What if your child is struggling to play the piano? Let say he is a bright 10 year-old boy who finds playing the piano difficult.  He just doesn’t get it! You ask yourself, why is he having this difficulty…he just seems to be unable to coordinate his fingers to play?   So, as any concerned parent, you seek professional help. But first,  you go on-line to research the possibilities for a solution to this problem and stumble across a website that says,   “Help your child become a piano virtuoso with simple finger exercises!”

Now wait a minute, that’s hard to believe right!? We all know that is illogical.  Doing simple finger exercises will not teach anyone how to become a skilled piano player! His fingers are strong enough to move the keys on the piano, his brain just does not know how to coordinate his fingers to play the music. The answer to his problem is found when you locate a good piano “coach” who can guide him along a process of learning the skills for playing the piano. Then with practice he will improve.  So, you dismiss the internet offer as another example of someone trying to promote an unproven and implausible self-help program.

Now let’s consider another scenario.  This time it is your 10-year-old son who is struggling to read and keep up in school. He  loses his  place easily when reading. He is  having trouble concentrating on a reading task and become very frustrated. He says his eyes hurt and sometimes he gets a headache when he reads. It sounds like he could be having a vision problem.

So you seek professional help and schedule him to have his eyes examined by your family optometrist, Dr. A.  Your son has his eye exam with Dr. A. and what you learn from the doctor is that his eyes are healthy and he has normal 20/20 eye sight. But,  he is having difficulty with coordinating his eyes together as a team when he tries to look at a book to read. Specifically he has trouble with his binocular vision (eye teaming). The doctor called it Convergence Insufficiency(CI). As it turns out, Convergence Insufficiency occurs in about 8-12% of children; affecting about 21.5 million people in the US (adults included).  Often times a person with CI (especially children) will experience symptoms involving  stress and strain around the eyes and have occasional double vision and avoidance behaviors. Often these symptoms look like ADD (Attention Deficit Disorder) too.

Doctor A. turns to you and says your child has a problem with proper eye coordination. His visual brain has not developed the correct neuromotor coordination abilities resulting in poor eye teaming when he attempts to do near vision work. This condition is treatable with 25-30 hours of office-based, doctor supervised, optometric vision therapy. While Dr. A.  does not provide this service in his office, he recommends another doctor whose practice is dedicated to treating patients with office-based optometric vision therapy and makes the referral.

Gosh, you were hoping for an easy fix like a new pair of glasses!  But what you are hearing is that it is much more complicated and will take several trips to another doctor over an extended period of time.

In the mean time, you think about it and decide to check around on your own and take your son to another doctor, Dr. B. for a second eye examination.  Dr. B. completes his eye exam of your son and agrees with the diagnosis…yes, he has CI. But this doctor’s approach is entirely different.  Dr. B. describes the problem with your son’s eyes is that he just has “weak eye muscles”  which need to be strengthened. He advises you that  your child’s problem can be solved  with some simple “eye exercises”! All you have to do is make his eye muscles stronger by asking him  to look at the tip of a  pencil as you move it closer to his nose.  In addition you are given some “work books” that have your son doing “tracking exercises”. You are puzzled by the lack of consistent treatment recommendations between the two doctors but since the recommendation is coming from a doctor, it must be true…right? Besides he accepts the minimal payment by your insurance and the treatment plan sounds a lot easier than what Dr. A was recommending. 

So…who do you believe? Why if both doctors agree on the diagnosis, don’t  they agree on the method of treatment? Who has got it right, Dr. A or Dr. B?

First, let’s remember the first example of the 10-year-old boy who was having trouble playing the piano. Is it logical to think that doing simple finger exercises will help him learn how to successfully play the piano? The answer seems pretty obvious right?

Surely the coordination of a person’s eyes is equally as complex as coordinating ones fingers to play a piano. So it would seem illogical that doing simple eye exercises would be effective at treating a problem with both eyes coordinating when attempting to read. However, over 50 years ago, many doctors were  taught that Convergence Insufficiency (CI) was a problem with eye muscle strength. While techniques in the area of visual rehabilitation were also beginning to emerge about that time, there were still some text books that the had the old-fashioned remedy for CI as just  a “series of simple eye exercises”. The problem was that the eye-exercise model of treatment was based on an assumption and not based on research.  Therefore, many doctors to this day still hang on to an old outdated model of treatment that was never based on proven research. 

 Therefore the answer to the question, “Who has got it right, Dr. A. or Dr. B”,  can only be answered based on double-blind multicenter research. What’s more, the research on the best methods to treat CI  was completed in 2008. It is a landmark study called the Convergence Insufficiency Treatment Trial (CITT). The CITT was funded with a $6.1 million grant  by the National Institute of Health and conducted through the National Eye Institute along with several sites around the country including Mayo Clinic and Bascom Palmer plus 6 Colleges of Optometry.

What this double-blind, multicenter research did was to compare office-based doctor supervised vision therapy (OBVT) to home based eye exercises called “pencil push-up therapy” as well as compared to a placebo, called “placebo therapy”

What did the research prove? It found that the “eye exercise therapy” had about the same effectiveness as the placebo. In fact the research proved that both the “eye exercise therapy” and the placebo therapy were found to be ineffective in treating Convergence Insufficiency.

However, office-based vision therapy was found to be effective and in subsequent research found to be the cure for convergence insufficiency. Dr A was correct!

 

The research is clear. So why do some doctors persist to advise patients about old-fashioned and ineffective treatment for Convergence Insufficiency? This can be difficult to answer in each case, but certainly when this condition, Convergence Insufficiency (CI) is accepted by the entire optometric and medical community as an important public health issue, then and only then will the majority of doctors get it right.

To address this fundamental public health problem and its realitive importance in the eye-care community, I wrote an article that was published in the Journal of Behavioral Optometry (Vol 21/2010/#2) entitled:  “Does Convergence Insufficiency Really Matter?” -(download) 

Dan L. Fortenbacher, O.D.,FCOVD

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