Can Treating Visual Problems Improve

Attention?Eric Borsting, OD MSEd

Professor

Marshall B. Ketchum University

Objectives

• Describe basic vision problems in eye coordination.

• How vision problems impact the child and family

• Description of current clinical trial.

CITT-ART Group

• Mitchell Scheiman, OD, Salus University (PI)• Eugene Arnold, MD, MSEd The Ohio State University• Eric Borsting, OD, MSEd• Susan Cotter, OD, MS• Christopher Chase, PhD, Western University of Health Sciences• Carolyn Denton, PhD, University of Texas• Richard Hertle, MD, Akron Children’s Hospital• Marjean Kulp, OD, MS, The Ohio State University• Gladys Mitchell, MS, The Ohio State University

Eye care practitioners and academic problems

• Why are we involved?• Common patient complaint

– My child does better when I read to him. Must be a vision problem

– Child or adult have symptoms of visual discomfort when reading.

• Controversies

Eyesight vs Eye Coordination

• Eyesight is the ability to see clearly• Eye coordination is the ability to use the

eyes efficiently when doing various activities

Eye Coordination

• Vergence or Eye Teaming• Accommodation or Eye Focusing• Oculomotor or Eye Tracking• Demonstration

Optometry’s Role

• AOA position statement– Diagnose and treat vision problems in children or

adults with academic problems. Goal is to improve visual function and reduce associated symptoms.

– Vision care and vision therapy should be part of a multidisciplinary approach to academic problems.

– Optometric Care of the Struggling Student– http://

www.aaopt.org/sites/default/files/Revised%20Oct%2018_BVPPO_Position_paper%20AAO%20website%20formatFINAL.pdf

Convergence Insufficiency

• Most common problem in eye teaming.• Recognized by optometry and

ophthalmology• Treated with vision therapy• Disagreement on the type of treatment

Behavioral component; what is the patient telling us?

• Children and Adult complain of variety of problems when reading and studying– Somatic

• My eyes hurt

– Perceptual• The print is blurry or distorted

– Performance• Slow reading and rereading

Convergence Insufficiency Symptom Survey (CISS)

• The 15 CISS questions were read to each subject while he or she looked at the response options.

• Responses scored on a 0 to 4 scale; never (0), infrequently (1), sometimes (2), fairly often (3), and always (4).

• Scores could range from 0 to 60.

CISS Questions

– Do your eyes feel tired when reading or doing close work?

– Do you have double vision when reading or doing close work?

– Do you have headaches when reading or doing close work?

– Do you lose your place when reading or doing close work?

CISS-scale

Never Infrequently Sometimes Fairly often

Always

0 1 2 3 4

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50

CI Symptom Survey Score

Pe

rce

nt

CI subjects

NormalsubjectsCutpoint = 16

Sensitivity = 95.7% Specificity = 85.7%

Academic Behavior Survey

• Academic Behavior Survey– 6 items– Completed by parent without child’s input– Scored on 0 to 4 scale; never (0), infrequently

(1), sometimes (2), fairly often (3), and always (4).

Survey Questions

• How often does your child have difficulty completing assignments?

• How often does your child have difficulty completing homework?

• How often does your child avoid reading or close work?

Survey Questions

• How often does your child make careless mistakes in school/homework?

• How often does your child appear inattentive during reading or close work?

• How often do you worry about your child’s school performance?

0 10 20 30 40 50 60 70

Completingassignments

Completinghomework

Avoids reading

Makes carelessmistakes

Appears inattentive

Worry aboutperformance

% responding "fairly often" or "always"

NBV Subjects

CI Subjects

Convergence Insufficiency Treatment Trail

• Compared office based treatment to placebo• Compared office to home based treatment• Improvement in CISS scores • Improvement in ABS scores• Office based treatment twice as effective as

home based treatments• Improvements in CISS and ABS score warrant

further investigation of reading and attention.

CISS Results

Convergence Insufficiency Treatment Trial

• Borsting E, Mitchell GL, Kulp MT, Scheiman M, Amster DM, Cotter S, Coulter RA, Fecho G, Gallaway MF, Granet D, Hertle R, Rodena J, Yamada T. Improvement in Academic Behaviors After Successful Treatment of Convergence Insufficiency. Optom Vis Sci 2012;89:12-18.

• Convergence Insufficiency Treatment Trial (CITT) Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol 2008;126:1336–49.

• Rouse M, Borsting E, Mitchell GL, Kulp M, Scheiman M, Amster D, Coulter R, Fecho G, Gallaway M, CITT Study Group. Academic behaviors in children with convergence insufficiency with and without parent-reported ADHD. Optom Vis Sci 2009;86:1169–77.

Looking at attention and CI

• Borsting E, Mitchell GL, Arnold LE, Sheiman M, Chase C, Kulp M, et al. Behavioral and Emotional Problems Associated With Convergence Insufficiency in Children: An Open Trial. Journal of Attention Disorders. 2013. Epub 2013/11/26.

Study

• Do children with CI have more ADHD like behaviors?– 53 school aged children with symptomatic CI– 8 children had parent reported ADHD.– Parents completed Conners 3 ADHD Index.

• 10 item scale• Behaviors most associated with ADHD

– Compared results to normative data.

Inattentive Symptoms more Common

Percent Responded Pretty or Very Much

0 10 20 30 40 50

Fidgets in seat

Restless/overatice

Fidgeting

Trouble organizing

Interrupts

Doesn't listen

Doesn't pay attention

Easily Distracted

Gives up easily

Inattentive

Treatment

• Examine whether successful treatment of CI was associated with a reduction in scores on the Connors 3 ADHD index.

• Non-randomized single treatment study with unmasked outcome visits.

Conners 3 ADHD Index

Baseline Week 24 Change0

10

20

30

40

50

60

70

62.6

52.8

9.9

Co

nn

er'

s A

DH

D In

de

x T

-sc

ore

Background

• CITT-ART– Convergence Insufficiency Treatment Trial –

Attention and Reading Trial• Funded by National Eye Institute May 1,

2014- April 2019• $8 M total funding• Study Chair: Mitch Scheiman, OD

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CITT-ART

• Convergence Insufficiency Treatment Trial-Attention and Reading

• https://clinicaltrials.gov/ct2/show/NCT02207517• CITT-ART is a multicenter study (8 locations around

the United States) of 324 children ages 9 to <14 years with symptomatic convergence insufficiency (CI). The purpose of this study is to see if office-based therapy for convergence insufficiency (CI) improves reading ability and attention.

Purpose

• Multicenter RCT of 324 children 9 to <14 years of age with symptomatic CI to:– Test the effects of CI treatment and of CI-symptom

improvement on measures of reading performance after 16 weeks of treatment

– Test the effects of CI treatment and of CI-symptom improvement on measures of attention after 16 weeks of treatment

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Study Design

• Participants randomized to 16 weeks of treatment with either – office-based vergence/accommodative therapy with

home reinforcement (OBVAT) – office-based placebo therapy with home reinforcement

(OBPT)

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Study Design

• Outcomes (reading and attention) will be assessed after 16 weeks of treatment

• One year follow up

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Study Design

• Masked Examinations– After 4, 8, 12 weeks of treatment– After 16 weeks of treatment

• Primary outcome examination

– At 12 months after treatment completion• Long term follow-up examinations

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Patients Receive:

• Paid study visits• Report of reading scores• Ongoing treatment if still symptomatic after

16 weeks

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