Convergence Insufficiency Treatment Study (CITS)

This study is currently recruiting participants. (see Contacts and Locations)
Verified June 2014 by Jaeb Center for Health Research
Sponsor:
Collaborator:
Information provided by (Responsible Party):
Jaeb Center for Health Research
ClinicalTrials.gov Identifier:
NCT01515943
First received: January 19, 2012
Last updated: June 12, 2014
Last verified: June 2014
  Purpose

The purpose of this study is to determine the effectiveness of home-based computer therapy for symptomatic convergence insufficiency (CI) compared to traditional home-based near target push-ups and placebo treatment.


Condition Intervention Phase
Convergence Insufficiency
Other: Active home-based computer vergence/accommodative therapy
Procedure: Near target push-ups
Other: Placebo home-based computer vergence/accommodative therapy
Procedure: Placebo yoked prism flippers
Phase 3

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Double Blind (Subject, Caregiver, Outcomes Assessor)
Primary Purpose: Treatment
Official Title: Effectiveness of Home-Based Therapy for Symptomatic Convergence Insufficiency

Resource links provided by NLM:


Further study details as provided by Jaeb Center for Health Research:

Primary Outcome Measures:
  • Successful treatment of convergence insufficiency (CI) for computer-based therapy versus near target push-up group comparison at 12 weeks [ Time Frame: 12 weeks after randomization (baseline) ] [ Designated as safety issue: No ]

    A treatment comparison of the proportion of subjects who are successfully treated for CI at the 12-week visit using logistic regression analysis, adjusting for baseline covariates. Success is defined according to whether all 3 criteria (below) are met as follows:

    1. Convergency Insufficiency Symptom Survey (CISS): Improvement of 9 or more points since baseline and an 12-week score of < 16 points
    2. Near point of convergence (NPC): 12-week/baseline NPC <0.763 and a mean 12-week NPC <6 cm
    3. Positive fusional vergence (PFV): 12-week/ baseline PFV > 1.419 and a mean 12-week PFV > 15 pd

  • Successful treatment of convergence insufficiency (CI) for the computer-based therapy versus placebo group comparison at 12 weeks [ Time Frame: 12-weeks after randomization (baseline) ] [ Designated as safety issue: No ]

    A treatment comparison of the proportion of subjects who are successfully treated for CI at the 12-week visit using logistic regression analysis, adjusting for baseline covariates. Success is defined according to whether all 3 criteria (below) are met as follows:

    1. Convergency Insufficiency Symptom Survey (CISS): Improvement of 9 or more points since baseline and an 12-week score of < 16 points
    2. Near point of convergence (NPC): 12-week/baseline NPC <0.763 and a mean 12-week NPC <6 cm
    3. Positive fusional vergence (PFV): 12-week/ baseline PFV > 1.419 and a mean 12-week PFV > 15 pd


Secondary Outcome Measures:
  • Successful treatment of convergence insufficiency (CI) for the near target push-up versus placebo group comparison at 12 weeks [ Time Frame: 12 weeks after randomization (baseline) ] [ Designated as safety issue: No ]

    A treatment comparison of the proportion of subjects who are successfully treated for CI at the 12-week visit using logistic regression analysis, adjusting for baseline covariates. Success is defined according to whether all 3 criteria (below) are met as follows:

    1. Convergency Insufficiency Symptom Survey (CISS): Improvement of 9 or more points since baseline and an 12-week score of < 16 points
    2. Near point of convergence (NPC): 12-week/baseline NPC <0.763 and a mean 12-week NPC <6 cm
    3. Positive fusional vergence (PFV): 12-week/ baseline PFV > 1.419 and a mean 12-week PFV > 15 pd

  • Convergence improvement at 12 weeks since randomization [ Time Frame: 12 weeks after randomization (baseline) ] [ Designated as safety issue: No ]

    Pairwise treatment group comparisons of the proportion of subjects with improved convergence will be performed at the 12 week visit using logistic regresion, adjusting for baseline covariates. Improvement is based on whether all 3 criteria (below) are met as follows:

