Description:
Orthoptic training refers to techniques designed to correct accommodative and convergence insufficiency (or convergence dysfunction). Regimens may include push-up exercises using an accommodative target of letters, numbers or pictures; push-up exercises with additional base-out prisms; jump-to-near convergence exercises; stereogram convergence exercises; and/or recession from a target. Orthoptic training is used to treat convergence insufficiency and has been investigated for treat attention deficient disorders, dyslexia and dysphasia.

For individuals who have convergence insufficiency who receive office-based orthoptic training, the evidence includes a TEC Assessment, several randomized controlled trials (RCTs) and nonrandomized comparative studies. Relevant outcomes are symptoms and functional outcomes. The most direct evidence on office-based orthoptic training comes from a 2008 RCT that demonstrated office-based vision or orthoptic training improves symptoms of convergence insufficiency in a greater percentage of patients than a home-based vision exercise program consisting of pencil push-ups or home computer vision exercises. Subanalyses of this RCT demonstrated improvements in accommodative vision, parental perception of academic behavior and specific convergence insufficiency-related symptoms. However, in this trial, as in others, the home-based regimen did not include the full range of home-based therapies, which may have biased results in favor of the orthoptic training. The evidence is insufficient to determine the effects of the technology on health outcomes.  

Clinical input has supported the use of office-based orthoptic training when home-based therapy has failed. Therefore, orthoptic training may be considered medically necessary in patients with convergence insufficiency whose symptoms have failed to improve with a home-based treatment trial of at least 12 weeks. Home-based therapy should include push-up exercises using an accommodative target, push-up exercises with additional base-out prisms, jump-to-near convergence exercises, stereogram convergence exercises, recession from a target and maintaining convergence for 30 to 40 seconds.  

For individuals who have learning disabilities who receive office-based orthoptic training, the evidence includes a TEC Assessment, as well as nonrandomized comparative and noncomparative studies. Relevant outcomes are functional outcomes. A 1996 TEC Assessment did not find evidence that orthoptic training improves outcomes for individuals with learning disabilities. Since that publication, peer-reviewed studies have not directly demonstrated improvements in reading or learning outcomes with orthoptic training. At least 2 earlier studies that have addressed other types of vision therapies reported mixed improvements in reading. The evidence is insufficient to determine the effects of the technology on health outcomes. 

Background  
Convergence insufficiency is a binocular vision disorder associated with defects in the eyes’ ability to turn inward toward each other (e.g., when looking at near objects). The diagnosis of convergence insufficiency is made when patients have a remote near point of convergence or difficulty in sustaining convergence in conjunction with sensations of visual or ocular discomfort at near vision. Symptoms of this common condition may include eyestrain, headaches, blurred vision, diplopia, sleepiness, difficulty concentrating, movement of print and loss of comprehension after short periods of reading or performing close activities. Prism reading glasses, home therapy with pencil push-ups and office-based vision therapy and orthoptics have been evaluated for the treatment of convergence insufficiency.  

Some learning disabilities, particularly those in which reading is impaired, have been associated with deficits in eye movements and/or visual tracking. For example, many dyslexic persons may have unstable binocular vision and report that letters appear to move around, causing visual confusion. 

Orthoptic training refers to techniques designed to correct accommodative and convergence insufficiency (or convergence dysfunction), which may include push-up exercises using an accommodative target of letters, numbers or pictures; push-up exercises with additional base-out prisms; jump-to-near convergence exercises; stereogram convergence exercises; and recession from a target.¹ A related but distinct training technique is behavioral or perceptual vision therapy, in which eye movement and eye-hand coordination training techniques are used to improve learning efficiency by optimizing visual processing skills.  

In addition to its use in the treatment of accommodative and convergence dysfunction, orthoptic training is being investigated for the treatment of attention deficient disorders, dyslexia, dysphasia and reading disorders.

Policy:
Office-based vergence/accommodative therapy may be considered MEDICALLY NECESSARY for patients with symptomatic convergence insufficiency if, following a minimum of 12 weeks of home-based therapy (e.g., pushup exercises using an accommodative target; pushup exercises with additional baseout prisms; jump to near convergence exercises; stereogram convergence exercises; recession from a target; and maintaining convergence for 30 – 40 seconds), symptoms have failed to improve.

Orthoptic eye exercises are considered NOT MEDICALLY NECESSARY for the treatment of learning disabilities.

Orthoptic eye exercises are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY for, including, but not limited, to:

• Slow reading.
• Visual disorders other than convergence insufficiency.

Policy Guidelines:
This policy addresses office-based orthoptic training. This policy does not address standard vision therapy with lenses, prisms, filters or occlusion (i.e., for treatment of amblyopia or acquired esotropia before surgical intervention).

Up to 12 sessions of office-based vergence/accommodative therapy, typically performed once per week, has been shown to improve symptomatic convergence insufficiency (CI) in children aged 9 to 17 years. If patients remain symptomatic after 12 weeks of orthoptic training, alternative interventions should be considered.

A diagnosis of convergence insufficiency is based on asthenopic symptoms (sensations of visual or ocular discomfort) at near point, combined with difficulty sustaining convergence.

