Visual and Vestibular

It has been a while since my last post. I have been travelling a lot and doing tons of reading.  Learning about the plasticity of the human brain has been truly fascinating. We are very complex organisms and we are only beginning to understand how the brain guides the whole body. Not one of our systems function in isolation.

Today, I had a very good case.  I have heard this scenario many times before. This gentleman woke up one morning and had a terrible case of vertigo.  He  had the Epley maneuver performed and that seemed to help the vertigo but he was left with a feeling of lightheadedness and mild headache. These symptoms increase dramatically upon walking especially in a mall or big box store.

This patient had a very clear case of VH.  The vestibular problem was able to be treated, but there was still an underlying visual component that needed to be addressed.  He had a very slight vertical misalignment with a very subtle head tilt.  When the proper prismatic correction was found his symptoms decreased dramatically within 20 minutes.  He once again felt grounded while he was walking. Again, we see how the vestibular and visual systems are connected. This case was a wonderful example of the power of prism!

My Teacher and Mentor

I would like to say a few things about my teacher and mentor Dr. Debby Feinberg. Dr. Debby is the most kind, humble and caring person I have ever had the pleasure to know. She still gets overjoyed when she can help a suffering person, even after 20 plus years of doing this work. So many of her patients,  and now mine, feel like they have lost hope. Coping with dizziness every day can destroy a persons life.  I learned from her that I my job is not only to address the visual systom, but also to find other practioners  to help our patients with other issues that are contributing to the symptoms. It is often a team effort to help heal this population.

 I am truly blessed to have found Dr. Debby. She has changed my life and my practice. I am hoping to really make an impact on people's lives, just like her.

Are You A Klutz?

A common theme that I have been hearing lately from my patients with VH is that they have always been clumsy. Walking into walls, knocking things over, stumbling all the time. One patient told me she always knew something was wrong because she would hit her shoulder into a door frame a few times a day. Ouch!

When the two eyes are not pointing to the same place our stereo vision is poor. Judging where our bodies are in space becomes very difficult.  These patients are constantly walking into things, tripping, and misjudging distances. It is wonderful how coordination can improve by aligning the eyes. Now I am not saying that all clumsy people have VH or binocular vision problems but some do.   Something to investigate if you always walk into door frames!

The Case of M

Today I would like to tell the story of patient M. M was a healthy active young woman with a wonderful life. Two and a half years ago she went on a family vacation. The vacation turned into a nightmare when everyone on the trip got a terrible fever virus, including M. Thankfully, the family recovered from this illness and all was well, That lasted a short period of time. Poor M happened to contract the stomach flu right after the last horrible virus.

After she successfully fought the flu, the dizziness began. She felt unbalanced and had a pressure compression type of pain in her left eye and on the side of her head.  She also feels a crackling in her left ear at times.  These symptoms interfered with every aspect of her life. She struggled through work and was losing all enjoyment of life.  Every ENT, neurologist, primary care doctor, she consulted found nothing wrong with her. Eventually, she was put on an antidepressant. Then she read about VH.

I actually think M had VH her whole life from her facial structure. One eye is clearly higher than the other and she has an extreme head tilt. Her brain was able to compensate for the misalignment and fuse the images before the two severe illnesses hit her back to back. I like to use the analogy of a tripod. The legs of the tripod consist of 3 systems. We need all 3 to be strong in order to be balanced. First is the ankles, feet, core all working together. Second is our vestibular system in the inner ear and last (but not least!) is our binocular visual system. If one leg is wobbly maybe a person can function, but if two of those legs on the tripod get wobbly, the tripod can't stand. This is what I believe happened to M. Her visual system leg was always wobbly but she was able to get by, then she had some type of damage to the vestibular leg of the tripod. The two wobbly legs were too much for her brain to deal with and all the systems of vertical heterophoria emerged.

The good news is that M's symptoms are decreasing as we are aligning her eyes. It is taking some time but progress is being made. I still believe there is an inner ear issue that needs to be addressed but I am very hopeful M will be able to enjoy her life again!

