As therapists, we often times see clients with vision needs that impact functional skills. Visual processing is a complex topic and convergence insufficiency is just one area. Read below to find out more about convergence in kids, to understand exactly what is convergence insufficiency, and how convergence plays into functional skills and learning.

**DISCLAIMER** I am not an optometrist, ophthalmologist or vision therapist. All information in this post is informational in nature only and should not be utilized in place of the appropriate professionals treatment and evaluations.

What is Convergence Insufficiency?

Vision is a hot topic among therapists these days. It’s a foundational skill that we often overlook, or don’t have a clue where to start even if we know that we need to address it. When our vision is impaired, so is our learning.

Need help addressing visual problems in the classroom? Here are classroom accommodations for visual impairments. 

Vision screenings done in the school nurses or pediatricians office only addresses acuity, resulting in other underlying vision concerns being missed.

These concerns can go unaddressed for long periods of time until the child has received remediation services, OT and other services to address the child’s deficits. By the time we realize that vision needs to be re-addressed the child is struggling and does not find academic work enjoyable.

Underlying vision concerns are often hard to detect, with convergence insufficiencies being one of the most common issues.

What is Convergence

Before we can talk about convergence insufficiencies, we need to address what typical, intact convergence patterns look like.  Simply put, convergence is our eyes ability to smoothly follow a moving target as a team, from a distance to a very near point, such as the tip of our nose.

Convergence is not only an active motor pattern, it is also a sustained motor pattern. Sustained convergence is utilized for the completion of near point work tasks. Intact convergence skills allow us to read, write, draw and catch a ball, and similar tasks with relative ease. When the system experiences difficulties, it can result in a convergence insufficiency.

Convergence insufficiency (CI) is an eye condition where the eyes have difficulty working together to focus on nearby objects. This can result in blurred or double vision, headaches, or eye strain—especially during near work like reading or using smartphone screens. In childhood, this condition may impact school performance and is sometimes mistaken for ADHD due to shared attention and visual symptoms.

Convergence Insufficiency

A convergence insufficiency is caused when the dynamic system of convergence/divergence is impaired or experiences stress. The impairment hinders the child’s ability to move their eyes in synchronized, coordinated, and smooth movements from a far point to a near point or near point to far point.

The ability to assume, and maintain sustained convergence patterns may also be significantly affected.

Causes of Convergence Insufficiency

Impairments to this system can stem from several different causes, with the most common reason being an eye muscle imbalance or weakness. Muscle imbalance and weakness can occur in one or both eyes. It is very dependent upon the child.

Other causes of a convergence insufficiency may be due to congenital neurological reasons, traumatic events, or other physical impairments that affect the eye. These are ​NOT​ the usual suspect for why a child experiences a convergence insufficiency and  should be ruled out by an optometrist or ophthalmologist if there is a reason to believe this is the case.

Contributing Factors

Convergence insufficiency may be linked to eye muscles not coordinating properly. In some cases, nerves sending the proper message to the muscles may be delayed, especially after illness, lack of sleep, or a brain injury. Constant exposure to smartphones, tablets, and digital devices can also strain the eyes. Tasks requiring focusing at different distances, like switching between a board and a notebook, can further challenge a child’s visual system.

Screening for a Convergence Insufficiency

The most recognizable form of a convergence insufficiency found during a vision screening, is when the child is unable to follow the tracking item to within one half inch of their nose. When this happens, the child’s eyes may appear to “bounce” or “snap” back to a midline position despite the child’s best effort to find the item. This can happen with one or both eyes, and it is important to note in your screening what happened. In more severe cases, the child is unable to move their eyes to follow the tracking item to their nose.

More commonly, the child may be able to complete the convergence/divergence patterns, but experiences headaches, complains about their eyes hurting or frequently rubs their eyes with sustained convergence activities such as reading and writing.

It is also important to note, if the child is unable to sustain convergence at the end of the convergence/divergence pattern screening for more than a few seconds. This can also be an indicator that the child has a convergence insufficiency. This is one of the hardest skill deficits to identify as it is very subtle and difficult to see at times. If you suspect a convergence insufficiency, look for other red flags to support your observations.

