Understanding Vertical Heterophoria, Superior Oblique Palsy, and Prism Glasses for Headaches, Dizzin

Vertical Heterophoria is probably one of the most important conditions you have never heard of when it comes to dealing with chronic headaches, dizziness, anxiety, and other symptoms. It is important because of its prevalence, how few people know of it, and the ease in which it can be treated. There is a very good chance that you or someone you know may be affected by this condition.

Vertical Heterophoria (also known as VH) literally means vertical misalignment of the eyes, although the condition includes horizontal misalignment of the eyes as well. Superior Oblique Palsy is a similar condition, but only one eye is misaligned, whereas both eyes are misaligned with Vertical Heterophoria. For simplicity’s sake, we will just refer to it as Vertical Heterophoria in this post.

The condition affects far more than just vision, with a plethora of symptoms that mimic much more serious conditions and diseases. The most alarming part is that your ophthalmologist and optometrist will not detect this condition with standard checkups and tests because the condition is virtually unknown of outside the handful of doctors who treat this condition. The good news is that the condition can be treated non invasively, safely, and with a high success rate when under the care of a proper doctor. The treatment is deceptively simple: a pair of glasses with prisms.

History

The symptoms of Vertical Heterophoria have been mentioned in the medical literature as far back as the 1880’s, although no effective treatment was ever discovered until recently. The current understanding and treatment of VH was discovered by Dr. Debby Feinberg O.D. of Bloomfield Hills, Michigan, whom I had the privilege of being a patient of. Dr. Debby discovered the treatment for VH in 1995, and it has become her life’s work since. All current knowledge of the condition is based on research she has performed and care she has provided her patients over the past 19 years. Dr. Debby has treated over 7,000 patients with this condition to date.

How Vertical Heterophoria Affects Patients

In order to understand how VH affects a person, it is important to first have a basic idea of how the eyes and vision work. When most people look around, the world they see is three dimensional with everything appearing as one. In reality, they are actually seeing two exact images of everything superimposed on top of each other. When the eyes are in perfect alignment, one image is taken from the left eye and another taken from the right eye. These two images are then fed simultaneously and seamlessly to the brain giving the illusion that there is only one image.

For a person with VH however, there is a vertical, horizontal, or combined vertical and horizontal misalignment of the eyes. Much like a normal person, one image is taken from the left eye and one from the right, but because a misalignment is present, the brain actually sees two separate and distinct images coming from the eyes. The brain recognizes that this is not appropriate and forces the eyes to align properly against their natural positions. This corrects the issue of seeing double, but places an immense strain and burden on the eyes and visual system. The results of this burden reach far beyond just vision.

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The figure above illustrates a person with normal vision on the left. The person on the right has a horizontal misalignment of the eyes. Vertical misalignments can occur as well.

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Patient Profile

VH is a condition that affects everyone equally across the population spectrum. There is no demographic when it comes to VH. It affects people of all ages, race, ethnicity, location, and sex equally. It is estimated that roughly 5 to 10% of the population suffers from this condition and the majority of them do not even know it. It is important to reiterate that this is due to the fact that virtually no doctors outside of Dr. Debby and her colleagues treat this condition.

Dr. Debby and her colleagues have literally treated patients from all over the country and all over the world. The farthest patient to travel for care is a patient who flew from Australia to see Dr. Debby in Michigan. I personally flew from New York to see her in Michigan. While I was there, I met a woman from Philadelphia, a couple from Rochester, NY, and a woman from Montana, all of whom travelled to Michigan for care. This illustrates how far reaching this condition is. Fortunately for those who live in the New York area, Dr. Debby recently began working with Dr. Cheryl Berger Israeloff O.D. in Garden City, NY who now offers care for VH and whom I am currently a patient of.

How It Is Acquired

Although VH can potentially affect everyone equally, there are two distinct ways in which a person ends up with the condition. The condition is either congenital (something you are born with) or acquired, usually through trauma for the latter.