Everyone Does Not See A Shadow

A patient of mine reported yesterday seeing a shadow overlapping image. She has been noticing this since childhood. This was a very intelligent woman, who is now in her 30's. She couldn't believe that everyone didn't see this way. It is so interesting to me to think about  a person's perception of their visual world. If someone saw a particular way their whole life, of course they would believe that was the view for everyone. It is like a person who is nearsighted and never had glasses. The first time they get glasses they are amazed at the details in the world. It is like that for a person who has vertical heterophoria. When the eyes are aligned, the shadow image goes away.  The patient experiences clarity, detail and depth perception sometimes for the first time in their lives!

This just drives home the point that as a good doctor, I need to ask questions and listen to the answers. How many times do I hear from a patient that they suffer from headaches but it isn't their eyes. Then I discover that it was their eyes all along. They were never asked the right questions.

King Devick and concussion

I am so excited to get my King Devick test today.  This eye movement test is used as a screening tool to determine if someone can go back into the game after a hit. It is very important to know a persons baseline score before a possible concussion occurs.  Tonight, my son will be doing that test!

Recently, Dr. Debby told me that she was able to improve King Devick scores substantially  after prismatic correction. This is very exciting news since this is another way we can quantify how the prismatic orthotic glasses we prescribe effect the visual system! Post concussive visual symptoms are on the rise.  We know that if these symptoms persist longer than 3 months, a binocular vision evaluation is needed. Many of these patients can be significantly helped with prism. Children are particularly vulnerable  to concussion since their brains have more space in the skull to move around. If your child plays a contact sport, like mine, please have a baseline King Devick test performed!

Visual vertigo and fear of flying

I was speaking with a couple of patients today about the symptoms they have been experiencing that are due to vertical heterophoria. The sensation of increased dizziness in certain environments seems to be a recurring theme in a very large percentage of my patients.  Malls, supermarkets, big box stores are some of the places where this extreme "visual vertigo" happens.

A woman today told me a story of her first time she had severe dizziness. She was walking in an airport terminal. One of those large airports with very long corridors to walk down to get to the gate. It was so bad that she couldn't even get on her flight.  If we examine all these spaces we notice a few similarities.  High ceilings, long aisles,  a lot of visual stimuli on the sides.  All that side visual stimuli, combined with the misalignment of the eyes leads to the dizzy or lightheaded feeling. This in turn causes anxiety.  If one gets dizzy in a certain place, there would be associated anxiety with having to go into that environment.

The woman today started me thinking. I wonder how many people that refuse to fly in a plane due to anxiety attacks are actually people with VH.  Maybe the anxiety is starting when they are walking in the terminal and not on the plane. Hmmm. I think I will start asking more questions about airports.

Everyone is popping a pill

Dr. Debby and I were having an interesting discussion yesterday about how many people are taking some type of anti anxiety medication.  I have even seen lately a rise in the number of teens on these meds. Our American culture is always looking for a quick fix in a pill, whether it is the over use of anxiety meds or antibiotics. Most of the television ads today are for a medication.

A very common symptom we hear very often is anxiety. Our vertical heterophoria patients can experience anxiety in malls, big box stores, supermarkets, and cars to name a few places. If the world starts spinning around and you feel unstable and unsafe in these environments,  well of course you are going to have anxiety. Doesn't that make sense. So many of these patients are put on medication because their doctors do not know how to solve this anxiety. This can make the problem worse for people with vertical heterophoria because these medications can effect the eye muscles. When the visual system is functioning properly and the dizziness goes away, the anxiety is also relieved. No pills, just prism.

Doc, how does that prism work?

I have been talking a lot about prism and how we can use it to align the eyes.  It dawned on me that a lay person may not understand how this actually works! A prism will move an image.  It really boils down to that basic concept.  If you hold a prism in front of one eye the image from that eye will move in certain direction and amount that can be measured.

Let take this one step further.  If one eye's image is too high and one is too low, they land on different points on the retina. The human brain does not like this and try to compensate to correct this problem causing the symptoms of vertical heterophoria. Using very precise amounts of prism we can move those images onto corresponding points on the retina.  When this is accomplished the symptoms of vertical heterophoria dramatically improve.

