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Receded near point of convergence not diagnostic of insufficiency
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A receded near point of convergence in patients with chronic concussion-related symptoms is not a diagnostic of convergence insufficiency, according to a study published in the American Journal of Ophthalmology.
“Our findings support prior observations that receded NPC [near point of convergence] is a common sequela in young patients after concussion and demonstrate that a receded NPC can persist for many months to even years after injury,” the authors wrote.
“However, our data illustrate that a receded NPC post-concussion is not synonymous with the diagnosis of convergence insufficiency,” they said.
Researchers conducted a retrospective review of data from patients diagnosed with concussions between August 2012 and January 2016. Eighty-three patients 21 years old and younger who had chronic concussion-related symptoms, normal visual acuity and received a complete sensorimotor evaluation were considered.
Of these 83 patients, 74 (89%) had receded NPC. Seventy patients with receded NPC (95%) also had an oculomotor disorder. Researchers found that 45% of patients with receded NPC had deficient near convergence ability, but only 36% were diagnosed with convergence insufficiency. Most patients with receded NPC also displayed an oculomotor disorder affecting accommodation, vergence or both (95%).
The authors concluded that receded NPC is associated with underlying oculomotor dysfunctions but cannot be considered diagnostic of convergence insufficiency. Data showed that some patients with receded NPC had only accommodative disorders or even convergence excess.
“Persistent symptomatic post-concussion patients with receded NPC should be referred to an eye care specialist for a comprehensive sensorimotor evaluation so that any underlying vergence or accommodative dysfunctions can be identified and the most appropriate treatment prescribed,” they wrote. – by Julia Lowndes
Disclosure: The authors report no relevant financial disclosures.
Perspective
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Bruce Moore, OD, FAAO
The ophthalmic literature on the ocular effects of traumatic brain injury (TBI) is replete with anecdotal as well as poorly defined diagnoses, methods and techniques. This makes interpretation confusing and too often of limited clinical value. These authors performed detailed and consistent assessment of the oculomotor and accommodative systems of 83 children with carefully defined TBI.
Receded near point of convergence was the most common vision-related clinical finding and, as they noted, the presence of receded near point of convergence is not synonymous with a diagnosis of convergence insufficiency. Accommodative dysfunction was also frequently present. The authors discuss the intimate relationship between the oculomotor and accommodative systems, making an important point that fully understanding these dynamics is critical to the treatment process, as there are significant individual differences between patients.
This study provides a perfect example of how to do a clinical study on a complicated subject. It is well-written, it is based on classical optometric practice and it clarifies a complex and confusing clinical topic. It will be considered a critical paper in our growing understanding of the diagnosis and treatment of TBI. It should be read by every clinician with an interest in TBI and accommodative and oculomotor anomalies.
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