Vision Therapy - Orthoptic Training for the Treatment of Convergence Insufficiency

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Medical Policy: 09.03.02 
Original Effective Date: March 1988 
Reviewed: March 2016 
Revised: March 2016 


Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.


Description: 

Orthoptics, also known as vision training or vision therapy, is a technique of eye exercises intended to improve or correct diagnosed visual dysfunctions.  Orthoptic training is usually prescribed by an ophthalmologist, optometrist or orthoptists (health professional uniquely trained to evaluate and manage childhood and adult eye movement abnormalities).

 

Orthoptic training/vision therapy has been proposed for individuals with the following visual dysfunctions:

  • Accommodative disorders-focusing problems
  • Amblyopia-lazy eye
  • Ocular motility dysfunction- eye movement disorders
  • Strabismus-misalignment of the eyes
  • Treatment of learning disabilities- particularly reading disorders including attention deficient disorder, dyslexia, dysphasia or other reading disorders
  • Vergence dysfunction-insufficiency in using both eyes together or 
  • Visual rehabilitation after traumatic brain injury or stroke

Convergence insufficiency is the inability to maintain binocular function (keeping the two eyes working together) while working at a near distance. Typically, one eye will turn outward (intermittent exotropia) when focusing on a word or object at near.  Symptoms of convergence insufficiency include diplopia (double vision), eyestrain, eye fatique, tension in and around the eyes, headaches when reading, and squinting or closing of one eye. Many patients will complain that they have difficulty concentrating on near work (computer, reading, etc.) and that the written words blur after prolonged periods of reading or if reading when tired. Not all symptoms are present in every patient with convergence weakness.


Convergence insufficiency is diagnosed by an ophthalmologist, optometrist or orthoptist after obtaining a history of the patient’s symptoms and measuring convergence ability. The examination includes determining the distance from the eyes that the patient can hold the eyes together without double vision (near point of convergence) and the amount of prism that can be placed in front of the eyes at a particular distance before double vision is seen (fusional vergence amplitude). Presence of any refractive errors, eye muscle dysfunction, or weaknesses in accommodation (near focusing) should also be determined.

 

During a routine eye examination, convergence weakness may be diagnosed even without the above mentioned symptoms. Some patients test in the office as having poor convergence; however, they are asymptomatic. This may be the result of true convergence weakness, but is often found when the patient is distracted, shy, overly excited or does not understand the directions given. These patients should either be retested at another time or simply watched for symptoms of diplopia or headaches with near work. A patient who is not having difficulty with near tasks but tests positive for convergence insufficiency does not require any treatment but should be followed.

  

Convergence insufficiency and stereoacuity is documented by:

  • Exodeviation at near at least 4 prism diopters greater than at far; AND
  • Insufficient positive fusional vergence at near (positive fusional vergence (PFV) less than 15 prism diopters blur or break) on PFV testing using a prism bar; AND
  • Near point convergence (NPC) break of more than 6 cm; AND
  • Appreciation by the patient of at least 500 seconds of arc on stereoacuity testing.   

Orthoptic training or vision therapy appears to be beneficial in the treatment of symptomatic convergence insufficiency and can be provided through home based therapy. Home based therapy should include push-up exercises using accommodative target of letters, numbers or pictures; push-up exercises with additional base-out prisms; jump to near convergence exercises; stereogram and convergence card exercises; recession from a target; and maintaining convergence for 30 to 40 seconds. There is also a computer based orthoptic program known as Computer Vergence System (CVS). The program uses random dot stereograms to form pictures that require bi-foveal fixation to stimulate the vergence system. The program gradually increases the amount of vergence required to appreciate the stereogram picture and can monitor progression on line. This may be used as part of the home therapy program and the results of the computer program are often followed by an eye care professional with print outs that can be brought in to the office visit.

 

For convergence insufficiency the vision therapy usually incorporates specific treatments in order to achieve the following: 

  • Normalize the near-point of convergence
  • Normalize fusional vergence ranges and facility
  • Minimize suppression
  • Normalize associated deficiencies in ocular motor control and accommodation
  • Normalize accommodative/convergence relationship
  • Normalize depth judgement and/or steropsis
  • Integrate binocular function with information processing

A vision therapy program for convergence insufficiency consists of at least 12 weeks of home based treatment (15 minutes per day, five or more days per week). For individuals whose symptoms have failed to improve with a trial of least 12 weeks of home based therapy, office based therapy may be considered for the treatment of continued symptomatic convergence insufficiency. The therapy is individualized, the procedures used and duration of the therapy are dependent upon the nature and severity of the problem being treated and the specific needs and compliance of the patient.