How will the prism glasses look? The glasses look to the outside world like normal regular glasses in a normal regular frame, but they are actually a visual orthotic device.  The glasses become your medicine.  No drugs,  just glasses.

Sometimes a little prism is all you need.

When I see a patient who takes a lot of prism, I like to demonstrate to my staff how the patient sees without their prism. Putting prism in front of a person whose eyes are not misaligned gives them the same symptoms of the patient. I gave a clip to my optician with prism on it for her to look out of.  She puts it on and says "Wow! this is great!" I see so clear!!!!

She always complained of not seeing clear enough to me.  Of course she didn't because she had a ghost image. She described it as seeing "smeary" always trying to focus. Interestingly, she did not complain of headache or dizziness at all, but she did have VH. With the prism glasses her world is so much easier.  Aligning her eyes gave her the binocular vision and dept perception that she was missing.

Now if a patient uses that world "smeary" or just not sharp enough, I immediately pull out my instruments from Dr. Debby and screen for VH. Sometimes, a little prism is all you need.

Did you get your "bell rung"?

As I am getting ready to pick up my son from football practice, I thought this was a good time to talk about concussion.  Concussion is a hot topic today in the media.  Parents, coaches, and doctors are becoming more aware of concussion and the devastating consequences it can have.

Patient who experience even a mild brain injury can be left with many post concussive symptoms. These can include headache, neck-ache, dizziness, anxiety, and reading difficulties. If theses symptoms persist after 3 months, the visual system may be to blame. These patients need to be screened for Vertical Heterophoria and superior oblique palsy. Prism glasses can dramatically improve these symptoms and improve the person's life!

If you had your "Bell Rung" and still have post concussion symptoms, please reach out we can help.

Now back to my son, football was not my idea. He know one time he gets hit in the head football is over for him!

Looking at faces

One of the things I do in my spare time is volunteer for the American Cancer Society's Look Good Feel Better program.  This is a class where I teach woman who are undergoing cancer treatment to put on makeup and educate them about wigs.  As I was teaching my class today I was observing all the women with facial assymetry. It is amazing how most of us are not symmetric, but there are varying degrees.

Facial assymetry, we are all born with it, some more than others. If the face is extremely assymetric this can cause vertical heterophoria.  One eye is physically lifted up higher than the other.  This causes the images to be on non corresponding points on the retina. The retina is like the film on the back of the eye. To make this simple, our brains just do not like this.  The way the body reacts to try to correct this problem is what causes the symptoms of headache and dizziness! It really make sense. If you suffer from headache and dizziness take a look at your bone structure. You may have vertical heterophoria.

What is "Normal"

One of my favorite quotes from a patient, " I feel normal!"  I wondered what she meant. What is normal. Normal to me may be different than someone else. Sometimes a discomfort is our normal because we don't know any different. We just deal and think everyone may feel this.

 This young woman never felt steady on her feet. She described it as "swimmy". She had searched for an answer for many years but all her doctors told her that she was fine.  She just accepted that the swimmy feeling was her "normal". She thought she would just have to live like that.  As fate would have it, she came to me right after I trained with Dr. Debby.

She had a clear case of vertical heterophoria.  As soon as she got her prism glasses, she shouted out now I feel normal! The swimmy feeling was gone. Her whole family calls me the Vision Godess now!

Sometimes hearing "I understand is all one needs."

Yesterday, I saw a new patient that found me through the Vision Specialists of Michigan website.  There is a link to my office as a doctor trained in the Feinberg Method.  He had searched for 4 years for an answer to his dizziness. Doctor after doctor told him that nothing was wrong with him. I heard his complaints and started my exam.  He had a  distinct vertical misalignment with his eyes.  At that visit his dizziness almost completely disappeared.

The best part of that visit was the smile and laughter on that man's face. He was so happy when I told him that every symptom he was feeling I had heard before from patients.  Just validation that this wasn't a psychological problem made is day.  The whole staff was smiling and giggling.

Yesterday was a great day.

If you suffer from headache, dizziness or double vision please reach out.
Dr. Cheryl

I always have a headache.

