Vertical Heterophoria

DEFINITION:

A sensorimotor anomaly of the binocular visual system characterized by a tendency for the eyes to vertically misalign.

 

SIGNS AND SYMPTOMS:

The signs and symptoms associated with vertical heterophoria may include, but are not limited to, the following:

1. reduced efficiency and productivity/diminished accuracy/inconsistent work product
2. diminished performance with time on task
3. diplopia (ICD: H53.2)/tendency to close or cover one eye
4. inaccurate/inconsistent depth judgment
5. pain in or around the eye (ICD: 13)
6. headaches (ICD: R51)
7. difficulty sustaining near visual function
8. avoidance of visually demanding tasks
9. inaccurate eye-hand coordination
10. eye turn, deviation (ICD:H51.9); compensatory head tilt (ICD:R29.3)
11. facial asymmetry
12. loss of place, repetition &/or omission of words &/or lines of print while reading
13. neck discomfort from postural adaptation
14. difficulty visually tracking &/or following objects
15. illusory movement
16. abnormal postural adaptation/abnormal working distance (ICD: 3)
17. spatial disorientation
18. photophobia (ICD: 149)
19. inconsistent visual attention/concentration and/or awareness
20. distractibility while performing visually demanding tasks
21. general fatigue (ICD: 83)
22. dizziness/vertigo (ICD: R42); especially during/after sustained visually demanding tasks
23. motion sickness (ICD: 3XXA)
24. incoordination/clumsiness (ICD: 8)
25. awareness of the need for volitional control of eyes
26. asthenopia (ICD: 149)

 

DIAGNOSTIC FACTORS:

Vertical heterophoria is characterized by one or more of the following diagnostic findings:

1. vertical heterophoria at distance and/or near
2. unbalanced supra/infra vergence ranges
3. restricted supra/infra vergence recoveries
4. vertical fixation disparity/associated phoria

 

THERAPEUTIC MANAGEMENT CONSIDERATIONS:

The doctor of optometry determines appropriate diagnostic and therapeutic modalities, and frequency of evaluation and follow-up, based on the urgency and nature of the patient’s conditions and unique needs. Vision disorders that are not totally cured through vision therapy may still be ameliorated with significant improvement in visual function and quality of life. The management of the case and duration of treatment would be affected by:

1. the severity of symptoms and diagnostic factors, including onset and duration of the problem
2. the complications of associated visual conditions
3. implications of patient’s general health, cognitive development, physical development, and effects of medications taken
4. etiological factors
5. extent of visual demands placed upon the individual
6. patient compliance and involvement in the prescribed therapy regimen
7. type, scope, and results of prior interventions

 

PRESCRIBED TREATMENT REGIMEN:

Some cases are successfully managed by the prescription of therapeutic lenses and/or prisms. Most vertical heterophoria cases require optometric vision therapy, which incorporates the prescription of specific treatments in order to:

1. develop fusional stability
2. enhance accommodative/convergence relationships
3. integrate binocular function with information processing
4. reduce vertical phoria
5. develop adequate fusional vergence ranges and stability in all positions of gaze at distance and near, enhance fusional vergence flexibility
6. integrate binocular skills with accurate motor responses
7. integrate binocular skills with other sensory skills (vestibular, kinesthetic, tactile, and auditory)
8. increase visual stamina/integrate newly established skills with information processing

 

DURATION OF TREATMENT:

The following treatment ranges are provided as a guide. Treatment duration will depend upon the particular patient’s condition and associated factors. When duration of treatment beyond these ranges is required, documentation of the medical necessity for additional treatment services may be warranted for third-party claims processing and review purposes.

1. The most commonly encountered vertical heterophoria usually requires 30 hours of office therapy.
2. Vertical heterophoria may require substantially more office therapy, if complicated by associated factors such as prior eye muscle surgery, non-comitant deviations, cerebral vascular accident, head trauma, and/or systemic conditions.

 

FOLLOW-UP CARE:

At the conclusion of the active treatment regimen, periodic follow-up evaluation is required. Should signs, symptoms, or other diagnostic factors recur, further therapy may be medically necessary.

Therapeutic lenses may be prescribed during or at the conclusion of active vision therapy to assist in the maintenance of long-term stability.