Our "Discovery” of Vertical Heterophoria
It was 1985, and I was on a double-date with the man who eventually became my
husband (Dr. Mark Rosner) and his brother (Dr. Arthur Rosner) and his soon-to-be wife.
We were driving along when I noticed Dr. Arthur Rosner was holding a large hand-held
prism up to one of his eyes. Being an optometrist, I recognized what it was and asked him
what he was doing with it. He explained that he had been having eye strain issues, and
had seen the chief of Ophthalmology at his medical school. He had a thorough eye exam,
yet nothing was found amiss. He maintained that there must be something wrong, as he
could feel the strain, and the doctor gave him the hand-held prism, with the instructions
to exercise his eyes with it to see if he could reduce the feelings of strain. “So, has it
helped?” I asked. “Not much” was his reply. So I suggested that he come in for an eye
exam, and if he really needed a prismatic correction, I could make it part of his
prescription in his lenses and he could wear it fulltime. It turned out he needed vertical
prismatic correction, and he became my first Vertical Heterophoria (VH) patient.
Unbeknownst to me, he had other symptoms that the prism lenses had corrected. Reading
was challenging, and he had difficulty with depth perception. He was a practicing ENT
physician, and as he cared for his patients, he realized that many of them who were
suffering with dizziness and headache did not have a problem with their inner ear (as
their inner ear testing had been normal). As he listened more closely to their histories, it
dawned on him that they were having symptoms similar to what he had experienced
because of his VH. Could it be that they had an eye alignment problem, too? He then
began to refer them to their eye care providers, but a funny thing happened. They all
came back saying that their evaluations had all been normal – no visual problems or
misalignments. This just didn’t make sense to him – they had the same symptoms after
all, how could this be?
One day in 1995 I got a call from him. “Debby, I want to send you some of my dizzy
patients.” “Why would you want to do that?” I said. “I’m an optometrist – I take care of
healthy people with blurry vision. I’ve never taken care of dizzy people.” Then he said,
“You took care of me, and I got better with prism lenses. These patients sound a lot like
me, and I think you can help them.” “OK,” I said, “I’ll see just a couple, and see what I
He initially sent me two sisters. They shuffled in using canes to help with their balance,
and they had sick-bags, in case they needed to vomit. And he thinks I can help these
people? I was beginning to think that this was strange, but they were here, so I examined
them. It turned out that they both indeed did have vertical misalignment, and both felt
markedly better with prismatic lenses.
This was almost unbelievable! I had never been trained in optometry school about this.
We knew about vertical misalignment, but for the most part we were discouraged from
even taking the measurements – they were hard to interpret, and they were difficult to use
to make adjustments to the lens prescription. If it wasn’t for my dad insisting that I take
those measurements when I was a new graduate, I would never have found the vertical
misalignment in Dr. Arthur Rosner or these two sisters.
And the symptoms – while we might have taught that eye misalignment could cause eye
pain (asthenopia) and maybe headache and some challenges reading, we had never been
taught that it could cause:
Pain symptoms: migraines, face pain
Vestibular symptoms: dizziness, vertigo, motion sickness (even as a child), nausea,
anorexia, drifting while walking, problems with balance and coordination, falling
Psychiatric symptoms: anxiety, agoraphobia, panic attacks, suicidal ideation,
overwhelmed in crowds or malls
Neck pain: due to head tilt
Visual symptoms: shadowed vision, difficulty being fit with glasses
Reading symptoms: visual hallucination of letters / words moving on the page, dyslexia,
skipping lines, difficulty with comprehension
And here I was helping all of these patients with medical problems with prismatic lenses!
I was only working part time (since my children were young at the time), but by 2004 I
had seen 500 VH patients. Dr. Arthur Rosner and I had by then developed a questionnaire
to help identify who might have VH (which has since been validated – the VHSQ
(Vertical Heterophoria Symptom Questionnaire)). We presented this information at the
AAO-HNS (American Academy of Otolaryngologists – Head and Neck Surgeons)
Annual Meeting in 2005, and it was well received.
About this time, a patient who had been injured in a car accident came in for treatment of
VH symptoms, and they did well. The next thing I know, I’m getting a call from the
patient’s PM&R (Physical Medicine and Rehabilitation) doctor, wanting to know more
about what I was doing. Her patient had been through all kinds of treatments but had
never responded like this – she was so much better! The more we talked, the more it
became apparent that this doctor also had VH symptoms from childhood. She came and
was evaluated as a patient, she did have VH, and she responded beautifully to prismatic
lenses. These experiences led her to realize that VH symptoms are almost the same as
“persistent post-concussive symptoms”, and that almost all of her brain injured patients
had these symptoms (she had a practice that specialized in brain injury). Could it be that
brain injury patients had VH, and if so, could they be helped with prismatic lenses?
The PM&R physician is Dr. Jennifer Doble, and the answer is appearing to be that TBI
patients do have VH, and the symptoms are markedly reduced with prismatic lenses. We
have currently evaluated and treated over 1000 brain injury patients with very positive
Review of the literature demonstrates that VH was initially identified by Dr. George T.
Stevens, an ophthalmologist, in 1887. He tried treating it with prism, but he used large
amounts and was unsuccessful, so he treated it surgically with good results, but no one
has been able to reproduce his work. The next person to significantly discuss VH was Dr.
Raymond Roy, an optometrist who wrote 11 articles describing his findings in the 1950s
and 1960s. He would patch an eye for 6 days in order to determine what misalignment
existed. This was not well received by his patients, and other eye care providers did not
pick up on his techniques. VH has been minimally described in the optometry texts
(Borish), and more extensively described in the ophthalmology tome edited by Duke-
Elder. The problem that has plagued identifying and researching VH is that the vertical
measurements are not very accurate, particularly in very small amounts. Our data
demonstrates that these measurements are actually very flawed, and this caused us to
develop other techniques to identify vertical misalignment that were not tied to these
measurements. This, and using very small increments of prism, have allowed us to finally
be able to identify and care for this suffering population of people.
To date, my office colleagues and I have seen over 7,000 of these patients. Our best
estimate is that VH affects 5-10% of the human population. I get e-mails and calls every
day from around the world asking for help, which makes me believe that our estimates
are correct. It is clear that this information needs to be disseminated broadly, so that those
who are suffering from this condition can be identified and treated. We have a long way
to go on that mission, and this book is part of that effort.
It appears that our “discovery” of VH was really a “re-discovery”. It is our hope that “the
third time is the charm,” and that this time we are successful in getting information about
VH into the hands of the professionals that can help patients with this condition, as well
as into the hands of the average person so they can “self-identify” themselves and get the
help they need.
It is clear to me that the history of VH is still being written, and I am looking forward to
the next chapters!
Debby Feinberg, O.D.