 

Convergence insufficiency can be complicated by:

  • Restricted fusional ranges: up to an additional 12 hours of therapy
  • Suppression: up to an additional 6 hours of therapy
  • An accommodative element: up to an additional 8 hours of therapy
  • Other diagnosed vision anomalies such as ocular motor dysfunction and accommodative disorder, may require additional therapy
  • Associated conditions such as stroke, head trauma or other systemic diseases may require additional therapy

Based on the available medical literature randomized clinical trials have demonstrated that vision therapy/orthoptic training improves symptoms of convergence insufficiency and that the majority of children age 9 to 17 years were asymptomatic after a 12 week treatment program. The published clinical studies show that a limited number of office visits are required for resolution of convergence insufficiency. The average number of office visits for convergence insufficiency is usually less than a dozen and can typically be prescribed on a 1-2 session per week basis in conjunction with a home program.        

 

At the conclusion of the active treatment regimen, periodic follow up evaluation should be provided. Therapeutic lenses may be prescribed in conjunction with the vision therapy

 

A maintenance program consists of activities that preserve the patient’s present level of function and/or prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. 

 

Summary
Patients with convergence insufficiency can be treated by various strategies, depending on the severity of symptoms. Studies have shown that vision therapy is the treatment of choice for convergence insufficiency. The recommended treatment includes a home based therapy program and supplemental office based therapy when home based therapy fails.

 

A vision therapy program for convergence insufficiency consists of at least 12 weeks of home based treatment (15 minutes per day, five or more days per week). For individuals whose symptoms have failed to improve with a trial of least 12 weeks of home based therapy, office based therapy may be considered for the treatment of continued symptomatic convergence insufficiency. Based on the available medical literature randomized clinical trials have demonstrated that vision therapy/orthoptic training improves symptoms of convergence insufficiency and that the majority of children age 9 to 17 years were asymptomatic after a 12 week treatment program. The published clinical studies show that a limited number of office visits are required for resolution of convergence insufficiency. The average number of office visits for convergence insufficiency is usually less than a dozen and can typically be prescribed on a 1-2 session per week basis in conjunction with a home program.        

 

Vision Therapy – Orthoptic Training for Other Indications

The therapeutic goal of vision therapy is to correct or improve visual dysfunction. Visual dysfunctions. Dysfunction that purportedly are treatable by vision therapy include accommodative disorders – focusing problems, amblyopia, strabismus, ocular motility dysfunction – eye movement disorders, visual rehabilitation after traumatic brain injury or stroke, and treatment of learning disabilities including ADD/ADHD, dyslexia and other reading disabilities.

 

Most studies evaluating the efficacy of vision therapy for visual disorders are small. In general, these studies are poorly designed and significant methodological flaws, and the data derived from them are relatively weak and inconclusive. There is some evidence to support the use of vision therapy that involves occlusion as a treatment for amblyopia and vision therapy that involves prism adaptation prior to surgery administered as a treatment for acquired estropia. However, large well designed studies comparing vision therapy with other treatment modalities, standardization of outcome measurements and the criteria for defining patient selection criteria are needed to evaluate vision therapy for visual dysfunctions adequately. 

 

