Changes in Reading Performance in School-aged Children with Symptomatic Convergence

Insufficiency after Treatment with Vision Therapy

Mitchell Scheiman, OD, FCOVD, FAAOProfessor, Pennsylvania College of Optometry at Salus University

Funded by:College of Optometrists in Vision Development

Co-authors

• Christopher Chase

• G. Lynn Mitchell

• Eric Borsting

• Marjean Kulp

• Susan Cotter

• CITT-RS Study Group

Previous CITT Studies

• Office-based vergence/accommodative therapy more effective when compared to pencil push-ups, computer vergence/ accommodative therapy or placebo therapy– Lower CI Symptom Survey score (CISS)– Closer near point of convergence (NPC)– Improved positive fusional vergence blur (PFV)

Secondary Outcome

• Academic Behavior SurveyHow often… Never

In-frequently

Some-times

Fairly often

Always

does your child have difficulty completing assignments at school?does your child have difficulty completing homework?does your child avoid or say he/she does not want to do tasks that require reading or close work?does your child fail to give attention to details or make careless mistakes in schoolwork or homework?does your child appear inattentive or easily distracted during reading or close work?do you worry about your child’s school performance?

Findings from CITT Full Study

• Parents of children with symptomatic CI reported more academic concerns compared to parents of children with normal binocular vision (Rouse et al 2009 OVS)

• Concerns among parents of CI children were significantly reduced after treatment if successful or improved (compared to non-responders; Borsting et al 2011 OVS*)

*In press

Next step: CITT Study Group

• Children with CI report symptoms when performing near tasks such as reading

• Parents of children with CI report worries about inability to attend to near academic tasks

• Symptoms of CI likely to interfere with academic tasks either directly or through their effect on attention

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CITT Proposed Theoretical Model

Immediate Effect

Long-Term Effect

CITT – Reading Study (CITT-RS)

• To evaluate attention and reading performance of school-age children with 3-sign convergence insufficiency (XP>N, NPC, PFV @N)– Compare to published normative values

• To assess the impact of 16 weeks of office-based vergence/accommodative therapy (OBVAT) on attention and reading performance

COVD FUNDED

Study design

• Ages 9 to 17 with symptomatic 3-sign CI• OBVAT procedures as used successfully in

previous CITT studies– 60-minute in-office visit with therapist– 15 minutes, 5 days/week of at-home therapy

• Clinical examinations 8, 12 and 16 weeks after initiation of OBVAT– Measured CISS, NPC and PFV

Study design

• Maintenance therapy performed after completion of week 16 examination until return for week 24 visit (8 weeks after completion of OBVAT)

• Standardized measures of attention and reading assessed at baseline and week 24– All testing performed during school year– Examiner masked to results of clinical testing (i.e.

treatment response measures)

Reading Measures

• Gray Oral Reading Test (GORT-4)– Rate, Accuracy, Fluency and Comprehension

• Test of Silent Word Reading Fluency (TOSWRF)• Test of Word Reading Efficiency (TOWRE)

– Phonemic decoding, Sight word reading

• Wechsler Individual Achievement Test (WIAT-II)– Word reading, Pseudoword reading, Reading

comprehension, Composite

Gray Oral Reading Test (GORT-4)

• Rate• Accuracy• Fluency• Comprehension

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Wechsler Individual Achievement Test, 2nd edition (WIAT-II)

• 3 subtests– Word Reading– Pseudoword Reading– Reading Comprehension

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WIAT Reading Comprehension

16

Test of Silent Word Reading Fluency

(TOSWRF)

Statistical methods

• Improvements in reading performance compared to zero using a one-sample t-test

• Spearman correlations (R) used to assess relationship between improvements in signs and symptoms of CI and improvements in reading ability

• Treatment outcome (successful, improved, non-responder) determined using signs/symptoms at weeks 16 and 24. Comparison between the treatment response groups performed

Results

• 48 children enrolled; 44 (92%) completed week 24 examination

• Mean age of 11.4 years (SD = 2.1; range 9 to 16 years)

