Coverage Policy Manual
Policy #: 1998008
Category: Medicine
Initiated: February 1998
Last Review: April 2024
  Orthoptic Training for the Treatment of Vision and Learning Disabilities

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. In addition to its use to treat convergence insufficiency, orthoptic training has been investigated for treating attention deficit disorders, dyslexia, and dysphasia.
 
Convergence insufficiency is a binocular vision disorder in the ability for the eyes to turn inward towards each other (e.g., when looking at near objects). 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, are associated with deficits in eye movements and/or visual tracking. For example, many dyslexic persons may have unstable binocular vision and report that letters may appear to move around, causing visual confusion. Orthoptics is a technique of eye exercises intended to improve eye movements and/or visual tracking and has been investigated in the treatment of attention deficient disorders, dyslexia, dysphasia, reading disorders, and vision disorders. Also known as vision therapy or ocular pursuit, the treatment may include the use of training glasses, prism glasses, or tinted or colored lenses.
 
This policy addresses office-based orthoptic training and does not address standard vision therapy with lenses, prisms, filters, occlusion, or penalization (for the treatment of amblyopia or acquired esotropia prior to surgical intervention).

Policy/
Coverage:
Effective, April 2017
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Office-based vergence/accommodative therapy meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for patients with symptomatic convergence insufficiency if, following a minimum of 12 weeks of home-based therapy (eg, 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 30-40 seconds), symptoms have failed to improve.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Orthoptic eye exercises for the treatment of any other indications including but not limited to the treatment of patients with learning disabilities, slow reading and visual disorders other than convergence insufficiency does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, orthoptic eye exercises for the treatment of any other indications including but not limited to the treatment of patients with learning disabilities, slow reading and visual disorders other than convergence insufficiency is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective, Prior to April 2017
Orthoptic eye exercises meet primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for the treatment of patients with convergence insufficiency when conservative (home-based) therapy has failed to improve symptoms.
 
Orthoptic eye exercises for the treatment of any other indications including but not limited to the treatment of patients with learning disabilities, slow reading and visual disorders other than convergence insufficiency does not meet member benefit primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For contracts without primary coverage criteria, orthoptic eye exercises for the treatment of any other indications including but not limited to the treatment of patients with learning disabilities, slow reading and visual disorders other than convergence insufficiency is considered investigational.  Investigational services are exclusions in most member benefit certificates of coverage.
 
 
Effective, March 2008
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.
 
Effective, February 1998
Orthoptic or pleoptic therapy is a contract exclusion.
 
 

Rationale:
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)
 
2010 Update
Convergence Insufficiency
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.
 
Learning Disabilities
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.
 
2012 Update
There is no additional scientific literature identified that would prompt a change in the coverage statement.
 
2013 Update
A search of the MEDLINE database was conducted through February 2013.  There was no new literature identified that would prompt a change in the coverage statement.  One non-randomized study for the treatment of convergence insufficiency was identified.  In 2011, Dusek et al. reported a study of 134 children with CI who had been referred to a tertiary care center in Austria for reading difficulties (Dusek, 2011). Thirty-two participants refused all treatment offered (control group), and the remaining children were given either 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 was carrying out the procedure correctly; compliance was verified on a weekly basis. All participants were examined for total reading time, reading error score, 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, amplitude of accommodation, binocular accommodative facility, and vergence facility. For example, reading speed improved by 21 seconds in the reading glasses group, 12 seconds in the computer exercise group, and 4 seconds in the control group. The mean amplitude of accommodation improved by 1.4 D in the reading glasses group, 1.0 D in the computer exercise group, and 0.3 D in the control group. The only significant improvement for the control group was vergence facility. Although this non-randomized study is limited by the potential for selection and performance bias, the results suggest that base-in prism reading glasses may be an effective treatment for CI and associated reading problems in children. Randomized placebo-controlled trials are needed to fully evaluate this treatment option.
 
In 2011, the American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists published a joint technical report on learning disabilities, dyslexia, and vision (Handler, 2011). The report states that reading disability, or dyslexia, is a language-based disorder, and treatment should be directed at this etiology. Although vision problems can interfere with the process of reading, children with dyslexia or related learning disabilities have the same visual function and ocular health as children without such conditions. The report concludes that there is inadequate scientific evidence to support the view that subtle eye or visual problems cause or increase the severity of learning disabilities and that 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 treatments for learning disabilities. In order to improve reading comfort, symptomatic convergence insufficiency in children can be treated with near-point exercises, prism convergence exercises, or computer-based convergence exercises. Near-point exercises generally consists of 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; recession from a target; and maintaining convergence for 30 to 40 seconds.
  
