Office-based Vision Therapy for Improving Reading and Attention in Children With Convergence Insufficiency

Following the success of the NEI-funded Convergence Insufficiency Treatment Trials (CITT), the next logical and important research issue is to determine if the successful treatment of symptomatic convergence insufficiency (CI) (i.e., improvement of symptoms and ophthalmic signs) impacts function (reading and attention). It is well documented that children with symptomatic CI report significantly more symptoms when reading and doing close work (e.g., blurred vision, headaches, double vision, loss of concentration, frequent loss of place, trouble remembering what was read), manifest more academic-impairing behaviors (e.g., difficulty finishing assignments), and score worse on parent ratings of attention compared to children with normal binocular vision. Because reduction of symptoms and adverse academic behaviors are established outcomes of successful treatment of CI, we propose to test the hypothesis that resolution of these symptoms and behaviors leads to improved reading performance and attention. Previous studies have found improvements in reading comprehension reading speed and accuracy after successful treatment of CI. In a recent pilot study, investigators also found significant improvement in reading comprehension and attention after 16 weeks of successful treatment of symptomatic CI with office-based vergence/accommodative therapy; however, there was no control group. To definitively determine whether the successful treatment of symptomatic CI positively impacts reading and attention requires a placebo-controlled randomized clinical trial. Objective: We propose a multicenter, placebo-controlled, randomized clinical trial (RCT) of 324 children ages 9 to \<14 years (Grades 3-8) with symptomatic CI. \[we will restrict recruitment to children who do not have significant single word reading deficits.\] Participants will be randomized to 16 weeks of treatment with either \[a\] office-based vergence/accommodative therapy with home reinforcement (OBVAT) or \[b\] office-based placebo therapy with home reinforcement (OBPT). Outcomes (reading and attention) will be assessed after 16 weeks of treatment. In addition, we will test the long-term effects on outcomes at 1 year after treatment completion. All analyses will test the null hypothesis of no difference in outcomes between the two treatment groups. Specific Aim 1 - Reading Performance: To compare reading comprehension outcomes for children with symptomatic CI who receive 16 weeks of OBVAT and OBPT treatment. The primary outcome measure of reading performance is the Wechsler Individual Achievement test (WIAT-III) reading comprehension subtest score. In secondary analyses, we will examine the effects of the treatment on word reading, pseudoword decoding, oral reading fluency, and listening comprehension. We also will examine the correlation of changes in CI symptoms and ophthalmic signs with reading outcomes. Analysis of the 1-year follow-up data will be used to determine if any gains in reading performance observed after 16 weeks of treatment are sustained. Specific Aim 2 - Attention: To investigate the effect of treatment on teacher- and parent-rated measures of attention for children with symptomatic CI who receive 16 weeks of OBVAT and OBPT intervention. The primary outcome measure of attention is the score on the Strengths and Weaknesses of ADHD Symptoms and Normal Behavior Scale (SWAN). In secondary analyses, we will examine the effects of treatment on a second parent-rated attention scale called the SNAP. We also will examine the correlation of changes in CI-symptoms and ophthalmic signs with attention outcomes. Analysis of the 1-year follow-up data will be used to determine if any gains in attention observed after 16 weeks of treatment are maintained. Scientific and Clinical Impact: The relationship between the treatment of symptomatic CI and its effect on reading and attention in children is unknown. The results of the proposed study will contribute to a better understanding of these relationships and help to resolve controversy surrounding this issue. The results will have important implications for educators, psychologists, eye professionals, and other health care providers who care for children with reading and attention problems and guide hypothesis development for future scientific investigations on evidence-based relationships between visual disorders and other developmental disorders in children.