Skip to main content


Log in

Comparison of home-based pencil push-up therapy and office-based orthoptic therapy in symptomatic patients of convergence insufficiency: a randomized controlled trial

  • Original Paper
  • Published:
International Ophthalmology Aims and scope Submit manuscript



To assess and compare the effectiveness of home-based pencil push-up therapy (PPT) and office-based orthoptic therapy (OBOT) in patients with convergence insufficiency.


In this randomized clinical trial, 176 symptomatic patients with convergence insufficiency, aged between 9 to 30 years, were randomly assigned to receive 6 weeks of home-based PPT (Group I) or OBOT (Group II) after determining refractive error, near point of convergence (NPC), convergence insufficiency symptom survey (CISS) score, near phoria and positive fusional vergences (PFV) at near. The participants of Group I underwent home-based PPT (pencil push-ups exercises15 minutes per day, daily for 6 weeks) and those of Group II OBOT (convergence fusional exercises on synoptophore for 20 min per day, 3 days a week, for 6 weeks) without home reinforcement. Patients were re-examined at 3 and 6 weeks after initiation of treatment. NPC and CISS score were the primary and secondary outcome measures, respectively. Statistical analysis was performed with the independent samples t-test, Friedman test and the analysis of variance (ANOVA). Statistical significance was indicated by p-value < 0.05.


Participants of both the groups had statistically significant improvement in NPC, CISS score, PFV and near phoria (p < 0.001), but there was no statistically significant difference between the two groups (p > 0.05). However, patients of Group II had significantly better PFV after final visit than those of Group I (p < 0.001).


Home-based PPT with good suppression control and with compliance ensured by log book entries, is a simple, cheap, less time consuming and comparably effective alternative to more expensive OBOT for patients suffering from CI. CTRI registration number: REF/2016/11/012,732, Date of registration 25/04/ 2016, Retrospectively Registered.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others


  1. Dusek WA, Pierscionek BK, McClelland JF (2011) An evaluation of clinical treatment of convergence insufficiency for children with reading difficulties. BMC Ophthalmol 11:21

    Article  Google Scholar 

  2. Scheiman M, Wick B (2002) Clinical management of binocular vision: heterophoric, accommodative and eye movement disorders. Lippincott Williams and Wilkins, Pa, pp 241–260

    Google Scholar 

  3. Scheiman M, Cooper J, Mitchell GL, de Land P, Cotter S, Borsting E et al (2002) A survey of treatment modalities for convergence insufficiency. Optom Vis Sci 79:151–7

    Article  Google Scholar 

  4. Jang JU, Park IJ (2015) Prevalence of general binocular dysfunctions among rural schoolchildren in South Korea. Taiwan J Ophthalmol 5:177–181

    Article  Google Scholar 

  5. Lara F, Cacho P, García A et al (2005) General binocular disorders: prevalence in a clinic population. Ophthalmic Physiol Opt 21:70–74

    Article  Google Scholar 

  6. Scheiman M, Gallaway M, Coulter R et al (1996) Prevalence of vision and ocular disease conditions in a clinical pediatric population. J Am Optom Assoc 67:193–202

    CAS  PubMed  Google Scholar 

  7. Wajuihian SO, Hansraj R (2016) Vergence anomalies in a sample of high school students in South Africa. J Optom 9:246–257

    Article  Google Scholar 

  8. Rouse MW, Borsting E, Hyman L et al (1999) Frequency of convergence insufficiency among fifth and sixth graders. The convergence insufficiency and reading study (CIRS) group. Optom Vis Sci 76:643–649

    Article  CAS  Google Scholar 

  9. Dhir BK (1961) Convergence Insufficiency. Indian J Ophthalmol 9:33–35

    Google Scholar 

  10. Deshpande SB, Ghosh RK (1991) Study of primary convergence insufficiency. Indian J Ophthalmol 39:112–114

    CAS  PubMed  Google Scholar 

  11. Cacho MP, Garcia MA, Ruiz MT (2010) Do we really know the prevalence of accommodative and non-strabismic binocular dysfunctions? J Optom 3:185–197

    Article  Google Scholar 

  12. Hussaindeen JR, Rakshit A, Singh NK, George R, Swaminathan M, Kapur S et al (2017) Prevalence of non-strabismic anomalies of binocular vision in Tamil Nadu: report 2 of BAND study. Clin Exp Optom 100(6):642–648

    Article  Google Scholar 

  13. Scheiman M, Cotter S, Rouse M, Mitchell GL, Kulp M, Cooper J et al (2005) Convergence Insufficiency Treatment Trial Study Group. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. Br J Ophthalmol 89:1318–1323

    Article  CAS  Google Scholar 

  14. Gallaway M, Scheiman M, Malhotra K (2002) The effectiveness of pencil push-ups treatment for convergence in sufficiency: a pilot study. Optom Vis Sci 79:265–267

