Convergence

Group 2
Contents
Factors that affect
01 Definition 05 Convergence

02 Mechanism of Convergence
06 Classification

Development of
03 Convergence 07 Anomalies of Convergence

Amplitude and Near Point of

04 Convergence
 1
Definition
What is Convergence?
What is Convergence?
• Convergence is the ability to look at a close source by turning the two eyes
inward toward each other. We depend on this visual ability for near-work
activities like desk work at school, working on a smartphone, and even catching a
ball in sports.

• Convergence is a disconjugate movement in

which both eyes rotate inward so that the lines
of sight intersect in front of the eyes.

• Allows bifoveal single vision to be maintained at

any fixation distance.

• Convergence does not deteriorate with increasing

age.

• The power of convergence can be increased by

exercises.
 2
Mechanism
How does Convergence happen?
 Mechanism of Convergence
● How does convergence in eye happens?
● In order for us to look at an object as it moves closer to
our face, the eyes must rotate inward toward the object.
Convergence is one of the unique eye movements that is not
conjugate (meaning the eyes move in the same direction) but are
instead termed disconjugate. Convergence is one of the three
reflexive visual responses elicited by interest in a near
object. Convergence requires a coordinated stimulation of some
extraocular muscles at the same time others are relaxed.
Convergence occurs by stimulation of the medial rectus muscle
of both eyes (third cranial [oculomotor] nerve) while
simultaneously relaxing the lateral recti (sixth cranial
[abduscens] nerve). When the eyes converge, the focusing
(accommodative) system is engaged, and the pupil get slightly
smaller. This set of three processes – technically termed
convergence, accommodation, and miosis – is known as the near
 Convergence Reflex
● Afferent pathway –the afferents from
medial recti travel centrally via the 3 rd
nerve to the mesencephalic nucleus of the
5th nerve, to a presumptive convergence
centre in tectal or pretectal region.
● Internuncial fibres : from the
convergence centre go to the Edinger
Westphal nucleus.
● Efferent pathway - along the 3rd nerve.
From the 3rd nerve efferent fibres of
convergence reflex relay in the accessory
ganglion, before reaching sphincter
 3
Development
When does convergence develop?
Development of Convergence
• There’s a study that shows that convergence had already develop on infants.

• The first months of the infants didn’t show accurate convergence until 6 weeks
of age and by 4 months of age the infants had a good convergence.

• Why do we need to increase the power of convergence? The reason we need to

increase the power is to help us maintain our focus specially on reading with no
blurriness and double vision. The power of convergence can be increased by
orthoptic exercises, reading glasses and computer vision therapy.
 4
Amplitude and Near Point

What is amplitude and near point of convergence?

Amplitude and Near Point of Convergence

• The amplitude of convergence is the difference in convergence power

exerted to maintain the eye in a position at rest and in a position of
maximum convergence.

• The near point of convergence is the closest point at which an object

can be seen singly during bifoveal vision when maximum convergence is
exerted.
 Convergence Amplitude
Convergence amplitudes are measured with base out prisms while the patient
focuses on a target at near. Normal convergence amplitudes are 38 prism diopters
at near and 14 prism diopters at distance. In general, fusional convergence
amplitudes of less than 15 to 20 prism diopters at near are a sign of
convergence insufficiency. It is important to measure the exodeviation ( A type
of strabismus in which the visual axes diverge; may be paralytic or concomitant,
monocular or alternating, constant or intermittent) in all positions of gaze to
rule out any eye muscle imbalance that could make the exodeviation greater in
downgaze. Measurements at near should be done in both primary position and
reading position. Superior oblique over action can cause an exodeviation greater
in downgaze and can be mistaken for Convergence Insufficiency.
 5
Factors
What are the factors that affect convergence?
Factors that Affect Convergence Insufficiency
Convergence Insufficiency might be caused by genes, passed on from families, and
using electronics such as mobile phones and computers for hours. Few health
conditions can also affect convergence. These include:

• Head injury and concussion

• Graves disease
• Myasthenia gravis
• Parkinson disease
• Alzheimer disease

Convergence Insufficiency is a common binocular vision disorder that could really

cause discomfort in doing even the simplest tasks, might it be at school or at
work. CI could also minimize job opportunities. This disorder cannot be easily
diagnosed though, you can easily pass eye chart exams even with CI, you should
opt to take a comprehensive eye exam from experts to be able to be diagnosed and
get treatments if ever you experience the symptoms of convergence insufficiency.
 6
Classifications
What are the classifications of convergence?
Classification of Convergence
According to Margaret Dobson Convergence may be summarised as consisting of three
parts, tonic, accommodational, and fusional (Maddox).

