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. 2020 Dec 2;12(12):CD006768.
doi: 10.1002/14651858.CD006768.pub3.

Interventions for convergence insufficiency: a network meta-analysis

Mitchell Scheiman  1 , Marjean T Kulp  2 , Susan A Cotter  3 , John G Lawrenson  4 , Lin Wang  5 , Tianjing Li  6
Affiliations

Interventions for convergence insufficiency: a network meta-analysis

Mitchell Scheiman et al. Cochrane Database Syst Rev. .

Abstract

Background: Convergence insufficiency is a common binocular vision disorder in which the eyes have a strong tendency to drift outward (exophoria) with difficulty turning the eyes inward when reading or doing close work.

Objectives: To assess the comparative effectiveness and relative ranking of non-surgical interventions for convergence insufficiency through a systematic review and network meta-analysis (NMA).

Search methods: We searched CENTRAL, MEDLINE, Embase, PubMed and three trials registers up to 20 September 2019.

Selection criteria: We included randomized controlled trials (RCTs) examining any form of non-surgical intervention versus placebo, no treatment, sham treatment, or other non-surgical interventions. Participants were children and adults with symptomatic convergence insufficiency.

Data collection and analysis: We followed standard Cochrane methodology. We performed NMAs separately for children and adults.

Main results: We included 12 trials (six in children and six in adults) with a total of 1289 participants. Trials evaluated seven interventions: 1) office-based vergence/accommodative therapy with home reinforcement; 2) home-based pencil/target push-ups; 3) home-based computer vergence/accommodative therapy; 4) office-based vergence/accommodative therapy alone; 5) placebo vergence/accommodative therapy or other placebo intervention; 6) prism reading glasses; and 7) placebo reading glasses. Six RCTs in the pediatric population randomized 968 participants. Of these, the Convergence Insufficiency Treatment Trial (CITT) Investigator Group completed four RCTs with 737 participants. All four CITT RCTs were rated at low risk of bias. Diagnostic criteria and outcome measures were identical or similar among these trials. The four CITT RCTs contributed data to the pediatric NMA, incorporating interventions 1, 2, 3 and 5. When treatment success was defined by a composite outcome requiring both clinical measures of convergence to be normal, and also show a pre-specified magnitude of improvement, we found high-certainty evidence that office-based vergence/accommodative therapy with home reinforcement increases the chance of a successful outcome, compared with home-based computer vergence/accommodative therapy (risk ratio (RR) 1.96, 95% confidence interval (CI) 1.32 to 2.94), home-based pencil/target push-ups (RR 2.86, 95% CI 1.82 to 4.35); and placebo (RR 3.04, 95% CI 2.32 to 3.98). However, there may be no evidence of any treatment difference between home-based computer vergence/accommodative therapy and home-based pencil/target push-ups (RR 1.44, 95% CI 0.93 to 2.24; low-certainty evidence), or between either of the two home-based therapies and placebo therapy, for the outcome of treatment success. When treatment success was defined as the composite convergence and symptom success outcome, we found moderate-certainty evidence that participants who received office-based vergence/accommodative therapy with home reinforcement were 5.12 (95% CI 2.01 to 13.07) times more likely to achieve treatment success than those who received placebo therapy. We found low-certainty evidence that participants who received office-based vergence/accommodative therapy with home reinforcement might be 4.41 (95% CI 1.26 to 15.38) times more likely to achieve treatment success than those who received home-based pencil push-ups, and 4.65 (95% CI 1.23 to 17.54) times more likely than those who received home-based computer vergence/accommodative therapy. There was no evidence of any treatment difference between home-based pencil push-ups and home-based computer vergence/accommodative therapy, or between either of the two home-based therapies and placebo therapy. One RCT evaluated the effectiveness of base-in prism reading glasses in children. When base-in prism reading glasses were compared with placebo reading glasses, investigators found no evidence of a difference in the three outcome measures of near point convergence (NPC), positive fusional vergence (PFV), or symptom scores measured by the Convergence Insufficiency Symptom Survey (CISS). Six RCTs in the adult population randomized 321 participants. We rated only one RCT at low risk of bias. Because not all studies of adults included composite success data, we could not conduct NMAs for treatment success. We thus were limited to comparing the mean difference (MD) between interventions for improving NPC, PFV, and CISS scores individually using data from three RCTs (107 participants; interventions 1, 2, 4 and 5). Compared with placebo treatment, office-based vergence accommodative therapy was relatively more effective in improving PFV (MD 16.73, 95% CI 6.96 to 26.60), but there was no evidence of a difference for NPC or the CISS score. There was no evidence of difference for any other comparisons for any outcomes. One trial evaluated base-in prism glasses prescribed for near-work activities and found that the prism glasses group had fewer symptoms compared with the placebo glasses group at three months (MD -8.9, 95% CI -11.6 to -6.3). The trial found no evidence of a difference with this intervention in NPC or PFV. No adverse effects related to study treatments were reported for any of the included studies. Excellent adherence was reported for office-based vergence/accommodative therapy (96.6% or higher) in two trials. Reported adherence with home-based therapy was less consistent, with one study reporting decreasing adherence over time (weeks 7 to 12) and lower completion rates with home-based pencil/target push-ups.

