Prism and Vertical Heterophoria

A couple of years ago I blogged about the pilgrimage that Orthodox Jewish patients were making to special practitioners and practices, as far away as England, for what they perceived to be “special prisms”.  I was and remain somewhat ambivalent about these practices.  On the one hand they raise awareness of the role of binocular function that is too often overlooked.  On the other hand they do nothing to dispel, and in some instances foster the notion that only Dr. X deals with prism.  Or that the prism lenses can only be made through special laboratories.

My ambivalence about the prism pilgrimage now extends to prism for vertical heterophoria.  A practitioner in Michigan is doing a wonderful job of creating awareness about symptomatic, uncompensated vertical phoria.  You can read the back story about Dr. Debby Feinberg in the Detroit Jewish News and Crain’s Detroit.


I bought a copy of her book which is interesting, and comprised largely of patient testimonials.  There is an extensive preview of it available online.

Walls Talk

Dr. Feinberg has appendices in the book with separate adult and pediatric vertical heterophoria symptom questionnaires.  They are useful, and a Likert Scale accompanies items similar in nature to the CISS but incorporating signs and symptoms specific to uncompensated vertical such as head tilt, neck pain, dizziness, and nausea.  Dr. Feinberg makes it clear that she is not the first one to note that uncompensated vertical heterophoria (VH) can cause significant binocular discomfort, but claims to be the first one successfully treating with prisms.  In a review of the literature she found that an ophthalmologist, Stevens, first identified it in 1887; an optometrist, Roy, wrote about in in the 1950s and 60s; and two ophthalmic textbook giants, Borish and Duke-Elder wrote about it, but with little consequence.  In her words, it appears that their “discovery” of VH is really a “re-discovery”.  As an aside, I was somewhat surprised that Dr. Feinberg omits mention of other sources addressing vertical phoria, the most obvious one coming to mind is Bruce Wick’s seminal chapter 20 years ago: Prescribing Prism for Patients With Vertical Heterophoria in Susan Cotter’s book Clinical Uses of Prism.

Dr. Feinberg describes herself as a Neurovisual Optometrist, and now offers a NeuroVisual Optometry Training Program.  So is there something here that is unique and proprietary?  You be the judge …


9 thoughts on “Prism and Vertical Heterophoria

  1. Shades of Irlen! Not the only one who uses ‘neuro-visual’ – as if there’s any other kind of ‘visual’. There’s one born every minute, it seems, and those who fly in to see them. I think I’ll write that book now, the one on ‘Boulet Syndrome’, aka hyperopia. ‘BS’, it seems, can only be addressed by the appropriate lens; these lenses will only be available through my clinic, and manufactured in a one-of-a-kind lab.

    Dr. B

  2. Thanks Dr. Press for sharing. I note the copyright on Dr. Feinberg’s book is 2013 and it is a good book. Too bad many commercial practices leave out tests for Vertical Imbalance, Amblyopia treatment and just refract and refer to O.M.D’s
    However as Dr. B mentions above a lot of us have been treating Vertical and Horizontal phorias since I attended ICO in 1968.
    I for one have not written books on my treatment but as stated in an earlier blog fixational disparity using the A.O. Vectograph slide and Keystone Skills and observing head tilt along with other tests help to prescribe the correct amount of prism as these tests are taken outside of the tiny refractor holes.
    It’s is nice feeling whe the patient reports the horizontal disparity lines do not line up but when they tilt their head the lines level out. Just a little vertical prism handheld makes them feel more comfy.
    Replying to Dr. B…I have to laugh when the big box optical’s tote that “only available at their store” but of course what they have is available and better though any private practice. HA, I joined them by my brand of thinnest lenses called Woven Air, registered trade mark, available at August Optical Medical and Natural Focus, my brand of PAL, and I love fighting Americas Best as we are Americas best not them. People see me and other O.Ds because they can’t wear the two pair for $39 including the exam (they actually paid more like $200)
    Because oops the poly and a/r etc is not included. August

  3. August, thank-you for reflecting the intended humour in my statement. It’s a hard thing to decide between the two poles here: Should we defer to a doc who has claimed to have ‘discovered’ vertical heterophoria, or to an OD who does not even test for it? BTW, I just had a 22yo female in with low end glasses in a -5.50 range: She is experiencing significant asthenopia and photophobia from BVD due to improper Rx’ing and an excessively large and mis-aligned frame. How do I know this? From assessing phoric posture. Always a slice chatting on this forum!