Diagnosing Convergence Insufficiency

A standard eye exam may not be enough to detect convergence insufficiency. Instead, specific testing performed by an eye doctor trained in binocular vision assessments is needed. This can include evaluating eye movements, testing convergence ability, and reviewing the history of the patient, especially after a concussion or brain injury. Diagnosis often involves identifying the symptoms of CI and determining whether there is a result of true convergence weakness.

Red Flags of Convergence Insufficiency

A convergence insufficiency is often hard to identify in screenings alone. Below are a list of skills that may be affected if a child is experiencing difficulties with convergence.

● Frequent headaches
● Rubbing of the eyes
● Covering one eye consistently
● Red or bloodshot eyes
● Distress with reading tasks
● Distress with near and far point copying tasks such as copying from the board
● Difficulty with catching a ball
● Use of a finger to track their place when reading
● Sleepiness or fatigue during near point work
● Motion sickness
● Blurred and/or double vision
● Words appearing to “jump” or “move” on the page

If the child is experiencing any of these signs, have their vision checked by an optometrist to rule out an eye muscle imbalance that may be causing a convergence insufficiency.

Symptoms of Convergence Insufficiency

Some of the most common symptoms of convergence insufficiency include eye fatigue, double vision (diplopia), headaches, and poor depth perception.

Children may demonstrate frequent mishaps, like tripping on uneven surfaces, frequent spilling, or a misjudgment of physical distances like missing stairs. They may also struggle with eye contact or seem to lose focus during tasks. In more rare cases, issues like vertigo and suppression of vision may occur.

Treatment of Convergence Insufficiency

Convergence insufficiencies are diagnosed by an optometrist or ophthalmologist. It is important to note that an OT cannot diagnose a convergence insufficiency. She/He can only report their observations and recommend follow up with the appropriate health care provider.

Upon seeing an optometrist, corrective lenses or vision therapy may be recommended based on the child’s needs. It is ​VERY​ important that the child wear his/her glasses and complete vision therapy if recommended as prolonged convergence insufficiencies can result in permanent eye strain and damage.

Once the child has received their corrective lenses, and if vision therapy has not been recommended, OT can help provide foundational skill remediation and exercises to promote the development of the child’s convergence skills.

One way to identify any convergence issues is with a screening tool like the Visual Screening Packet. This resource contains tools for occupational therapy practitioners to identify visual convergence challenges. The therapy provider can then offer activities and supports for any issues that are identified. The screening resource can then be used to assess improvements following therapy sessions.

Be on the lookout for my next post, ​Activities to Improve Convergence Skills​ to further fill your vision tool box. Also be sure to check out my OT Vision Screening Packet for useful forms and handouts to help you identify convergence insufficiencies and other vision concerns.

Treatment Options for Convergence Insufficiency

Convergence insufficiency treatment may involve active treatment methods such as pencil push-ups, computer programs, or in some passive treatment plans, prism glasses or prism lenses. In rare cases, surgery may be required, such as for intermittent exotropia.

However, most treatment is non-invasive and focuses on improving convergence ability over time. Getting enough sleep and reducing screen time can also support recovery. Therapy may be customized depending on whether the individual struggles with stationary objects, close object focus, or near work tasks.

Supporting Children with Convergence Insufficiency

When working with children in therapy or classroom settings, it’s important to recognize symptoms of CI and consider how they affect academic and physical performance. Poor posture, stumbles, and struggles with stairs may indicate visual difficulties.

Classroom accommodations, proper lighting, and breaks from screen time can reduce symptoms. Collaboration with caregivers and vision professionals ensures a comprehensive approach to care.

Occupational Therapy Vision Screening Tool

This visual screening tool was created by an occupational therapist and provides information on visual terms, frequently asked questions regarding visual problems, a variety of visual screening techniques, and other tools that therapists will find valuable in visual screenings.

In this blog post we are covering all things vision impairment and occupational therapy. Visual Impairments such as convergence insufficiency, impaired visual saccades, or other visual problems like blurred vision can present as a problem in the classroom. Students with visual impairments will flourish with effective classroom accommodations for visual problems. Below, you will find strategies that school-based occupational therapists can use as accommodations for addressing visual needs while meeting educational goals.

