Binocular Vision Correction for the Treatment of Vestibular Disorders by Drs

TH 5018 NE 15 AVE · PORTLAND, OR 97211 · FAX: (503) 229-8064 · (800) 837-8428 · [email protected] · VESTIBULAR.ORG

Binocular Vision Correction For the Treatment of Vestibular Disorders By Drs. Debbie Feinberg & Mark Rosner

BINOCULAR VISION DYSFUNCTION appears to be identifying the AND VERTICAL HETEROPHORIA: A misalignment and correcting it. These repetitive cycles of misalignment / BRIEF HISTORY realignment appear to lead to an overuse Binocular vision dysfunction (BVD) of the eye alignment muscles, which can encompasses a group of conditions where result in the symptoms of VH. These the two eyes have difficulty working include dizziness, headaches, anxiety, together as a team, resulting in a vertical neck pain and difficulty with balance and or horizontal (or both) misalignment coordination.3,4,5,6,7,8,9,10,11 between the line of sight of one eye with the other eye. When the amount of The body may also try to correct VH (i.e. misalignment is large (strabismus or to realign the images) by tilting the head, heterotropia) double vision or diplopia which can cause neck pain. results. When the amount of misalignment is subtle (heterophoria), CAUSES single or fused imagery is maintained, The two main causes of VH are brain but at the cost of overusing the vision injury (e.g. TBI/concussion, stroke), and alignment mechanisms, resulting in congenital causes. Both causes can occur medical symptoms instead of diplopia. at any age.

As defined above, vertical heterophoria WHY IS VH NOT BEING (VH) is a subset of BVD. Recently published research theorized that VH is DIAGNOSED? occurring due to a lack of coordination Although VH was first described in the between the two main vertical eye 19th century12, the medical community alignment mechanisms, the vision (or has made little progress in identifying and oculomotor) system and the balance (or treating this condition, most likely vestibular) system, and that the initial because the standard vision alignment problem is a faulty vertical alignment tests are not sensitive enough to find signal from the vestibular system.1,2 If these subtle left unchecked, this would precipitate misalignments1,2,13,14,15,16,17,18,19,20. vertical double vision, which would be poorly tolerated. The oculomotor system

THE DIAGNOSIS AND TREATMENT agoraphobia, feeling overwhelmed or OF VH anxious in large spaces (e.g. a mall)

The first step is to take a thorough To aid in obtaining a detailed history and medical history. VH has a very broad set to screen for those who might have VH, a of symptoms, many of which are not validated questionnaire (Binocular Vision commonly appreciated by the medical Dysfunction Questionnaire or BVDQ) can community to be associated with a vision be used that includes questions from all problem. of the major symptom groups and asks

the patient to assess the frequency of Symptoms their symptoms. A score of >/= 15

appears to be suggestive of VH.  Pain symptoms: headache, face

ache/sinus pain, eye pain or pain with PHYSICAL FINDINGS eye movements  Head tilt symptoms: neck ache and upper back pain due to a head tilt There are physical findings associated  Dizziness / Vestibular symptoms: with VH, including the presence of a head dizziness, lightheadedness, off- tilt (Figure 1), a unilateral furrowed brow, balance feeling, motion sickness, an asymmetrical nausea, poor depth perception, lack of face (Figure 2), coordination, unsteadiness or drifting pulling to one side to one side, disorientation when walking,  Reading symptoms: difficulty with unsteady gait, concentration, fatigue with reading, and discomfort difficulty with reading comprehension, when observing a skipping lines, using a line guide (e.g. finger finger) to maintain one’s place, words approaching your running together, losing one’s place nose  Routine visual symptoms: blurred (convergence vision, difficulty with close-up vision, testing). difficulty with night vision, eye strain, sore eyes Establishing  Binocular vision symptoms: double or the diagnosis overlapping vision, shadowed vision, Once a patient light sensitivity, difficulty with glare or has been reflection, closing one eye while identified by reading their symptoms and/or physical findings  Psychological symptoms: feeling as someone who may have VH, a overwhelmed or anxious in a crowd, complete ocular and vision exam is performed. Near sightedness,

