Orthoptic or pleoptic therapy is an exclusion in some member's certificate of coverage.

 

Orthoptic or pleoptic therapy does not meet Primary Coverage Criteria.  Indications for intervention, the type of intervention and the timing of any intervention are all unclear.  There is an ongoing trial to address these questions.

 

Orthoptic/pleoptic therapy is considered investigational and not covered for contracts without Primary Coverage Criteria.  Investigational services are a member benefit exclusion.

 

 

 

From the American Academy of Pediatrics, 1998: Learning disabilities are common conditions in pediatric patients. The etiology of these difficulties is multifactorial, reflecting genetic influences and abnormalities of brain structure and function. Early recognition and referral to qualified educational professionals is critical for the best possible outcome. Visual problems are rarely responsible for learning difficulties. No scientific evidence exists for the efficacy of eye exercises (“vision therapy”) or the use of special tinted lenses in the remediation of these complex pediatric developmental and neurologic conditions.

 

Scheiman et al, in a pilot study reported in 2005, concluded vision therapy/orthoptics was more effective than pencil push-ups or placebo vision therapy/orthoptics in reducing symptoms and improving signs of convergence insufficiency in children 9-18 yrs of age.  This study enrolled only 47 children in 3 treatment groups but only 38 were included in the final analysis.  This study was designed as a pilot study to prepare the CITT Study Group for a large scale randomized clinical trial.  

 

"Based on an assessment of claims and a study of published data, the consensus of ophthalmologists regarding visual training is that, except for near point of convergence exercises, visual training lacks documented evidence of effectiveness." (Helveston, 2005)

 

In 2008, the multi-center Convergence Insufficiency Treatment Trial investigator group reported a randomized controlled trial of 221 children with symptomatic convergence insufficiency. The children were randomized to 1 of 4 treatment conditions; home-based pencil push-ups; home-based-computer vergence/accomodative therapy and pencil push-ups; weekly office-based vergence/accommodative therapy with home exercises; or weekly office-based placebo exercises with home reinforcement of the placebo exercises.  Blinded evaluation following 12-weeks of treatment showed successful or improved outcomes on the Convergence Insufficiency Symptom Survey (CISS) for 73% of patients treated with office-based therapy, 43% with home pencil push-ups, 33% with home computer exercises, and 35% of patients in the placebo control group.  For office-based orthoptic training, the average CISS improved from 30 at baseline to 15 at the final assessment, which was significantly better than the other 3 groups.  The group  practicing pencil push-ups at home improved from an average CISS score of 28 to 21 at 12-weeks; similar scores were obtained for the home computer exercise group and the office-based placebo group.  At one-year follow-up, 88% of the 32 children who were asymptomatic (CISS<16) 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 (CITT Study Group, 2009). Therefore, the policy has been changed to indicate that orthoptic training meets primary coverage criteria of effectiveness for the treatment of convergence insufficiency.

 

A 2005 systematic review of the applicability and efficacy of eye exercises found that there was no clear scientific evidence to support the use of eye exercises for other disorders aside from convergence insufficiency, including learning disabilities and dyslexia (Rawstron,2005).

 

Several recent studies report that poor reading in children who do not have dyslexia or attention deficits may be related to impairments in accommodation or convergence, suggesting the need for an optometric evaluation (Grisham, 2007) (Palomo-Alvarez, 2008) (Ponsonby, 2009). Additional studies are needed to evaluate whether treatments for poor convergence or accommodation improve reading performance in this population.  

 

In August 2009, 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 statement concerning vision therapy for learning disabilities and dyslexia.  “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”.

 

There is insufficient evidence to evaluate the effect of orthoptic training in children or adults who are slow readers without identified learning disabilities or symptoms of convergence insufficiency , or for the treatment of other visual disorders.

 

 

 

  

 

 

 

 

In a small randomized comparative study, Momeni-Moghaddam and colleagues examined the effectiveness of pencil push-up therapy versus office-based vision therapy in individuals with convergence insufficiency (n=60; mean age, 21.3 years) (Momeni-Moghaddam, 2015). Subjects received either PPT or office-based therapy without home intervention, and underwent reevaluation at 4 and 8 weeks after the start of treatment. With 1 exception, the 2 groups did not differ significantly in terms of the near point of convergence, phoria, and positive fusional vergence. After 4 and 8 weeks of follow-up, the positive fusional vergence was significantly more improved in the PPT group (p=0.001). Study authors suggest that PPT and office-based vision therapy are largely comparable for treatment of convergence insufficiency.

 

 

 

 

 

In 2014, Ramsay et al reported results from a non-RCT on a computerized vergence training program in 13- to 14-year-old patients with dyslexia (Ramsay, 2014). 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).