Vertical Heterophoria – A Different Look at Being Level-Headed.

I am not a student of fine art and although I appreciate the talent involved in being an artist, I never developed appreciation for much of anything that adorns the walls of the world’s museums of fine art.  That may change someday.  Who knows?

But the topic of this post really has little to do with art, or at least not the art of painting.  Pablo Picasso painted this picture to the left and what got my attention was the exaggerated placement of her eyes, one higher than the other.   My google search of Picasso’s works reveal multiple paintings of women, most of whom have one eye set noticeably higher than the other.  Photos of Picasso seemed to reveal that he had one eye higher than the other also, but that’s hard to tell based on a snapshot.

And that leads me to my latest obsession with my patients, so to speak, which is the frequent diagnosis of what’s called a vertical heterophoria.  The lady in the painting has it and so far two of my patients this morning have it.  I’ve sat on this topic for a couple of months because I wanted to compare the similarities between the patients that have this condition before reporting on it.  So here goes…

As I’ve written about in earlier posts, vision is complicated.  The front of the eye has to focus light directly on to the retina in the back of the eye just like the movie projector has to focus it’s light directly on to the movie screen.  If the light is focused too far in front or behind that screen (retina), the image will be out of focus.  But just as important for clear vision, is the eyes’ ability to work in unison and aim on a level plain with each other (binocular vision).  If the eyes are not in sync, visual acuity can get worse.

I will admit that in my earlier years of practice, I simply didn’t understand the importance of binocular vision.  We had classes on the subject in optometry school, but I recall that they were, well…boring beyond belief.  None of my clinic instructors emphasized the importance during my early patient encounters, and so I learned how to go through an eye exam without worrying too much about how well the eyes worked together.  Then after graduating, I went to work in a busy practice and often skipped that evaluation altogether giving what I thought were thorough eye exams.  But I had just oversimplified the complicated nature of vision and, for the most part, made most all of my patients happy.

But every now and then, I think back to some of the patients in which I never really could figure out why I couldn’t get them to see a little better.  And now I think I know why…they had a problem with their binocular vision and very likely a vertical heterophoria.

************So here’s where it gets good and hopefully you’re still with me.  Here’s the typical patient scenario of a patient who I diagnose with a vertical heterophoria:

Most of these patients complain of eye strain and headaches, especially related to near activities.  They may call them migraines and they may often be light sensitive both indoors and outdoors.

Most of these patients have a history of motion sickness or at least admit to difficulty reading in a moving vehicle and most likely they hate riding in the back seat of a moving vehicle.

Most of these patients have developed some sort of compensating head tilt towards the left or right shoulder.  I believe this tilt is used to level out their visual world just like we’d see the bubble move on the level when trying to hang a picture straight on a wall.

Most of these patients admit to a history of neck and more likely shoulder pain on only one side (left or right).  They are no stranger to chiropractors or massage therapists.  Older patients additionally have lower back pain that has worsened over the years.

Many younger patients have been diagnosed with reading or attention deficit difficulties.  I’ve seen patients with this condition under 10 years old who already see a chiropractor regularly.  Are you kidding me???

Some of these patients become very uncomfortable in places crowded with lots of people.

Many have been diagnosed with fibromyalgia or chronic fatigue syndrome.  They have tried all sorts of ways to manage their pain, yet nothing has really helped.  Since looking closer at this vertical deviation, I have yet to see a patient with either of the diagnoses that did not have a vertical heterophoria.

These patients tend to be grumpier and just look worn out.  Technicians and staff may dislike dealing with them because of this, even if they’ve been with the practice for years.

I’ve seen a couple of patients with a history of scoliosis who were diagnosed.  Is there a connection?  One study I found seems to think so.

Six members of the staff have it.  My wife has it.  And I have a mild one also.  And I suspect my mother-in-law has it too.  She HATES riding in the backseats of cars, especially in the mountains of Lake Tahoe when I’m driving.  But that’s another story…

So I don’t know if I’m on to something big or on to nothing at all.  But there are some incredible similarities amongst these patients.  I’ve said it before, every decision we make in our life is based not on what we see, but how we see the world.  If our world is not level, the brain tends to dislike that and will find a way to compensate.  Why not a head tilt?  Do it all your life and why wouldn’t your neck or shoulders start to feel the effects of it?  Why wouldn’t that translate down to your back?

***(Edit: Forgot to include this section in original post)  So I try to help them by prescribing prism oriented vertically, either base up or base down.  I do quite a bit of trial framing in the exam room in order to make sure the patients can handle this new part of their prescription.  Usually it’s only as small as 0.50 diopters, so I only prescribe it in to one lens.  If it’s a higher amount, I will balance it between both lenses.  Usually, they will be back shortly with family members to tell me how they’re doing.  After just two months of doing this and losing count of how many times I’ve done it, I’ve only had to remove the prism once (talk about jinxing myself).  Two people have told me they haven’t had a single headache since then.  At this point, I don’t schedule them back for follow up visits but I’m thinking about changing that.

I’ve contacted some local chiropractors back in Keene and their interest is lukewarm at best.  I’m hoping I can sit down with one soon to see if any of this makes sense to them based on their training.  I would love to team up with one or all of them to help people with pain, if possible.

So that takes me back to Picasso.  Did he deal with this problem himself?  I couldn’t find that he had any reported history of any of the conditions I listed above.  But it was thought that Vincent van Gogh’s Starry Night  was possibly painted that way because he was near-sighted.  If anyone knows more about Picasso, please let me know.

In the meantime, check out this website:  This is an eye doctor in Michigan who has made a living helping patients with this condition.  She has a ton of great information that helped me look further in to this.

