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Ask Dr. Julie: What Is Vertical Phoria And How Is It Treated?

vertical phoria

Hi, I’m Dr. Julie Steinhauer. And on this segment of Ask Dr. Julie, a great question came in about vertical phoria. This is kind of a position of the eyes at rest, where one eye might tend to kind of jump up out of alignment or be higher than the other. It doesn’t necessarily mean that that’s happening all the time. It might just kind of happen moderately and just some of the times. There’s kind of a fine line between what we call a vertical phoria, which is, again, like an eye resting position versus a strabismus, where the eye is actually turning. The eye is actually turning.

There’s a larger angle associated with that usually, and maybe some more frequency that that’s occurring. This can happen for a number of reasons. We see it often with traumatic brain injury of any kind, whether you’ve gotten hit on the head, you’re in a car accident and suffered from like whiplash, had a concussion. Maybe you’ve had a stroke or something else has occurred. Maybe you even had a brain tumor and had to have brain surgery. Those are all different types of traumatic brain injury. We just don’t tend to think about them that way.

Even whenever you kind of crack your head on maybe the lift of the car, like the back end of the car, and you’re in there digging for something in the back and all of a sudden you bonked your head on it, that would be a traumatic brain injury. Even though it’s a different one in comparison to say something else like you were in a car accident, that would be a different type. Now, what do we do to treat vertical phorias or vertical strabismus? We’ve said that it can be like a minor position of the eye at rest sometimes or one eye will rest up a little bit higher at times.

Also, it can be a strabismus where the eye jumps up out of alignment and is significantly misaligned with the other eye. It can actually alternate between the two eyes. It may change depending on the angle that you’re looking at. If you’re looking straight ahead, it might not be that bad. But if you have a problem with the muscles and/or a nerve associated with the muscles of the eye, it might change and be off more when you look off to the side or even up at a corner, there may be a bigger discrepancy.

All of those things need to be addressed, especially if you’re like, “Well, gosh, when I’ve looked up and over my shoulder for driving or something or up into the right for whatever, then I notice double vision.” That could be potentially this problem with your vertical alignment of the eyes. What people typically tend to see if they have a vertical misalignment problem is they’ll get a double image up and down, or it will go at a diagonal. If it’s at a diagonal, it means that you have a lateral or horizontal component to problems with the eyes lining up and that vertical component as well. Now, what do we do to fix and correct these things? Well, first of all, one treatment that’s out there that a lot of doctors like to utilize is prescribing prism. Now, if you’ve followed me for any length, you know that I have a pretty big idea about that. I’m not very quiet about it. I’m pretty blunt about my feelings about prescribing prisms.

We do use them in the clinic for treatment purposes, but we don’t generally try to prescribe them long-term in glasses. We might use some short-term for short periods of time. But prescribing them long-term is kind of like prescribing a crutch. We want to train your brain to align the eyes and use the two eyes together. Even if you’ve had something like a fourth nerve palsy, our goal is to train your brain to align and use your two eyes together as a team without a prism.

Now, if at the end of your therapy you need a little bit of something in order to kind of seal the deal and make things align the rest of the way for you, then certainly we might prescribe a prism. But I have to tell you that most of our patients are adamant in not wanting it after all of the hard work they’ve gone to, to get things single on their own through a lot of hard work and vision therapy. Now, vision therapy is two parts. It is electrical, which is the syntonics. We talk about photosyntonics all the time. There is actually a very specific filter. It’s kind of a blue colored filter that helps with aligning the eyes vertically. It truly sends signals to the muscles of the eyes on how to align themselves when looking in different positions. We tell our patients when they’re doing their syntonics that if you have a problem up into the right, we want you to move your eyes in different areas because the brain needs to get kind of like an electrical signal to the muscles in those different areas in order to correct things.

We’ll tell our patients to look in different areas so that you’re getting signals to those muscles, so the brain can help learn how to figure out how to align the eyes. Now, the other thing is that in addition to the syntonics, what we are going to recommend is just traditional vision therapy, which is kind of a more mechanical means and a bit more repetitive of training your brain and eyes how to function together so that you can get rid of either the vertical phoria or the vertical strabismus. And remember, the vertical phoria is usually kind of like a smaller resting position. The vertical strabismus is going to be a little bit larger, and it’s going to be there more often. It might cause you to lose your place with reading. It might cause you to see double vision, either up and down or at a diagonal, and it may cause you to feel dizzy or nauseous or experience kind of almost like a vertigo kind of symptoms.

There are so many things about vertical phorias or strabismus that you may experience that are worthy of being corrected and treated and not just given prisms for, so that you can control it for the rest of your life. Now, it does take hard work. It takes lots of energy, lots of time, and really being patient with yourself to learn how to do this, and especially if you’ve had maybe like a fourth nerve palsy or traumatic brain injury, and that’s the result that you’ve gotten.

I hope it’s answered the question that kind of came in off of the internet for us about vertical phorias and what we do to treat them. If, again, you want to connect with us, our phone number if you’re local is 618-288-1489. If you’re not local, go to our website at Fill out either the questionnaire, or the second thing that you can do for us, which would be awesome, if you’re just ready to commit is schedule a consultation. There’s a button. Just click it. It will take you through all the details.