Be sure to check out our resource on vision as a starting point.

Other resources that are helpful include:

• Visual perception
• Visual perception through play
• Visions role in learning 
• Visual motor integration 
• Development of eye-hand coordination

Definition of Visual Impairment

Visual impairment can mean a lot of things. Basically, this is any vision disability where eyesight is impacted. Vision impairment is a term used to describe any reduction in a person’s ability to see that cannot be fully corrected with glasses, contact lenses, medication, or surgery. It can affect one or both eyes and may involve difficulty with visual acuity (clarity), visual fields (peripheral vision), or how the brain processes visual information.

Vision impairment includes a wide range of conditions, from mild vision loss to complete blindness. It can impact daily activities such as reading, writing, navigating environments, recognizing faces, or participating in school and work tasks. The World Health Organization defines vision impairment as a presenting visual acuity worse than 20/60 in the better eye, and blindness as worse than 20/400.

In occupational therapy, vision impairment is considered in the context of how it affects function, independence, and participation in meaningful activities.

Types of Visual Impairment

Occupational therapy works with an enormous variety of diagnoses and conditions. There can be many reasons for a visual difficulty. These can occur in childhood or at any age.

Here’s a list of diagnoses and eye conditions associated with visual impairment:

1. Blindness (Legal blindness)
2. Partial blindness/Partial sight
3. Low vision
4. Cortical visual impairment (CVI)
5. Diabetic retinopathy
6. Retinopathy of prematurity (ROP)
7. Glaucoma
8. Macular degeneration (age-related macular degeneration) 
9. Retinitis pigmentosa
10. Cataracts
11. Amblyopia
12. Strabismus
13. Nystagmus
14. Optic nerve hypoplasia
15. Optic neuritis
16. Albinism (ocular or oculocutaneous)
17. Coloboma
18. Leber congenital amaurosis
19. Stargardt disease
20. Usher syndrome
21. Anophthalmia
22. Microphthalmia
23. Retinal detachment
24. Cone-rod dystrophy
25. Hemianopsia
26. Ocular toxoplasmosis
27. Uveitis
28. Keratoconus
29. Achromatopsia
30. Batten disease
31. Congenital cataracts
32. Stroke(CVA)

Ways OT can help: 

There are so many ways an occupational therapy professionals can help with vision needs. We have a full list with more examples below.

• Adapt tasks and environments (contrast, lighting, positioning).
• Use tactile, auditory, and kinesthetic compensatory strategies.
• Incorporate vision-related goals into play, self-care, school, and leisure tasks.
• Collaborate with vision specialists (e.g., Teachers of the Visually Impaired, Orientation & Mobility instructors).
• Promote safe mobility through environmental modifications and task adaptations.
• Build strength, balance, and core stability through play or movement-based interventions.
• Support motor development with hands-on guidance and tactile cues.
• Collaborate with physical therapists and orientation & mobility specialists as needed.
• Encourage self-advocacy and confidence in movement through supportive, success-based activities.
• Offer large print options
• Work alongside a behavioral optometrist or vision rehabilitation professional like vision therapy
• Training in various devices and supports in various environments
• Work with a mobility specialist

Visual Impairment Accommodations for the Classroom

The fact is, vision impacts learning. When visual problems exist, it can be be helpful to next address what to do about those problems to maximize learning. Often times when vision is discussed as a concern, a parent or caregiver may push back saying that the child has had their vision checked, and that they can see fine. Despite education, and handouts, the parent still resists getting a more in-depth vision evaluation for their child. Now what? Good news is that there are some accommodations that can be made in the classroom to assist the child. These strategies are also great for kiddo’s who already have glasses but are still struggling.

What are accommodations for visual problems?

Accommodations are strategies set forth that allow a student to change the method of how learning happens. Accommodations for visual problems can address visual needs through changes in seating, presentation of visual information, test information, or classroom activities without modifying what is tested, completed, or taught.

The visual accommodations listed below are means for addressing visual problems without changing classroom expectations for learning.