2014 Update
A literature search conducted through February 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
In 2012, the CITT group reported findings from a post hoc analysis of this RCT related to the effect of convergence insufficiency treatment on specific types of symptoms attributable to convergence insufficiency (Barnhardt, 2013). The overall CISS scale was divided into 2 subscales: a performance-related subscale consisting of 6 symptoms related to visual efficiency when reading or performing near work, such as loss of place with reading, and the eye-related subscale consisting of 9 symptoms specific to visual function or asthenopic-type complaints, such as eye pain. Each subscale was reported as an average of the items in its category, with a range of values from 0 to 4. Subjects were grouped into those with or without a “treatment response”, defined as an improvement of at least 8 points in their CISS scale. At baseline, scores on the overall CISS scale and the performance-related subscale were statistically significantly higher for children with parent-reported attention deficit hyperactivity disorder (ADHD) than for those without parent-reported ADHD (34.1 vs 29.5 for the overall CISS scale; 2.8 vs 2.2 for the performance related subscale). Those with a “treatment response” on the overall CISS score demonstrated improvements in both the performance-related subscale and the eye-related subscale of a mean 1.1 points. Further research is needed into whether the treatment-related improvement in performance-related symptoms seen with orthoptics training translates into improvements in reading performance and attention.
 
In 2013, Borsting et al published results from a single-arm, multicenter, study, the Convergence Insufficiency Treatment Trial–Reading Study (Borsting, 2013). Investigators evaluated parent-reported behavioral and emotional problems at baseline among 53 children with symptomatic convergence insufficiency and changes in parent-reported behavioral and emotional problems after 16 weeks of office-based vergence accommodative therapy. The intervention was consistent with that administered in the CITT trial. Parent-reported ADHD symptoms were assessed with the Connors 3 ADHD index and behavioral/emotional symptoms with the 120-item Child Behavior Checklist (divided into 3 competency-related subscales and 8 symptoms-related subscales). Of the 53 children enrolled, 48 consented to office-based therapy and 44 completed therapy and provided posttreatment data. After completion of therapy, the authors found a significant within-subject improvement in CISS scores and in scores on the Connors 3 ADHD index (effect size d=0.58, significantly different from zero). The 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 the symptom-related subscales, there were statistically significant improvements in the anxious/depressed, somatic complaints and internalizing problems scales. This study provides some evidence that ADHD-like and emotional/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 are substantial limitations that preclude making definitive conclusions about the efficacy of this treatment.
 
2017 Update
A literature search conducted through February 2017 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
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.
 
ONGOING AND UNPUBLISHED CLINICAL TRIALS
Some currently unpublished trials that might influence this review are listed below:
 
Ongoing:
(NCT02207517) Convergence Insufficiency Treatment Trial – Attention and Reading Trial (CITT-ART); planned enrollment 324; projected completion date April 2019).
 
Unpublished:
(NCT01515943) Effectiveness of Home-Based Therapy for Symptomatic Convergence Insufficiency; planned enrollment 204; projected compleiotn date June 2015 (completed).
 
2018 Update
A literature search was conducted using the MEDLINE database through February 2018. There was no new information added that would prompt a change in the coverage statement.
 
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).
 
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2019. No new literature was identified that would prompt a change in the coverage statement.
 
2020 Update
A literature search was conducted through February 2020.  There was no new information identified that would prompt a change in the coverage statement.   
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2021. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Scheiman et al conducted a systematic review and network meta-analysis of RCTs that evaluated nonsurgical treatments for convergence insufficiency (Scheiman, 2020). 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.
 
In 2019, results of the Convergence Insufficiency Treatment Trial - Attention & Reading Trial (CITT-ART) were published (CITT, 2019). 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 (Chen, 2021). 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 (CITT, 2019). 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 published results of an RCT in 176 children and young adults (aged 9 to 30 years, mean 19 years) with symptomatic convergence insufficiency (Singh, 2021). 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 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 (Alvarez, 2020). 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).
 
