VERTICAL HETEROPHORIA (VH)
Timothy C. Hain, MD • Page last modified:
August 27, 2022
A vertical heterophoria is a vertical misalignment of the eyes. A vertical phoria means that the eyes are aligned with both eyes viewing, but when one eye is covered, the covered eye drifts up or down. A phoria is not the same thing as a tropia. A tropia means that the eyes are looking in different directions, with eyes open as well.
The presence of a vertical phoria has been found to be associated with symptoms of motion sickness. Vertical phorias may also cause symptoms of double vision, head tilt, and eyestrain. A recent study found that correcting for the vertical heterophoria with spectacle prisms reduced symptoms of motion sickness in 50% of patients. (Jackson and Bedell, 2012)
Vertical phoria is also associated with concussion and a variety of other illnesses.
- Quercia et al (2015) reported that vertical heterophoria is found in dyslexics.
- Matheron and Kapoula (2015) reported that VH is common in chronic pain patients. The same authors reported that low back pain patients do better with prism cancellation of their VH (2011).
- Rosner et al (2016) suggested that "Neutralizing prismatic lenses are an effective treatment of headache, dizziness and anxiety in patients with persistent post-concussive symptoms and VH. "
- Asper et al (2015) stated that vertical yoked prisms did not affected horizontal phoria. Of course, vertical and horizontal prisms are in different directions.
- Dobie et al (2010) reported that "treatment of the vertical heterophoria with individualized prismatic spectacle lenses resulted in a 71.8% decrease in subjective symptom burden and a relative reduction in VHS-Q score of 48.1%. It appears that vertical heterophoria can be acquired from TBI."
- Jackson and Bedell (2012) reported "Prisms that reduced the phoria of subjects with vertical phorias > 0.75 pd reduced motion sickness symptoms in 2 of the 4 subjects tested." This is not a large 'n'.
- Matheron and Kapoula (2008) reported that postural control is better in individuals with vertical orthophoria (VO).
- Graf et al (2003) reported that the time constant of vertical phoria adaptation to a prism was roughly 31 minutes. This is very fast !
- Kono et al (2002) reported that phoria adaptation is slower in patients with cerebellar disturbances. This result varies from an earlier paper of one of the authors of this page (Hain) suggesting the opposite for horizontal phoria adaptation.
- Maxwell and Schor (1994) reported that there were two types of short term phoria adaptation. Schor also was the author or coauthor on several other papers regarding spatial aspects of vertical phoria adaptation.
- Eskridge and Rutstein (1985) reported on vertical fixation stability and the effect of prism.
Very little has been written about vertical heterophoria. There are several recent papers suggesting that vertical heterophoria can be acquired from TBI, and that treatment with prisms is helpful. More study of this is needed. Chicago dizziness and hearing has a visual vertigo specialist and we can evaluate for this condition.
Vertical phoria adaptation is fast (time constant of about 30 minutes). One would think that this response should not be due to durable changes in neural "wiring".
- Asper, L., et al. (2015). "The Effects of Vertical Yoked Prism on Horizontal Heterophoria." Optom Vis Sci 92(10): 1016-1020.
- Doble, J. E., et al. (2010). "Identification of binocular vision dysfunction (vertical heterophoria) in traumatic brain injury patients and effects of individualized prismatic spectacle lenses in the treatment of postconcussive symptoms: a retrospective analysis." PM R 2(4): 244-253.
- Eskridge, J. B. and R. P. Rutstein (1986). "Clinical evaluation of vertical fixation disparity. Part IV. Slope and adaptation to vertical prism of vertical heterophoria patients." Am J Optom Physiol Opt 63(8): 662-667.
- Eskridge, J. B. and R. P. Rutstein (1985). "Clinical evaluation of vertical fixation disparity. Part II. Reliability, stability, and association with refractive status, stereoacuity, and vertical heterophoria." Am J Optom Physiol Opt 62(9): 579-584.
- Graf, E. W., et al. (2003). "Comparison of the time courses of concomitant and nonconcomitant vertical phoria adaptation." Vision Res 43(5): 567-576.
- Hain, T. C. and A. E. Luebke (1990). "Phoria adaptation in patients with cerebellar dysfunction." Invest Ophthalmol Vis Sci 31(7): 1394-1397.
- Jackson DN, Bedell HE. Vertical heterophoria and susceptibility to visually induced motion sickness. Strabismus, 20(1), 17–23, 2012
- Kono, R., et al. (2002). "Impaired vertical phoria adaptation in patients with cerebellar dysfunction." Invest Ophthalmol Vis Sci 43(3): 673-678.
- Matheron, E. and Z. Kapoula (2015). "Incidence of vertical phoria on postural control during binocular vision: what perspective for prevention to nonspecific chronic pain management?" Med Hypothesis Discov Innov Ophthalmol 4(1): 27-30.
- Matheron, E. and Z. Kapoula (2011). "Vertical heterophoria and postural control in nonspecific chronic low back pain." PLoS One 6(3): e18110.
- Matheron, E. and Z. Kapoula (2008). "Vertical phoria and postural control in upright stance in healthy young subjects." Clin Neurophysiol 119(10): 2314-2320.
- Maxwell, J. S. and C. M. Schor (1994). "Mechanisms of vertical phoria adaptation revealed by time-course and two-dimensional spatiotopic maps." Vision Res 34(2): 241-251.
- Quercia, P., et al. (2015). "The distinctive vertical heterophoria of dyslexics." Clin Ophthalmol 9: 1785-1797.
- Rosner, M. S., et al. (2016). "Treatment of vertical heterophoria ameliorates persistent post-concussive symptoms: A retrospective analysis utilizing a multi-faceted assessment battery." Brain Inj 30(3): 311-317.
- Schor, C., et al. (1993). "Spatial aspects of vertical phoria adaptation." Vision Res 33(1): 73-84.