Our friend and colleague, Robert Nurisio, COVT, has been revisiting core concepts in vision over the last week through his marvelous blog, VT Works. A commenter on his blog of July 31, Prism Revisited, remarked:
Curious about her books on prism, I went on Amazon and ordered Yolanda’s paperbacks – one called My Silent Disability (2013) and the other titled My Life After Agoraphobia, What Now? (Volume 1), published in 2017. My Silent Disability is a quick read that introduces the reader to Ms. Antonino’s lifelong struggles with agoraphobia.
Prism doesn’t make its appearance until page 116 of the 138 page book, and it is a very specific application based on the treatment approach advanced by Dr. Debby Feinberg about whom we’ve blogged before. Yolanda found Dr. Feinberg only by doing an online search for agoraphobia and your eyes, discovering Vision Specialists of Michigan and the concept of Vertical Heterophoria/Binocular Vision Dysfunction under the umbrella of what Feinberg/Rosner term “NeuroVisual Medicine“.
Yolanda shares what she describes as “My Journey Through the Prism World”. She relates that prior to her initial evaluation, Dr. Feinberg advised her to go off the Xanax she was taking for anxiety and panic attacks, something that did not sit well with Yolanda’s psychiatrist. Apparently her first go-round with prism did not go well either, as the Rx mailed to her created double vision. Yolanda called Dr. Feinberg’s office and was told to discontinue the glasses until she returned for further evaluation. She came back two months later, and that visit went better, receiving glasses with prism the following day that didn’t elicit double vision. What Yolanda describes is essentially a version of prism adaptation testing, and a gradual easing into environments that would have formerly triggered panic attacks. Her symptoms gradually improved through a set of adjustments in the prism power prescribed.
Yolanda writes: “Optometrists are told in school not to worry if there is a problem with this type of condition, and that the eyes will compensate for any difficulty … I had never been tested for the condition of Heterophoria. There are doctors out there who do put prisms in the glasses, but the glasses usually don’t work, and the patient eventually has to abandon them. This is because this particular field takes special understanding, and this is not taught in medical school.” Suffice it to say that those statements should be qualified on several levels: all optometry students are taught about heterophoria; all are taught about Panum’s area and the relative intolerance for small vertical misalignments compared to horizontal ones; and what is taught in medical school about heterophoria has no bearing on the optometric curriculum. Of course what individual optometrists do with the information they are taught in school is another matter, and therefore sweeping generalizations such as the prism in glasses prescribed by most doctors usually doesn’t work should be made with caution. But where does that perception come from?
Before continuing I want to make one point very clear: I do not begrudge Dr. Feinberg’s success. In fact, I commend her passion and dedication. Nor does either paperback authored by Yolanda contain an endorsement from Dr. Feinberg. A more restrained view of prism is presented in a video on Dr. Feinberg’s website in which a professional colleague remarks “For people who have demonstrated binocular vision difficulties, these glasses can provide great benefit. Not for everybody. We have to be careful that we not just presume that these glasses are a panacea. But for people with demonstrated binocular vision issues, of which I am one, I think there’s some compelling evidence that’s starting to mount.”
Listening to Dr. Feinberg’s presentation on Gary Gerber’s Power Hour, you’ll hear that there are specific performance tests she uses to judge the impact of the small amounts of vertical prism she measures, for example immediate improvement on stereopsis testing and on King-Devick Saccade Testing. I respect that Dr. Feinberg and colleagues have presented coursework on this at the AOA meeting and have recruited patients for clinical trials.
Let’s venture to Yolanda’s slim, 33 page follow-up paperback, which is even more assertive.
On the opening page she writes that there are over 1.8 million Americans age 18 and over who suffer from Agoraphobia. And every single one of of them has Vertical Heterophoria (VH). If you have one, you have the other. That is because Vertical Heterophoria is the cause of Agoraphobia (that is a direct quote). On the pages that follow, Yolanda shares some other interesting thoughts. One is that the standard definition of Agoraphobia is “fear of open spaces”, but a better explanation would be “inability to define spatial awareness”. She identifies spatial awareness as the ability to understand your body and how it fits into space. Balance, she notes, depends on information received by the brain from the eyes, muscles and joints and vestibular organs. Binocular Vision Disorder, or BVD, requires that conscious effort be directed toward spatial awareness. Vertical Heterophoria creates conflict between the principal components of balance.
Head tilts are commonly associated with Vertical Heterophoria, and Dr. Feinberg conceives of the continuum of small amounts of VH and subtle head tilts, to the larger head tilts as occur in Superior Oblique Palsy. One may find Yolanda’s paperbacks to be dogmatic, but there is no doubting her passion and sincerity in sharing her experiences and perspectives, and promoting Dr. Feinberg’s work from a patient’s point of view.