    1. Convergency Insufficiency Symptom Survey (CISS): Improvement of 9 or more points since baseline
    2. Near point of convergence (NPC): 12-week/baseline NPC <0.763
    3. Positive fusional vergence (PFV): 12-week/ baseline PFV > 1.419

  • Successful treatment of convergence insufficiencey (CI) according to clinical measures at 12 weeks [ Time Frame: 12-weeks after randomization (baseline) ] [ Designated as safety issue: No ]

    Pairwise treatment group comparisons of the proportion of subjects who are successfully treated for CI based on clinical measures at the 12-week visit using logistic regression analysis, adjusting for baseline covariates. Success is defined according to whether both criteria (below) are met as follows:

    1. Near point of convergence (NPC): 12-week/baseline NPC <0.763 and a mean 12-week NPC <6 cm
    2. Positive fusional vergence (PFV): 12-week/ baseline PFV > 1.419 and a mean 12-week PFV > 15 pd

  • Successful treatment of convergence insufficiency (CI) based on signs/symptoms at 12 weeks [ Time Frame: 12 weeks after randomization (baseline) ] [ Designated as safety issue: No ]
    Pair-wise treatment group comparisons of the proportion of subjects who are successfully treated for CI based on signs/symptoms at the 12-week visit using logistic regression analysis, adjusting for baseline covariates. Success is based on the Convergency Insufficiency Symptom Survey (CISS) defined as improvement of 9 or more points since baseline and an 12-week score of < 16 points.

  • Prevalence of convergence insufficiency (CI) recurrence 6 months after discontinuing treatment among subjects who were successfully treated at 12 weeks. [ Time Frame: 6 months after the 12-week visit ] [ Designated as safety issue: No ]
    An estimate and 95% confidence interval will be computed using the exact binomial method to determine the proportion of subjects (overall and by treatment group) who are no longer successfully treated 6 months after the 12 week visit. Non-success (recurrence) will be defined as failure to meet each of the 3 criteria as defined in the primary outcome measures.

  • Successful treatment of convergence insufficiency at 12 weeks according to subgroup factors [ Time Frame: 12 weeks after randomization (baseline) ] [ Designated as safety issue: No ]
    Exploratory analyses will be utilized to assess treatment group differences in success proportions within predefined subgroups according to baseline factors. Success will be defined using the 3 criteria outlined in the primary outcome measures. Interpretation of subgroup analyses will depend on whether there are any statistically significant differences among the treatment group comparisons for the primary outcome measures.

  • Relationship between successful treatment of convergence insufficiency (CI) and attention-deficit/hyperactivity disorder (ADHD) signs/symptoms at 12 weeks [ Time Frame: 12 weeks after randomization (baseline) ] [ Designated as safety issue: No ]
    The purpose of this objective is to determine if successful treatment of CI reduces the reported symptoms/signs of ADHD as measured by the Strengths and Weaknesses of ADHD symptoms and Normal behavior scale (SWAN). An analysis of covariance (ANCOVA) will be performed to compare mean scores from the SWAN questionnaire according to CI success status at 12 weeks, adjusting for baseline scores. Success will be defined using the 3 criteria outlined in the primary outcome measures.

  • Prevalence of convergence insufficiency (CI) recurrence 12 months after discontinuing treatment among subjects who were successfully treated at 12 weeks. [ Time Frame: 12 months after the 12-week visit ] [ Designated as safety issue: No ]
    An estimate and 95% confidence interval will be computed using the exact binomial method to determine the proportion of subjects (overall and by treatment group) who are no longer successfully treated 12 months after the 12 week visit. Non-success (recurrence) will be defined as failure to meet each of the 3 criteria as defined in the primary outcome measures.


