An OT treats CI

The process the author uses to treat convergence insufficiency has been very efficient, effective and repeatable. Symptoms are generally resolved in 8-10 visits for neuro-typical children and adolescences. This treatment process does not include the assessment of primitive reflexes though many of the activities (not by design) may help to integrate these retained reflexes. Treatment sessions are twice a week for one hour and home programs consist of a brock string performed 3-4 minutes in the morning and afternoon. The patient returns for their annual eye exam one year later and typically remain symptom-free.

The Referral

Most of the referrals are made by Dr. Mark Obenchain OD, a binocular vision/peds specialist. He is a graduate of Indiana University where he completed a residency in binocular vision and pediatrics. He accepts all insurances and Medicaid.

Our patients cover a board spectrum of demographics with approximately 2/3rds being neuro-typical and the remaining 1/3rd having an additional diagnosis such as ADHD, Autism, or other developmental delays. A complete pediatric eye exam with cycloplegic dilation is performed on every child under the age of 18 regardless of complaints.

The doctor diagnoses CI when:

• The patient shows near point of convergence greater than 6cm after 5 trials
• Exophoria at near great than 6 PD
• NPC does not improve with (+) lenses (ruling out pseudo-CI)
• Patient complaints consistent with CI (headaches, reading problems, etc)

The OT Evaluation

The occupational therapy evaluation begins with a medical history, medication history and a discussion of academic performance and hobbies.

The following testing is performed:

• extraocular movements
• tracking
• stereopsis
• near point of accommodation
• near point of convergence
• Developmental Eye Movement Test
• Beery VMI, Visual Perception and Motor Tests
• Observations are made during proactive and rotator 3 activities on Sanet Vision Integrator for eye-hand coordination, posture, and balance. This performed while the patient stands on a balance board.

The author does not assess visual perception at this time. The patient has been diagnosed with a near vision problem which could taint the results of this test. An OT evaluation is also an untimed code making the 30-45 minute test not efficient to perform at this time. If visual perceptual problems exist after meeting all CI related goals, then visual perception is assessed and treated.

The Goals

The therapy goals are specific and measurable as well as being tied to function.

1. LTG–Pt to demonstrate age-appropriate visual skills
   1. STG–Pt to demonstrate near point convergence< 6 cm on 5 trials
   2. STG–Pt to fuse 15 BO loose prism to demonstrate improved fusion skills for improved reading and close tolerance.
   3. STG–Pt to complete 20/30 Rock card with 2.00 flipper in 60-90 seconds to demonstrate age-appropriate accommodation skills to improve the reading and close work tolerance.
   4. Complete Developmental Eye Movement test with age-appropriate ratio to demonstrate improve ocular motor accuracy for reading tasks.
   5. STG–Pt to demonstrate age-appropriate visual-motor integration as tested by Beery VMI
2. LTG–Pt to be (I) in use brock string to support in clinic treatment.

The Treatment Protocol

The below protocol has been effective and repeatable with most neuro-typical children ages 6 and up. The author has modified activities for children that have difficulties with these tasks which lengthens the number of treatment sessions but is still effective in meeting the above goals.

1. On the Sanet Vision Integrator
   1.  Proactive, performed monocular using R/B glasses while standing on balance board, the therapist holds the head still while the patient alternates touching dots with right then left hands regardless of the placement of dots.
   2. Rotator 3, monocular, while on balance board. May touch with any hand, verbal cues to recall alphabet as needed.
2. Convergence activities
   1. Tranaglyph slides with the goal of reaching 30 BO and 12 BI.
   2. Loose prism Jump Vergences with “circle X square” tranaglyph for binocular feedback.
3. Accommodation
   1. Accommodative Rock task, monocular
4. Saccades 2 tasks on Sanet Vision Integrator, while on balance board, monocular with R/B glasses, head held still as needed. The goal is to achieve 100% accuracy .5 interval with words.
5. After improving with these tasks, pt may be progressed to aperture arm, often challenged with 1.00 flipper to maintain focus
6. Visual-motor integration tasks, tracing shapes, copying geoboard forms on paper and/or chalkboard/SVI and other visual-motor tasks.
7. HTS Autoslide performed at the end of the session

CPT code 97530- therapeutic activities, a timed code, is used for all sessions.

The Outcome

The patient is discharged upon reaching all goals as stated above on two consecutive visits. When this has occurred there have been no re-referrals for CI. There is also a resolution to many other symptoms including

• resolution of headaches
• improve reading fluency
• a resolution to letter reversals in most cases
• improve handwriting
• improvement is self-esteem