Preferential Seating

Preferential seating means a lot of different things to every professional. Typically, it mean that the kiddo is placed at the front of the room, closest to the teacher where they can receive an increased level of support from the teacher. However, this is not necessarily the best for a child with vision deficits. There are a few keys points to preferential seating for kiddos with vision deficits that should be considered.

● Proximity to the board
● Direction in which the child is facing in relation to the board or main work area
● Level of visual distractions around the room including posters, boards and other children
● Is the goal of seat work and need for use of board to achieve completion of work?

Proximity to the Board

Being closest to the board is not necessarily the best position for a child facing vision challenges particularly if they are not acuity based in nature.

For instance, a child that is struggling with saccades and tracking may not succeed in a front and center position. This would challenge their eyes constantly to look in all directions for information. A better position for them would be to the left or to the right in the first 2-3 rows. This would limit the amount of tracking to either side that would need to be completed.

This position would also benefit a child with who struggles with filtering visual information and needs information to be limited on one side.

When recommending a seat based on proximity to the board, it is important to think about what challenges the kiddo is facing visually and to recommend a seat that promotes success.

Face the Front

Is the Child Facing the Board?

There are a lot of classroom set-ups these days that have children not facing the board or at an awkward angle. This is okay if the child is not expected to copy work from the board or utilize information from the main learning space.

When it doesn’t work, is when the child needs to utilize this information. It is best to have the child facing the board straight on or with a slight angle if they are not seated in the center. Limit turning of the head over 45 degrees to prevent eye strain and an increased chance of the child losing their place when copying.

There are times that it is appropriate to have the child’s back to the board and main learning space. I will get to that in just a moment.

Reduced Visual Distractions

Limiting visual distractions and over stimulation is a large part in helping kids with visual deficits. If there is too much information in front of them or around them, they are more likely to get lost visually, leading to more time needed to complete tasks and increases in errors when copying or missing written steps.

This is one of the few times that it is okay to have a child’s back to the board or main work area. Especially, if the child does not need to see the main area. Typically, this is the case for lower levels of education such as kindergarten through second grade, or when the curriculum begins to focus on board directed teaching.

Other ways to limit visual distractions are to keep the main learning space clear of extraneous posters, charts or decorations, along with conscious choices for seating the child. Having the child’s back to busy walls and a large portion of their peers can be helpful.

Most people think that windows are distractions for kiddos, but for a child with vision deficits, sitting near or facing a window can give a much needed visual “break” from stimulation. So don’t rule out a window seat yet!

Increased White Space

Worksheets can be very overwhelming for a child with a visual deficit. They may have a hard time reading a busy worksheet, completing a math worksheet or miss parts of multi-step directions.

One way to help avoid this is to provide increased white space. White space refers to the amount of blank or void areas on a piece of paper. The higher the amount of white space, they less likely a child with vision deficits is to struggle.

This means limiting the number of math problems on a page from 6 to 3 for example. Or utilizing the Handwriting Without Tears lined paper versus traditional triple lined paper.

Sometimes changing the handout or worksheet is not an option and other strategies need to be utilized. The use of an extra sheet of paper to block out extra information can be helpful in creating the white space that is needed.

Decreased Visual Distractions

I touched on this in preferential seating section in regards to the overall placement of the child in the room. However, visual distractions can also come from items in the child’s work space. Distractions may include name tags, behavior systems, letter lines, a peer across from them and even work to be completed. These visual distractions may cause the kiddo to feel visually unorganized leading to the appearance of sloppy work and poor time management, and even signs of anxiety.

One way to help eliminate visual distraction within the workspace is to limit what is on the child’s desk. Keep the kiddo’s work space limited to a name tag and one other item. If other items are needed on the desk or workspace, have them arranged so that they are not in the child’s direct line of sight while working.

For instance, crayon boxes and utensils may be shared at a table or grouping of students. Have the items place to the left or right of the child so that their direct line of sight is clear.

Also limit that amount of ‘work’ that is place in front of the kiddo. I say ‘work’ lightly as most ‘work’ for kids are worksheets and craft projects. By presenting one item at a time, it can help the child’s visual space remain clear and help them stay visually organized and on task.

Visual Structure for Reading and Writing

Sometimes limiting visual distractions is not enough support for visual organization. Sometimes, the child needs even more structure to support successful learning patterns and work completion.