Convergence insufficiency and stereoacuity are documented by:

• Exodeviation at near at least four prism diopters greater than at far.
• Insufficient positive fusional vergence at near (PFV < 15 prism diopters blur or break) on PFV testing using a prism bar.
• Near point of convergence (NPC) break of > 6 cm.
• Appreciation by the patient of at least 500 seconds of arc on stereoacuity testing.

Benefit Application:
BlueCard^®/National Account Issues
Orthoptic eye exercises may be offered by orthoptists, optometrists or ophthalmologists. In many Plans, orthoptic training is a contract exclusion.

Rationale    
Evidence reviews assess the clinical evidence to determine whether the use of a technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to function including benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of a technology, two domains are examined: the relevance and the quality and credibility. To be relevant, studies must represent 1 or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice. The following is a summary of the key literature to date.

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African American, Asian, Black, Latino and Native American]; LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflective of and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g., women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Orthoptic Training for Convergence Insufficiency
Clinical Context and Therapy Purpose
Convergence insufficiency is a binocular vision disorder associated with defects in the eyes’ ability to turn inward toward each other (e.g., when looking at near objects). The diagnosis of convergence insufficiency is made when patients have a remote near point of convergence or difficulty in sustaining convergence in conjunction with sensations of visual or ocular discomfort at near vision. Symptoms of this common condition may include eyestrain, headaches, blurred vision, diplopia, sleepiness, difficulty concentrating, movement of print, and loss of comprehension after short periods of reading or performing close activities. Prism reading glasses, home therapy with pencil push-ups, and office-based vision therapy and orthoptics have been evaluated for the treatment of convergence insufficiency.

The purpose of orthoptic training in individuals who have convergence insufficiency is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does the use of orthoptic training in patients who have convergence insufficiency improve net health outcomes?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with convergence insufficiency.

Interventions
The treatment being considered is in-office orthoptic training. Orthoptic training refers to techniques designed to correct accommodative and convergence insufficiency (or convergence dysfunction).

Comparators
The comparator of interest is standard management of convergence insufficiency with at-home vision training exercises.

Outcomes
The general outcomes of interest are symptoms and functional outcomes.

Timing of intervention is approximately 12 weeks of in-office training, followed by 6 months of at-home training. Follow-up at 1 year or more is preferable.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Systematic Reviews
At least 2 systematic reviews have addressed the role of orthoptic training for convergence insufficiency. A systematic review by Rawston et al. (2005) assessing the applicability and efficacy of eye exercises found that small controlled trials and a large number of cases supported their use in the treatment of convergence insufficiency.² Scheiman et al. (2020) conducted a systematic review and network meta-analysis of RCTs that evaluated nonsurgical treatments for convergence insufficiency.³ Six trials in children (n = 968) were analyzed. When treatment success was defined as a composite of normal clinical convergence parameters and a prespecified magnitude of improvement, office-based vergence/accommodative (orthoptic) training with home reinforcement was more likely to lead to a successful outcome than home-based computer training (risk ratio, 1.96; 95% confidence interval [CI], 1.32 to 2.94) and home-based pencil/target push-up training (risk ratio, 2.86; 95% CI, 1.82 to 4.35). An analysis that defined treatment success as a composite of both improved convergence parameters and improved symptoms found that office-based training with home reinforcement was more effective than home-based computer training (risk ratio, 4.65; 95% CI, 1.23 to 17.54) or home-based pencil push-up training (risk ratio, 4.41; 95% CI, 1.26 to 15.38); however, these findings were based on low-certainty evidence. Six RCTs in adults were included, but none compared office-based and home-based orthoptic training. Three trials in adults compared office-based training to placebo; results were limited and the authors concluded that the benefit of orthoptic training in adults was less clear overall than in children.

Randomized Controlled Trials
In 2008, the Convergence Insufficiency Treatment Trial Study Group reported on an RCT of 221 children with symptomatic convergence insufficiency.⁴ Symptoms were evaluated by the Convergency Insufficiency Symptom Survey, a 15-item survey with a final score ranging from 0 (least symptomatic) to 60 (most symptomatic). Scores of less than 16 were considered “asymptomatic,” and a decrease of 10 or more points was considered “improved.” On blinded evaluation after 12 weeks of treatment (99% completion rate), 73% of patients treated with office-based therapy were considered to be successful or improved on the composite outcome of Convergency Insufficiency Symptom Survey, near point convergency, and positive fusional vergency, as defined above, compared with 43%, 33%, and 35% of those treated with home pencil push-ups, home computer exercise, or placebo, respectively. At 1-year follow-up, 88% of the 32 children who were asymptomatic at the completion of the 12-week office-based treatment program remained successful or improved; 67% of the home-based pencil push-up group remained successful or improved.⁵ A limitation of this RCT is that near point exercises generally consisted of multiple therapies, making it difficult to correlate outcomes with specific modalities.

