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. 2019 Jul 10:13:25.
doi: 10.3389/fnint.2019.00025. eCollection 2019.

Dizziness and Convergence Insufficiency in Children: Screening and Management

Sylvette R Wiener-Vacher  1   2 , Sidney I Wiener  3 , Layla Ajrezo  1 , Rima Obeid  1 , Damir Mohamed  4 , Priscilla Boizeau  4 , Corinne Alberti  4   5 , Maria Pia Bucci  1   2
Affiliations

Dizziness and Convergence Insufficiency in Children: Screening and Management

Sylvette R Wiener-Vacher et al. Front Integr Neurosci. .

Abstract

Objective: In children screened for dizziness with vergence disorders, we tested short and long term efficacy of orthoptic vergence training (OVT) and instructions to reduce screen usage.

Methods: Prospective study: Of the 179 children referred for vertigo or dizziness (over 3 years) with ophthalmological disorder as the only problem after complete oto-neuro-vestibular testing, 69 presented vergence insufficiency, and 49 accepted to participate in this study. 109 healthy children served as controls. All subjects had classic orthoptic evaluation and video binocular movement recordings during various oculomotor tasks. Patients were evaluated before OVT (M0), 3 months after the end of OVT (M3) and 9 months after the end of OVT (M9). Statistics compared orthoptic and oculomotor parameters between patients and controls over time with one-way ANCOVA, and mixed models, controlling for age and gender.

Results: Patients reported vertigo that was usually rotatory, lasting <15 min, associated with or alternating with headache (50%). Their exposure to small video screens and TV was intensive (∼3.6 h per day). At M0, all orthoptic and oculomotor parameters were statistically different in patients relative to controls (p < 0.0001) except for divergence. At M3, vertigo symptoms had disappeared in all of the patients, and all eye movement parameters improved significantly (p < 0.0001). At M9, this improvement remained stable or continued.

Conclusion: Vergence disorders (assessed by abnormal orthoptic and oculomotor parameters) can generate symptoms of dizziness in children. Orthoptic treatment and instruction to reduce screen usage has a significant and long term effect on vertigo symptoms as well as oculomotor performances. Dizzy children should be screened for vergence disorders.

What this study adds: Dizziness in children can be associated exclusively with insufficient convergence. Orthoptic training and instructions to reduce screen exposure made dizziness symptoms disappear and improved all eye movement parameters for 6 months. Vergence disorders should be screened for in dizzy children.

Keywords: orthoptic training; pediatric; saccades; vergence disorders; vertigo; video screen usage.