  4. In my experience, most doctors pick up amblyopia because most doctors do acuity. Some doctors pick up phorias because some doctors do a cover test. Occasionally a doctor finds that an orthophoric patient has reduced prism and lens flexibility because occasionally a doctor checks for prism and lens flexibility, flexibility between the muscles inside and outside of the eye. It seems that the more checking you do, the more problems you find. The thing you definitely want to avoid is case history. As soon as you ask, patients start revealing all sorts of symptoms that previously were diagnosed as neurosis. For which we prescribe placebo rather than stretch our models.

  5. Dr. B. & Dr. C. Yes, patients start talking about divorce problems, and attempt to show scars from surgery on their legs and on their chest, yes, I said chest, they even want to take off their cloths to show everything. Yes, I always keep the exam room doors open a bit. I like the “low end glasses” name, it fits well. And patients tell me the low end doctors have staff giving the patient glasses without any adjustment at all.
    I meant V.T for the amblyopia in that there is no referral, just the outdated patching, without follow up. No treatment like Dr. Fortenbacher and Dr. Press have taught me.
    Finally, since the CL companies are assisting us with pricing policies, the box store doc’s and the 800 stores would be out of business were it not for spectacles. We no longer get requests for cl prescriptions as we call the patient before releasing the information with a better deal. Maybe the frame providers will follow Maui Jim and Oakley so the playing field will be level there as well. And we are way ahead of low end stores with our medical expertise…they don’t want that business, there is no money in it for them as they don’t know how to bill and they don’t want the follow up visits. One box store person who started his 30 box stores in Flint, Michigan (Eli) (passed away) told me once he only wanted the patient one time as people move around anyway. I don’t know whether to laugh or cry.

  6. A different perspective: Coming out of the Univ of Houston’s College of Optometry in 2000, I felt I’d gained very little applicable knowledge of binocular vision defects. I went to work in a very busy primary care practice in Houston and usually glossed over BV testing 99% of the time. I didn’t believe in VT because our training was so limited at UHCO and I can’t recall ever recommending it while I practiced there.

    Then I moved to New Hampshire in 2009 to start all over. My patient schedule was light so I had time to do some reading. I stumbled upon Merrill Bowman’s work and tried some base-in prism in my own Rx and truly felt a difference in the comfort of my vision. I examined my entire staff and many of them experienced a noticeable improvement in their vision. Then I started prescribing to my patients with amazing results and I have long ago lost track of how many times I’ve prescribed both horizontal and vertical prism in to my patients glasses based on their BV findings and subjective feedback..

    I discovered Dr Feinberg’s work shortly thereafter and contemplated taking her course, but she was asking for more money than I was willing to pay for her knowledge.

    About a year later, at this practice in New Hampshire, I had an occupational therapist approach me with interest in helping more young patients with BV problems. We hired her and started our own VT practice. And it was there, that I saw the wonders of VT first hand. I became a believer.

    This VT practice lasted less than a year because I decided to move back to San Antonio, TX. Meanwhile I continued to prescribe prism daily. I started getting referrals from a vestibular physical therapist after one of her patients claimed that I’d “cured” him with prism. She’s sent me dozens of patients since and I’ve helped most of them, but I stress to them that I’m not curing them.

    But now I’ve come full circle. Last month I jumped at the chance to purchase a local vision therapy practice from a retiring VT doc. He agreed to stay on to mentor me while he finishes with the patients that he has currently enrolled. And now I will start sending the vestibular patients to VT as needed.

    All this to say that I give Dr Feinberg lots of credit for finding a very small niche and running with it as far as she can. Drs. Bowman and Feinberg opened my eyes to the importance of binocular vision and for that I feel like I’m a better eye doctor.

  7. Thank you very much for taking the time to comment, Dr. Deviney. I left the open invitation of “You Be The Judge”, and your perspective is a bit of a counterbalance to Drs. Boulet, Krymis, and Cook. I purposely wanted to reserve any value judgement in this instance and again thank you for taking the time to comment and share your experiences and insights.

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