Following the publication of the main results of the Convergence Insufficiency Treatment Trial, a number of reanalyses were performed. The effectiveness of these forms of vision therapy (pencil push-ups, home computer exercises, office-based vision therapy) in improving accommodative amplitude in 164 (74%) of the 221 children who had coexisting accommodative dysfunction with convergence insufficiency was reported by the Convergence Insufficiency Treatment Trial Study Group in 2011.⁶ Of the 164 children with accommodative dysfunction, 63 (29%) had a decreased amplitude of accommodation, 43 (19%) had decreased accommodative facility (latency and speed of the accommodative response), and 58 (26%) had both. After 12 weeks of treatment, increases in amplitude of accommodation were significantly greater in the 3 active groups (range, 5.8 – 9.9 diopters) compared with office-based placebo therapy (2.2 diopters). The percentage of children who no longer showed decreased amplitude of accommodation was 91.4% for office-based therapy, 79.3% for home computer therapy, 74.1% for home pencil push-ups, and 35.7% for placebo treatment. Accommodative facility improved by 9.4 cycles per minute for office-based therapy, 7.0 cycles per minute for home computer-based therapy, 5.0 cycles per minute for home pencil push-ups, and 5.5 cycles per minute for office-based placebo therapy; only the office-based therapy showed significantly greater improvement than office-based placebo therapy. One year after completion of therapy, recurrence of decreased accommodative amplitude was found in 5 (11%) of 44 children and in 4 (12.5%) of 32 children who did not undergo subsequent treatment.

The effect of successful treatment for convergence insufficiency on parents’ perception of academic behavior in the 218 children who completed this trial was also reported by the Convergence Insufficiency Treatment Trial group (2012).⁷ Participants were classified as successful (n = 42), improved (n = 60), or nonresponder (n = 116) after 12 weeks of treatment. This study used the Academic Behavior Survey, a 6-item questionnaire (scoring range, 0 – 24 points) developed by the Convergence Insufficiency Treatment Trial Study Group to quantify parents’ perceptions of the frequency of adverse behaviors exhibited by children when reading or performing school work (5 questions) and overall parental concern about the child’s academic performance (1 question). Mean Academic Behavior Survey score at baseline was 12.85 points, which improved by 4.0, 2.9, and 1.3 points in children classified as successful, improved, and nonresponder, respectively. Improvements in Academic Behavior Survey scores correlated with reductions in symptom level (r = 0.29), but not changes in measures of convergence. Although the Academic Behavior Survey has not been validated outside of this study, the effect sizes in the successful and improved groups were 0.9 and 0.7, representing a clinically meaningful change.

In 2012, the Convergence Insufficiency Treatment Trial Study Group reported on a post hoc analysis of this RCT evaluating the effect of convergence insufficiency treatment on specific types of symptoms.8, Outcomes were measures on the Convergency Insufficiency Symptom Survey, which has 2 subscales: a performance-related subscale consisting of 6 symptoms related to visual efficiency when reading or performing near work (e.g., loss of place with reading) and an eye-related subscale consisting of 9 symptoms specific to visual function or asthenopic-type complaints (e.g., eye pain). Those with a “treatment response” (improvement of at least 8 points) on the overall Convergency Insufficiency Symptom Survey score demonstrated improvements in both the performance-related subscale and the eye-related subscale (mean, 1.1 points). Further research is needed to determine whether the treatment-related improvement in performance-related symptoms seen with orthoptics training translates into improvements in reading performance and attention.

In 2019, results of the Convergence Insufficiency Treatment Trial — Attention & Reading Trial (CITT-ART) were published.⁹ Children with convergence insufficiency were randomized to 16 weeks of weekly office-based vergence/accommodative therapy or office-based placebo therapy. Both groups performed home exercises 15 minutes per day, 5 days per week. The study outcomes for convergence ability and symptoms were the same as the outcomes in the Convergence Insufficiency Treatment Trial. After 16 weeks, mean Convergence Insufficiency Symptom Survey scores had decreased from baseline by -11.8 (95% CI, -13.4 to -10.3) and -10.4 (95% CI, -12.4 to -8.4) in the therapy and placebo groups, respectively, which was statistically similar between groups. There was no difference in the proportion of patients in each group that achieved normal or improved symptoms. Significantly more patients in the therapy group versus the placebo group met the criteria for normal or improved near point of convergence (p < 0.001) and positive fusional vergence (p < 0.001). Several composite outcomes for treatment success found significant improvements with therapy versus placebo. Interpretation of the symptom comparisons in this trial may be limited by the clinically relevant improvement in symptoms in the placebo group. Results for accommodation were published separately by Chen et al. (2020).¹⁰ Among the 288 children in the CITT-ART study with decreased accommodative amplitude or facility, normal amplitude (69% vs. 32%; p < 0.0001) and facility (85% vs. 49%; p < 0.0001) were achieved by significantly more patients in the therapy group compared to the placebo group, respectively. In a separate publication, results for improvement in reading comprehension were not significantly different between the therapy and placebo groups.¹¹ Reading comprehension subtest scores of the Wechsler Individual Achievement Test, Third Edition (WIAT-III) increased by 3.68 points in the therapy group and 3.8 points in the placebo group (difference -0.12; 95% CI, -1.89 to 1.66). All other reading outcome measures were also similar between groups.

Singh et al. (2021) published results of an RCT in 176 children and young adults (aged 9 to 30 years, mean 19 years) with symptomatic convergence insufficiency.¹² Patients were randomized to 6 weeks of office-based orthoptic therapy (3 times per week) or home-based pencil push-up exercises (15 minutes per day). At study end, there was no difference between groups in near point of convergence or Convergence Insufficiency Symptom Survey scores, but there was a significantly greater improvement in positive fusional vergence with office-based therapy compared to home-based exercises (p < 0.001). Limitations of this study include lack of blinding, a wide range of patient ages, short duration compared to other studies, 20% to 30% loss to follow-up leading to a lack of power, and the study was conducted at a single center in India.