farsightedness and astigmatism must be when the patient, wearing the correct identified and corrected prior to assessing aligning (or prism) lenses for 10-20 the patient’s binocular vision status. minutes, experiences a marked reduction Traditionally the next step in the or even elimination of their VH assessment of VH involves the use of symptoms. vertical alignment measurements such as vertical vergence, Von Graefe phoria Progressive Relaxation testing at near and at far, cover test and In patients with VH, the eye alignment red lens test. However, as previously muscles are tense and over-worked and mentioned, these tests are not sensitive cannot relax quickly enough to allow the enough to identify the subtle patient to wear the full amount of misalignments of VH1,2,13-20. To address realigning prism immediately. Therefore, this deficiency, an alternative technique the first prescription contains less than for identifying the subtle vertical the full amount of needed prism, and is misalignment was developed. Named worn for approximately 2-4 weeks. This Prism Challenge, the technique consists allows the eye alignment muscles to of the incremental addition of small units experience Progressive Relaxation, after of neutralizing vertical prism (usually which the patient will be able to accept 0.25D) to a trial frame containing the the full amount of prism needed (which is patient’s refractive prescription. The incorporated into their second set of subtle vertical misalignment is identified lenses). (and the diagnosis of VH is established) Once treatment is completed (in about two visits), patients experience significant improvement, averaging an 80% reduction in symptoms.

Since VH is often not identified, many patients suffer for years without the proper diagnosis and treatment. Some patients may be told that their symptoms are due to migraines, atypical Meniere’s, psychogenic dizziness, anxiety and panic disorders, ADD/ADHD, as well as other conditions. Treatment for these conditions typically yields inadequate relief of symptoms.

CASE STUDY RESEARCH Sarah, a mechanical engineer, was Dr. Debby Feinberg and her research injured in a car accident in which she team have been researching VH since suffered a traumatic brain injury (TBI). 1995, with the discovery that certain One year into her recovery she continued patients with dizziness actually had VH as to experience a myriad of symptoms, the cause, and that treatment with including dizziness, headache, nausea, aligning lenses immediately and markedly neck pain, eye strain, fatigue, and reduced symptoms.22 It was then anxiety. She found it difficult to walk and discovered that some TBI patients with drive and also had trouble focusing, persistent post-concussive symptoms had reading, and writing. She received VH and responded to aligning lenses with traditional treatment provided to patients a 70-80% reduction of with TBI but her symptoms did not symptoms.23,24,25,26,27 It was also found improve. that VH plays a role in certain patients with headache and anxiety.28,29 A case By the time Sarah was referred for a series of 126 patients with VH was specialized binocular vision evaluation presented at the semiannual Barany (NeuroVisual evaluation) she was two Society meeting May, 2016 in Seoul, S. years into her recovery and had been Korea.30 through speech therapy, occupational therapy, physical therapy, and vision SUMMARY therapy. Unfortunately, these treatments  Subtle vision misalignment can be gave her only marginal relief from her congenital / spontaneous or symptoms. Sarah’s NeuroVisual precipitated by a brain injury / evaluation revealed that she had a subtle concussion, and has many non-visual vision misalignment (VH). She was symptoms including dizziness and prescribed aligning eyeglass lenses, and other vestibular symptoms, headache, in a matter of minutes her symptoms neck ache, anxiety, and difficulty were markedly reduced. Within one week reading. her occupational therapist and  Head tilt during normal upright neuropsychologist noted significant posture and difficulty with gait and improvement. At the completion of balance are common physical signs. treatment (8 weeks) her symptoms were  Current vision tests are not sensitive reduced by 80% and she was able to live enough to find these subtle her life more fully, participating in many misalignments. activities she wasn’t able to prior to  People have suffered for years and wearing aligning lenses. have been incorrectly diagnosed with many other conditions, with the resulting treatment for those

