Purpose : To explore the relationship between
convergence insufficiency and academic behaviors in children and to compare the scores on academic behavior
survey (ABS) and convergence insufficiency symptom survey (CISS) between
children with convergence insufficiency (CI) and children with normal binocular
vision (NBV).

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Methods: Detailed orthoptic evaluation was performed among 9 to 16
years old children to determine the children with CIs and classify them into
three different CI groups (1-sign CI, 2-sign CI and 3-sign CI). ABS survey was
done among 205 parents whose children was diagnosed with CIs and among100
parents whose children have NBV. The parents were not allowed to consult with
their child during the survey. Convergence insufficiency symptom survey (CISS)
was also administered to both group of children.

Results: Mean ABS score of CI group (11.39 ± 3.89) was significantly
higher as compared to NBV group (4.8 ± 2.36, p 2 D for their age, amblyopia, constant
strabismus, history of strabismus surgery, high refractive error (>6 D
myopia, >5 D hyperopia, >4 D astigmatism), anisometropia of >2 D
spherical equivalent, manifest or latent



Visual Acuity (VA)
was assessed both monocularly and binocularly with an ETDRS chart at a distance
of 4 metres.. VA was recorded in the Snellen fraction. Objective and subjective
refractions were performed in all cases. Slit lamp examination was performed
and fundus was evaluated with an ophthalmoscope to rule out glaucoma and any
retinal abnormalities.

Detailed orthoptic
examination was performed. Cover test was done for both near and distance at 40
cm and 6 m respectively to rule out any latent or manifest deviation. Prism
cover test (PCT) for both near and distance was performed to measure amount of
latent or manifest deviation. Near point of convergence (NPC) and near point of
accommodation (NPA) was assessed by Royal Air Force (RAF) ruler. Positive
fusion vergence (PFV) was measured using prism bar at near and distance.
Stereopsis was assessed using Titmus Fly Test at 40 cm using polarized glasses
with the subject’s habitual refraction.

CISS form was
administered to the subject. It was a face to face interview. Each of the
question in CISS was read aloud and described to the child. The child chose the
frequency of occurrence of symptom from five possible responses (never,
infrequently, sometimes, fairly often and always) (4,7,8,8′,9).Similarly,
parent of the subject was given ABS form and was asked to rate each item on the
survey on basis of observation of their child’s behavior during reading, doing
schoolwork or homework. During the survey, neither the child nor the parents
were allowed to discuss with

each other (1,6). Since the questionnaire was in English, we
translated the questions in nepali for those who were not able to understand

Data analysis

Data entry and
analysis was done using Statistical Package for the Social Sciences (SPSS)
version 20. Appropriate statistical tools were implemented as required.
Comparison of the mean score on the ABS between the two patients groups was
performed using paired -t test. Pearson correlations were used to assess the
relationship between ABS score given by parents and CISS scores given by the




 Table 1: Gender distribution of study





CI group


87(42.4) MKD1 x2 x3 








NBV group













The purpose of the
study was to explore the relationship between academic behaviors and
convergence insufficiency in school children. Our results showed that the
children with symptomatic CI scored significantly higher on the ABS
questionnaires when compared to children with NBV. The CISS score also resulted
in similar findings which showed the presence of greater level of symptoms like
feeling discomfort, hurting of eyes, diplopia, difficulty to focus, frequent
need to re-read etc. in children of CI group compared to children with NBV. The
frequency of symptoms reported by the child in CISS was associated with ABS
scores given by the parents. We judged that CI might be the cause of adverse
academic behaviors in children with CI.


We also investigated
the relationship between the clinical signs of CI with CISS as well as ABS. The
result showed significant correlation between them (p 8
exo to 1SD to 7? to 1SD to