Alvarez et al. (2020) conducted the Convergence Insufficiency Neuro-mechanism in Adult Population Study, a small RCT (N = 50) that compared 6 weeks of twice weekly office-based vergence/accommodation therapy and office-based placebo therapy in young adults (aged 18 to 35 years) with symptomatic convergence insufficiency.¹³ All patients performed home-based computer exercises 10 minutes per day, 3 days per week. Outcomes included change in near point of convergence, positive fusional vergence, and Convergence Insufficiency Symptom Survey scores. Both near point of convergence (p < 0.01) and positive fusional vergence (p < 0.001) were significantly improved with office-based therapy compared to placebo, but there was no difference between groups in symptom scores (2.3 points; 95% CI, -8.3 to 4.6; p = 0.6).

Tables 1 and 2 summarize the key RCTs in patients with convergence insufficiency.

Table 1. Summary of Key Randomized Controlled Trial Characteristics

Study; Trial	Countries	Sites	Dates	Participants	Interventions
					Active	Comparator
Convergence Insufficiency Treatment Trial Study Group (2008)4	U.S.	9	2005 – 2006	Children aged 9 to 17 years, exodeviation at or near at least 4Δ greater than at distance, insufficient positive fusional convergence, receded near point of convergence of ≥ 6 cm break, best corrected visual acuity of 20/25 in both eyes at distance and near, Convergence Insufficiency Symptom Survey score ≥ 16, not previously treated with pencil push-up or vergence orthoptic therapy	Office-based vergence therapy with home reinforcement; weekly visits and 15 minutes/day, 5 days/week for 12 weeks; n = 60	Home-based pencil push-up therapy; 15 minutes/day, 5 days/week for 12 weeks; n = 54 Home-based computer vergence therapy with pencil push-ups; 20 minutes/day, 5 days/week for 12 weeks; n = 53 Office-based placebo therapy with home reinforcement; weekly visits and 15 minutes/day, 5 days/week for 12 weeks; n = 54
CITT-ART Investigator Group (2019); CITT-ART9	U.S.	9	2014 – 2017	Children aged 9 to 14 years with exodeviation at or near at least 4Δ greater than at distance, insufficient positive fusional convergence, receded near point of convergence of ≥ 6 cm break, best corrected visual acuity of 20/25 in both eyes at distance and near, Convergence Insufficiency Symptom Survey score ≥ 16, not previously treated with office-based or home-based vergence therapy	Office-based vergence therapy with home reinforcement; weekly visits and 15 minutes/day, 5 days/week for 16 weeks; n = 206	Office-based placebo therapy with home reinforcement; weekly visits and 15 minutes/day, 5 days/week for 16 weeks; n = 104

CITT-ART: Convergence Insufficiency Treatment Trial — Attention & Reading Trial; RCT: randomized controlled trial.

Table 2. Summary of Key Randomized Controlled Trial Results  

Study	Change in Convergence Insufficiency Survey Symptom scorea (mean, 95% CI)	Symptoms resolved or improved at end of studyb	Convergence ability normal or improved at end of studyc
Convergence Insufficiency Treatment Trial Study Group (2008)4	N = 221	N = 218	N = 218
Office-based vergence therapy	-14.8 (-17.2 to -12.4)	72.9%	72.9 – 95.0%
Home-based pencil push-up therapy	-7.1 (-9.6 to -4.5)	47.1%	56.6 – 77.4%
Home-based computer vergence therapy with pencil push-ups	-6.0 (-8.6 to -3.4)	38.5%	59.6 – 77.0%
Office-based placebo therapy	-7.8 (-10.4 to -5.3)	42.6%	44.5 – 59.3%
Mean difference (95% CI); p-value	Office-based vergence therapy vs. home-based pencil push-ups: 7.9 (4.4 to 11.4); p < 0.001 Office-based vergence therapy vs. home-based computer vergence therapy with pencil push-ups: 8.4 (4.9 to 11.9); p < 0.001	Office-based vergence therapy vs. home-based pencil push-ups: p = 0.008 Office-based vergence therapy vs. home-based computer vergence therapy with pencil push-ups: p = 0.006	Office-based vergence therapy vs. home-based pencil push-ups: p < 0.05 Office-based vergence therapy vs. home-based computer vergence therapy with pencil push-ups: p < 0.05
CITT-ART Investigator Group (2019); CITT-ART9,	N = 311	N = 311	N = 311
Office-based vergence therapy	-11.8	61.8%	92.4 – 95.5%
Office-based placebo therapy	-10.4	58.7%	50.0 – 67.3%
Mean difference (95% CI); p-value	1.5 (-3.8 to 0.8); p = 0.21	p = NS	p < 0.001

CI: confidence interval; CITT-ART: Convergence Insufficiency Treatment Trial — Attention & Reading Trial; NS: not significant.
^a Based on the Convergence Insufficiency Symptom Survey, a 15-item survey with scores ranging from 0 (least symptomatic) to 60 (most symptomatic). A score of <16 is considered asymptomatic, and a decrease of ≥ 10 points is considered improved.
^b Asymptomatic (Convergence Insufficiency Symptom Score < 16) or improved (change in Convergence Insufficiency Symptom Score ≥ 10 points).
^c Based on near point convergency and positive fusional vergency. A “normal” near point convergency was defined as < 6 cm, and an improved near point convergency was defined as an improvement (decrease) of > 4 cm from baseline to follow-up. To be classified as having normal positive fusional vergency, a patient had to pass Sheard’s criteria (i.e., positive fusional vergency blur, or if no blur, then a break value at least twice the near phoria magnitude) and have a positive fusional vergency blur/break of > 15 prism diopters. Improvement in positive fusional vergency was defined as an increase of ≥ 10 prism diopters from baseline to follow-up.