    Article  Google Scholar 

  15. Scheiman M, Mitchell GL, Cotter S, Kulp MT, Cooper J, Rouse M et al (2005) A randomized clinical trial of vision therapy/ orthoptics versus pencil push-ups for the treatment of convergence insufficiency in young adults. Optom Vis Sci 82:583–595

    Article  Google Scholar 

  16. Serna A, Rogers DL, McGregor ML, Richard PG, Don LB (2011) Treatment of symptomatic convergence insufficiency with a home-based computer orthoptic exercise program. J AAPOS 15:140–143

    Article  Google Scholar 

  17. Hustan PA, Hoover DL (2015) Treatment of symptomatic convergence insufficiency with home-based computerized vergence system therapy in children. J AAPOS 19:417–421

    Article  Google Scholar 

  18. Momeni-Moghaddam H, Kundart J, Azimi A, Hassanyani F (2015) The effectiveness of home-based pencil push-up therapy versus office-based therapy for the treatment of symptomatic convergence insufficiency in young adults. Middle East Afr J Ophthalmol 22:97–102

    Article  Google Scholar 

  19. Aletaha M, Daneshvar F, Mosallaei M, Bagheri A, Khalili MR (2018) Comparison of three vision therapy approaches for convergence insufficiency. J Ophthalmic Vis Res 13:307–314

    Article  Google Scholar 

  20. Tiwari N, Paul U, Paritekar P (2017) Retrospective study of effect of therapy on computer vision syndrome patients having convergence insufficiency. Kerala J Ophthalmol 29:97–101

    Article  Google Scholar 

  21. Hassan LI, Ibrahim SM, Abdu M (2017) Efficacy of home-based vision therapy for convergence insufficiency in secondary schools’ students. Sudanese J Ophthalmol 9:5–9

    Article  Google Scholar 

  22. Jang JU, Jang JY, Hyung KT, Moon HW (2017) Effectiveness of vision therapy in school children with symptomatic convergence insufficiency. J Ophthalmic Vis Res 12:187–92

    PubMed  PubMed Central  Google Scholar 

  23. Passmore JW, Maclean F (1957) Convergence insufficiency and its managements; an evaluation of 100 patients receiving a course of orthoptics. Am J Ophthalmol 43:448–456

    Article  CAS  Google Scholar 

  24. Cooper J, Duckman R (1978) Convergence insufficiency: Incidence, diagnosis, and treatment. J Am Optom Assoc 49:673–680

    CAS  PubMed  Google Scholar 

  25. Birnbaum MH, Soden R, Cohen AH (1999) Efficacy of vision therapy for convergence insufficiency in an adult male population. J Am Optom Assoc 70:225–232

    CAS  PubMed  Google Scholar 

  26. Kim KM, Chun BY (2011) Effectiveness of home-based pencil push-ups (HBPP) for patients with symptomatic convergence insufficiency. Korean J Ophthalmol 25:185–188

    Article  Google Scholar 

  27. Patwardhan SD, Sharma P, Saxena R, Khanduja SK (2008) Preferred clinical practice in convergence insufficiency in India: a survey. Indian J Ophthalmol 56:303–306

    Article  Google Scholar 

  28. Rouse MW, Borsting EJ, Mitchell GL, Scheiman M, Cotter SA, Cooper J et al (2004) Validity and reliability of the revised convergence insufficiency symptom survey in adults. Ophthalmic Physiol Opt 24:384–390

    Article  Google Scholar 

  29. Griffin JR, Grisham JD (2002) Binocular anomalies: Diagnosis and vision therapy, 4th edn. Butterworth-Heinemannp, Boston, Mass, pp 412–427

    Google Scholar 

  30. Scheiman M, Gallaway M, Frantz KA, Peters RJ, Hatch S, Cuff M et al (2003) Near point of convergence: test procedure, target selection, and normative data. Optom Vis Sci 80:214–225

    Article  Google Scholar 

  31. R: Zhong B, (2009) How to calculate sample size in randomized controlled trial? J Thorasic Dis 1:51–54

    Google Scholar 

Download references


This study was funded by All India Institute of Medical Sciences, Rishikesh. Grant number: 20/IM/2016.

This study was compliant with the ethical standards of institutional research committee.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Anupam Singh.

Ethics declarations

Conflict of interest

Author Anupam Singh has received research grants from All India Institute of Medical Sciences, Rishikesh. All of the above enlisted authors declare that there is no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Declaration of HELSINKI and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Written informed consent was obtained from all individual participants included in the study. In case of minors, informed consent from the parents/legally authorized representatives of the participants was obtained along with assent.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Singh, A., Saxena, V., Yadav, S. et al. Comparison of home-based pencil push-up therapy and office-based orthoptic therapy in symptomatic patients of convergence insufficiency: a randomized controlled trial. Int Ophthalmol 41, 1327–1336 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: