Presentation for C-REAL's Round Table Hot Topic Series March 2015 Event " Can Treating Visual Problems Improve Attention?" presented by Dr. Eric Borsting.

1. Can Treating Visual
Problems Improve
Attention?
Eric Borsting, OD MSEd
Professor
Marshall B. Ketchum University

2. Objectives
• Describe basic vision problems in eye
coordination.
• How vision problems impact the child and
family
• Description of current clinical trial.

3. 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

4. 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

5. 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

7. Eye Coordination
• Vergence or Eye Teaming
• Accommodation or Eye Focusing
• Oculomotor or Eye Tracking
• Demonstration

9. 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%2
0Oct%2018_BVPPO_Position_paper%20AAO%2
0website%20formatFINAL.pdf

10. Convergence Insufficiency
• Most common problem in eye teaming.
• Recognized by optometry and
ophthalmology
• Treated with vision therapy
• Disagreement on the type of treatment

11. 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

12. 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.

13. 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?

14. CISS-scale
Never Infrequently Sometimes Fairly
often
Always
0 1 2 3 4

15. 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
Percent
CI subjects
Normal
subjectsCutpoint = 16
Sensitivity = 95.7%
Specificity = 85.7%

16. 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).

17. 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?

18. 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?

19. 0 10 20 30 40 50 60 70
Completing
assignments
Completing
homework
Avoids reading
Makes careless
mistakes
Appears inattentive
Worry about
performance
% responding "fairly often" or "always"
NBV Subjects
CI Subjects

20. 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.

21. CISS Results

22. 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.

23. 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.

24. 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.

25. 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

26. 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.

27. Conners 3 ADHD Index
62.6
52.8
9.9
0
10
20
30
40
50
60
70
80
90
Baseline Week 24 Change
Conner'sADHDIndexT-score

28. 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
28

29. 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.

30. 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
30

31. 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)
31

32. Study Design
• Outcomes (reading and attention) will be
assessed after 16 weeks of treatment
• One year follow up
32

33. 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
33

34. Patients Receive:
• Paid study visits
• Report of reading scores
• Ongoing treatment if still symptomatic after
16 weeks
34