Tables 3 and 4 display notable limitations identified in each study.

Table 3. Study Relevance Limitations

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Duration of Follow-upe
Convergence Insufficiency Treatment Trial Study Group (2008)4				3 — harms briefly described in text
CITT-ART Investigator Group (2019); CITT-ART9	3 — patients with learning or developmental disabilities were not excluded		2 — placebo involved some eye exercises and may have had a therapeutic effect

CITT-ART: Convergence Insufficiency Treatment Trial — Attention & Reading Trial
The evidence limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment. 
^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4. Not the intervention of interest.
^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 4. Study Design and Conduct Limitations

Study	Allocationa	Blindingb	Selective Reportingc	Data Completenessd	Powere	Statisticalf
Convergence Insufficiency Treatment Trial Study Group (2008)4		1 — office vs. home therapy
CITT-ART Investigator Group (2019); CITT-ART9

CITT-ART: Convergence Insufficiency Treatment Trial — Attention & Reading Trial
The evidence limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
^a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.
^b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.
^c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^d Data Completeness key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).
^e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference.
^f Statistical key: 1. Analysis is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Analysis is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4. Comparative treatment effects not calculated.

Nonrandomized Comparative Studies
Shin et al. (2011) reported on a nonrandomized comparative study of office-based vision therapy.¹⁴ Fifty-seven children with symptomatic convergence insufficiency or combined convergence insufficiency and accommodative insufficiency were divided into a treatment and a sham control group, matched by age and sex. Vision therapy was performed in the school clinic 2 times a week with instructions for home exercises to be performed for 15 to 25 minutes a day during the week. After 12 weeks of office-based vision therapy, the mean College of Optometrists in Vision Development-Quality of Life questionnaire score decreased from 27.07 to 10.40, and near point convergency improved from 8.67 to 3.20 in the children with convergence insufficiency. Mean positive fusional vergency improved from 13.93 to 26.80. Sixty-seven percent of the children were considered to have been cured, and 82% were improved. There were no significant changes between baseline and 12-week follow-up for the control group. Of the 20 children in the treatment group who completed a 1-year follow-up, 3 (15%) showed recurrence.

Dusek et al. (2011) reported on a nonrandomized comparative study of 134 children with convergence insufficiency who had been referred to a tertiary care center in Austria for reading difficulties.¹⁵ Thirty-two participants refused all treatment offered (control group); the remaining children were given base-in prism reading glasses (n = 51) or computerized home vision therapy (n = 51) based on preference. Parents were instructed to ensure that their child carried out the procedure correctly; compliance was verified weekly. All participants were examined for total reading time, reading error score, the amplitude of accommodation, and binocular accommodative facility at baseline and after 4 weeks. Prismatic reading glasses were not worn during testing. Significant improvements were found in the prism glasses and computer exercise groups for total reading time, reading error score, the amplitude of accommodation, binocular accommodative facility, and vergence facility. For example, reading speed improved by 21 seconds in the reading glasses group, by 12 seconds in the computer exercise group, and by 4 seconds in the control group. Mean amplitude of accommodation improved by 1.4 diopters in the reading glasses group, by 1.0 diopters in the computer exercise group, and by 0.3 diopters in the control group. The only significant improvement for the control group was vergence facility. Although this nonrandomized study had the potential for selection and performance bias, the results suggested that base-in prism reading glasses might be an effective treatment for convergence insufficiency and associated reading problems in children.

Lee et al. (2014) reported on results from a small nonrandomized, controlled trial of vision therapy in children with vergence insufficiency and symptomatic ADHD.¹⁶ Of 1,123 children (age range, 8 – 13 years) who were screened for ADHD, 81 were identified as having symptomatic ADHD; of those, 16 were identified as having accommodative dysfunction on binocular function testing. Eight subjects received vision therapy, and the remainder acted as a control group; eligibility criteria for vision therapy included: high exophoria at near vision (³6 prism diopters), exophoria at near vision at least 4 prism diopters greater than at distant vision, a receded near point of convergence break (³6 cm), or insufficient positive fusional vergency at near vision, failing Sheard’s criterion (positive fusional vergency less than twice the near phorias), or a minimum positive fusional vergency of 15 prism diopters or less base-out blur or break. Vision therapy included progressive home- and office-based convergence and accommodative exercises over 12 weeks. At the 12-week follow-up, intervention group subjects demonstrated improvements in near point convergency (11.50 to 4.38 cm; p < 0.05), breakpoint of near positive fusional vergency (11.88 to 32.38 cm; p < 0.01), recovery point of near positive fusional vergency (6.38 to 19.75 cm; p < 0.01), and near exophoria (12.00 to 7.81 cm; p < 0.05). ADHD symptoms, as measured by the parent-reported Korea-ADHD Rating Scale, improved from 23.25 at baseline to 17.13 (p < 0.05) after vision therapy. Only within-group comparisons were reported. Control group subjects did not demonstrate improvements in vision metrics or Korea-ADHD Rating Scale scores.