Congenital

For some who are born with the condition, the symptoms of VH are present from birth. Most of these patients are unaware that something is wrong because they simply have nothing to compare their reality to. They assume that everyone else sees and experiences the world the same way. The symptoms are generally more tolerable earlier in life, leading the patient to believe they are normal. More symptoms surface and become more intense as they age and the body begins to undergo stress. How, when, and what symptoms surface varies from patient to patient.

For others born with this condition, the symptoms of the condition can lay dormant for many years and surface much later on in life. This can range from early adulthood to as late as the patient’s 50’s and 60’s. These patients are actually symptom free throughout this period. The body is extremely resilient and will cope with the burden of this condition for as long as it can. As the patient begins to age however, the stress overloads the system and the body begins to break down. Some patients experience a gradual onset of more and more symptoms, while others are bombarded with a variety of issues all at once.

Acquired

VH can also be acquired, most commonly by trauma to the head or from a Traumatic Brain Injury (TBI). Any trauma to the head including accidents, falls, sports injuries, or blows to the head can bring on the onset of VH. It is important to note that even seemingly minor incidents such as a slight fall can be all it takes. The trauma either physically shifts the alignment of the eyes or causes a shift in the way the brain operates and processes what it is receiving from the eyes.

Of the 7,000 patients Dr. Debby has treated, roughly 1,000 of them are from trauma and Traumatic Brain Injury patients. It is estimated that half of all current TBI patients in the general population with persistent post concussive symptoms can be helped with prism glasses.

The Exception

In addition to the two main ways in which VH is acquired, there is a third way that is much less common and which I am a part off: patients with neck injuries and neck misalignments.

Upon being evaluated by Dr. Debby, it was determined that I had both a vertical and horizontal misalignment of my eyes and I was promptly prescribed a pair of prism glasses. The glasses helped alleviate some of my symptoms, although a lot of them persisted. Dr. Debby suspected an underlying neck condition and urged me to have my neck checked. I met a highly specialized chiropractor who confirmed I had a severe neck misalignment. A month after being under chiropractic care and having my neck in proper alignment, I was reevaluated. It was determined that my vertical misalignment had resolved and all I had left was the smallest amount of horizontal misalignment possible. There was a direct correlation between the misalignment of my neck and the misalignment of my eyes.

Impossible as it may seem, this actually makes sense physiologically. If you look at the anatomy of the head and neck, three of the twelve cranial nerves that innervate the eyes and control the movement of the eyes actually emerge from the brainstem. If there is an injury or neck misalignment interfering with the brainstem and these cranial nerves, it is conceivable as to how this may have an effect on the alignment of the eyes.

Symptoms

The symptoms are far reaching and usually mimic those of much more serious and life threatening conditions. Most are neurological in nature. Because most of the symptoms are nonspecific, many people go many years and even their whole lifetimes without ever finding the answer to their problems. Most patients will have completely worked their way through the medical community before being properly diagnosed with VH.

The symptom of VH includes:

Eyestrain
Discomfort from visual activities and light sensitivity
Blurred or double vision
Headaches- all varieties including migraines, tension headaches, and cluster headaches
Dizziness- Vertigo and Ataxia
Unsteadiness
Chronic tilting of the head to one side
Neck pain and neck aches
Facial Pain
Nausea and motion sickness
Feeling overwhelmed in crowds or public spaces
Anxiety

More painful than the symptoms themselves however, are the countless number of patients who have been told there is nothing wrong with them, they are seeking medication, or that they are just plain crazy. This is simply not true. The symptoms of VH are very real.

Diagnosis and Treatment

Diagnosis of VH is performed through a very thorough and comprehensive eye exam using equipment and techniques developed by Dr. Debby. It is an eye exam probably unlike any other a patient has had before, yet is completely non invasive. The tests are more akin to very simple visual games.