One strategy is to provide the child with graph paper to write on. This is very structured and provides concrete boundaries for letter orientation, sizing, and spacing. It also provides visuals for completing math problems in straight lines.

Other forms of visual structure include colored lines to indicate top and bottom of the lines for writing, along with highlighted “spacer” lines for completion of longer work.

Color coding can also be a helpful tool in providing visual structure for older children. It be as general as a different colored folders/notebooks for each subject to allow the child to quickly scan and find what they need, to as complex as writing parts of a math equation in different colors. Or even going as far as to writing the parts of a paragraph in different colors.

Visual structure can be as simple, or as complex as it’s needed to be to meet the kiddo’s needs.

Each child is different and finding the right visual supports is a trial and error process that takes time and patience to work through. Evaluating the child’s weaknesses will help to determine the best supports and path for success in the classroom despite their visual challenges.

More resources that can help with understanding and advocating for visual impairments:

What is Visual Processing and Visual Efficiency?


Visual Saccades and Learning


What is Visual Tracking?


What is Convergence Insufficiency?

What if you suspect vision problems?

Now what?  When vision problems are suspected after a screening by the OT, it is best practice to refer the family to a developmental optometrist.


A developmental optometrist will complete a full evaluation and determine the need for corrective lenses, vision therapy or a home program to address vision concerns.


As occupational therapists, it is imperative that we rule out vision problems before treating handwriting or delays in visual motor integration, to ensure the best possible trajectory of development and success for the child.

Occupational Therapy Vision Screening Tool

Visual Impairments and Occupational Therapy

One thing about a visual impairment that we don’t often think of at first is the body awareness and orientation aspect. These areas can really impact functional skills, which our primary goal in occupational therapy. 

There are other things we want to consider as well when we work with the child with a visual challenge. These items are listed below and they can be part of our evaluation as well as treatment interventions. We’ll want to add these factors to our documentation of therapy treatment sessions when we are offering our accommodations or rehabilitation services because each area listed might impact quality of life and life skills.

Because the school based OT helps with the child’s educational performance and participation, these are areas we should be aware of when creating treatment plans.

• Peripheral vision
• Vision loss or level of challenge
• Visual acuity
• Low vision and resulting needs
• Visual fields
• Visual tracking
• Visual attention
• Visual memory

Occupational therapy Evaluation for Visual Impairment

Occupational therapy plays a key role in supporting individuals with visual impairments by addressing how vision affects daily function and participation. When working with children or adults with visual impairments, OTs consider several key areas as part of an OT evaluation: 

Visual Acuity

• Clarity or sharpness of vision.
• Affects reading, writing, recognizing faces, and seeing details in the environment.

Visual Fields

• The entire area a person can see without moving their eyes or head.
• Peripheral field loss can affect safety, mobility, and spatial awareness.

Visual Tracking (Oculomotor Skills)

• The ability to follow a moving object or maintain focus on an object while the head moves.
• Impacts reading fluency, copying from the board, and ball skills.

Visual Scanning

• The ability to scan a space or environment efficiently.
• Important for locating objects, navigating spaces, and reading.

Visual Attention

• Focusing on relevant visual information while ignoring distractions.
• Affects classroom performance, self-care routines, and task completion.

Visual Discrimination

• Telling the difference between similar-looking objects, letters, or shapes.
• Impacts handwriting, reading, and puzzles.

Visual Memory

• Recalling visual information after seeing it.
• Essential for spelling, following directions, and remembering routines.

Visual Figure-Ground

• Distinguishing an object from a background.
• Important for finding items in a cluttered space or reading text on a busy page.

Depth Perception

• Understanding spatial relationships between objects.
• Crucial for mobility, stairs, catching a ball, and pouring liquids.

Eye-Hand Coordination

• Using visual input to guide fine motor tasks.
• Affects handwriting, dressing, cutting, and feeding.

Visual Motor Integration

• Coordinating visual perceptual skills with motor output.
• Impacts drawing, writing, and tool use.