In 2014, the American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists reaffirmed the joint policy statement on pediatric learning disabilities, dyslexia, and vision (Joint statement, 2014).
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2022. No new literature was identified that would prompt a change in the coverage statement.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2023. No new literature was identified that would prompt a change in the coverage statement.
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2024. No new literature was identified that would prompt a change in the coverage statement.
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through March 2024. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:
92065Orthoptic training, with continuing medical direction and evaluation; performed by a physician or other qualified health care professional
92066Orthoptic training; under supervision

References: Alvarez TL, Scheiman M, Santos EM, et al.(2020) 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

American Academy of Pediatrics, Committee on children with disabilities, AAP, AAO, AAPOS.(1998) Learning disabilities, dyslexia, and vision: a subject review. Pediatrics, 1998; 102:1217-1219.

American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus and American Association of Certified Orthoptists.(2009) Joint Statement-Learning Disabilities, Dyslexia, and Vision. Pediatrics 2009; 124;837-844.

Barnhardt C, Cotter SA, Mitchell GL et al.(2012) Symptoms in children with convergence insufficiency: before and after treatment. Optom Vis Sci 2012; 89(10):1512-20.

Borsting E, Mitchell GL, Arnold LE et al.(2013) Behavioral and Emotional Problems Associated With Convergence Insufficiency in Children: An Open Trial. J Atten Disord 2013.

Chen AM, Roberts TL, Cotter SA, et al.(2021) Effectiveness of vergence/accommodative therapy for accommodative dysfunction in children with convergence insufficiency. Ophthalmic Physiol Opt. Jan 2021; 41(1): 21-32. PMID 33119180

CITT-ART Investigator Group.(2019) 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

CITT-ART Investigator Group.(2019) 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

Clarke MP, Wright CM, Hrisos S, et al.(2003) Randomised controlled trial of treatment of unilateral visual impairment detected at preschool vision screening. BMJ 2003;327;1251.

Cleary AS, Stewart HK, Weir CR.(2006) Are orthoptic exercises an effective treatment for convergence and fusion deficiencies? Strabismus, 2006; 14:183-9.

Convergence Insufficiency Treatment Trial Study Group.(2008) Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol 2008; 126(10):1336-49.

Convergence Insufficiency Treatment Trial Study Group.(2009) Long-term effectiveness of treatments for symptomatic convergence insufficiency in children. Optom Vis Sci 2009; 86(9): 1096-103.

Dusek WA, Pierscionek BK, McClelland JF.(2011) An evaluation of clinical treatment of convergence insufficiency for children with reading difficulties. BMC Ophthalmol 2011; 11:21.

Grisham D, Powers M, Riles P.(2007) Visual skills of poor readers in high school. Optometry 2007; 78(10):542-9.

Handler SM, Fierson WM.(2011) Section on Ophthalmology and Council on Children with Disabilities AAoO, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists,. Pediatrics 2011; 127(3):e818-56.

Hatt S, Gnanara L.(2006) Interventions for intermittent exotropia. Cochrane Database of Systematic Reviews 2006, Issue 3; Art No,:CD003737.

Helveston EM.(2005) Visual training: current status in ophthalmology. Am J Ophthal 2005; 140:903-10.

Joint statement:(2014) learning disabilities, dyslexia, and vision reaffirmed 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. Accessed February 3, 2021

Momeni-Moghaddam H, Kundart J, Azimi A, et al.(2015) 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. Jan-Mar 2015;22(1):97-102. PMID 25624682

Palomo-Alvarez C, Puell MC.(2008) Accommodative function in school children with reading difficulties. Graefes Arch Clin Exp Ophthalmol 2008; 246(12):1769-74.

Ponsonby AL, Williamson E, Smith K, et al.(2009) 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.

Ramsay MW, Davidson C, Ljungblad M, et al.(2014) Can vergence training improve reading in dyslexics? Strabismus. Dec 2014;22(4):147-151. PMID 25333204

Rawstron JA, Burley CD, Elder MJ,(2005) A systematic review of the applicability and efficacy of eye exercises. J Pediatr Ophthalmol Strabismus 2005; 42(2):82-8.

Scheiman M, Kulp MT, Cotter SA, et al.(2020) Interventions for convergence insufficiency: a network meta-analysis. Cochrane Database Syst Rev. Dec 02 2020; 12: CD006768. PMID 33263359

Scheiman M, Mitchell GL, et al.(2005) A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmol, 2005; 123:14-24.

Scheiman M, Mitchell GL, et al.(2008) The convergence insufficiency treatment trial: design, methods, and baseline data. Ophthalmic Epidemiol, 2008; 15:24-36.

Singh A, Saxena V, Yadav S, et al.(2021) 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. Jan 04 2021. PMID 33392946


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