. These lasted about 20 minutes per night, every night. He loved the hands-on exercises and HATED the computer exercises, which were more demanding and less forgiving - the computer was a harsh task master, and if you did not complete a task in the time required you had to do it again. I thought both types of exercises were solid and lead him to practice some easily understood and identifiable goals. They also taught him some practical techniques for making his eyes do his bidding. I did not feel there was any "woo" in these exercises -- these were real exercises with realistic expectations and when done right they yielded stable, repeatable results.

We felt we began seeing improvements in his reading comfort/speed after about 8-10 weeks. I felt his improvements continued after that point, but he made his most improvements early on.

After completing a 10 month course of therapy, his test results on exit showed a significant improvement over his pre-therapy test results - his convergence scores had improved by about 70%, IIRC, and he was now in the bottom third of the "normal" range, as opposed below normal range as he had been prior to therapy. His comfort while reading improved quite a bit and his grades went up, which may have happened for a variety of reasons but we feel it is very likely that the vision therapy helped, as he was definitely able to read more efficiently than before the therapy. As for baseball, his hitting improved, but even though he was seeing the ball better and taking better at bats, he still wasn't a good enough hitter to make his team (and he ultimately switched to cross country and that has worked out fantastically for him, so none of us have any complaints there).

The bottom line is that for our son, the vision therapy was a success and was worth the money and effort. It wasn't exactly easy for us or for him, nor was it cheap, but we do feel it was money well spent. He is now 15 and a sophomore in high school. He moved up to AS English this year and received straight A's in his last reporting period (yeah, I'm bragging a bit, but we're proud of him). I can't give all of the credit to his vision therapy, but I know it played a positive role in his current situation.

The above is offered for what it's worth. Feel free to MeMail me/us if you have any questions we can help answer.
posted by mosk at 2:04 PM on October 24, 2016

Have you read Fixing My Gaze?
posted by oceano at 2:19 PM on October 24, 2016

I had vision therapy as an adult for strabismus/CI, after two different surgeries to treat it had reverted after ~ 5 years.

1) It absolutely helped with my double vision, nearly as much as surgery did.
2) It helped address a balance issue that I had my whole life. Before the therapy, I used to trip and fall often. I used to be laid up for several days or more with a bad skinned knee or sprained ankle at least once a year. It hasn't happened in the ten years since.
3) The balance issue resolved permanently, but when I stopped doing my exercises my muscle issues did tend to come back. This may be because I had the therapy as an adult.

Basically, vision therapy is physical therapy for your eye muscles. It is extremely helpful and effective for eye muscle problems. It will help with problems that are caused by eye muscle issues, like double vision, eyestrain headaches, and some balance/coordination issues. It will not magically cure problems that aren't caused by eye muscle issues. Vision therapy isn't going to make someone suddenly not have autism or dyslexia, but it very much helped me with my coordination and double vision.

That reminds me. I need to start doing my exercises again.
posted by oblique red at 9:48 AM on October 25, 2016 [1 favorite]

Response by poster: Just a brief update - we're now several weeks in, and I'm happy to say that although they are hard, and a big time commitment, the eye exercises seem to be making a difference. I noticed a week or so before his first progress check that Micropanda seemed to be reading more, and then at the progress check itself, they measured significant improvement in his ability to focus at close range (using tests that had not been repeated on a weekly basis). The last week or so, he's been reading nonstop.

I'm overjoyed for him: he's always loved books, and spent an inordinate amount of time looking at his books, and he's had the actual reading skills for a long time, but he's never been able to sit down and read a whole book start to finish on his own. Until now. I checked him out a pile of books from the library on Saturday, and we had to return them all for new ones on Sunday. We still need to be careful to choose books with sufficiently large print and wide print spacing (topic of an upcoming Ask!), but I'm hopeful that this too will improve as he keeps working.

Thanks to all for your helpful comments.
posted by telepanda at 12:56 PM on February 28, 2017

« Older Can I include logos/signs in my documentary film...   |   What Would Jorah (Mormont) Say? Newer »
This thread is closed to new comments.