Once measurements have been taken and all the tests performed, the patient is fitted with a pair of trial glasses containing a specific amount of prism based on the patient’s data. From that point on, it is just a matter of adjusting the amount of prism until the prescription that provides the patient with the most comfort is found. The results of the glasses are almost instantaneous, with patients feeling a significant reduction in their symptoms. In most cases, patients will know within their first visit whether the prism glasses will help them or not.

After the proper prescription is found, it is simply a matter of having the glasses made. It is important to note that while most patients will have a significant reduction of symptoms with their first pair of glasses, follow up visits and adjustments to the prescription may be needed in order to maintain or improve the reduction of symptoms even more. The eyes and brain can only take so much change at once, and may be ready for more prism once it has adapted to this new but natural way of seeing.

How the Prism Glasses Work

The glasses work by incorporating a prism into the lens. A prism takes any light that passes through it and bends it at a certain angle. How much the prism bends the light is dependent on the strength or prescription of the prism. The prism also controls the direction in which the light is bent. A vertical prism bends the light up or down while a horizontal prism bends the light in or out (left or right). Combining a vertical and horizontal prism bends the light diagonally.

In this sense, the prism or prisms in the lens takes the images (light) passing through it and is able to shift (bend) them in any direction and at any angle. Shifting the images to where the eyes naturally want to be in their misaligned position relieves the strain and tension on the visual system without causing the brain to receive two images any longer. There is actually nothing wrong with the eyes themselves being misaligned. It is the brain’s natural intolerance to seeing double and forcing the eyes to align against their natural positions that burdens the system.

Prism Glasses Versus Other Treatments

Prism glasses for the treatment of Vertical Heterophoria are a completely unique treatment. There are other treatments and therapies aimed at improving symptoms from visual imbalance, but they are different in many key aspects.

Vision Therapy

One of the more common (but still extremely unknown) therapies is Vision Therapy. Vision Therapy is a form of vision rehabilitation that is designed to help patients relearn to use their eyes properly again. For a variety of reasons, the ability to use both eyes together properly becomes weaker and weaker for many people. Vision Therapy aims to retrain the patient to use both eyes properly through a variety of exercises. These exercises train patients in visual skills such as accommodation, eye teeming, focusing, and scanning. Vision therapy provides many great benefits to patients, but can only offer benefits for visual issues from a horizontal plane (side to side). Vertical (up and down) muscles can’t be consciously controlled and as a result, there are no exercises available to help train these muscles. Rather than training these vertical muscles, the prism glasses moves the images to where the eyes want to be naturally. At the end of the day, Vision Therapy is still a very powerful tool. In fact, utilizing Vision Therapy after a patient has been fitted with the proper prism glasses can enhance progress exponentially.

Prism Glasses

Prism glasses have been used as a treatment option for many years, but with a completely different approach. Prism glasses have been typically used in cases where there is an obvious and large measurable deviation of eye alignment. For many patients with VH, there will be no detectable misalignment of the eyes with conventional tests because the brain is forcing the eyes to align themselves. The tests developed by Dr. Debby are able to detect the underlying eye misalignment even when the eyes seem perfectly aligned.

The treatment for VH developed by Dr. Debby is also based on the idea of progressive relaxation. This is the idea that the eyes are only able to tolerate minuscule amounts of prism initially. This is usually a result of being forced to hold the eyes in alignment for so long. While conventional prism usage usually prescribes a large amount of prism at first, the prism glasses for VH uses tiny amounts of prism at first. In fact, many patients are only able to tolerate one diopter of prism at first, which is the smallest amount of prism possible. After the eyes are given the chance to relax and become more comfortable with a little prism, they become ready for a stronger prism. As the eyes continue to relax further and further, more and more prism is added until the correct and actual amount of prism the patient needs is reached. Patients typically change prescriptions 3-6 times before finding the final and most comfortable prescription for them. Patients typically experience the most relief from the initial pair of prism glasses, with each subsequent prescription change enhancing the improvements the patient feels.

