Purpose The objectives of the present study were to evaluate whether investigator bias influenced the Convergence Insufficiency Symptom Survey (CISS) scores of children with normal binocular vision (NBV) in our original validation study, reevaluate the usefulness of the cut-off score of 16, and reexamine the validity of the CISS. Methods Six clinical sites participating in the Convergence Insufficiency Treatment Trial (CITT) enrolled 46 children 9 - <18 years with NBV. Examiners masked to the child’s binocular vision status administered the CISS. The mean CISS score was compared to that from the children with NBV in the original, unmasked CISS study and also to that of the 221 symptomatic CI children enrolled in the CITT. Results The mean (±SD) CISS score for 46 subjects with NBV was 10.4 (±8.1). This was comparable to that from our prior unmasked NBV study (mean = 8.1(± 6.2); p = 0.11), but was significantly different from that of the CITT CI group (mean = 29.8 ± 9.0; p < 0.001). Eighty-three percent of these NBV subjects scored less than 16 on the CISS, which is not statistically different from the 87.5% found in the original unmasked study (p = 0.49). Conclusions Examiner bias did not affect the CISS scores for subjects with NBV in our prior study. The CISS continues to be a valid instrument for quantifying symptoms in 9 to <18 year-old children and these results confirm the validity of a cut-point of ≥ 16 in distinguishing children with symptomatic CI from those with NBV.

To compare patching and atropine as treatments for moderate amblyopia in children younger than 7 years. Methods: In a randomized clinical trial, 419 children younger than 7 years with amblyopia and visual acuity in the range of 20/40 to 20/100 were assigned to receive either patching or atropine at 47 clinical sites. Main Outcome Measure: Visual acuity in the amblyopic eye and sound eye after 6 months. Results: Visual acuity in the amblyopic eye improved in both groups (improvement from baseline to 6 months was 3.16 lines in the patching group and 2.84 lines in the atropine group). Improvement was initially faster in the patching group, but after 6 months, the difference in visual acuity between treatment groups was small and clinically inconsequential (mean difference at 6 months, 0.034 logMAR units; 95% confidence interval, 0.005-0.064 logMAR units). The 6-month acuity was 20/30 or better in the amblyopic eye and/or improved from baseline by 3 or more lines in 79% of the patching group and 74% of the atropine group. Both treatments were well tolerated, although atropine had a slightly higher degree of acceptability on a parental questionnaire. More patients in the atropine group than in the patching group had reduced acuity in the sound eye at 6 months, but this did not persist with further follow-up. Conclusion: Atropine and patching produce improvement of similar magnitude, and both are appropriate modalities for the initial treatment of moderate amblyopia in children aged 3 to less than 7 years.

Purpose To investigate symptom patterns and evaluate the relationship between patient characteristics and symptom severity before and after treatment for symptomatic children with convergence insufficiency (CI). Methods In a randomized clinical trial, the Convergence Insufficiency Symptom Survey (CISS) was administered pre- and post-treatment to 221 children 9 to <18 years with symptomatic CI. Frequency of symptom type was determined at baseline, mean change in performance-related versus eye-related symptoms for treatment responders was compared, and the relationship between patient characteristics and symptom severity at baseline for the entire cohort and after treatment for those who responded to treatment, was determined. Results At baseline, the score for performance-related symptoms was greater than that for eye-related symptoms (mean response of 2.3 vs. 1.8, p<0.001) regardless age, sex, race/ethnicity, or presence of parent-reported ADHD. Symptom severity increased with age for both the overall and eye-related subscale scores (p=0.048, p=0.022, respectively). Children with parent-reported ADHD were more symptomatic (p=0.005) than those without parent-reported ADHD because of a higher performance-related score (p<0.001). A significant and equal improvement (p<0.01) for the performance-related and eye-related symptoms was found in treatment responders. Girls had significantly lower performance-related symptoms than boys (p=0.014) and African-American children reported less eye-related symptoms than White children (p=0.022). Children without parent-reported ADHD had significantly less symptoms overall and less eye-related symptoms than children with parent-reported ADHD (p=0.019, p=0.011, respectively). Conclusions Because of a high frequency of both performance- and eye-related symptoms, clinicians should perform a targeted history that addresses both types of symptoms to help identify children with symptomatic CI. Future study regarding the relationship of CI and symptoms and their potential influence on ADHD, reading performance, and attention is warranted.