Give a cycloplegic prescription to provide clear retinal images at all distances.

Consider over minus lenses to stimulate accommodation. But be aware the patients with convergence insufficiency often have concurrent accommodative insufficiency. If the amplitude of accommodation is below the normal range then over minus is not recommended.

Eye exercises such as distance-near-distance jump and push-up using accommodative targets at distance and near. Advise the patient to make a distance target consisting of a few letters around newspaper headline size, and place it on a wall or door at eye line-height. Advise the patient to make a near target of newspaper column-sized print on a stiff card. Advise the patient to hold the near target at arm’s length in the primary position of gaze and to look, with both eyes open from the near target to the distance target and back. Each movement from near to distance is one cycle. Repeat 10 cycles and then hold the card at half arm’s length, repeat 10 cycles, then hold the card at quarter arm’s length and repeat 10 cycles. Repeat full, half, and quarter arms’ length cycles again. Repeat this combined sequence once per day for around 14 days and then review. Combine with stereograms to build up fusional reserves if appropriate. Encourage parents to sit, observe, encourage, and help children and teenagers. Ask the child/parent to keep a diary of days done, what was done, how difficult it was and how the eyes felt, and to bring the diary to the next review.

If failing all of the above (or the patient did not want to or was unable to undertake exercises) and symptoms still exist consider prisms.

 

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