Outlook

Prognosis for patients diagnosed with VH and prescribed prism glasses is extremely positive. Patients report an average reduction of symptoms by 80%, which is an astounding figure when compared with alternative options. As mentioned earlier, patients will know within the first visit if the prism glasses will indeed help them. There is no trial period or adjustment process to gauge the effectiveness of the glasses. Patients will experience an immediate significant reduction of symptoms with things improving more and more as the body is given time to adjust.

Many patients who are on medications for their symptoms are also able to lower the strength of their medication and eventually stop their medication altogether. Since treatment of VH addresses the underlying cause, medication aimed at treating the symptoms are no longer necessary.

Is Vertical Heterophoria the Cause or Effect?

If you think you might be experiencing Vertical Heterophoria, it is important to try and distinguish whether it is the cause of your symptoms, or whether VH is a secondary condition to something else. As with many conditions, it is sometimes hard to decipher between the two. While prism glasses have done wonders for many, they are not the answer for everyone.

My first pair of prism glasses actually made my dizziness much worse and I was suffering horrible symptoms for a month even after I stopped wearing them. It was a kind of dizziness I had never experienced, and even now, I sometimes feel the dizziness. Subsequent prism glasses were better than the first, but they never resolved my issues the way they did for others. After getting my atlas adjusted however, my eye misalignment went away and I was able to tolerate regular glasses without prisms. I have encountered other patients who had their eye misalignment issues resolved after getting neck work done.

I want to stress the importance of this because I feel it is really important to find the root cause of whatever ails you. From my experience and research, getting neck work done from a chiropractor, physical therapist, and Cranio Sacro Therapist can alter or resolve eye misalignment issues, eliminating the need for prism glasses altogether. Cranial work can also alter the structure of the skull, eliminating the need for prism glasses as well. In my opinion, it would be wiser to try these options first, given they would address the most primary cause possible. If they don’t work, then obviously trying the prism glasses should be a consideration. That is better than getting the glasses, getting the neck work done, and having to redo the whole process of testing for and getting new glasses especially if one of the doctors who treat the condition is not close to you.

Nonetheless, which step you decide to take first is ultimately up to you.

The Next Step

If you think that you or someone you know might have VH, the first step is to take the Online Vertical Heterophoria Questionnaire (link below). It is a questionnaire designed specifically to screen for patients who might have the condition. If you match the criteria for VH, one of the doctors will contact you and discuss everything in detail with you.

Within Driving Distance of Care

If you live within driving distance of one of the doctors, I strongly urge you to consider going for an evaluation even if it is a few hours away. A simple eye exam and pair of glasses can be all it takes to relieve you of your suffering. All without medication or invasive procedures. You owe it to yourself.

Travelling for Care

If you live further away or if travelling for care is more of an undertaking for you, you should still take the online questionnaire and consult with the doctor on the phone. In addition, I would recommend ordering a copy of the book “If the Walls of My Exam Room Could Talk” by Dr. Debby Feinberg (link below). It is a book of patient accounts by 40 of Dr. Debby’s patients. These are not one of two paragraph testimonials, but full accounts of each of these patient’s experiences. If reading gives you symptoms, you can purchase the Kindle version of the book and have your Kindle read the book to you, which is what I did. The stories in this book were the decisive factor in my own decision to finally get on a plane and go to Michigan.

Travelling far away in search of medical care for a medical condition you’ve probably never heard of can be an extremely daunting prospect. There are financial considerations, personal obligations to consider, and the possibility that you may not find the answer you hoped of. I went to Michigan with money borrowed from friends and family, having every single symptom on the list, unable to see or read properly, barely able to drive, and without telling anyone where I was going or what I was doing. It was by far the hardest and scariest thing I’ve ever done in my life, but I knew it was something I had to do. If you truly feel that you might have VH, I strongly implore you to consider it.

Reaching Out

If you still have uncertainties after you’ve done all your research, please do not hesitate to contact me with any questions or concerns you might have. I’ve been down that road and know exactly how it feels. I will provide whatever insight and advice I can. Living with the symptoms of VH can be extremely trying, but they are that much more defeatable when you realize you are not alone.

I wish you the very best.

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