1.) Tonic
• According to (Lee TE & Kim SH), tonic convergence is the mechanism used to
bring the eyes from this position into the physiologic position of rest and is
presumably brought about by the tonus of the extra ocular muscle.
• Extra ocular Muscles Tonus
- According to (Constantino & Schiavi, 2016), innervation factors have been long
since considered to be somehow implicated in the etiology and pathogenesis of
concomitant strabismus, due to the close relationship between accommodation and
convergence. Nevertheless, if refractive errors and anomalies of the
accommodation mechanism may be suspected to be one of the causes of certain
types of strabismus, it is evident that refractive errors and/or excessive or
decreased accommodative convergence alone cannot explain the exact origin of
concomitant strabismus.
Classification of Convergence
• According to (M Rosenfield , K J Ciuffreda, G K Hung, B Gilmartin), Tonic
Vergence is considered to move the eyes from an anatomical position of rest
(which would be the eye's position if it were not innervated) to the
physiological position of rest.
• According to medical definition, Phoria is a latent (hidden) eye deviation. The
eyes appear to be straight, but when covering an eye and breaking fusion, the
eyes assume a position away from normal alignment.

There are two example of phoria

A.) Esotropia
• According to Dr. Micheal Garin 2017, Esophoria 
is a tendency of the eyes to want to turn more
inward than necessary when an individual is
viewing an object at near or at distance which
may cause the individual to experience
eyestrain and other symptoms.
Classification of Convergence
B.) Exotropia
According to Debra Sullivan, Ph.D., MSN, R.N., CNE, COI,
Exophoria is a condition of the eyes. When you have exophoria,
there's a problem with how your eyes coordinate their movements.
It occurs when your eyes tend to drift outward or one eye drifts
away from the other.
 
2.) Accommodative
• According to Wikipedia, Accommodative convergence is that portion of the range of 
inward rotation of both eyes (i.e. convergence) that occurs in response to an increase in 
optical power for focusing by the crystalline lens (i.e. accommodation)

Too much accommodative convergence less accommodative convergence

Classification of Convergence
3.) Fusional
• According to Bynocs’ “Exercise your Eyes”, Fusional Vergence is the movement of both eyes that
enables the fusion of monocular images producing binocular vision. It is used clinically to
check the ability of convergence and divergence. Convergence is the disconjugate movement in
which both eyes rotate inwards for bifoveal single vision. It does not deteriorate with age
like accommodation but can be affected in visually demanding situations. Fusional convergence
is a reflex produced to ensure that similar retinal images are projected onto corresponding
retinal areas. Near Point of Convergence (NPC) is the closest point at which an object can be
seen as single during bifoveal vision.

Two types of fusional Convergence

Positive Fusional vergence when the eyes Negative Fusional vergence when the eyes turn
inward esophoria turn outward exophoria
 7
Anomalies
What are the anomalies in convergence?
Anomalies of Convergence
1.) Convergence insufficiency (CI)
• Inability to maintain or obtain adequate convergence over certain period time
without undue effort.
• Commonest cause of asthenopia.
 Aetiology
A. Primary or idiopathic – wide IPD, general debility, overwork.
B. Refractive errors- uncorrected high hypermetropia and myopia
C. Presbyopia
D. Muscular imbalances- exophoria, intermittent exotropia and vertical muscle
imbalances.
Convergence Insufficiency
• Clinical features:
Commonly seen in school childrens, prolonged near workers, prescise workers
like jewelers, painters. And pts are presented with a symptom complex called
Asthenopia.
1. Symptoms of muscle fatigue includes eye ache , headache , eyestrain,
difficulty to change focus itching burning sense..
2. Symptoms of difficulty to maintain binocular vision include intermittent
diplopia , blurred near vision and crowing of letters, symptomatic relief
gained on closing one eye .

• Diagnostic points
CI can be confirmed by following diagnostic points:
1. Remote NPC i.e. more than 10 cm
2. Reduced fusional convergence for near
3. Reduced prism convergence value
4. Sometimes associated with Exophoria at near and orthophoria at distance
5. NPA remains normal mostly (so pts with CI suspect must necessarily measured
for NPA)
Anomalies of Convergence
2.) Convergence paralysis
• It is defined as total lack of ability to overcome base out prism.
• Uncommon condition confused with convergence insufficiency.

Etiology :
- Occurs secondary to organic disease of brain especially at corpora quadrigemina
and nuclei of 3rd cranial nerve .

Clinical features:
1. Complete absence of convergence
2. Exotropia and crossed diplopia on attempted near fixation
3. Adduction remains normal.
4. Accommodation is usually normal but reduced and absent sometimes.
Convergence Paralysis
• Parinauds syndrome: convergence paresis a/w vertical gaze palsy
• Pretectum posterior commissure syndrome also a/w convergence paralysis
 
Diagnostic points of convergence paralysis (Bielschowsky’s criteria)
1. Evidence of intra cranial disease
2. Crossed diplopia on attempted near fixation
3. Reproducible findings on subsequent examinations
4. Preservation of accomodation and pupillary rxn
 
Differential diagnosis:
1. Often confused with functional convergence insufficiency so must be differentiated from it
by using base out prisms.
2. In this prism base out test pts with paralysis will have diplopia immediately but pts with
CI can cope certain value of prism power.