Thank you for reading and please contact me with any questions.

About admin

Eye/vision doctor in San Antonio. Serious sports fan. Goofy dad. Husband who tries hard. Never met a bag of beef jerky that I didn't like. Except salmon. San Antonio, TX ·
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  • Nancy Deviney

    Very interesting – the possible connection between migraines, back seat riding, etc and vertical heterophoria. What would I do if I couldn’t read in a car!

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  • zeinab

    Hello.I am a 24 year old girl from Iran.
    Thank you very much for your post .
    I have all the symptoms you listed above, except headache (Thanks God!). I am a student for master of computer engineering, and in recent 2 years have had a lot of difficulties about my education.after a period of heavy study for some exam, my eyes got very tired and it ached for 1 or 2 months when I studied even for a very short while. after that, It became so sensitive.
    I would be very thankful if you explain your method with more details about the prism and the results you achieved about your patients, so that I can show your writing to some eye specialist and ask him to help me in that way.
    Thank you

    • Hello Zeinab. Thank you for reading. The methods used can be quite lengthy, at least to type out in this post. Whoever tests you should use a combination of a unilateral and alternating cover test. Any associated phoria testing that is available will be helpful. All phoropters used for refraction should contain Risley prisms to do dissociated horizontal and vertical phoria testing as well. I usually place loose prisms in front of any prescription while my patient is viewing objects near and far to check their initial response. I’m sorry this is not very detailed but if your eye care provider doesn’t know what these tests are, then he or she will not be able to help you. I wish you luck in finding help.

  • Patrick


    I live in Oklahoma, and I’m having a very difficult time in finding a doctor who is familiar with VHS and treatment here. Would you by chance know of any possible doctors in the Midwest who do? Perhaps through a professional association, etc?



  • Hello Patrick,
    I’m not sure what part of Oklahoma you are in, but I did a web search and found Also Here’s a place in Norman: Last, but not least: These folks should have an understanding that should help you. Good luck.

  • Jul

    Wow, this was so interesting for me to stumble across! I’ve been struggling with lightheadedness, headaches, motion sickness, neck pain, and almost every other symptom of this. I’m glad to see that you and others in the field are diagnosing vertical heterophoria. i’d never heard of it until just a couple days ago, and I’m fairly confident (as multiple doctors and tests have ruled out pretty much everything else!) that this is my problem. I’m curious if you happen to know of anyone in the Minnesota area that would be good to speak to about this. I’ve been attempting some internet searches but I guess I’m not positive where to start to find someone that could diagnose/treat this. (The closest one I’ve found for certain is Dr. Debby from that you mentioned, who is a 13 hour drive for me.) Thank you!

    • Hello Jul, and thanks for reading my post. I’ve done a search on vision therapy in the Minneapolis region and here is one link you should check out: Here is another: And another:

      Vision therapy centers are connected with eye doctors who have specific interests in binocular vision problems like the type that you may very well have. I hope one of these clinics can be helpful! Good luck!

    • Patrick

      Thanks Jason! I will take a look and make an appointment. I really appreciate you taking the time to look in the area for me.

  • tamara

    I live in Minnesota and everyone of these symptoms fits with what I have been dealing with. I would like to get this checked out but am having a hard time finding anywhere in Minnesota that i can go to. I live near Anoka County.

  • So impressed with doctors like you who strive to keep on learning, as well as take the time to educate others. Thank you for that.

    I suffered with Vertical Heterophoria for three decades but it wasn’t diagnosed until I saw Dr Debby Feinberg at the Vision Specialists of Michigan in Nov 2011. I found it particularly interesting when you mentioned the following:

    “Many have been diagnosed with fibromyalgia or chronic fatigue syndrome. They have tried all sorts of ways to manage their pain, yet nothing has really helped. Since looking closer at this vertical deviation, I have yet to see a patient with either of the diagnoses that did not have a vertical heterophoria.”

    “I’ve seen a couple of patients with a history of scoliosis who were diagnosed. Is there a connection? One study I found seems to think so.”

    I’ve been diagnosed with all of the above, and wonder the same myself.

    • Hi Jasmine! Thanks so much for reading. I read some posts on your blog re: your visit to Birmingham. I love you VH FAQ page! Do you mind if I link that to my blog? Dr D

      • Don’t mind at all, Dr. D.

  • Yolanda

    I see this article is pretty old but I have written a book on this subject because I suffered from this for 40 years. My book is entitled “My Silent Disability, by Yolanda Antonino. I also have a blog at I am a patient of Dr. Debbie Feinstein of Vision Specialists of Michigan. She is a pioneer in this field and is helping thousands of patients. I hope you continue to help people with this and I also hope you will contact Dr. Debbie for more help. She is always looking for doctors who would like to learn her technique. All the best, Yolanda

  • Jason Deviney

    Thank you for reading Yolanda. I’m sorry I didn’t respond sooner. I will look for your book and I have helped many patients with this condition over the years. I also have talked to Dr. Debbie a few times and I’m hoping I can learn more from her.

  • Andra Stowe

    I was looking for a little
    bit of “easy to digest” information on this subject just now. May I
    just tell you how MUCH I enjoyed your explanation? It is difficult for many in
    the medical field to make topics not only understandable, but also interesting!
    Kudos to you. I surely wish you were located near Utah – I have a few
    Chiropractors who would LOVE to work on this type of project with you! I love
    the fact that you are willing to tie the body together as a whole instead of
    trying to parcel out each piece.

    • Jason Deviney

      Thank you Andra! I didn’t get any notice of your comment or I would have responded sooner.