Learning Disabilities, Dyslexia and Vision
Learning disabilities constitute a diverse group of disorders in which children generally possess at least average intelligence have problems processing information or generating output. Their etiologies are multifactorial and reflect genetic influences and dysfunction or brain systems. Reading disability, or dyslexia, is the most common learning disability. It is a receptive language-based learning disability that is characterized by difficulties with decoding, fluent word recognition, rapid automatic naming, and/or reading comprehension skills. These difficulties typically result from a deficit in the phonologic component of language that makes it difficult to use the alphabetic code to decode the written word. Early recognition and referral to qualified professionals for evidence-based evaluations and treatment are necessary to achieve the best possible outcome. Because dyslexia is a language based disorder, treatment should be directed at this etiology. Remedial programs should include specific instruction in decoding, fluency training, vocabulary, and comprehension. Most programs include daily intensive individualized instruction that explicitly teaches phonemic awareness and the application of phonics. Vision problems can interfere with the process of reading, but children with dyslexia or related learning disabilities have the same visual function and ocular health as children without such conditions. Currently, there is inadequate scientific evidence to support the view that subtle eye or visual problems cause or increase the severity of learning disabilities. Scientific evidence does not support the claims that visual training, muscle exercises, ocular pursuit- and- tracking exercises, behavioral /perceptual vision therapy, “training” glasses, prisms, and colored lenses and filters are effective direct or indirect treatments for learning disabilities. There is no valid evidence that children who participate in vision therapy are more responsive to educational instruction than children who do not participate. Per the American Academy of Ophthalmology policy statement regarding learning disabilities, dyslexia and vision one of the recommendation states: diagnostic and treatment approaches for dyslexia and other learning disabilities that lack scientific evidence of efficacy such as behavioral vision therapy, eye muscle exercises, or colored filters and lenses are not endorsed or recommended.       

 

Based on review of the medical literature there is lack of quality data on the efficacy of vision therapy for treating dyslexia and other reading and learning disabilities. Most of the study results were found to be inconsistent and the studies themselves are flawed by serious design limitations e.g. small sample sizes, poorly defined patient criteria. In addition, the use of visual therapies is not supported by current specialty society guidelines. 

 

Practice Guidelines and Position Statements

 

American Academy of Ophthalmology
Convergence Insufficiency
Orthoptic training (vision therapy) is the primary treatment modality used by most eye care professionals for the treatment of convergence insufficiency (CI). The plasticity of the fusional convergence reflex system allows patients to improve their convergence amplitudes with simple exercises. There are numerous different types of eye exercises; however, the primary treatment modalities for CI include home based exercise, in-office exercises, computer vergence exercises or a combination of these. Some studies have suggested that performing both the home based exercises and the computer program is more effective than either modality performed on its own.

 

Eye care professionals will sometimes prescribe both in-office and home based CI exercises. Occasionally patients will require additional treatment strategies such as anti-suppression or extra time and assistance with the exercises and will require in-office treatment.

 

Conventional Convergence Exercises:

  • Gradual convergence exercises
  • Convergence cards
  • Stereograms
  • Vergence facility exercises
  • Base out prism exercises
  • Computer based convergence exercises

Idiopathic convergence insufficiency responds very well to convergence exercises and has a very high reported success rate. Published success rates vary between 70 to 80% depending on the patient population and study size.


American Academy of Pediatrics, American Academy of Ophthamology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists (2011): Issued a joint statement concerning pediatric learning disabilities, dyslexia and vision. Scientific evidence does not support the claims that visual training/therapy, muscle exercises, ocular pursuit-and-tracking exercises, behavioral/perceptual vision therapy, training glasses, prisms, and colored lenses and filters are effective direct or indirect treatments for learning disabilities. There is no valid evidence that children who participate in vision therapy are more responsive to educational instruction than children who do not participate. The reported benefits of vision therapy, including nonspecific gains in reading ability, can often be explained by the placebo effect, increased time and attention given to students who are poor readers, maturation changes, or the traditional educational remedial techniques with which they are usually combined. Other than convergence insufficiency treatment, the optometric claims that vision therapy improves visual efficiency cannot be substantiated.


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Prior Approval: 

 

Not applicable


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Policy: 

Medically Necessary
Office based orthoptic training/vision therapy in children and adolescents may be considered medically necessary for the treatment of symptomatic convergence insufficiency up to 12 visits only, if following a minimum of 12 weeks of home based therapy (e.g. push-up exercises using accommodative target of letters, numbers or pictures; push-up exercises with additional base-out prism exercises; jump-to-near convergence exercises; stereogram and convergence card exercises; and recession from a target and maintain convergence for 30-40 seconds), symptoms have failed to improve.

 

Office based orthoptics training/vision therapy in children and adolescents for the treatment of symptomatic convergence insufficiency exceeding 12 visits will be considered not medically necessary.

