Therapeutic Neuroplasticity: Reshaping Brain Networks in Convergence Insufficiency

Significance 

Convergence Insufficiency (CI) is a common issue with the way our eyes work together, and it can make everyday activities like reading, writing, and using screens much harder than they should be. People with CI often struggle with eye strain, headaches, blurred or double vision, and trouble concentrating. In a world where digital devices and near-vision tasks are an unavoidable part of daily life, finding better ways to manage CI has become more important than ever. Therapies like Office-Based Vergence and Accommodative Therapy (OBVAT) have been proven to help with CI and improve how the eyes function. Still, there is a lot we do not fully understand how these treatments work and without knowing exactly how the brain responds to therapy, it is hard for clinicians to personalize and fine-tune treatments. One promising way to study the brain’s response is through resting-state functional connectivity (RSFC) using functional magnetic resonance imaging (fMRI). This technique looks at how different parts of the brain communicate with each other when someone is at rest, giving a glimpse into the brain’s default networks and its ability to adapt. Although researchers have mapped brain regions involved in eye alignment tasks—like the cerebellum and visual cortex—however, they have not yet investigated how OBVAT therapy actually change these connections. To this account, new study published in Journal CNS Neuroscience & Therapeutics and conducted by Postdoctoral fellow Dr. Farzin Hajebrahimi, Ayushi Sangoi, Elio Santos, and led by distinguished professor Tara Alvarez from the Department of Biomedical Engineering at the New Jersey Institute of Technology alongside Professor Mitchell Scheiman from the Salus University and assistant Professor Dr. Suril Gohel from the Rutgers University School of Health Professions,  the researchers wanted to understand how OBVAT therapy rewires the brain’s oculomotor vergence network and validate its impact on both neural connectivity and clinical outcomes. By linking changes in RSFC to symptom improvements, their work offers a more complete picture of how CI rehabilitation truly works.

The researchers designed a randomized, double-blind clinical trial which helped ensure the results were unbiased and reliable. A total of 51 individuals, aged 18 to 35, all experiencing symptoms of CI, took part in the study. They were split into two groups—one group received OBVAT, while the other underwent a placebo treatment. To measure the results, participants went through detailed evaluations before and after the six-to-eight-week treatment period. The team looked at key signs of CI such as how well the eyes could work together (positive fusional vergence, or PFV) and how close the eyes could focus without losing alignment (near point of convergence, or NPC). Alongside these clinical checks, participants underwent brain scans using resting-state fMRI which allowed the researchers to see how different parts of the brain were communicating with each other. They focused on specific areas known to play a role in eye movements, like the cerebellar vermis, frontal eye fields, and primary visual cortex to figure out how OBVAT might actually change the way these brain regions interact. The authors found that in the group that received OBVAT, the connections between several key brain areas grew stronger—especially between the supplementary eye fields and the primary visual cortex, and between the cerebellar vermis and other parts of the network involved in controlling eye movements. These changes in brain connectivity were absent in the placebo group, making it clear that OBVAT had a unique and measurable effect. What’s more, the strengthened connections were directly linked to improvements in clinical signs like PFV and NPC, showing that the therapy was not just easing symptoms but actually changing how the brain functions. One of the significant findings was the central role of the cerebellar vermis which showed the most significant changes in connectivity, which makes sense given its crucial job in fine-tuning eye movements and maintaining binocular vision. Another exciting result was that the primary visual cortex appeared to be working more efficiently which suggested that OBVAT was enhancing both motor and sensory processing. In contrast, the placebo group showed no meaningful changes, either in their brain scans or clinical outcomes. This stark difference highlighted just how effective OBVAT is in addressing the underlying brain issues tied to CI, offering new hope for better treatments and understanding of this condition.

In conclusion, the study by professor Tara Alvarez and colleagues is significant for both vision science and neurorehabilitation. For the first time, researchers showed that improvements in clinical markers like positive fusional vergence and near point of convergence are directly tied to changes in how different areas of the brain connect and communicate. This discovery fills an important gap, linking what happens behaviorally during treatment to the underlying brain activity driving those changes. The findings suggest that OBVAT is doing much more than just easing the symptoms of CI. It is actually reshaping how the brain’s oculomotor vergence network works. Strengthened connections between areas like the cerebellar vermis, the supplementary eye fields, and the primary visual cortex reveal how the therapy improves coordination between sensory input and motor control. This new understanding opens the door to improving treatments, tailoring them to meet the unique needs of individuals and even creating new tools to track progress. For example, changes in brain connectivity could one day serve as reliable, objective biomarkers to help guide therapy and replace less precise symptom surveys. Moreover, many other conditions, like traumatic brain injury, stroke, or Parkinson’s disease, involve similar issues with eye movement and attention. The techniques used in this study—blending advanced brain imaging with clinical measures—could be applied to better understand and treat these conditions too.  Additionally, the new study challenges the old way of thinking about CI as purely a mechanical issue with the eyes. Instead, it shows that CI has deeper roots in how the brain functions. Indeed, this shift in perspective could inspire future research into other visual conditions like amblyopia or strabismus, looking at how similar brain-centered approaches might help.