In a small randomized comparative study, Momeni-Moghaddam et al. (2015) compared the effectiveness of pencil push-up therapy with office-based vision therapy in 60 individuals who had convergence insufficiency (mean age, 21.3 years).¹⁷ Subjects received either pencil push-up therapy or office-based therapy without home intervention and underwent reevaluation at 4 and 8 weeks after the start of treatment. With a single exception, the 2 groups did not differ significantly regarding the near point convergency, phoria, and positive fusional vergency. After 4 and 8 weeks of follow-up, positive fusional vergency was significantly more improved in the pencil push-up therapy group (p = 0.001). Study authors suggested that pencil push-up therapy and office-based vision therapy were largely comparable for treatment of convergence insufficiency.

Noncomparative Studies
Borsting et al. (2016) published the results of a single-arm multicenter study, the Convergence Insufficiency Treatment Trial Reading Study.¹⁸ Investigators evaluated parent-reported behavioral and emotional problems at baseline among children with symptomatic convergence insufficiency and after 16 weeks of office-based vergence accommodative therapy. The intervention was consistent with that administered in the Convergence Insufficiency Treatment Trial. Parent-reported ADHD symptoms were assessed with the Conners 3 ADHD Index and behavioral and emotional symptoms with the 120-item Child Behavior Checklist. Of the 53 children enrolled, 48 consented to office-based therapy and 44 completed therapy and provided posttreatment data. After completion of therapy, there were significant within-subject improvements in Convergency Insufficiency Symptom Survey scores and Conners 3 ADHD Index scores (d = 0.58, significantly different from zero). Subjects also demonstrated statistically significant improvements in the Child Behavior Checklist competency-related subscale related to school performance but not to social- or activities-related performance. On Child Behavior Checklist’s symptom-related subscales, there were statistically significant improvements in the anxious/depressed, somatic complaints, and internalizing problems subscales. This study provided some evidence that ADHD-like and emotional and behavior problems may improve among children with symptomatic convergence insufficiency after office-based vision therapies. However, the study’s small size and lack of a control group preclude drawing definitive conclusions about the efficacy of this treatment.

Section Summary: Orthoptic Training for Convergence Insufficiency
At least 2 systematic reviews support the efficacy of orthoptic training for convergence insufficiency, especially in children. The most direct evidence on office-based orthoptic training comes from a 2008 RCT that demonstrated that office-based vision training improves symptoms of convergence insufficiency in a greater percentage of patients than a home-based vision exercise program. Subgroup analyses of this RCT demonstrated improvements in accommodative vision, parental perception of academic behavior, and specific convergence insufficiency-related symptoms. However, in this trial, as in others, the home-based regimen did not include the full range of home-based therapies, which may have biased results in favor of the orthoptic training. Another RCT published in 2019 did not find a difference in symptoms of convergence insufficiency between office-based orthoptic training plus home exercises and office-based placebo therapy plus home exercises, possibly due to notable improvements in symptoms in the placebo group.

Orthoptic Training for Learning Disabilities
Clinical Context and Therapy Purpose
Some learning disabilities, particularly those in which reading is impaired, have been associated with deficits in eye movements and/or visual tracking. For example, many dyslexic persons may have an unstable binocular vision and report that letters appear to move around, causing visual confusion.

The purpose of orthoptic training in individuals who have learning disabilities is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does the use of orthoptic training in patients who have learning disabilities improve net health outcomes?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with learning disabilities, including attention deficit disorders, dyslexia, dysphasia, and reading disorders. Diagnosis of learning disabilities should be conducted by a qualified, licensed professional. Attention deficit disorder can be diagnosed by professionals qualified and licensed to do so, as well as by psychiatrists and physicians, although only medical doctors can prescribe medication.

Interventions
The treatment being considered is office-based orthoptic training for learning disabilities.

Comparators
The comparator of interest is standard management of learning disabilities. The practices currently being used to treat learning disabilities vary depending on the type of disability, but they could include receiving special services at school such as individualized education programs and accommodations.

Outcomes
The general outcome of interest is functional outcomes.

