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Local doctors treat patients worldwide to correct rare eye condition.

Drs. Debby and Paul Feinberg have treated more than 7,000 patients suffering from vertical heterophoria. (Photos by Brett Mountain)

My chiropractor thought there might be a problem with my eyes,” said Marcy Forta of Oak Park. “Something was wrong with my neck, and his adjustments weren’t working as they should have. He referred me to Dr. Debby Feinberg, who he had heard of through another patient of his.”

Feinberg diagnosed Forta with an eye condition known as vertical heterophoria (VH).

Forta, who suffered from horrible neck and shoulder pain for years, never imagined it came from an eye problem. VH causes one eye to see images at a different level than the other, making  the eyes fight for alignment. This causes a whole host of issues ranging from blurred and double vision, headaches, dizziness, head tilt, nausea, motion sickness, unsteadiness when walking — the list goes on and on.

“I used to get regular massages in addition to going to the chiropractor, and I took a lot of Motrin,” Forta said, “but a lot of my neck and shoulder pain was alleviated when I started wearing the glasses Dr. Feinberg made. Not all of the pain was gone, but it was enough that I felt significant relief.”

Feinberg, 55, along with her father, Dr. Paul Feinberg, 86, and their colleague Dr. Morrie Dubin treat patients from across the country and the world. This is because they run the only ophthalmologist practice in the country that treats vertical heterophoria, which affects about 5 percent of the total population. “We’ve found only one other doctor in Germany who also treats this,” Paul Feinberg said.

The Beginning
Debby Feinberg’s journey with VH started in 1985 with her brother-in-law, Dr. Arthur Rosner, an ear, nose and throat (ENT) doctor.

“I was with him one day when he pulled out a wedge prism to read with,” she said. “He explained that a doctor from medical school gave it to him to help with eye strain he had when reading.”

When she asked him if the prism helped, he responded negatively.

She believed she could help him, so he came into the office for an exam. “I thought that if I put prisms in his glasses, it might alleviate his strain,” she said. Her hunch proved to be right.

Twelve years after she treated Rosner, he came to her with an idea.

“As an ENT, Arthur sees a lot of dizzy patients because dizziness is typically an inner-ear problem,” Debby said. “He wasn’t able to help some of them, so he tried sending those patients to other eye doctors because he thought they might suffer from VH as he does.”
    At first, he resisted sending the patients to Debby because they are related, but the other ophthalmologists he sent them to were unable to help.

“He explained to me that these patients sounded like he did before he started wearing prism glasses, and he thought I could help them as I helped him 12 years ago,” she said. “I was doubtful, but I agreed to see a few.”

She found she was able to help most of the patients Arthur sent her. As she saw more and more patients with VH, her husband, emergency physician Dr. Mark Rosner, conducted research that led him to discover Raymond Roy. In the 1950s, Roy had an insight as to how prisms could help people with VH. “For whatever reason, no one picked up on his work at the time,” Mark said.

A prism with a range of strengths demonstrates the effectiveness of its magnification. Using the experience of the Feinbergs and Dubin in treating VH plus information Mark discovered when researching, the team at Vision Specialists of Michigan in Bloomfield Hills perfected the process of using prisms to treat patients with VH. Since 1995, they have treated more than 7,000 VH patients who, on average, get 70 to 80 percent better.

Manifestations
“Our patients come to us with medical histories full of MRIs and visits to various kinds of doctors,” Paul Feinberg said. This is because the symptoms VH presents do not appear to be eye-related when you first look at them; typically, when someone suffers from dizziness or anxiety their first instinct is not that they have an eye problem.

Dizziness can cause anxiety, which can lead to agoraphobia. “People with VH can get very overwhelmed in large, open, busy spaces such as a mall or stores like Home Depot,” Debby explained. “Some also feel too anxious to drive.”

Another effect of VH is that kids are sometimes tagged as having attention deficit disorder because they have trouble reading. “If a kid is in second grade and he’s told to read something in class,” Mark said, “he’s not going to sit still for very long if he literally can’t do what he’s told.”

Reading presents a challenge because the eyes view images on two different levels, making skipping lines and losing one’s place common.

People may be born with VH, as it does run in families, but it also can develop as a result of asymmetry in the face or trauma to the head, in addition to other factors.

“Some of my patients have been told they’re crazy because they look fine, but they have all these symptoms,” Debby said. “People tell them they’re hypochondriacs because they’ve been sent to different doctors with no relief.”

The Internet has played a large role in helping Debby, Paul and Dubin find people with VH. “A lot of people Google their symptoms and up pops our Website with a list of symptoms and a possible explanation,” she said. On the Website, people who think they may have VH can fill out a questionnaire. The results are sent to Debby’s email, and she responds to each submission with a phone call.