Estimated Enrollment: 600
Study Start Date: June 2012
Estimated Study Completion Date: February 2018
Estimated Primary Completion Date: September 2017 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Active Comparator: Computer-based therapy (CBT)
The CBT group will be assigned active home-based computer vergence/accommodative therapy (15 minutes/day) plus placebo yoked prism flipper therapy (5 minutes/day) for a total of 20/minutes per day, 5 days per week for the 12-week treatment phase.
Other: Active home-based computer vergence/accommodative therapy
At enrollment, subjects will be prescribed 15 minutes/day of active home-based computer therapy for 5 days/week during the 12 week treatment phase. Active home-based computer therapy will be provided the Home Therapy System (HTS) computer software and will include both fusional vergence and accommodative therapy. Subjects will perform the computer therapy while wearing red/blue glasses and accommodative therapy will be performed using the HTS accommodative flippers. Please refer to the procedures manual for further details.
Other Name: Home Therapy System (HTS, Home Vision Therapy, Inc.)
Procedure: Placebo yoked prism flippers

Subjects will be prescribed 5 minutes/day of placebo yoked prism flipper therapy for 5 days/week during the 12 week treatment phase. This procedure utilizes a 4 pd base right/4 pd base left prism flipper and "Accommodative Hopping Cards". Subjects view the text on the card through the prisms at 40 cm, perform the appropriate task and then flip the prism flipper to the other side after each word before proceeding to the next line. Please refer to the procedures manual for further details. The task remains constant, but the nature of the procedure changes with time:

  • Weeks 1-4: View the target through prism flippers
  • Weeks 5-8: Wear red-blue filter glasses while viewing the text through prism flippers
  • Weeks 9-12: Wear polaroid glasses while viewing the text through prism flippers
Active Comparator: Near target push-up (NTP)
The NTP group will be assigned placebo home-based computer vergence/accommodative therapy (5 minutes/day) plus near target push-ups (15 minutes/day) for a total of 20/minutes per day, 5 days per week for the 12-week treatment phase.
Procedure: Near target push-ups
At enrollment, subjects will be prescribed 15 minutes/day (3 sessions of 5 minutes each) of near target push-ups (NTP) for 5 days/week during the 12-week treatment phase. An alphabet pencil will be used as the target and an index card placed in the background will provide physiological diplopia control. With the pencil positioned at arm's length directly between the subject's eyes, the subject will slowly bring the pencil toward his/her nose while focusing on the small letter on the pencil. When the subject is no longer able to maintain a single image of the pencil, he/she will slowly move the target away from the nose until the pencil becomes single again. This procedure will be repeated several times. Please refer to the procedures manual for further details.
Other Name: Pencil push-ups
Other: Placebo home-based computer vergence/accommodative therapy
At enrollment, subjects will be prescribed either 5 minutes/day (NTP group) or 15 minutes/day (Placebo group) of placebo home-based computer therapy for 5 days/week during the 12 week treatment phase. Placebo computer-based therapy will be provided by the Home Therapy System (HTS) computer software. The vergence procedures are similar to the active version, however, the tasks will be modified to ensure no demand on the vergence system and no accommodative therapy is included in the placebo version. Please refer to the procedures manual for further details.
Other Name: Home Therapy System (HTS, Home Vision Therapy, Inc.)
Placebo Comparator: Placebo
The placebo group will be assigned placebo home-based computer vergence/accommodative therapy (15 minutes/day) plus placebo yoked prism flipper therapy (5 minutes/day) for a total of 20/minutes per day, 5 days per week for the 12-week treatment phase.
Other: Placebo home-based computer vergence/accommodative therapy
At enrollment, subjects will be prescribed either 5 minutes/day (NTP group) or 15 minutes/day (Placebo group) of placebo home-based computer therapy for 5 days/week during the 12 week treatment phase. Placebo computer-based therapy will be provided by the Home Therapy System (HTS) computer software. The vergence procedures are similar to the active version, however, the tasks will be modified to ensure no demand on the vergence system and no accommodative therapy is included in the placebo version. Please refer to the procedures manual for further details.
Other Name: Home Therapy System (HTS, Home Vision Therapy, Inc.)
Procedure: Placebo yoked prism flippers

