Convergence Insufficiency (CI) is one of the most common binocular vision disorders, where the eyes struggle to work together during near tasks. This often leads to symptoms such as eye strain, headaches, blurred vision, difficulty reading, skipping lines, and poor concentration during near work.
Clinical research strongly supports vision therapy as the most effective treatment for CI, especially the structured protocol used in the CITT (Convergence Insufficiency Treatment Trial).
This article provides evidence-backed, step-by-step exercises used in real clinical settings for improving convergence insufficiency. These exercises can be used as home therapy or in-office therapy, depending on optometrist guidance.
1. Pencil Push-Ups (Clinical Version)
Pencil Push-Ups are one of the most commonly prescribed home exercises, but it’s important to follow a clinical method rather than the incorrect version circulating online.
Clinical Indication
- Mild to moderate CI
- Home reinforcement exercise
Equipment
Any pencil with a high-contrast letter, number, or sticker on the tip
Step-by-Step Clinical Instructions
1. Hold the pencil at arm’s length, directly in front of your nose.
2. Focus on the letter/target on the pencil.
3. Slowly move the pencil towards your nose while keeping the target single and clear.
4. Stop immediately when:
- the target becomes double (diplopia), OR
- the eyes feel they are “pulling apart.”
5. Move the pencil slightly back until it becomes single again.
6. Restart the movement towards your nose.
7. Perform 3 sets of 10 push-ups, twice daily.
Notes
- Most effective when combined with in-office vergence therapy
- Research shows pencil push-ups alone are less effective than office therapy, but still valuable as home reinforcement
2. Brock String Exercise (Scientifically Validated)
The Brock String is a classic orthoptic tool used in clinics to train convergence, vergence ranges, and visual fixation.
Equipment
1 Brock string (you can buy one or make one)
Step-by-Step Clinical Instructions
1. Attach one end of the Brock string to a fixed point (door handle, wall hook).
2. Hold the other end against your nose.
3. Place 3 beads on the string:
- Green bead at 40 cm
- Yellow bead at 70 cm
- Red bead at 130 cm
4. Fix your focus on the nearest bead.
5. You must see:
- One bead
- When you looking at near bead the pattern should be "V"
- Looking at middle bead the pattern is "X"
- Looking at farthest beas the pattern is "A"
6. If the bead is double or missing the pattern:
- Blink
- Refocus
- Re-center your alignment
7. Shift your gaze to the middle bead, then the far bead.
8. Repeat the cycle for 5 minutes, twice daily.
Clinical Notes
Helps improve:
- Convergence
- Antisuppression
- Binocular alignment
- Critical for vergence flexibility training
3. Barrel Card Exercise (Near Vergence Training)
Barrel card training is a validated vergence exercise used in many binocular vision clinics.
Equipment
1 Barrel Card (three red barrels + three green barrels)
Step-by-Step Clinical Instructions
1. Hold the barrel card vertically between your eyes.
2. The largest barrels should be nearest to your nose.
3. Look at the closest barrel pair and make them fuse into one barrel.
4. You should see:
- One fused barrel
- Two faint background images of the opposite color
5. Shift to the middle barrel and repeat fusion.
6. Shift to the smallest barrel farthest away and fuse it.
7. Complete 15 fusion attempts, twice a day.
Clinical Notes
- Improves convergence range
- Teaches sustained near alignment
- Helps reduce suppression during near work
4. Near–Far Hart Chart (Vergence Flexibility Training)
This exercise improves the ability to switch focus between near and far objects — a major difficulty in CI patients.
Equipment
- 1 Near Hart Chart
- 1 Distance Hart Chart placed 10 ft away
Step-by-Step Clinical Instructions
1. Hold the near chart at 40 cm.
2. Place the distance chart on a wall at a minimum of 3 meters (10 feet).
3. Read one letter/row from the near chart.
4. Quickly shift and read the next letter/row from the distance chart.
5. Continue alternating near → far → near → far.
6. Maintain:
- Single vision
- Clear focus
- No head movement (eyes only)
7. Continue for 5 minutes daily.
Clinical Notes
- Improves vergence facility
- Helps with reading endurance
- Recommended for teens and adults with CI
5. Jump Convergence (In-Office + Home Exercise)
A dynamic version of vergence exercise used widely in clinical settings.
Equipment
Two targets:
- 1 near (40 cm)
- 1 distance (6–10 feet)
Step-by-Step Clinical Instructions
1. Place the near target at 40 cm.
2. Focus on it until the target appears:
- Clear
- Single
3. Shift quickly to the far target.
4. Regain single, stable vision.
5. Jump back to the near target.
6. Repeat 30 cycles.
Clinical Notes
- Builds speed and accuracy of convergence
- Used in nearly all CITT protocols
- Helps with “losing place while reading” symptoms
6. Push-up with Prism (Office-Based Vergence Therapy)
This exercise is performed under optometrist supervision using base-out prism lenses.
Clinical Purpose
- Enhances fusional vergence
- Part of advanced in-office therapy
Step-by-Step Clinical Instructions (Clinic Only)
1. Patient fixates on a near target.
2. Clinician introduces BO prism in front of one eye.
3. Patient maintains single binocular vision.
4. Prism amount is gradually increased.
5. Therapy continues until fusion breaks, then reduced again.
Clinical Notes
- Strong evidence of effectiveness (CITT)
- Not advised for home use
- Requires diagnostic oversight and safety management
7. Computer-Based Vergence Therapy (CITT-Based Programs)
Digital therapy tools were included in the Convergence Insufficiency Treatment Trial.
Examples
- Home Therapy System (HTS)
- Vision Therapy Software (e.g., Optics Trainer)
Clinical Notes
- Improves vergence facility
- Combines antisuppression + eye-teaming
- Works best when combined with in-office therapy
References
1. Convergence Insufficiency Treatment Trial (CITT)
2. Simran D, “A Study Determining the Efficacy of Brock String Therapy in the Treatment of Convergence Insufficiency”
3. Jung Un Jang,"Effectiveness of Vision Therapy in School Children with Symptomatic Convergence Insufficiency".
4. Sara S, Aberra A, "Comparative Effectiveness of different therapies for Convergence Insufficiency".
5. Preethi Anie E, Heber A, "Effectiveness of Vision Therapy in Managing Convergence Insufficiency and Accommodative Dysfunction: A Comprehensive Review".
