It may be your eyes:
Treatment of Vertical Heterophoria Ameliorates Persistent Post-Concussive Symptoms: A Retrospective Analysis Utilizing a Multi-Faceted Assessment Battery

Treatment of Vertical Heterophoria Ameliorates Persistent Post-Concussive Symptoms:

A Retrospective Analysis Utilizing a Multi-Faceted Assessment Battery


  • Primary objective: To examine the effectiveness of neutralizing prismatic lenses for reduction of headache, dizziness and anxiety in patients with persistent post-concussive symptoms and vertical heterophoria (VH).
  • Background: Approximately 5–10% of patients with traumatic brain injury (TBI) develop persistent post-concussive symptoms. Many rehabilitation/treatment modalities are tried, but are largely unsuccessful, indicating a need for more effective treatment.
  • Design and method: This retrospective study included 38 patients with persistent post-concussive symptoms, who were diagnosed by an optometric binocular vision sub-specialist with VH (a sub-set of binocular vision dysfunction [BVD] that manifests as vertical eye and image misalignment). Data was collected both before and after prism application and included validated survey instruments for headache, dizziness, anxiety and BVD symptom burden; subjective rating (0–10 scale) of headache, dizziness and anxiety severity; and a sub-analysis of the BVD survey instrument questions that pertain specifically to headache, dizziness and anxiety. Upon conclusion of treatment, subjective assessment of overall improvement of heterophoria symptoms was obtained utilizing a 10 cm visual analogue scale.
  • Outcomes: Results demonstrated marked reduction in all measures of headache, dizziness and anxiety (19.1–60.8%) and an overall subjective improvement of VH symptoms of 80.2%. Conclusions: Neutralizing prismatic lenses are an effective treatment of headache, dizziness and anxiety in patients with persistent post-concussive symptoms and VH.


Brain injury is a common occurrence, with recent estimates that TBI is responsible for 280 000 hospitalizations and 2.2 million emergency department visits annually in the US alone [1]. While the majority of patients with concussion can expect a full recovery, persistent post-concussive symptoms can

occur in ~ 5–10% of patients, despite many different types of therapies, treatments and medications. Identification of an effective treatment modality would be of great benefit to this cohort.

It is well established that vision dysfunction (including binocular vision dysfunction [BVD]) is precipitated by TBI. Previous work has identified vertical heterophoria (VH; a sub-set of BVD that manifests as vertical eye and image misalignment) in a group of patients with persistent

post-concussive symptoms and that treatment of the misalignment with neutralizing prismatic lenses resulted in marked reduction of the headache, dizziness and anxiety in that cohort.

Estimates of vertical eye misalignment range from 7–52%, with best estimates at ~ 20% of the general population. These wide ranges testify to the difficulties involved in the identification, quantification and treatment of vertical misalignment. There appear to be three main factors contributing to this difficulty:

  1. The many associated symptoms of vertical misalignment are diverse. While they are often associated with numerous other medical conditions, they usually are not associated with vision misalignment.
  2. The battery of tests used to identify and quantify vertical misalignment fail to accurately determine the magnitude and orientation of prism needed. These tests include both dissociated phoria tests (Von Graefe phorias [near and far], vertical vergence testing, red lens test. Bernell light box with Maddox rod, Titmus tester) and associated phoria tests (Mallett unit, Wesson Card, AO Vectographic slide). For example, patients who are eventually determined to have symptomatic VH can have test results that indicate no vertical misalignment or that indicate a hypophoria when a hyperphoria is present.
  3. The amount of neutralizing prism does not appear to correlate with severity of symptoms. Patients can be very symptomatic with only small amounts of misalignment.

With a lack of clear and actionable vertical alignment diagnostic tests and the diverse nature of BVD symptoms and symptom severity, VH is rarely diagnosed by the current vision and general medical communities. Instead these patients are evaluated by many different providers and are subjected to multiple tests and their symptoms are incorrectly ascribed to a variety of medical conditions including atypical migraines, muscle tension headaches, sinusitis, Meniere’s disease (typical and atypical), anxiety, panic attack, Attention Deficit Disorder/Attention Deficit

Hyperactivity Disorder (ADD/ADHD), convergence insufficiency, reading or learning disability and persistent postconcussive symptoms. This necessitated the creation of a new method to diagnose vertical eye misalignment to allow for the identification of patients who are amenable to treatment with neutralizing prismatic lenses [2]. This method, known as the Prism Challenge test, is utilized in this study and is described in the Methods section.