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Figures

FIGURE 1
FIGURE 1
Clinical screening for vergence insufficiency. This test includes 2 steps: (A) Looking for an abnormally long NPC during convergence (normal value ≤ 7 cm). (Left) Small targets were child-friendly stickers pasted onto tongue depressors. (Middle) The subject is instructed to fixate on the target as it was moved away from and toward the nose. (Right) As the target approaches the nose, the child must indicate when the target appears double and/or the clinician detects the distance, where smooth binocular eye movements cease and convergence breaks, with one eye ceasing fixation. This corresponds to the NPC. (B) Testing for misalignment of the eyes (heterophoria). (Right) Each eye is covered and uncovered by the clinician’s hand while the child fixates on a far target (dashed line and arrow in photo on left). If the eyes remain stable there is no misalignment. If one eye moves when uncovered this indicates a heterophoria.
FIGURE 2
FIGURE 2
The LED target set up (overhead view). LEDs were presented as targets on a board placed at the child’s eye level. The subject was seated in a dark room, with the head stabilized via a headrest supporting the forehead and chin. Calibration was made during binocular viewing at the beginning of the session (Lions et al., 2013). The child was instructed to look at targets randomly presented at 20° from the midline either at 150 cm (a distance not requiring vergence) or at 20 cm (where convergence is continuously required). Eye movements between adjacent distal targets (between LEDs B and A or B and C) involve saccades alone with no convergence. Eye movements between near targets (E and F or E and D) involve saccades alone with constant convergence. Vergence movements (convergence and divergence alone) were performed for targets presented along the medial plane (convergence from B to E and divergence from E to B). Combined saccade+vergence movements are involved when the target change of distance and laterality from the midline (saccades+divergence between E and A, or E and C, and saccades+convergence B and D, or B and F).
FIGURE 3
FIGURE 3
Clinical patterns of symptoms of vergence insufficiency in the patient group (A) duration of the sensation (B) associated symptoms, and (C) sensation perceived. Note that sensation of rotation is never an intense continuous rotatory vertigo as observed in acute vestibular loss.
FIGURE 4
FIGURE 4
Near point of convergence (A), far and near convergence (B) and divergence (C) measured with ORTE (mean ± standard deviation). Brackets indicate statistically significant comparisons. At M3 the NPC values for the patient group (A) improved relative to M0 and were not significantly different from controls. Amplitudes of near (gray circles) and far (black circles) convergence (B) improved significantly in patients at M3 and M9 and these values were greater than controls. Divergence amplitudes (C) were not significantly different in patients relative to controls at M0, M3, and M9. For all statistical values see Supplementary Tables S2, S3.
FIGURE 5
FIGURE 5
Gain of eye movements measured in OCME for the six test conditions (mean ± standard deviation). For combined saccades+vergence, the saccadic and vergence components are shown individually and labeled: sacc. component, conv. component, and div. component. Statistically significant differences are indicated by braces. Gains at M0 were lower in patients than in controls (C) for all eight conditions. At M3, gains were not significantly different from control values for far saccades, convergence, divergence, and combined saccades with divergence but were still significantly different from controls for near saccades and for both components of saccades combined with convergence. For all statistical values see Supplementary Tables S5, S6.
FIGURE 6
FIGURE 6
Latencies measured in OCME in the six test conditions (mean and standard deviation). Only statistically significant differences were indicated: top row braces shows differences between M0 vs. M3, M0 vs. M9, and M3 vs. M9 and bottom row shows all differences with controls. Latencies at M0 were significantly longer in patients compared to controls for all conditions tested. At M3 latencies decreased significantly for all conditions after OVT, reaching shorter latencies than controls for near and far saccades. For all statistical values see Supplementary Tables S5, S6.
FIGURE 7
FIGURE 7
Velocities of eye movements measured in OCME in the eight conditions in controls, and in patients at M0, M3, and M9 (mean and standard deviation). Only statistically significant differences were indicated: top row braces shows differences between M0 vs. M3, M0 vs. M9, and M3 vs. M9 and bottom row shows all differences with controls. Velocities at M0 were significantly lower in patients compared to controls in all conditions except for convergence+saccade, likely because of a compensatory increase of saccade velocity. After training the velocities were still significantly lower in patients than controls for far and near saccades, and for combined saccades with convergence and divergence. In contrast, velocities of vergence movements (alone or combined with saccades) in patients reached values not significantly different from or even higher than controls. For all statistical values see Supplementary Tables S5, S6.
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References

    1. Ajrezo L., Wiener-Vacher S., Bucci M. P., Bui-Quoc E. (2016). Influence of screen exposure on vergence components from childhood to adolescence. J. Ophthalmol. Eye Res. 4 170–177.
    1. Alvarez T. L., Jaswal R., Gohel S., Biswal B. B. (2014). Functional activity within the frontal eye fields, posterior parietal cortex, and cerebellar vermis significantly correlates to symmetrical vergence peak velocity: an ROI-based, fMRI study of vergence training. Front. Integr Neurosci. 8:50. 10.3389/fnint.2014.00050 - DOI - PMC - PubMed
    1. Alvarez T. L., Vicci V. R., Alkan Y., Kim E. H., Gohel S., Barrett A. M., et al. (2010). Vision therapy in adults with convergence insufficiency: clinical and functional magnetic resonance imaging measures. Optom. Vis. Sci. 87 E985–E1002. 10.1097/OPX.0b013e3181fef1aa - DOI - PMC - PubMed
    1. Anoh-Tanon M. J., Brémond-Gignac D., Wiener-Vacher S. (2000). Vertigo is an underestimated symptom of ocular disorders: dizzy children do not always need MRI. Pediatr. Neurol. 22 49–53. 10.1016/s0887-8994(00)00140-5 - DOI - PubMed
    1. Brandt T. (2003). Vertigo: its Multisensory Syndromes, 2nd Edn London: Springer.

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