Authors' conclusions: Current research suggests that office-based vergence/accommodative therapy with home reinforcement is more effective than home-based pencil/target push-ups or home-based computer vergence/accommodative therapy for children. In adults, evidence of the effectiveness of various non-surgical interventions is less clear.

Trial registration: ClinicalTrials.gov NCT03431454 NCT00347581 NCT00347945 NCT00338611 NCT02207517 NCT01515943.

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Conflict of interest statement

Dr. Mitchell Scheiman is the Study Chair of the Convergence Insufficiency Treatment Trial (CITT) Study Group. Drs. Susan Cotter and Marjean Kulp also served as investigators for the CITT trials. This group completed five included trials in this review. Dr. Scheiman was the co‐Protocol Chair for PEDIG 2016 study and Drs. Cotter and Kulp were two of the clinical site principal investigators for this trial.

Figures

1
1
Study flow diagram
2
2
Risk of bias summary.
3
3
Network graph for the children's network Number of trials: 4 Number of participants analyzed: 737
4
4
Composite convergence outcome: achieved normal and improved NPC and PFV: NPC is normal (<6cm) and has improved by ≥4cm; PFV is normal (passing Sheard's criterion and a PFV break > 15 ∆) and has improved ≥ 10 ∆. The certainty of evidence was rated 'high' if all domains were of 'no concerns.' The certainty of evidence was rated 'moderate' if two or more domains were of 'some concerns.' The certainty of evidence was rated 'low' if two or more domains were of 'major concerns' or one domain of 'major concerns' plus one domain of 'some concerns.' CI: confidence interval.
5
5
Composite signs (convergence) and symptoms outcome: achieved normal and improved NPC, PFV, and Convergence Insufficiency Symptom Score (CISS): NPC is normal (<6cm) and has improved by ≥ 4cm, PFV is normal (passing Sheard's criterion and a PFV break > 15∆) and has improved ≥ 10 ∆, and CISS is normal (< 16) and has improved ≥ 10 points. The certainty of evidence was rated 'high' if all domains were of 'no concerns.' The certainty of evidence was rated 'moderate' if two or more domains were of 'some concerns.' The certainty of evidence was rated 'low' if two or more domains were of 'major concerns' or one domain of 'major concerns' plus one domain of 'some concerns.' CI: confidence interval.
6
6
Network graph for the adults' network Number of trials: 3 Number of participants analyzed: 107
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References

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References to ongoing studies

CTRI/2018/05/013560 {published data only}
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NCT03593031 {published data only}
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References to other published versions of this review

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