The purpose of this paper is to expand upon the previous report utilizing a much broader array of measurements in order to examine the effectiveness of neutralizing prismatic lenses for reduction of headache, dizziness and anxiety in patients with persistent post-concussive symptoms and VH.

Read the full research paper with figures (PDF)

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  • American Academy Optometry
  • American Optometric Association
  • Michigan Optometric Association
  • VEDA
  • Neuro Optometry Rehabilitation Association

Dr. Sandy DiPonio earned her optometry degree from Illinois College of Optometry in 1996. She is a highly skilled and experienced eye care professional dedicated to giving her patients of all ages excellent and compassionate care. She has a wide variety of experience in binocular vision, pediatric and adult eye care, ocular disease and contact lens fitting. She strives to provide each of her patients the best quality of life they can achieve with their vision through knowledge and education of treatment options.

Dr. DiPonio is a member of the American Optometric Society and Michigan Optometric Society.

Dr. Sally Hoey has been practicing optometry since graduating from Michigan College of Optometry in 2001. During her time in optometry school, she developed an interest in binocular vision, culminating in a senior thesis involving binocular vision.

Prior to joining Vision Specialists of Michigan, Dr. Hoey specialized in the diagnosis and treatment of vision-related learning problems as well as other binocular vision disorders. Her other areas of interest include specialty contact lens fittings and treating dry eye. Dr. Hoey strives to provide her patients with clear, comfortable vision while meeting their individual needs at the same time.

Dr. Hoey had the opportunity to provide eye care on an optometric mission trip to Guyana, South America and vision screenings at a local medical clinic. She is a member of the American Optometric Association, Michigan Optometric Association, Metropolitan Detroit Optometric Society and the College of Optometrists in Vision Development.

Dr. Jennifer Place graduated with honors from Michigan College of Optometry in 2001.

Before joining Vision Specialists of Michigan, she specialized in treating pediatric and adult patients with binocular vision disorders and vision-related learning problems, as well as fitting specialty contact lenses and managing various types of ocular disease. She enjoys working with patients with unique visual needs, and she takes great pride in providing all patients with highly customized care.

Dr. Place has volunteered for Opening Eyes, a program that provides eye exams to the athletes of the Michigan Special Olympics, and she participated in an international mission to St. Lucia to provide eye care to those in need. Dr. Place is a member of the Detroit Optometric Society, the Michigan Optometric Association, the American Optometric Association, the College of Vision Development, and the Optometric Extension Program Foundation.

Dr. Mary Jo Ference has been practicing optometry since 1990 upon graduating from Ferris State University- Michigan College of Optometry, and is certified in Low Vision Rehabilitation. She has worked at Sinai-Grace Hospital systems for over 20 years before joining Vision Specialists of Michigan in 2013 to work with binocular vision disorders. Her clinical areas of expertise include visual rehabilitation of pediatric and adult patients who have suffered from brain trauma, injury or disease. She has taught both optometry and ophthalmology residents at Sinai Grace Hospital. Dr. Ference has sat on numerous boards, including Sinai Grace Hospital, Berry Out-Patient Surgical Center, and Seedlings Braille Books for the Blind. She is actively involved in area school districts to provide education, training and access for students, teachers, OT’s and PT’s to eye care service rehabilitation information. Dr. Ference has lectured extensively nationally and internationally.

Dr. Debby Feinberg began practicing Optometry in Oakland County in 1983, upon graduating from Illinois College of Optometry. She joined her father, Dr. Paul C. Feinberg, at Mall Optical Center, which was located in Summit Place Mall.

Since 1995 Dr. Feinberg has been developing the field of NeuroVisual Medicine which is the optometric subspecialty that identifies and treats neurological / medical symptoms that originate directly or indirectly in the visual system.

Dr. Feinberg has been performing pioneering work with Binocular Vision Dysfunction (BVD), a condition where a vision misalignment (frequently subtle) creates difficulties with the two eyes working together to create a single 3-dimensional image, and difficulties with the two eyes following that image as it moves.

The symptoms caused by BVD are not usually associated with problems with the visual system, and include headache, dizziness, anxiety and panic, persistent post-concussive symptoms, gait instability and balance problems, frequent falls, neck pain, motion sickness, nausea, and reading and learning problems.

In 2004. Dr. Feinberg established Vision Specialists of Birmingham, specifically designing the practice to accommodate the needs of the NeuroVisual Medicine patient.

In 2011, the office moved to its current location in Bloomfield Hills and updated its name to Vision Specialists of Michigan.