Treatment of convergence paralysis:

3. Base in prism to eliminate diplopia at near.
4. Plus lens along with base in prism to the patients having accomodation weakness
5. Occlusion of one eye at near work to eliminate diplopia.
6. Eye surgery is contraindicated.
Anomalies of Convergence
3.) Convergence spasm
• Condition characterized by intermittent episode of maximum convergence usually associated with
accommodative spasm.
 
Etiology
1. Functional causes ( associated with hysteria and neurosis )
2. Organic causes ( organic lesions , head traumas , pituitary adenomas )

Clinical features:
3. Extreme convergence ( intermittent )
4. Homonymous diplopia
5. Blurring of vision due to accommodative spasm (near triad)
6. Miosis (near triad)
7. High induced myopia (> 5D)

Management
8. Neurological evaluation needed
9. Psychiatrical evaluation revels hysteria or neurosis
Convergence Spasm
Treatment of functional spasm of convergene includes:
1. Prolonged atropinization
2. Alternate monocular occlusion ( alternative of atropinization) atropinization
 
Therapies to improve near point of convergence are.
3. Advancement exercise like pencil push up exercise.
4. Jump convergence exercise with spot card & brock string ex.
 
Therapies to improve amplitude of fusional convergence.
5. Convergence exercise with prism
6. Convergence exercise with Major Amblyoscope
7. Convergence card (Albee dot exercise)
8. Convergence exercise with diploscope
9. Cat stereogram ex. in uncrossed position.
References
● https://bjo.bmj.com/content/bjophthalmol/25/2/66.full.pdf
● Lee TE & Kim SH. Accommodative and tonic convergence and anatomical contracture in partially
accommodative and non‐accommodative esotropia. Ophthalmic Physiol Opt 2012, 32, 535– 538. doi:
10.1111/j.1475‐1313.2012.00924.x
● Costantino Schiavi, "Extraocular Muscles Tension, Tonus, and Proprioception in Infantile Strabismus: Role
of the Oculomotor System in the Pathogenesis of Infantile Strabismus —Review of the Literature",
Scientifica, vol. 2016, Article ID 5790981, 8 pages, 2016.
● https://doi.org/10.1155/2016/5790981
● https://www.bynocs.com/features/fusional-vergence/
● https://www.2020detroit.com/author/burmanadmin/
● https://www.healthline.com/health/exophoria
● https://www.healthline.com/health/exophoria#:~:text=Exophoria%20is%20a%20condition%20of,drifts%20away%20f
rom%20the%20other
.
● https://www.2020detroit.com/esophoria_exophoria/#:~:text=Esophoria%20is%20a%20tendency%20of,experience%20
eyestrain%20and%20other%20symptoms
.
● https://www.google.com/url?sa=i&url=https%3A%2F%2Fnotes.childrenshospital.org%2Fesotropia-crossed-eye-oph
thalmologist%2F&psig=AOvVaw04dnSczs_LaimcN6XIhc1S&ust=1619505444209000&source=images&cd=vfe&ved=2ahUKEwjo
y_2GppvwAhUOvZQKHYTUCssQr4kDegUIARDHAQ
● https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.seevividly.com%2Finfo%2FLazy_Eye%2FStrabismus%2FExo
tropia&psig=AOvVaw2JN5QPlJxhSmnTe6u46RsV&ust=1619505834684000&source=images&cd=vfe&ved=0CA0QjhxqFwoTCPC0z
ff9nPACFQAAAAAdAAAAABAD
References
● Primary care optometry by Theodore Grosvernor
● Squint & orthoptics by AK khurana
● Clinical visual optics by Bennett & Rabbetts 
● https://www.slideshare.net/mobile/bipinkoirala3/convergence-amp-its-anomalies#:~:text=%EF%82%B4Amplitude
%20of%20convergence%3A%2D,in%20position%20of%20maximum%20convergence
.
● Convergence and Divergence (seevividly.com)
● https://www.aoa.org/healthy-eyes/eye-and-vision-conditions/convergence-insufficiency?sso=y
● https://www.webmd.com/eye-health/convergence-insufficiency#1 
● https://www.healthline.com/health/eye-health/convergence-insufficiency#treatments
● https://www.cedars-sinai.org/health-library/diseases-and-conditions/c/convergence-insufficiency.html
● https://pubmed.ncbi.nlm.nih.gov/8113005/
Thank you for listening!
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