Normative values for the nearpoint of convergence of elementary schoolchildren

Nearpoint of convergence (NPC) values of 8 to 10 cm are widely used to diagnose binocular dysfunctions such as convergence insufficiency. However, there are no published age-related normative values in the literature to substantiate these values. Subjects were 297 schoolchildren in kindergarten, third grade, and sixth grade who had passed a school-based Modified Clinical Technique vision screening. Each child had the NPC break and recovery taken three times using a standardized protocol developed by the Convergence Insufficiency and Reading Study group. The examiners used an Astron International (ACR/21) Accommodative Rule with a movable column of 20/30 letters as the target. For each grade, the distribution of NPC break was right skewed, with a concentration of values between 1 and 6 cm. At least 85% of the subjects in each grade had an NPC break < or = 6 cm. NPC break values (mean +/- SD) were 3.3 +/- 2.6 cm for kindergartners, 4.1 +/- 2.4 cm for third graders, and 4.3 +/- 3.4 cm for sixth graders, and the means were found to be statistically different (analysis of variance, p = 0.031). NPC recoveries (mean +/- SD) for the three groups were 7.3 +/- 4.8 cm, 8.7 +/- 4.2 cm, and 7.2 +/- 3.9 cm, respectively, which were also significantly different (analysis of variance, p = 0.027). The recovery distributions were more symmetric and less skewed than those for break. For each grade level, there was a strong positive relationship between NPC recovery and NPC break, but the difference between NPC recovery and break had a low correlation with the NPC break. Kindergartners had somewhat better NPC breaks than third or sixth graders, whereas no clear age trend was present for NPC recovery. A supporting study using a random sample of clinic patients (aged 10-12 years) suggests that patients with NPC breaks > 6 cm are more than twice as likely to be symptomatic than patients with NPC breaks < or = 6 cm. Based on these results and the NPC break distributions in this study, a clinical cutoff value of 6 cm is suggested for patients of elementary school age. A cutoff value in the 6- to 10-cm range is recommended for children of elementary school age in a screening context. The exact value within this range depends on the level of concern with identifying patients who have visual signs and symptoms associated with a receded NPC.