 

A vision therapy program for convergence insufficiency consists of at least 12 weeks of home based treatment (15 minutes per day, five or more days per week). For individuals whose symptoms have failed to improve with a trial of least 12 weeks of home based therapy, office based therapy may be considered for the treatment of continued symptomatic convergence insufficiency. Based on the available medical literature randomized clinical trials have demonstrated that vision therapy/orthoptic training improves symptoms of convergence insufficiency and that the majority of children age 9 to 17 years were asymptomatic after a 12 week treatment program. The published clinical studies show that a limited number of office visits are required for resolution of convergence insufficiency. The average number of office visits for convergence insufficiency is usually less than a dozen and can typically be prescribed on a 1-2 session per week basis in conjunction with a home program. If a patient remains symptomatic after 12 weeks of orthoptic training/vision therapy alternative interventions should be considered (i.e. continued home therapy program, home based computer vergence exercises, behavioral visual therapy, anti-suppression or surgery). Therefore, visits that exceed 12 office based therapy visits will be considered not medically necessary.           

 

Investigational
Orthoptics training/vision therapy is considered investigational for all other indications.

 

Based on peer reviewed literature the available data supporting the use of orthoptics training/vision therapy for indications other than convergence insufficiency is weak and inconclusive and derived primarily from uncontrolled studies with significant methodologic flaws. Other than convergence insufficiency treatment, the optometric claims that orthoptic training/vision therapy improves visual efficiency cannot be substantiated and therefore is considered investigational for all other indications.





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Procedure Codes and Billing Guidelines: 

  • To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
  • 92065 for orthoptic and/or pleoptic training, with continuing medical direction and evaluation

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Selected References: 