conditions providing only minimal Emergency Physician with more than 30 relief. years of clinical experience. He has been  The diagnosis of VH is confirmed actively involved in binocular vision when the patient experiences dysfunction (BVD) and vertical immediate and marked reduction of heterophoria (VH) research since 2005, symptoms with aligning eyeglass which has been presented locally, lenses. nationally and internationally, and  The average patient experiences an published in peer reviewed journals. He 80% reduction of symptoms by the helped develop the Binocular Vision end of treatment. Dysfunction Questionnaire (BVDQ) that  The Binocular Vision Dysfunction identifies patients that most likely have Questionnaire (BVDQ) is a validated BVD and VH. He is the co-author (with tool for identifying those who might Dr. Feinberg) of “If The Walls of My Exam have subtle vision misalignment. Room Could Talk,” a book about VH patients and their experiences with subtle THE AUTHORS vision misalignment and treatment with Dr. Debby Feinberg, owner of Vision aligning lenses. He is Co-Director of the Specialists of Michigan and Director of NeuroVisual Medicine Training Program, Clinical Care, Vision Specialists Institute, designed to train others to diagnose and has been performing pioneering work treat subtle vision misalignment. with binocular vision dysfunction (BVD) and vertical heterophoria (VH). Her REFERENCES research has been presented locally, nationally and internationally, and 1. Doble JE, Feinberg DL, Rosner MS, published in peer reviewed journals. She Rosner AJ. Identification of binocular is the author of a book about VH patients vision dysfunction (vertical and their experiences with subtle vision heterophoria) in traumatic brain injury misalignment and treatment with aligning patients and effects of individualized lenses. She is Co-Director of the prismatic spectacle lenses in the NeuroVisual Medicine Training Program, treatment of postconcussive designed to train others to diagnose and symptoms: A retrospective analysis. treat subtle vision misalignment. She PM R 2010;2:244-53. helped develop the Binocular Vision 2. Rosner MS, Feinberg DL, Doble JE, Dysfunction Questionnaire (BVDQ) that Rosner AJ. Treatment of vertical identifies patients that most likely have heterophoria ameliorates persistent BVD and VH. post-concussive symptoms: A retrospective analysis utilizing a Dr. Mark Rosner is Director of Education multi-faceted assessment battery. and Research at Vision Specialists Brain Injury 2016;Early Online:1-7. Institute, and a board certified

DOI: 13.Karania R, Evans BJ. The Mallet 10.3109/02699052.2015.1113564 Fixation Disparity Test: influence of 3. Borish IM. History and Eye Strain. In: test instructions and relationship with Clinical Refraction. 3rd ed. Chicago, Symptoms. Opthal. Physiol. Opt. IL: The Professional Press, Inc.; 1975, 2006;26:507-522 327-338 14.Wick BB. Prescribing Vertical Prism: 4. Borish IM. Analysis and Prescription. How Low Can you Go? Journal of In: Clinical Refraction. 3rd ed. Optometric Vision Development Chicago, IL: The Professional Press, 1997;28:77-85. Inc.; 1975, 866 15.Borish IM. Clinical Refraction. 3rd ed. 5. Bixenman WW. Vertical Prisms. Why Chicago, IL: The Professional Press, Avoid Them? Surv of Ophthalmol. Inc.; 1975. p 866. 1984;29:70-8. 16.Borish IM. Clinical Refraction. 3rd ed. 6. Schrier M. Practice Notes on Chicago, IL: The Professional Press, Hyperphoria. BJOD. 1997;5:68-9. Inc.; 1975. p 871. 7. Roy RR. Symptomatology of Binocular 17.Duke-Elder S, Wybar K. Anomalies of Stress. Optom Wkly. 1958;49:907- binocular fixation. . In: Duke-Elder S, 912 Wybar K, editors. System of 8. Duke-Elder S, Wybar K. Anomalies of Opthamology. Volume 6. St. Louis, Binocular Fixation. In: System of MO: The C. V. Mosby Company; Ophthalmology. Vol. 6. Ocular Motility 1973. p 530-536. and Strabismus. St. Louis, MO: The C. 18.Gall R, Wick B. The symptomatic V. Mosby Company; 1973, 1973, patient with normal phorias at 536;553 distance and near: what tests detect a 9. Staab JP, Ruckenstein MJ. Expanding binocular vision problem? Optometry the Differential Diagnosis of Chronic (St. Louis, Mo.) 2003;74(5):309-322. Dizziness. Arch Otolaryngol Head 19.Gray LS. The prescribing of prisms in Neck Surg. 2007;133:170-176. clinical practice. Graefe's Archive for 10.Furman JM, Jacob RG. Psychiatric Clinical and Experimental Dizziness. Neurology. 1997;48:1161- Ophthalmology 2008;246(5):627- 1166. 629. 11.Guerraz M, Yardley L, Bertholon P, et 20.Schroeder TL, Rainey BB, Goss DA, al. Visual Vertigo: Symptom Grosvenor TP. Reliability of and Assessment, Spatial Orientation and comparisons among methods of Postural Control. Brain. measuring dissociated phoria. 2001;124:1646-1656 Optometry & Vision Science 12.Stevens, GT. Functional Nervous 1996;73(6):389-397. Diseases. New York, NY: D. Appleton 21.Schow T, Teasdale TW, Rasmussen and Company ,1887:200-203 MA. Validation of the Vertical Heterophoria Symptom Questionnaire