The limited available literature showed that approximately 12 sessions over 5 weeks are needed to assess results. Longer-term follow-up was not indicated.¹⁹

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Systematic Review
A 2005 systematic review evaluating the applicability and efficacy of eye exercises found no clear scientific evidence to support the use of eye exercises for other disorders (e.g., learning disabilities, dyslexia), except convergence insufficiency.²

Randomized Controlled Trials
Two studies focused on the use of tinted lenses and eye patching as a technique to steady binocular vision for dyslexia. Stein et al. (2000) reported on results of a randomized trial in which 143 dyslexic children were instructed to wear yellow-tinted glasses with or without the left lens occluded.²⁰ Children were instructed to wear these glasses when reading or writing. Significantly more children given occluded glasses gained stable binocular vision in the first 3 months (59%) compared with children given unoccluded glasses (36%). Christenson et al. (2001), however, found no difference in reading ability of children with dyslexia and abnormal binocular vision tested with and without occluded, blue-tinted lenses.²¹

Nonrandomized Comparative Studies
Ramsay et al. (2014) reported on results from a non-RCT assessing a computerized vergence training program in 13- to 14-year-old patients with dyslexia.¹⁹ Twelve subjects with dyslexia were treated with the computerized vergence training program, receiving an average of 11.75 sessions over 5 weeks; 12 control students included were not treated. All subjects underwent vision testing and were not diagnosed with convergence insufficiency. The computerized training program involved the generation of a computerized stereogram, which appears in 3 dimensions with convergent vision. For the intervention groups, reading speed improved from 87.83 to 95.58 words read per minute from baseline to follow-up (p < 0.006); reading speed was unchanged from baseline to follow-up for the control group (85.00 words per minute at baseline to 89.37 words per minute at follow-up; p < 0.123). Mean improvement in reading speed from baseline to follow-up did not differ significantly between groups (p < 0.123).

Several studies have reported that poor reading in children with dyslexia or attention deficits may be related to impairments in accommodation or convergence, suggesting the need for an ophthalmologic and orthoptic evaluation.^22,23,24

Section Summary: Orthoptic Training for Learning Disabilities
Peer-reviewed studies have not directly demonstrated improvements in reading or learning outcomes with orthoptic training. At least 2 earlier studies that addressed other types of vision therapies reported mixed improvements in reading.

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Clinical Input From Physician Specialty Societies and Academic Medical Centers
While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from 4 physician specialty societies (5 reviewers) and 3 academic medical centers while this policy was under review in 2011. Although input supported the use of office-based orthoptic training when home-based therapy had failed, some reviewers indicated that home-based therapy would typically include more exercises than pencil push-ups. Recommended were push-up exercises using an accommodative target, push-up exercises with additional base-out prisms, jump-to-near convergence exercises, stereogram convergence exercises, recession from a target, and maintaining convergence for 30 to 40 seconds.

Practice Guidelines and Position Statements
Guidelines or position statements will be considered for inclusion in Supplemental Information if they were issued by, or jointly by, a U.S. professional society, an international society with U.S. representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

American Academy of Pediatrics et al.
In 2009 (reaffirmed in 201425,), the American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists issued a joint policy statement on pediatric learning disabilities, dyslexia, and vision. For vision therapy, the statement concluded:

“Currently, there is no adequate scientific evidence to support the view that subtle eye or visual problems cause learning disabilities. Furthermore, the evidence does not support the concept that vision therapy or tinted lenses or filters are effective, directly or indirectly, in the treatment of learning disabilities. Thus, the claim that vision therapy improves visual efficiency cannot be substantiated. Diagnostic and treatment approaches that lack scientific evidence of efficacy are not endorsed or recommended.”

In 2011, these same 4 associations also published a joint technical report on learning disabilities, dyslexia, and vision.1, This report concluded: “There is inadequate scientific evidence to support the view that subtle eye or visual problems cause or increase the severity of learning disabilities. … Scientific evidence does not support the claims that visual training, muscle exercises, ocular pursuit-and-tracking exercises, behavioral/perceptual vision therapy, ‘training’ glasses, prisms, and colored lenses and filters are effective direct or indirect treatments for learning disabilities.”

U.S. Preventive Services Task Force Recommendations
Not applicable.

Ongoing and Unpublished Clinical Trials
Some currently ongoing and unpublished trials that might influence this review are listed in Table 5.

Table 5. Summary of Key Trials

NCT No.	Trial Name	Planned Enrollment	Completion Date
Ongoing
NCT03908112	Interventions for Convergence Insufficiency in Concussed Children (ICONICC)	264	March 2025

NCT: national clinical trial.