Occupational therapy plays a key role in supporting individuals with visual impairments by addressing how vision affects daily function and participation. When working with children or adults with visual impairments, OTs consider several key areas:

1. Visual Acuity

• Clarity or sharpness of vision.
• Affects reading, writing, recognizing faces, and seeing details in the environment.

2. Visual Fields

• The entire area a person can see without moving their eyes or head.
• Peripheral field loss can affect safety, mobility, and spatial awareness.

3. Visual Tracking (Oculomotor Skills)

• The ability to follow a moving object or maintain focus on an object while the head moves.
• Impacts reading fluency, copying from the board, and ball skills.

4. Visual Scanning

• The ability to scan a space or environment efficiently.
• Important for locating objects, navigating spaces, and reading.

5. Visual Attention

• Focusing on relevant visual information while ignoring distractions.
• Affects classroom performance, self-care routines, and task completion.

6. Visual Discrimination

• Telling the difference between similar-looking objects, letters, or shapes.
• Impacts handwriting, reading, and puzzles.

7. Visual Memory

• Recalling visual information after seeing it.
• Essential for spelling, following directions, and remembering routines.

8. Visual Figure-Ground

• Distinguishing an object from a background.
• Important for finding items in a cluttered space or reading text on a busy page.

9. Depth Perception

• Understanding spatial relationships between objects.
• Crucial for mobility, stairs, catching a ball, and pouring liquids.

10. Eye-Hand Coordination

• Using visual input to guide fine motor tasks.
• Affects handwriting, dressing, cutting, and feeding.

11. Visual Motor Integration

• Coordinating visual perceptual skills with motor output.
• Impacts drawing, writing, and tool use.

OT Considerations

• Adapt tasks and environments (contrast, lighting, positioning).
• Use tactile, auditory, and kinesthetic compensatory strategies.
• Incorporate vision-related goals into play, self-care, school, and leisure tasks.
• Collaborate with vision specialists (e.g., Teachers of the Visually Impaired, Orientation & Mobility instructors).

In addition to sensory processing and perceptual aspects, visual impairments often come with physical challenges that occupational therapists must consider. These physical issues can impact mobility, posture, coordination, and overall independence. Here are key physical areas related to visual impairment that OTs address:

Postural Control and Stability

• Children or adults with visual impairment may adopt compensatory postures (e.g., tilting the head, leaning forward) to optimize remaining vision.
• Poor postural control can affect sitting balance, endurance, and core strength, limiting participation in seated tasks like handwriting or meals.

Gait and Mobility

• Visual impairment may lead to cautious, unsteady walking, wider stance, or shuffling.
• Individuals may avoid movement altogether due to fear of falling, leading to decreased physical activity and muscle weakness.

Balance and Vestibular Integration

• The visual system plays a large role in maintaining balance.
• Without reliable visual input, individuals rely more heavily on vestibular and proprioceptive systems, which can be underdeveloped or dysregulated.

Motor Planning (Praxis)

• Difficulty visualizing actions before performing them can lead to trouble with sequencing, initiating, or completing motor tasks.
• This affects dressing, navigating environments, and tool use (like scissors or utensils).

Spatial Orientation and Body Awareness

• Visual cues help us understand where we are in space and how to move around obstacles.
• Visual impairment can lead to reduced spatial judgment, making tasks like reaching, climbing, or navigating stairs more difficult.

Delays in Gross and Fine Motor Skills

• Infants and young children with visual impairments may miss out on visually-motivated movement (e.g., reaching, crawling, walking), leading to motor delays.
• Fine motor skill development can also be impacted due to limited visual feedback.

Fatigue and Overuse

• Individuals with visual impairments may experience increased fatigue due to constant physical and cognitive effort to compensate.
• Overuse injuries (especially in the neck, shoulders, and hands) can result from repetitive adaptive strategies (e.g., leaning, squinting, using mobility aids).

Colleen Beck, OTR/L has been an occupational therapist since 2000, working in school-based, hand therapy, outpatient peds, EI, and SNF. Colleen created The OT Toolbox to inspire therapists, teachers, and parents with easy and fun tools to help children thrive. Read her story about going from an OT making $3/hour (after paying for kids’ childcare) to a full-time OT resource creator for millions of readers. Want to collaborate? Send an email to contact@theottoolbox.com.