Subjects will be prescribed 5 minutes/day of placebo yoked prism flipper therapy for 5 days/week during the 12 week treatment phase. This procedure utilizes a 4 pd base right/4 pd base left prism flipper and "Accommodative Hopping Cards". Subjects view the text on the card through the prisms at 40 cm, perform the appropriate task and then flip the prism flipper to the other side after each word before proceeding to the next line. Please refer to the procedures manual for further details. The task remains constant, but the nature of the procedure changes with time:

  • Weeks 1-4: View the target through prism flippers
  • Weeks 5-8: Wear red-blue filter glasses while viewing the text through prism flippers
  • Weeks 9-12: Wear polaroid glasses while viewing the text through prism flippers

Detailed Description:

Convergence insufficiency (CI) is a common and distinct binocular vision disorder that affects approximately 4% of school age children and adults in the United States. Convergence insufficiency is often associated with symptoms such as frequent loss of place while reading, loss of concentration, having to re-read, reading slowly, poor comprehension, sleepiness, blurred vision, diplopia, headaches, and/or eyestrain. A recently completed randomized clinical trial, the Convergence Insufficiency Treatment Trial (CITT), demonstrated that a 12-week program of office-based vergence/ accommodative therapy with home reinforcement was more effective than home-based near target pencil push-ups, home-based computer accommodative therapy plus pencil push-ups, or office-based placebo therapy in treating the symptoms and signs associated with symptomatic CI in children 9 to 17 years of age.

While the home-based therapies in the CITT were not as effective as office-based vergence/accommodative therapy there was some improvement noted. Currently, many eye care professionals only offer home-based therapy, while others suggest passive treatment with base-in prism. At a Pediatric Eye Disease Investigator Group (PEDIG) meeting (Tampa, January 2009), the results of a poll of attendees indicated that a large majority of pediatric ophthalmologists continue to recommend home-based near target push-ups as the initial treatment approach for children with symptomatic CI in spite of the CITT results.

There are significant differences in contact time, complexity, and cost between office-based and home-based therapy for CI. Many clinicians believe that the less costly and less complex treatment option should be attempted first. Although home-based therapy using computer software is becoming more popular, no prospective data are available to demonstrate the effectiveness of home-based vision therapy using computer software compared to home-based near target push-ups or home-based placebo computer therapy. A prospective clinical trial is therefore needed to determine the effectiveness of home-based computer therapy for symptomatic CI compared to traditional home-based near target push-ups and placebo treatment.

The current study is a multi-center randomized clinical trial to evaluate the effectiveness of home-based computer vergence/accommodative therapy and home-based near target push-ups in children 9 to <18 years of age with symptomatic CI.

  Eligibility

Ages Eligible for Study:   9 Years to 17 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  1. Age: 9 to <18 years
  2. Patient has access to a computer with a CD/DVD drive and internet access for the next 12 weeks
  3. Best-corrected visual acuity of ≥20/25 in each eye at distance and near
  4. Exophoria at near at least 4 pd greater than at distance
  5. Reduced positive fusional convergence at near (<20 pd or fails Sheard's criterion that the PFV measures less than twice the magnitude of the near phoria). PFV is recorded as the prism magnitude where vision is first blurred (or break if no blur is reported).
  6. Near point of convergence of ≥6 cm break
  7. Randot Preschool stereoacuity of at least 400 seconds of arc
  8. CI Symptom Survey score ≥16
  9. No use of a plus add for near or base-in prism for at least 2 weeks preceding enrollment
  10. Patient must be wearing appropriate refractive correction (spectacle or contact lenses) for at least 2 weeks prior to enrollment if refractive error is present (based on a cycloplegic refraction within the last 6 months) that meets the following:

    • Myopia more than -0.75D spherical equivalent (SE) in either eye
    • Hyperopia more than +2.00D SE in either eye
    • SE anisometropia >1.00D
    • Astigmatism > 1.00D or > 1.50D of meridional difference in either eye Refractive correction for patients meeting the above refractive error criteria must meet the following guidelines:
    • SE anisometropia must be within 0.25D of the full anisometropic correction.
    • Astigmatism cylinder must be within 0.50D of full correction and axis must be within 5 degrees.
    • For hyperopia, the spherical component can be reduced by up to 1.50D at investigator discretion provided the reduction is symmetrical and results in residual (i.e., uncorrected) SE hyperopia that does not exceed +2.00D.
    • For myopia, the SE must be within 0.25D of the full myopic correction.
  11. Parent and patient understand the protocol and are willing to accept randomization.
  12. Parent has home phone (or access to phone) and is willing to be contacted by Jaeb Center staff.
  13. Relocation outside of area of an active PEDIG site within the next 15 months is not anticipated.