Some of her patients are international and though it may seem like a long flight from Europe to Detroit, Debby said, “Wouldn’t it be worth it to you to make the trip if it meant you could be rid of your headaches, double vision, anxiety, dizziness?” If a patient is not from the area, she speaks to them at great length before they make the trip so she can be more certain she can help them.

The Process
“Debby spends as much time as it takes with each person,” said Forta. “She is so patient and gives everyone 100 percent of her attention. It’s evident that she cares about each patient and wants to help them.”

The initial visit takes two to three hours, as Debby spends an hour just talking to the patient so she can understand their history. She then has them try on “tester” prisms before fitting them for an official pair. The patient wears the tester pair in the office for a period of time “to make sure it works well for them before they leave,” Debby explained.

Often it only takes a patient 20 minutes to feel relief from their symptoms after trying on a prism. “It’s so gratifying to see a person lighten up and immediately start feeling better,” Paul said.

Because of a process called progressive relaxation, patients need to come in two weeks after their initial appointment because the eye muscles will have adjusted further. “We don’t start with a lot of prism,” Paul explained. “We start with a little bit to make sure it works and doesn’t overwhelm the eyes, and then we add more or take it away as they need.” Some patients need to come in for additional visits as their eyes adjust further.

Link To Brain Injury
Through their work with VH, the doctors discovered a link between traumatic brain injury (TBI) and vertical heterophoria. Mark explained, “TBI creates a bad or false signal between different nerves,” which can cause the eyes to misalign. Of the practice’s 7,000 VH patients, Debby says around 2,000 of them have been TBI patients.

They first started working with TBI patients when they treated Physical Medicine and Rehabilitation (PM&R) Dr. Jennifer Doble for VH. Doble was initially referred to the practice through a patient of hers, and through conversations with the Feinbergs and Dubin, she realized that some of her TBI patients had symptoms of VH.

“The TBI patients we see, they’ve gone through physical and occupational therapies,” Paul said, “but they still aren’t fully recovered despite their therapies.”

Doble runs a concussion clinic at St. Joseph Mercy Ann Arbor Hospital and encourages her patients to be evaluated for VH if they still experience post-concussive symptoms three months after their injury.

Path To Science

The father-daughter team has treated VH at their Bloomfield Hills practice for 17 years.

Aside from Roy and another doctor from the 1800s, there is no scientific research on VH, but Debby, Paul, Dubin, Doble and Mark Rosner are working to change that. “This is just a private practice,” said Mark, who is not part of the practice, but of the VH research team. “It’s not the University of Michigan, but we’re doing research and writing articles just as they are.”

Two statisticians have validated Debby’s questionnaire, which has evolved over the past 17 years — one from U-M and one from St. Joseph Mercy Hospital of Ann Arbor. The team plans for it to be published in conjunction with an article in the near future.

Recently, they presented posters with broad summaries of their research findings, “snapshots” as Debby called them, at the International Brain Injury Conference in Scotland in March, the Anxiety Disorder Association Conference in Virginia in April, and the American Headache Society Conference in Los Angeles in June.

“Before people can write papers, they do posters,” explained Debby. Doble, Debby, Mark and Arthur did write a paper on VH and TBI that was published in the peer-reviewed PM&R Journal in April 2010.

Members of the team also have spoken at conferences around the country and world. Arthur Rosner recently spoke at a conference on dizziness in Stockholm and lectured at the University of Edinburgh in Scotland.

In May, Debby was invited to speak to doctors at Johns Hopkins University by Dr. John Carey, who she refers patients to if they have an ear-related dizziness. She spoke to 17 doctors —  ENTs, neurologists, ophthalmologists —  none of whom had heard of vertical heterophoria.

“The most important event is when Dr. Doble and I present 17 years of research to colleagues at the EastWest Eye Conference in October,” Debby said. “They’ll think it’s a little unusual. I’m anticipating they’ll say, ‘Really? Prisms like that?’”

The ultimate goal for the team is to receive a National Institute of Health grant so they are able to fund a research project with a true double-blind study with hundreds of patients. “We’re doing an in-office double-blind study currently, but it’s not to the scale that we really need,” Debby explained.

“If we can get a grant for that study, it will further legitimize our work in the science arena, which will allow us to help more people,” she said. “Anything we can do to let people know there is hope and help for them, that they can actually be helped, that’s so amazing for them. I love being able to offer that, and I want to be able to help more people,” she said. 

Go to www.vsofm.com to take the VH  questionnaire and learn more.

By Marielle Temkin, JN Intern

 

 

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