Convergence insufficiency (CI), a prevalent binocular vision disorder in adults and children, is characterized by greater exophoria at near than at distance, reduced fusional convergence amplitude, receded near point of convergence, and a reduced accommodative convergence over accommodation ratio (AC/A). CI is associated with symptoms that include double/blurred vision, eyestrain, and headaches when engaged in reading or other near work, thus interfering with activities of daily living. The recent NEI/NIH multi-center randomized clinical trial, the Convergence Insufficiency Treatment Trial (CITT), demonstrated the effectiveness of Office-Based Vergence and Accommodative Therapy with home reinforcement (OBVAT) for CI, reporting 73% of patients have sustained improvements of vision function and symptoms. Our team published the first fMRI neural substrate data evoked using convergence eye movements in CI patients before and then post- OBVAT. Our results support that with the reduction of visual symptoms, the following were observed: 1) an increase in the percent signal change of functional activity in the frontal eye fields, posterior parietal cortex and the cerebellar vermis, 2) an increase in convergence peak velocity, 3) a decrease in the near point of convergence, 4) an increase in positive fusional amplitude, and 5) a reduction in the amount of exophoria at near.5 The aims of our current proposal are to test the following two hypotheses as potential underlying mechanisms of CI that may be improved post OBVAT: 1) a reduced ability to adapt vergence in near and far space via the 'slow' component of vergence and 2) a reduced ability to quickly diminish disparity error via the 'fast' component of vergence. Not only will our quantitative methods integrated with established CITT standards address important questions about potential mechanisms causing CI, our proposal seeks to identify how a validated vergence therapy may remediate symptoms. Our proposal will determine whether either of these two potential mechanisms are causing CI by quantifying the following: 1) rate and magnitude of phoria adaptation, 2) forced vergence fixation disparity curves, 3) peak velocity of convergence eye movements (studying visual cues such as disparity, accommodation and proximal stimuli in isolation and combination), and 4) the functional activity of the fast and slow vergence neural substrates prior to, and then after, OBVAT. The assembled study team is particularly knowledgeable in terms of OBVAT, convergence insufficiency, optometry, vision science, oculomotor research, functional imaging, modeling and statistics with the necessary resources to successfully complete both aims of this study. Results from our project's aims can lead to targeted treatments with improved success rates, potentially reducing the time to remediate symptoms, and ultimately reducing health care costs.

Public Health Relevance

Convergence insufficiency (CI) is a prevalent binocular vision disorder with symptoms that include double/blurred vision, eyestrain, and headaches when engaged in reading or other near work that negatively impacts activities of daily living. CI is present in 4% of the population where approximately 27% of CI patients do not improve even with validated therapy. Our project studies two potential mechanisms causing CI which may be improved via validated therapy by quantifying phoria adaptation, neural substrates and behavioral eye movements. This knowledge can lead to targeted therapeutic interventions, improved success rates, reduction in the time to remediation, and reduced healthcare costs.

National Institute of Health (NIH)
National Eye Institute (NEI)
Research Project (R01)
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Special Emphasis Panel (SPC)
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Araj, Houmam H
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Rutgers University
Biomedical Engineering
Schools of Engineering
United States
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Yaramothu, Chang; Santos, Elio M; Alvarez, Tara L (2018) Effects of visual distractors on vergence eye movements. J Vis 18:2
Santos, Elio M; Yaramothu, Chang; Alvarez, Tara L (2018) Comparison of symmetrical prism adaptation to asymmetrical prism adaptation in those with normal binocular vision. Vision Res 149:59-65
Scheiman, Mitchell M; Talasan, Henry; Mitchell, G Lynn et al. (2017) Objective Assessment of Vergence after Treatment of Concussion-Related CI: A Pilot Study. Optom Vis Sci 94:74-88
Alvarez, Tara L; Kim, Eun H; Yaramothu, Chang et al. (2017) The influence of age on adaptation of disparity vergence and phoria. Vision Res 133:1-11
Alvarez, Tara L; Kim, Eun H; Granger-Donetti, Bérangère (2017) Adaptation to Progressive Additive Lenses: Potential Factors to Consider. Sci Rep 7:2529
Talasan, Henry; Scheiman, Mitchell; Li, Xiaobo et al. (2016) Disparity vergence responses before versus after repetitive vergence therapy in binocularly normal controls. J Vis 16:7
Alvarez, Tara L (2015) A pilot study of disparity vergence and near dissociated phoria in convergence insufficiency patients before vs. after vergence therapy. Front Hum Neurosci 9:419
Alvarez, Tara L; Jaswal, Raj; Gohel, Suril et al. (2014) Functional activity within the frontal eye fields, posterior parietal cortex, and cerebellar vermis significantly correlates to symmetrical vergence peak velocity: an ROI-based, fMRI study of vergence training. Front Integr Neurosci 8:50
Jaswal, Rajbir; Gohel, Suril; Biswal, Bharat B et al. (2014) Task-modulated coactivation of vergence neural substrates. Brain Connect 4:595-607