About the author

Dr. Gohel is an Assistant Professor in Rutgers University, School of Health Professions. His research is focused on understanding human brain function during resting state and in task conditions, and how it is disrupted by a cognitive challenge and in clinical populations. His primary research interest is the investigation of temporal dynamics of resting state fMRI signals with the goal of understanding interactions between network properties of the brains. His work has shown recovery of the brain’s functional integration over short (~36 Hours) and long (~6 months) time period ensuing traumatic brain injury (Gohel, Bharath et al., 2015), differences between  drug-naive schizophrenia patients and healthy volunteers (Gohel et al., 2018) and in brain tumor populations (Gohel, Laino et al.,2018). He also focuses on leveraging BIG data from neuroimaging to develop analysis methods and techniques to amplify the neuronal component of the BOLD fMRI signal and to establish reliability and reproducibility of resting state fMRI signal and underlying neuronal component.

About the author

Dr. Scheiman is currently Associate Dean of Research and Professor at the Pennsylvania College of Optometry at Drexel University. He graduated from the New England College of Optometry in 1975, completed a residency in vision therapy at SUNY, State College of Optometry and has spent the last 49 years specializing and teaching in the area of pediatric optometry, binocular vision disorders and vision therapy. Dr. Scheiman is a diplomate and past Chair of the Binocular Vision, Perception and Pediatric Optometry Section of the American Academy of Optometry.  He has written 3 textbooks and has over 240 published papers and his work has been cited more than 17,800 times. In the past 34 years he has spent a considerable portion of his time engaged in NEI-funded and DoD-funded research in various roles including, study chair, protocol chair and principal investigator in a number of studies including the Correction of Myopia Evaluation Trial (COMET), Collaborative Observational Study of Myopia in COMET Children (COSMIC), the Convergence Insufficiency Treatment Trial (CITT) Pilot Study, the CITT Large Scale RCT, the CITT-Art RCT, and numerous other studies on amblyopia, intermittent exotropia, and concussion-related vision disorders. He was recently awarded a 4-year Department of Defense (D0D) grant award to study concussion-related oculomotor disorders. In recent years he was inducted into the American Optometric Association National Optometry Hall of Fame, the American Academy of Optometry Hall of Fame, and was the 2017 Glenn A. Fry Award, recipient from the American Academy of Optometry Foundation.

About the author

Farzin Hajebrahimi, PhD

Postdoctoral Research Associate
Vision and Neural Engineering Laboratory
Department of Biomedical Engineering
New Jersey Institute of Technology

Biography: Farzin Hajebrahimi is a postdoctoral research associate in the Department of Biomedical Engineering at the New Jersey Institute of Technology (NJIT). His research focuses on understanding the neural mechanisms underlying different neurological diseases using functional magnetic resonance imaging (fMRI) and exploring how rehabilitative approaches can normalize altered functional activity and connectivity. He earned his PhD in 2020 and was recognized with awards from the Federation of European Neuroscience Societies, the Human Brain Project, and the University of Bordeaux, enabling him to participate in scientific meetings and workshops. In 2023, he joined Rutgers University as a postdoctoral research fellow in the Department of Health Informatics. Subsequently, he transitioned to the Vision and Neural Engineering Laboratory at NJIT’s Department of Biomedical Engineering where he studies patients with post-concussion syndrome. His prior research includes studying patients with Parkinson’s disease to investigate how fMRI can stratify cognitive impairment stages and assess the effectiveness of innovative interventions, such as virtual reality-based training. His research mission is to leverage fMRI technologies to uncover mechanisms of various neurological disorders and evaluate the impact of non-invasive therapeutic approaches on disease modification. He serves as an academic editor and ad hoc reviewer for several scientific journals. He is also an active member of the Society for Neuroscience and the Organization for Human Brain Mapping.

About the author

Tara Alvarez, PhD, FAAO, FAIMBE, FNAI

Distinguished Professor Department of Biomedical Engineering
Director of the Vision and Neural Engineering Laboratory 

Biography: Tara Alvarez, Ph.D. is a distinguished professor of biomedical engineering, director and founder of the Vision and Neural Engineering Laboratory and director of the Undergraduate Biomedical Engineering Program. After her Ph.D. (BME, Rutgers) and research at Bell Labs (1998 -2001), she helped found NJIT’s BME Department in 2001.  Her laboratory seeks to understand fundamental mechanisms of vergence rehabilitation.  She founded a start-up company OculoMotor Technologies Inc. (OMT) and is currently the chief scientific officer. With her alumni OMT is developing a system using virtual reality to diagnosis and rehabilitate oculomotor motility dysfunctions. She is a fellow of American Institute of Medical and Biological Engineering and the National Academy of Inventors. She is a Diplomate of BVPPO Section of the American Academy of Optometry.  She is currently funded through an NIH R01 and DoD grant to study the effectiveness of Office-Based Vergence and Accommodative Therapy in those with persistent post concussive symptoms with convergence insufficiency.  The mission of her research is to understand the underlying neural mechanisms that lead to a sustained reduction in visual symptoms and to take that knowledge, integrated with technology, to develop new diagnostic and therapeutic interventions that can be used for personalized point-of-care.

Reference 

Hajebrahimi F, Sangoi A, Scheiman M, Santos E, Gohel S, Alvarez TL. From convergence insufficiency to functional reorganization: A longitudinal randomized controlled trial of treatment-induced connectivity plasticity. CNS Neurosci Ther. 2024 ;30(8):e70007. doi: 10.1111/cns.70007.

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