BUSINESS: Practice Insights: Vision Specialists of Michigan

Care for Vertical Heterophoria

In 1995, my brother-in-law, Dr. Arthur Rosner, an ENT surgeon, called with a request: Evaluate several patients who experienced dizziness without a vestibular cause. [Ten years earlier, I treated Dr. Rosner for vertical heterophoria (VH), which helped his balance, coordination and reading difficulties.]

When these patients visited, some used canes or carried nausea bags. Where my evaluation found VH, microprism lenses markedly reduced or eliminated the patients’ symptoms. Since that day, my colleagues and I have corrected underlying heterophoria in more than 10,000 people and, in doing so, often alleviated symptoms that were debilitating and painful. To help educate independent O.D.s on VH, I developed the NeuroVisual Medicine Training Program.

Here, I discuss VH and how I treat patients who suffer from this binocular disorder.


VH, a vertical misalignment of the eyes, can occur at any age. The two main causes are brain injury, such as concussion, and congenital causes. It is estimated that VH affects at least 10% of the U.S. population (33 million).

Patients with VH can be plagued by dizziness, anxiety, headache, gait and balance disturbances, neck pain, reading and learning challenges, binocular vision symptoms and photosensitivity. These patients may have been diagnosed as having migraines, panic and anxiety disorders and ADD/ADHD, among other disorders.


Because symptoms of VH are not considered to be of a visual etiology, patients are not routinely evaluated by an eye care professional. As a result, I receive referrals from a diverse set of providers who have learned that our practice may provide symptomatic relief for some patients who have experienced minimal/inadequate relief from multiple medications/treatments/therapies. Additionally, all patients who present for annual eye care at our practice fill out a Binocular Vision Dysfunction Questionnaire to help me identify VH.


Once I identify a patient as a VH suspect, I perform a complete ocular and vision exam. To identify subtle misalignments of VH and to determine the prescription required, I introduce small incremental units (0.25D) of vertical prism to a trial frame that contains the patient’s refractive prescription, a technique known as Prism Challenge.

I have found that addressing VH with the appropriate microprism lenses results in a reduction of symptoms by about 30% to 50% within minutes. By the end of the treatment protocol (usually two visits), the average patient experiences an 80% improvement.


VH can be billed via medical insurance or, if the patient lacks coverage, through a private pay model. As it is a time/labor-intensive visit, O.D.s should bill appropriately for their time and procedures. The initial evaluation is scheduled for 80 minutes; a second assessment exam is scheduled for 50 minutes.

In my experience, the capture rate for microprism glasses is 80%, with second pair sales about 35%. The high capture rate is likely due to the fact that the lenses contain microprism and require exacting manufacturing accuracy, so they cannot be purchased online.


VH treatment provides a critical service to patient; it can also offer significant practice benefits. At a time when the field of optometry faces several large challenges, I have found that VH management can help a practice continue along a path of success and growth. OM

See the expanded article, “The Case for Vertical Heterophoria Care”. It contains additional information and resources, including a copy of the Binocular Vision Function Disorder Questionnaire.