• 52% females

Results

• Highly symptomatic on CI Symptom Survey (CISS)– Mean = 30.2 (SD = 9.1, range 17 to 53)

• Receded near point of convergence (NPC)– Mean = 14.5 cm (SD = 8.6; range 6.2 to 36 cm)

• Poor positive fusional vergence blur (PFV)– Mean = 10.4 Δ (SD = 4.1, range 3.3 to 23.3 Δ)

Improvements in Reading

• No significant improvements in GORT-IV, TOSWRF, TOWRE and WIAT-II Single Word Reading subscales

• Significant improvement in other 2 WIAT-II subscales and composite– Pseudoword reading – Reading comprehension – Composite

Correlations with Signs and Symptoms

• Improvements in WIAT-II Pseudoword Reading, Reading Comprehension and Composite measure were not correlated with:– CISS (R ranges from 0.13 to 0.25)– NPC (R ranges from -0.13 to -0.06)– PFV (R ranges from 0.0 to 0.27)

Association with Treatment Response

• Classified treatment response using CISS, NPC and PFV at week 16– Successful if CISS less 16 (asymptomatic), NPC better

than 6cm and Normal PFV– Improved if CISS less than 16 OR improvement ≥ 10

• NPC < 6cm OR improvement ≥ 4

Or• Normal PFV OR improvement ≥ 10

– Non-responder

Association with Treatment Response

• No association between treatment response and improvements in WIAT-II Pseudoword Reading or Composite subscales (p-values > 0.15)

• Improvements in WIAT-II Reading Comprehension were related to treatment response (p = 0.011)– Successful significantly greater improvements

compared to either improved or non-responder

Mean Improvement on Standard Score of WIAT2 Comprehension

Secondary Analysis

• Gray Oral Reading test (GORT)• Analysis of oral reading

– Type of Errors– Frequency of errors

9 year-old 4th grade girl

MeasurePre-

OBVATPost-

OBVATNPC Break (cm) 24 3

PFV Blur (∆) 6 50

Accommodative Amplitude (D) 7.7 18.2

Distance Phoria (∆) -10 -14

Near Phoria (∆) -25 -20

Accommodative Facility (cpm) 0.5 26

CISS 33.5 0

Reading Pre-OBVAT

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Reading Post-OBVAT

GORT - 3 Most Common Reading Type Errors

Reading ErrorProportion of Total Errors Pre-OBVAT

Substitution 45.2%

Pause (5-sec) 0.0%

Decoding (10-sec) 0.3%

Self-correction 18.0%

Addition 4.3%

Repetition 21.5%

Mispronunciation 4.9%

Skip a line 0.2%

Omit a word 5.6%

Reading Errors Decreased

Substitution

p = .01

Self-correction Repetition

Reading Fluency Improved

p < .0001 p = .03

Conclusions

• Significant improvements in reading comprehension as measured by the WIAT II

• These improvements were related to treatment response at week 16 but not related to improvements in each individual sign/symptom

Conclusions

After OBVAT, speed improved 12% and accuracy increased 14%

About 85% of reading errors were substitution, self-correction and repetitionIn part, speed improved because of reduction in repetition errors

These improvements may not be found in standard reading tests because tasks are not timed and the most common CI errors are not counted.

Limitations

• No comparison group– Are significant improvements also clinically

relevant?

• Limited masking of examiners

• Short follow-up time to assess reading improvements

Future CITT Studies

• CITT- Attention and Reading Study (CITT-ART)– Submitted Sept 25, 2011– Review March-April 2012

• Multi-center randomized clinical trial to study the effect of VT on attention and reading– 10 clinical sites– 7 OD sites (PCO, OSU, SCCO, SUNY, WUCO, UAB,

NOVA)– 3 MD sites Mayo Clinic, Bascom Palmer, Akron Children’s

Hospital)

CITT-ART

• 12 weeks of VT– Office-based– Home-based

• Measure attention and reading at:– Baseline– 12 weeks– 6, 12 and 24 months after treatment ends