References  

1. Handler SM, Fierson WM, Section on Ophthalmology SM. Learning disabilities, dyslexia, and vision. Pediatrics. Mar 2011; 127(3): e818-56. PMID 21357342
2. Rawstron JA, Burley CD, Elder MJ. A systematic review of the applicability and efficacy of eye exercises. J Pediatr Ophthalmol Strabismus. 2005; 42(2): 82-8. PMID 15825744
3. Scheiman M, Kulp MT, Cotter SA, et al. Interventions for convergence insufficiency: a network meta-analysis. Cochrane Database Syst Rev. Dec 02 2020; 12(12): CD006768. PMID 33263359
4. Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. Oct 2008; 126(10): 1336-49. PMID 18852411
5. Scheiman M, Kulp M, Cotter S, et al. Long-term effectiveness of treatments for symptomatic convergence insufficiency in children. Optom Vis Sci. Sep 2009; 86(9): 1096-103. PMID 19668097
6. Scheiman M, Cotter S, Kulp MT, et al. Treatment of accommodative dysfunction in children: results from a randomized clinical trial. Optom Vis Sci. Nov 2011; 88(11): 1343-52. PMID 21873922
7. Borsting E, Mitchell GL, Kulp MT, et al. Improvement in academic behaviors after successful treatment of convergence insufficiency. Optom Vis Sci. Jan 2012; 89(1): 12-8. PMID 22080400
8. Barnhardt C, Cotter SA, Mitchell GL, et al. Symptoms in children with convergence insufficiency: before and after treatment. Optom Vis Sci. Oct 2012; 89(10): 1512-20. PMID 22922781
9. CITT-ART Investigator Group. Treatment of Symptomatic Convergence Insufficiency in Children Enrolled in the Convergence Insufficiency Treatment Trial-Attention Reading Trial: A Randomized Clinical Trial. Optom Vis Sci. Nov 2019; 96(11): 825-835. PMID 31651593
10. Chen AM, Roberts TL, Cotter SA, et al. Effectiveness of vergence/accommodative therapy for accommodative dysfunction in children with convergence insufficiency. Ophthalmic Physiol Opt. Jan 2021; 41(1): 21-32. PMID 33119180
11. CITT-ART Investigator Group. Effect of Vergence/Accommodative Therapy on Reading in Children with Convergence Insufficiency: A Randomized Clinical Trial. Optom Vis Sci. Nov 2019; 96(11): 836-849. PMID 31651592
12. Singh A, Saxena V, Yadav S, et al. Comparison of home-based pencil push-up therapy and office-based orthoptic therapy in symptomatic patients of convergence insufficiency: a randomized controlled trial. Int Ophthalmol. Apr 2021; 41(4): 1327-1336. PMID 33392946
13. Alvarez TL, Scheiman M, Santos EM, et al. Convergence Insufficiency Neuro-mechanism in Adult Population Study Randomized Clinical Trial: Clinical Outcome Results. Optom Vis Sci. Dec 2020; 97(12): 1061-1069. PMID 33186192
14. Shin HS, Park SC, Maples WC. Effectiveness of vision therapy for convergence dysfunctions and long-term stability after vision therapy. Ophthalmic Physiol Opt. Mar 2011; 31(2): 180-9. PMID 21309805
15. Dusek WA, Pierscionek BK, McClelland JF. An evaluation of clinical treatment of convergence insufficiency for children with reading difficulties. BMC Ophthalmol. Aug 11 2011; 11: 21. PMID 21835034
16. Lee SH, Moon BY, Cho HG. Improvement of Vergence Movements by Vision Therapy Decreases K-ARS Scores of Symptomatic ADHD Children. J Phys Ther Sci. Feb 2014; 26(2): 223-7. PMID 24648636
17. Momeni-Moghaddam H, Kundart J, Azimi A, et al. The effectiveness of home-based pencil push-up therapy versus office-based therapy for the treatment of symptomatic convergence insufficiency in young adults. Middle East Afr J Ophthalmol. 2015; 22(1): 97-102. PMID 25624682
18. Borsting E, Mitchell GL, Arnold LE, et al. Behavioral and Emotional Problems Associated With Convergence Insufficiency in Children: An Open Trial. J Atten Disord. Oct 2016; 20(10): 836-44. PMID 24271946
19. Ramsay MW, Davidson C, Ljungblad M, et al. Can vergence training improve reading in dyslexics?. Strabismus. Dec 2014; 22(4): 147-51. PMID 25333204
20. Stein JF, Richardson AJ, Fowler MS. Monocular occlusion can improve binocular control and reading in dyslexics. Brain. Jan 2000; 123 ( Pt 1): 164-70. PMID 10611130
21. Christenson GN, Griffin JR, Taylor M. Failure of blue-tinted lenses to change reading scores of dyslexic individuals. Optometry. Oct 2001; 72(10): 627-33. PMID 11712629
22. Grisham D, Powers M, Riles P. Visual skills of poor readers in high school. Optometry. Oct 2007; 78(10): 542-9. PMID 17904495
23. Palomo-Alvarez C, Puell MC. Accommodative function in school children with reading difficulties. Graefes Arch Clin Exp Ophthalmol. Dec 2008; 246(12): 1769-74. PMID 18751994
24. Ponsonby AL, Williamson E, Smith K, et al. Children with low literacy and poor stereoacuity: an evaluation of complex interventions in a community-based randomized trial. Ophthalmic Epidemiol. 2009; 16(5): 311-21. PMID 19874111
25. Joint statement: learning disabilities, dyslexia, and visionreaffirmed 2014. American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists, et al. https://www.aao.org/clinical-statement/joint-statement-learning-disabilities-dyslexia-vis. Updated July 2014. 

Coding Section

Codes	Number	Description
CPT	92065	Orthoptic and/or pleoptic training, with continuing medical direction and evaluation
ICD-9 Procedure	95.35	Orthoptic training
ICD-9 Diagnosis	315.00-315.09	Developmental reading disorder coding range
	378.83	Other disorders of binocular eye movements, convergence insufficiency or palsy
HCPCS	V2799	Vision service, miscellaneous
ICD-10-CM (effective 10/01/15)	H51.11-H51.12	Convergence insufficiency and excess code range
	F81.0	Specific reading disorder
ICD10-PCS (effective 10/01/15)		Not applicable. ICD-10-PCS codes are only used for inpatient services. Policy is only for outpatient services.
Type of Service	Vision
Place of Service	Physician's Office

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.  

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward    

01012024 NEW POLICY 

05/17/2024 Annual review, no change to policy intent.