Pencil push-ups treatment (PPT) is a commonly prescribed eye exercise approach for convergence insufficiency (CI). They are also called or categorized as near point of convergence exercises. Typically, this exercise is done with a pencil but any object with the shape of a pencil could work. Pencils used in PPT can have an alphabet or other characters on it to stimulate the accommodative system. If the patient does not know their letters yet, the optometrist may opt for a more familiar symbol like animal or shape and have the patient look at that while they perform the pencil pushup task.
PPT usually have letters on them to allow the patient to focus their accommodative system to one place on the pencil while it is moved closer and farther from the nose. The goal is to keep the pencil clear (not blurry) and single (not double) for as long as possible while moving the pencil close and far from the nose. Typically, patients hold the pencil with their arm outstretched and then slowly bring it close to their nose. Patients may be directed to look at each letter of the alphabet while moving the pencil close and far. As with any vision therapy tool, the patient must be engaged in the protocol in order to have an overall effect on the visual system. Without the engagement of the patient then the tool is not useful in changing the brain to allow for an efficient binocular system. Some could speculate that this is the reason that PPT are not considered useful in the treatment of convergence insufficiency.
It is an eye exercise in which a pencil is held directly in front, at arm’s length. The pencil is then drawn slowly towards the nose. The exerciser follows the pencil with his/her eyes, trying to keep it in clear focus. When the pencil starts to appear as a double image, the pencil should be drawn away from the nose again. The exercise is repeated several times per session, for several sessions per day. The aim is to correct binocular visual disorders, in particular strabismus.
There are several studies evaluating the effectiveness of in-office vision therapy vs pencil pushups. One such study revealed that after 12 weeks of therapy the convergence insufficiency score was significantly reduced in the in-office vision therapy group from 32.1 to 9.5. However, after 12 weeks of pencil pushups the convergence insufficiency score decreased from 29.3 to 25.9. It is of particular interest to note that pencil pushup therapy was found to be no more effective than the placebo therapy.
It is important to remember that the Convergence Insufficiency Symptom Survey used for the Convergence Insufficiency Treatment Trial established that a score of 16 or greater is considered significant for symptoms associated with Convergence Insufficiency. Comparing the established score of 16 to the score of 9.5 following 12 weeks of in-office vision therapy and to the score of 25.9 following 12 weeks of pencil pushups, it is easy to understand why pencil pushups are considered an ineffective form of therapeutic treatment.
Studies indicate that office-based vision therapy with home reinforcement is the most effective treatment for convergence insufficiency. Home-based treatment with pencil pushups hasn't been shown to be as effective. But home treatment costs less and is more convenient and more readily available. In short, your home therapy should include more than just PPT to be as effective as possible and as comprehensive as possible.
If you have been prescribed PPT by a Developmental Optometrist as part of an overall comprehensive Vision Therapy program, then, yes you should use your pencil pushups. From the information above you can tell that, pencil pushups alone are no better than placebo in studies. This makes them not as effective as a stand alone treatment when compared to an overall comprehensive vision therapy program. How often you should use PPT is usually directed by your doctor, but, to make a change in your vision, it is important to use this (and other protocols) at least 5x/week.
PPT is not indicated as a useful tool in the treatment of Convergence Insufficiency so it is important that you are not just using this as a way to solve that binocular vision disorder. If this is the only protocol your doctor prescribed, it is best to have a second opinion from a developmental or neuro-optometrist. Your doctor may also assign pencil pushups to be used with an eye patch. Covering one eye and using the pencil and then covering the other eye while using the pencil. After each eye has cycled through the pencil pushups, your doctor may recommend that you use the protocol with both eyes open. When you use the PPT with just one eye, you may notice a difference in ability between your two eyes. This is normal. The hope is to get both eyes working at equal performance to promote binocularity. Binocularity is the goal of any comprehensive vision therapy program.
There are no known side effects of pencil pushups. However, you may experience headaches or eye strain as it is associated with near convergence tasks. You may notice that the pencil doubles less than it did before you started or that you feel less headaches and that you are able to use the pencil pushups for longer. As with anything, it gets easier overtime to train the brain to effectively use pencil pushups if that is what has been prescribed to you. You may experience blurry vision as the pencil gets closer to your nose as well. This is normal. This is your accommodation system lacking in power to make it clear as it gets closer. Practice keeping the pencil clear and single (not double) and, as you continue to use it, it will be clear and single for longer.
The Effectiveness of Home-based Pencil Push-up Therapy Versus Office-based Therapy for the Treatment of Symptomatic Convergence Insufficiency in Young Adults: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4302485/
THE EFFECTIVENESS OF PENCIL PUSHUPS TREATMENT FOR CONVERGENCE INSUFFICIENCY: https://www.aaopt.org/detail/knowledge-base-article/effectiveness-pencil-pushups-treatment-convergence-insufficiency
Pencil Push-Ups Not Helpful for Convergence Insufficiency https://www.medscape.com/viewarticle/455363
Pencil Push-Up Vision Therapy Eye Exercise for Convergence by Dr. Vicky Fischer