Are you told that you have bad sinus problems with sinus headache but nothing shows up on a scan of your sinuses? Do this little test next time you feel that pressure around your eyes that you think is sinus headache. Rate this headache on a scale of one to ten, one being very mild to ten being the worst headache you have ever had. Then cover one eye and relax while looking at an object in the distance. Do this for 5 minutes. Rate your headache after the 5 minutes are up. If your pain has significantly decreased, then there is a good likelihood that a binocular vision problem is causing your headaches.

Please feel free to email me at drcbisraeloff@gmail.com if you suffer from headache, dizziness or double vision.

I think I may have Vertical Heterophoria not anxiety.

A quick post today about people who are told they have anxiety disorder. If you get panic attacks in the car, mall, supermarket, big box store, or any space with tall ceilings and you get vertigo symptoms  at those places you may have visual vertigo stemming from your visual system. It is a slight misalignment of your eyes - Vertical heterophoria.  The ENTs actually call these patients "Mall Patients" !  We can help you align your eyes and you are back to a normal life.  I am hoping this blog along with a new website will be constructing soon will start educating patients and practitioners of this common but under diagnosed  condition.

I woke up one morning and the world was spinning!

I have heard this complaint many times. Frequently, from someone who was pregnant or just given birth.  The story of a woman,  I saw recently is very typical.

L was so happy after finally having a baby girl after 2 sons.  One morning shortly after coming home with her baby, she woke up with the world spinning.  She went to her primary care who sent her to ENT,  then neurologist.  All MRI's were fine.  They told her she had postpartum depression.  When she reported that she was not depressed at all, she was dizzy,  her doctors just dismissed her.

She happened to find Vision Specialists of Michigan website and then the link to me.  I was the closest doc to her in the country.  It turns out that she had a decompensated phoria due to the stress of the birth.  That means that her eyes were always slightly misaligned but her brain was always able to take the 2 images from the eyes and fuse them together to get one.  The stress of giving birth probably took that ability away.  Her slightly vertically misaligned eyes lead to her seeing a ghost image because the images were on non corresponding points on her retinas.  The eye muscles were trying to fuse the images giving the brain signals of movement but the inner ear signaled no movement.  This lead to the dizziness.  As soon as we aligned her eyes the dizziness went away.  No drugs, no therapy,  just glasses.

Tomorrow,  I will describe what the ENT's  call their Mall patients.

Prism vs. Prozac

Could the cause of your dizziness, headache, anxiety be coming from your eyes? Many people who suffer from these symptoms have a relatively unknown binocular vision disorder called vertical heterophoria. Symptoms can also include light sensitivity, neck ache, head tilt, facial pain, unsteady feeling while walking, and motion sickness.  Patients often have gone to neurologists, ENT, ophthalmologists, etc.  When all testing comes our normal they are sent to a psychiatrist. The good news is that this can be treated with the proper  prismatic correction in a simple pair of glasses.

I came to learn about this condition while reading an optometric journal about Dr. Debby Feinberg.  People travel from all over the world to be seen by Dr. Debby. ( Just google her. She is called the headache guru of Michigan.) She is currently doing research with the pain management specialists at the University of Michigan and has been published in a number of medical journals.  I thought her work was so interesting that I emailed her.  I am proud to say that I am one of the first doctors in the country trained in her very specific and effective technique to diagnosis and treat this condition.

I will be posting different case histories here so people can read about others with VH.  Today, I will talk about one of my most gratifying cases. A woman who came to me for a routine eye exam complaining of headaches around her eyes.  She was told that she had sinus headaches for the past 29 years. The pain started 29 years ago when her son was born. (Often, symptoms begin after a major stress on the body such as pregnancy, illness, or brain injury.)  I started asking her other questions and had her fill out a vertical heterophoria symptom questionnaire. This questionnaire helps to determine if the symptoms are caused by a vision problem. She scored very high.  After a month of wearing  prism prescription glasses she came for her follow up visit a new person. She reported that her "sinus headaches" were gone. It was her eyes all along. She started to cry and gave me a hug.

In the future, I will describe other cases and discuss the different ways this subset of binocular vision disorders develop in detail.  Please feel free to contact me at drcbisraeloff@gmail.com if you think you may be suffering from VH.