The Vestibular System and EOMs – Part 3

As fate would have it, Janice is a 57 year-old patient who I evaluated yesterday and embodies a lot of the principles of visual-vestibular dysfunction or dis-integration that we’ve been discussing.

custom_doctor_choices_13788Here is the chronology as her history unfolded.  Janice began experiencing double vision about six years ago.  She first sensed something was wrong one day while driving, and wasn’t able to focus correctly.  In due time she began to have difficulty with watching TV.  She went to her ophthalmologist (OMD) who said everything was fine, but gave Janice an Rx for astigmatism.  Janice returned to the OMD, reporting that her distance vision was clearer now.  Clear enough to notice that she had distinct double vision.  The OMD referred Janice to a colleague who specialized in ocular motility disorders.  She advised Janice that the double vision wasn’t really a problem, but prescribed plan lenses with Fresnel prism, 1^ BO for each eye.  That seemed to do the trick for Janice’s divergence insufficiency with eso diplopia at distance.  That is, until it didn’t. Janice decompensated fairly rapidly, to the point where she was back for more prism.  The OMD increased the Fresnel to a total of 4, and then 6, and then 8, and then 10, and then 13 prism diopters.

Janice is fond of saying that whenever she faces obstacles and can’t get satisfactory answers, she decides to scope out solutions on her own.  She learned that there was something called optometric vision therapy and she asked the ocular motility specialist about it.  “Oh no”, was the response.  “Vision therapy can’t help for double vision.  It only works when you have a problem with eye muscle control up close, and your problem is at distance.  We’ll just keep increasing your prism until the double vision gets bad enough that you’re a candidate for eye muscle surgery.”  (Is it any wonder that VT is still a relatively well-kept secret?)


Janice decided to seek another opinion, so her family doc referred her to a neuro-ophthalmologist.  MRIs, EEGs, and a litany of other rule-out tests were ordered, and test results were all clean.  Janet’s double vision kept unravelling all the while.  She sought a fourth opinion from another neuro-ophthalmologist who said he didn’t see anything of concern, but she had narrow angles and referred her to a glaucoma specialist who still monitors her every six months but without any intervention.

In the interim, Janice had a pair of trifocal glasses made up with ground prisms, 6^ in one eye and 7^ in the other eye.  She was as double and dizzy as Hilary Clinton (see here), but unlike Hilary she had no acquired brain injury to blame.  Much like Stereo Sue, in desperation Janice sought out an optometrist on her own.  She stumbled across the directory and picked the closest provider to her.  He, for the first time, explained divergence insufficiency to her and reviewed treatment options including vision therapy.  Janice decided to have eye muscle surgery, anticipating that she would do post-surgical therapy to stabilize her outcome.  How did it go?  Stay tuned for Part 4.



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