Exclusion Criteria:

  1. ≥2 logMAR line difference in best-corrected visual acuity between the two eyes
  2. Constant or intermittent exotropia at distance; constant exotropia at near
  3. Any esotropia at distance or near
  4. Distance exophoria > 10 pd
  5. History of strabismus surgery
  6. Anisometropia ≥2.00D in any meridian between the eyes
  7. Prior intraocular or refractive surgery
  8. Primary vertical heterophoria greater than 1 pd
  9. Diseases known to affect accommodation, vergence, and ocular motility such as multiple sclerosis, Graves orbitopathy, myasthenia gravis, diabetes mellitus, or Parkinson disease
  10. Current use of any ocular or systemic medication known to affect accommodation or vergence such as anti-anxiety agents (e.g., Librium or Valium), anti-arrhythmic agents (e.g., Cifenline, Cibenzoline), anti- cholinergics (e.g., Motion sickness patch (scopolamine), bladder spasmolytic drugs (e.g., Propiverine), hydroxychloroquine, chloroquine, phenothiazines (e.g., Compazine, Mellaril, Thorazine), tricyclic antidepressants (e.g., Elavil, Nortriptyline, Tofranil)
  11. Near point of accommodation >20 cm in the right eye
  12. Manifest or latent nystagmus evident clinically
  13. History of chronic headaches unrelated to reading activity
  14. Active symptomatic allergic conjunctivitis
  15. Developmental disability, mental retardation, attention deficit hyperactivity disorder (ADHD), or learning disability diagnosis that in the investigator's discretion would interfere with treatment or evaluation
  16. Household member or sibling already enrolled in the CITS OR previously enrolled in the CITT
  17. Household member is an eye professional, ophthalmic technician, ophthalmology or optometry resident, orthoptist, or optometry student, or employed in an eye care setting
  18. Acquired brain injury
  19. Previous office- or home-based vision therapy, orthoptics, home-based near- target push-ups, pencil push-ups, or home-based computer therapy
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01515943

Contacts
Contact: Ray Kraker, MSPH 888-387-8686 pedig@jaeb.org
Contact: Chelsea Costa 888-387-8686 pedig@jaeb.org

Locations
United States, Pennsylvania
Everett & Hurite Ophthalmic Association Recruiting
Cranberry TWP, Pennsylvania, United States, 16066
Contact: Darren L Hoover, MD    412-288-0885    idocdlh@comcast.net   
Principal Investigator: Darren L Hoover, MD         
Pennsylvania College of Optometry Recruiting
Philadelphia, Pennsylvania, United States, 19141
Contact: Mitchell M Scheiman, OD    215-276-6057    mscheiman@salas.edu   
Principal Investigator: Mitchell M Scheiman, OD         
Sponsors and Collaborators
Jaeb Center for Health Research
Investigators
Study Chair: Mitchell M Scheiman, OD Jaeb Center for Health Research
Study Chair: Darren L Hoover, MD Jaeb Center for Health Research
  More Information

No publications provided

Responsible Party: Jaeb Center for Health Research
ClinicalTrials.gov Identifier: NCT01515943     History of Changes
Other Study ID Numbers: CITS, 2U10EY011751
Study First Received: January 19, 2012
Last Updated: June 12, 2014
Health Authority: United States: Federal Government

Keywords provided by Jaeb Center for Health Research:
Convergence insufficiency

Additional relevant MeSH terms:
Ocular Motility Disorders
Central Nervous System Diseases
Nervous System Diseases
Cranial Nerve Diseases
Eye Diseases

ClinicalTrials.gov processed this record on August 26, 2014