  • Institute For Clinical Systems Improvement's Technical Assessment Report TA #68; Vision Therapy,  January 2003
  • National Guideline Clearinghouse; Esotropia and exotropia. [NGC:2770] March 2003
  • Ziring PR, et al.  Learning Disabilities, Dyslexia, and Vision: A Subject Review (RE9825). American Academy of Pediatrics Policy Statement Volume 102, No 5 November 1998, 1217-1219.
  • Robinson GL, Foreman PJ. Scotopic sensitivity/Irlen Syndrome and the use of coloured filters: a long-term placebo controlled and masked study of reading achievement and perception of ability. Perceptual and Motor Skills1999August;89(1):83-113.
  • Simmers AJ, Bex PJ, Smith FK, Wilkins AJ. Spatiotemporal visual function in tinted lens wearers. Investigative Ophthalmology and Visual Sciences 2001 March;42(3):879-84.
  • Scheiman M, Mitchell GL, Cotter S, Cooper J, Kulp M, Rouse M, Borsting E, London R, Wensveen J; Convergence Insufficiency Treatment Trial Study Group.  A randomized clinical trial of treatments for convergence insufficiency in children.  Arch Ophthalmol. 2005 Jan; 123(1):14-24.
  • American Academy of Pediatrics. Learning Disabilities, Dyslexia, and Vision: A Subject Review. Pediatrics 1998; 102(5):1217-1219. A statement of reaffirmation for this policy was published on August 1, 2008. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;102/5/1217)
  • Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. 2008 Oct;126(10):1336-49.
  • ECRI Institute. Vision Therapy for Eye Disorders. Plymouth Meeting (PA): ECRI Institute; 2010 Jan 27. 14 p. [ECRI hotline response]. Also available: http://www.ecri.org.
  • ECRI Institute. Vision Therapy for Treating Eye Disorders. Plymouth Meeting (PA): ECRI Institute; 2012 May. [Hotline response]. Available at: http://ecri.org.
  • Borsting E, Mitchell GL, Kulp MT, Scheiman M, et al. Improvement in academic behaviors after successful treatment of convergence insufficiency. Optom Vis Sci. 2012; 89(1):12-18.
  • Henderson M, Questioning the benefits that coloured overlays can have for reading in students with and without dyslexia. Journal of Research in Special Educational Needs. 2012 June. 
  • American Academy of Pediatrics, Learning Disabilities, Dyslexia and Vision: A Joint Technical Report. Pediatrics Vol.127 No. 3 March 1, 2011. http://pediatrics.aappublications.org
  • American Optometric Association. Fact Sheets on Optometric Vision Therapy, Reimbursement Packet. January 2011.
  • National Guideline Clearing House. Care of the Patient with Accommodative and Vergence Dysfunction. www.guideline.gov
  • American Association for Pediatric and Ophthalmology and Strabismus: Convergence Insufficiency; Vision Therapy. www.appos.org
  • Borsting E, Mitchell GL, Arnold LE, et al. Behavioral and Emotional Problems Associated with Convergence Insufficiency in Children: An Open Trial. J Atten Disord. Nov 22 2013
  • Handler SM, Fierson WM, Section on Ophthalmology and Council on Children with Disabilities AAoO, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists,.Learning disabilities, dyslexia, and vision. Pediatrics. Mar 2011;127(3):e818-856. PMID 21357342
  • Scheiman M, Gwiazda J, Li T. Non-surgical interventions for convergence insufficiency. Cochrane Database Syst Rev. 2011(3):CD006768. PMID 21412896
  • Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. Oct 2008;126(10):1336-1349. PMID 18852411
  • Convergence Insufficiency Treatment Trial Study Group. Long-term effectiveness of treatments for symptomatic convergence insufficiency in children. Optom Vis Sci. Sep 2009;86(9):1096-1103. PMID 19668097
  • Scheiman M, Cotter S, Kulp MT, et al. Treatment of accommodative dysfunction in children: results from a randomized clinical trial. Optom Vis Sci. Nov 2011;88(11):1343-1352. PMID 21873922
  • Borsting E, Mitchell GL, Kulp MT, et al. Improvement in Academic Behaviors After Successful Treatment of Convergence Insufficiency. Optom Vis Sci. Nov 10 2012. Jan;89(1):12-8
  • Barnhardt C, Cotter SA, Mitchell GL, et al. Symptoms in children with convergence insufficiency: before and after treatment. Optom Vis Sci. Oct 2012;89(10):1512-1520. PMID 22922781
  • Scheiman M, Rouse M, Kulp MT, et al. Treatment of convergence insufficiency in childhood: a current perspective. Optom Vis Sci. May 2009;86(5):420-428. PMID 19319008
  • Shin HS, Park SC, Maples WC. Effectiveness of vision therapy for convergence dysfunctions and long-term stability after vision therapy. Ophthalmic Physiol Opt. Mar 2011;31(2):180-189. PMID 21309805
  • Dusek WA, Pierscionek BK, McClelland JF. An evaluation of clinical treatment of convergence insufficiency for children with reading difficulties. BMC Ophthalmol. 2011;11:21. PMID 21835034
  • Borsting E, Mitchell GL, Arnold LE, et al. Behavioral and Emotional Problems Associated With Convergence Insufficiency in Children: An Open Trial. J Atten Disord. Nov 22 2013. PMID 24271946
  • Lee SH, Moon BY, Cho HG. Improvement of Vergence Movements by Vision Therapy Decreases K-ARS Scores of Symptomatic ADHD Children. J Phys Ther Sci. Feb 2014;26(2):223-227. PMID 24648636
  • Ramsay MW, Davidson C, Ljungblad M, et al. Can vergence training improve reading in dyslexics? Strabismus. Dec 2014;22(4):147-151. PMID 25333204
  • United States Preventative Services Task Force (USPSTF) Visual Impairment in Children Ages 1-5, January 2011. Also available at www.uspreventativeservicestaskforce.org
  • American Academy of Ophthalmology. Convergence Insufficiency. EyeWiki. Also available at www.eyewiki.aao.org
  • UpToDate. Causes of Horizontal Strabismus in Children. David K. Coats M.D., Evelyn A Paysse M.D.. Topic last updated July 27, 2015. Also available at www.uptodate.com
  • Lavrich JB. Convergence Insufficiency and its current treatment. Curr Opin Ophthalmol 2010 Sep;21(5):356-60
  • Lambert J. Vision therapy and computer orthoptics: evidence-based approach to use in your practice. Am Orthopt J 2013;63:32-35
  • Whitecross S. Vision therapy: are you kidding me? Problems with current studies. Am Orthopt J 2013;63:36-40
  • Dusek WA, Pierscionek BK, McClelland JF. An evaluation of clinical treatment of convergence insufficiency for children with reading difficulties. BMC Ophthalmol. 2011;11:12
  • National Eye Institute. More Effective Treatment Identified for Common Childhood Vision Disorder. Also available at https://nei.nih.gov/news/pressrelease/101308

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Policy History: 

 

 

Date                                       Reason                                 Action

August 2011                          Annual review                       Policy renewed

July 2012                               Annual review                       Policy renewed

June 2013                              Annual review                       Policy revised

April 2014                              Annual review                       Policy revised

March 2015                           Annual review                       Policy renewed

March 2016                           Annual review                       Policy revised


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