Working Diagnosis:
Convergence insufficiency with intermittent exophoria

Treatment:
Because the patient was asymptomatic, no additional treatment was performed.

Outcome:
The patient was returned to full contact activity and finished the season with no additional issues. The patient plans to pursue competitive collegiate athletics. Moving forward, a formal recommendation was made that these findings be noted as his baseline and listed appropriately on future preparticipation evaluations to prevent unnecessary workup should he sustain further injury.

Author's Comments:
Two types of pathological unilateral, lateral gaze dysfunction exist: exophoria and exotropia. Exophoria is when the unilateral gaze defect is provoked, so it's visible intermittently. Exotropia is when the abnormality is constant, so it's always visible. Intermittent exophoria affects less than one percent of the general population (1). Exophoria can lead to exotropia.

Convergence insufficiency is a specific type of exophoria (2). Therefore, someone with convergence insufficiency will experience exophoria when looking at close objects, while someone with a more general exophoria may or may not have difficulty converging on a close object.

Convergence insufficiency is a disorder of the binocular vision that occurs when the eyes have difficulty maintaining fusion due to the lateral deviation of one eye while looking at nearby objects (3). Convergence insufficiency is an eye-teaming problem, not an eyesight problem, and can even affect people with 20/20 vision (4). While convergence insufficiency can be asymptomatic, it often causes symptoms of headaches, blurry vision, diplopia, eye pain, and can even lead to sensations of print moving while reading (3). Some people with convergence insufficiency describe difficulty with concentration and reading comprehension (3).

American high school tackle football players have a high rate of sports-related concussions, the highest of any other sport (5). Most of the brain's neural pathways control eye movement and vision, so it's no surprise that sport related concussion can lead to ocular dysfunction (6). A 2016 study by Master et al suggests a high prevalence of ocular pathologies after even mild traumatic brain injuries (7). A 2021 study by Scheiman et al suggests that convergence insufficiency has a prevalence of 2-17% in the general population and an even higher rate, up to 49% in patients who've sustained a head trauma and can be present in approximately 60% of patients with chronic post-concussion symptoms (8, 9). Undiagnosed and, therefore, under-treated convergence insufficiency does not pose a significant health risk (3). However, convergence insufficiency, or any ocular changes, can be an important indicator of concussion severity and should not be ignored. While VOMS is a highly accurate and reliable concussion screening tool, it can have a variable false-positive rate, ranging from 10-20% depending on the population tested (10, 11). However, any baseline change in vision or ocular exam warrants additional workup. Moreover, this case highlights the importance of thorough exams during preparticipation physicals, as well as obtaining baseline data including near point of convergence, to best evaluate injury severity.

Editor's Comments:
From a sports medicine perspective, this case underscores the critical importance of the pre-participation examination conducted by the physician or medical team responsible for covering an athlete�s events. Establishing a clear baseline including the identification of congenital or long-standing anomalies on physical examination can prevent unnecessary concern and costly investigations following sports-related injuries.
In this instance, prior awareness of the patient�s ocular status could have significantly reduced the emotional and financial burden associated with further testing for both the patient and his family. As the author notes, the patient�s diagnosis of convergence insufficiency is benign and relatively common, with a prevalence of 2 to 17 percent in the general population.
This case is broadly applicable to many benign anomalies that can be detected during pre-participation evaluations. It therefore behooves clinicians to document such findings and communicate them clearly to patients, parents, and athletic trainers. Doing so not only helps avoid unnecessary work-ups but also ensures that each athlete�s baseline health status is accurately established and readily available for future reference.

References:
1.Govindan M, Mohney BG, Diehl NN, Burke JP. Incidence and types of childhood exotropia: a population-based study. Ophthalmology. 2005;112(1):104-108. doi:10.1016/j.ophtha.2004.07.033
2.Scheiman M, Kulp MT, Cotter SA, Lawrenson JG, Wang L, Li T. Interventions for convergence insufficiency: a network meta-analysis. Cochrane Database Syst Rev. 2020;12(12):CD006768. Published 2020 Dec 2. doi:10.1002/14651858.CD006768.pub3
3.Goering M, Drennan KB, Moshirfar M. Convergence Insufficiency. [Updated 2023 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554390/
4.Russ, M.Optom DRL B. Optom (Hons). How Is Convergence Insufficiency Diagnosed? Optometrists.org. https://www.optometrists.org/vision-therapy/vision-therapy-for-children/convergence-insufficiency-2/how-is-convergence-insufficiency-diagnosed/
5.Centers for Disease Control and Prevention. Sports- and recreation-related TBIs and concussions. https://www.cdc.gov/heads-up/data/index.html#cdc_data_surveillance_section_2-concussion-rates-by-sport. Accessed April 26, 2025.
6.Rauchman SH, Zubair A, Jacob B, et al. Traumatic brain injury: Mechanisms, manifestations, and visual sequelae. Front Neurosci. 2023;17:1090672. Published 2023 Feb 23. doi:10.3389/fnins.2023.1090672
7.Master CL, Scheiman M, Gallaway M, et al. Vision Diagnoses Are Common After Concussion in Adolescents. Clin Pediatr (Phila). 2016;55(3):260-267. doi:10.1177/0009922815594367
8.Scheiman M, Grady MF, Jenewein E, et al. Frequency of oculomotor disorders in adolescents 11 to 17 years of age with concussion, 4 to 12 weeks post injury. Vision Res. 2021;183:73-80. doi:10.1016/j.visres.2020.09.011
9.Trieu LH, Lavrich JB. Current concepts in convergence insufficiency. Curr Opin Ophthalmol. 2018;29(5):401-406. doi:10.1097/ICU.0000000000000502
10.Kontos AP, Monti K, Eagle SR, et al. False-Positive Rates and Associated Risk Factors on the Vestibular-Ocular Motor Screening and Modified Balance Error Scoring System in US Military Personnel. J Athl Train. 2022;57(5):458-463. doi:10.4085/1062-6050-0094.21
11.Moran RN, Covassin T, Elbin RJ, Gould D, Nogle S. Reliability and Normative Reference Values for the Vestibular/Ocular Motor Screening (VOMS) Tool in Youth Athletes. Am J Sports Med. 2018;46(6):1475-1480. doi:10.1177/0363546518756979

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