(VHS-Q) In Patients with Balance Lecture given at BIAMI 2013 Annual Problems and Binocular Visual Fall Conference, Lansing Michigan. Dysfunction after Acquired Brain 27.Rosner MS, Feinberg DL, Doble JE, Injury. Soj Psychology. 2016. Rosner AJ. Treatment of vertical 22.Rosner AJ, Feinberg DL. Vertical heterophoria ameliorates persistent heterophoria: a common cause of post-concussive symptoms: A dizziness and headache. retrospective analysis utilizing a Otolaryngology-Head and Neck multi-faceted assessment battery. Surgery. 2005 Aug 31;133(2):P41-2. Brain Injury 2016;Early Online:1-7. 23.Feinberg DL, Doble JE. A Common DOI: and Treatable Cause of Post- 10.3109/02699052.2015.1113564 Traumatic Headache and Dizziness: 28.Rosner MS, Feinberg DL, Zasler ND. Vertical Heterophoria Syndrome. Chronic Headache Amelioration with Lecture given at BIAMI 2008 Annual Prismatic Lens Treatment of Vertical Fall Conference, Lansing Michigan. Heterophoria. Headache 2012 May 1 24.Doble JE, Feinberg DL, Rosner MS, (Vol. 52, No. 5, pp. 899-899). Rosner AJ. Identification of binocular 29.Rosner MS, Warren R, Feinberg DL. vision dysfunction (vertical Prism vs. Prozac: A Novel Approach to heterophoria) in traumatic brain injury the Amelioration of Anxiety with patients and effects of individualized Prismatic-Lens Treatment of Vertical prismatic spectacle lenses in the Heterophoria. Poster presentation at treatment of postconcussive the Anxiety Disorders Association of symptoms: A retrospective analysis. America Annual Meeting. 2012. PM R 2010;2:244-53. 30.Rosner MS, Feinberg DL, Rosner AJ. 25.Rosner MS, Feinberg DL, Doble JE, Chronic Dizziness, Headache and Rosner AJ. A Retrospective Analysis of Anxiety Improved By Treatment of Vertical Heterophoria Treatment and Vertical Heterophoria: A Retrospective Amelioration of Post-concussive Analysis. Oral presentation. 29th Disorder Symptoms Via a Multifaceted Barany Society Meeting, Soul, S. Assessment Battery. Poster Korea. June 2016. presentation. Ninth World Congress © 2016 Vestibular Disorders Association on Traumatic Brain Injury. Edinburgh, Scotland. 2012. VEDA’s publications are protected under 26.Feinberg DL, Rosner MS, Doble JE. An copyright. For more information, see our permissions guide at vestibular.org. Unsuspected But Treatable Cause Of Persistent Post-Concussive This document is not intended as a substitute Symptoms: Vertical Heterophoria. for professional health care

TH 5018 NE 15 AVE · PORTLAND, OR 97211 · FAX: (503) 229-8064 · (800) 837-8428 · [email protected] · VESTIBULAR.ORG

Did this free publication from VEDA help you?

Thanks to VEDA, vestibular disorders are becoming widely recognized, rapidly diagnosed, and effectively treated.

VEDA’s mission is to inform, support, and advocate for the vestibular community.

You can help! Your tax-deductible gift makes sure that VEDA’s valuable resources reach the people who can benefit from them most – vestibular patients like you!

JOIN VEDA TO DEFEAT DIZZINESS™ By making a donation of:  $40  $75  $100  $250  $1,000  $2,500 Senior discounts are available; contact us for details.

Members receive a Patient Toolkit, a subscription to VEDA’s newsletter, On the Level - containing information on diagnosis, treatment, research, and coping strategies - access to VEDA’s online member forum, the opportunity to join V-PALS, a pen-pals network for vestibular patients, and more!

For healthcare professionals: Individual and clinic/hospital memberships are available. Professional members receive a subscription to VEDA’s newsletter, a listing in VEDA’s provider directory, co-branded educational publications for their patients, access to a multi-specialty online forum, and the opportunity to publish articles on VEDA’s website. For details, call (800) 837-8428, email [email protected] or visit https://vestibular.org/membership.

MAILING INFORMATION Name ______

Address ______City ______

State/Province ______Zip/Postal code ______Country ______

Telephone ______E-mail ______ Send my newsletter by email (Free)  Send my newsletter by mail (U.S. – Free; $25 outside the U.S.) PAYMENT INFORMATION  Check or money order in U.S. funds, payable to VEDA (enclosed)  Visa ______ MC Card number Exp. date (mo./yr.) CSV Code  Amex ______Billing address of card (if different from mailing information)

Or visit us on our website at https://vestibular.org to make a secure online contribution.