NeuroVisual Medicine... thoughts?

**Pete Hanlin** · 05-24-2018, 01:57 PM

(Disclaimer- Essilor employee)

I was speaking at a conference last week and ended up in a lengthy discussion with Dr. Debby Feinberg, OD- who operates and organization called NVM Institute (NeuroVisual Medicine). Their website is http://nvminstitute.org

To summarize NVM's concept, they suggest that at least 10% of the general population is affected by at least some degree of Binocular Vision Dysfunction (BVD), with symptoms ranging from headaches, dizziness, and neck pain the whole way up to anxiety and panic attacks. It would seem providing these patients with low amounts of prism (i.e., as little as 0.25D) to resolve small differences in vertical alignment results in a significant reduction/elimination of certain symptoms. They have a number of patient and practitioner testimonials regarding the results patients have experienced.

Honestly, I had seen some coverage on this specialty in the past and didn't give it much thought (or was skeptical at best). However, in speaking with Dr. Feingberg I found myself thinking there's a lot of common sense (optically speaking) in what she is saying. So, I thought I would see if anyone in the Optiboard community specializes in this area (or is employed in a practice that does). Essilor has no particular financial interest (that I'm aware of), I'm just professionally curious.

One of the interesting things Dr. Feinberg mentioned was using traditional Varilux Comfort as a progressive of choice. When I was still dispensing, traditional Comfort used to be my go to lens for any patient with prescribed prism (rationale being the lens had a "sweet spot" that helped the brain figure out exactly where to look- which could be an advantage for a visual system where binocularity is challenged).

**Tallboy** · 05-24-2018, 02:27 PM

Interesting. Is there any data beyond patient/doctor testimonials?

**Pete Hanlin** · 05-24-2018, 02:54 PM

Their informational packet includes a white paper: Mark S Rosner, Debby L Feinberg, et.al., Treatment of vertical heterophoria ameliorates persistent post-concussive symptoms: A retrospective analysis utilizing a multi-faceted assessment battery. Brain Injury, 30(3), 311-317.

The conclusion of the paper is: "Neutralizing prismatic lenses are an effective treatment of headache, dizziness and anxiety in patients with persistent post-concussive symptoms and VH."

I'm not necessarily trying to be a NVM advocate- just something I find intriguing. Other reading I've done in the past regarding VT (which is a completely different specialty) has also piqued my interest. The reading was a long time ago, but as I recall one study involved a large population of young boys in the juvenile detention system- the discovery being a very large % had visual challenges. VT was given to a test group and the study found the control group (that received no VT) was far more likely to become repeat offenders compared to the group that had VT.

Even though VT is different from NVM, it feeds into the same thought- namely, I would guess a lot of children and adults diagnosed as having ADHD, unexplained dizziness, etc. are actually being affected by an undiagnosed visual problem related to non-refractive conditions. In the 15 years I dispensed, there were those patients whose symptoms I could not dismiss- even though their eyeglass lenses were spot on and they could see 20/20. As I've delved more and more into the nuances of progressive design during my years at Essilor, it is very clear that the human visual system is incredibly complex- and the ability to resolve 1 minute of arc in perfect contrast is perhaps not a very comprehensive or complete measure of overall quality of vision.

**drk** · 05-24-2018, 06:02 PM

Sorry. Crap.

Here's how you know: if 1/2^ was "all that", everyone with any lens power in their glasses whatsoever would be walking around with a head tilt to get them some.

I knew this nice OD who was great guns about 1^ BI or 1/2^ BI as a panacea for everything from bunions to memory loss. I couldn't get him to understand that every myope at -3.00 or so GETS AUTOMATIC BI when they converge to read. He'd hear nothing of it.

**Robert Martellaro** · 05-24-2018, 06:13 PM

it sounds like a call out to the prescribers to look under more stones (binocular balance, phoria testing etc.).

You've probably seen this, maybe others will dig it.

These results suggest that when the accommodative system decreases in presbyopic subjects, the adaptive role of vergence and phoria systems may become critical when adapting to new visual environments such as those created when using PALs.

https://www.nature.com/articles/s41598-017-02851-5

I also use the Comfort for Prism RXs, not so much because it's a good PAL, but because it's a good semifinished PAL.

Best regards,

Robert Martellaro

**Robert Martellaro** · 05-24-2018, 06:16 PM

Originally Posted by drk

I couldn't get him to understand that every myope at -3.00 or so GETS AUTOMATIC BI when they converge to read. He'd hear nothing of it.

Yup. That's why I use the distance IPD for myopes for SVNO.

Robert

**Pete Hanlin** · 05-24-2018, 06:16 PM

Yes, and that thought occurred to me as well in the past. I mean, prior to LASIK I was a -4.75 myope, and you could move the OC all over the place without bothering me. So are the experiences of the patients simply a placebo effect (even the patients in a controlled study)? I don't know- that's why I'm thinking aloud on-line.

Could it be that individuals with good binocular vision are capable of dealing with disruptions (e.g., looking away from OC in any lens with power), but individuals who have a slight misalignment need to be put in a default state from which they can deal with disruptions? I 100% agree that minute variations in prism do not affect most people (and up to a 0.33D variance is considered within acceptable standards- although ANSI is more focused on manufacturing capabilities than visual elasticity). However, I've also had experiences with patients that could reliably detect tiny errors in their eyewear (and could also tell when their eyewear was "perfect").

**drk** · 05-25-2018, 12:39 PM

Originally Posted by Robert Martellaro

Yup. That's why I use the distance IPD for myopes for SVNO.

Robert

Nuanced. Like.

**drk** · 05-25-2018, 12:50 PM

Here's how you know:

Dr. Debby Feinberg, OD-

Not all ODs are quacks, but we have a high proportion.

who operates and organization called NVM Institute (NeuroVisual Medicine).

"Neuro" = impressive buzzword
"Medicine" = uh, no.
Sounds like they've developed a whole new branch of medical science! Awesome!

Their website is http://nvminstitute.org

"Institute" = how impressive their practice is an "institute".
.org, mind you. Not .com.

Binocular Vision Dysfunction (BVD)

Hey, they've coined a fancy term. Scary-sounding! (Sensing the propaganda-approach they're using? It's the wording.)

symptoms ranging from headaches, dizziness, and neck pain the whole way up to anxiety and panic attacks.

Yeah, and every chiropractor, psychologist, nutritionist, and massage therapist will say the exact same thing.

low amounts of prism (i.e., as little as 0.25D) to resolve small differences in vertical alignment results in a significant reduction/elimination of certain symptoms.

Small solutions don't fix big problems.

testimonials

When there is a complete and utter dearth of scientific evidence, a nice emotional appeal from a kid who was flunking but for these magic glasses goes a very long way.

GARBAGE.

**drk** · 05-25-2018, 12:54 PM

Pete, you're right, though.
Some people have very fragile systems.

**Pete Hanlin** · 05-25-2018, 02:27 PM

(Understanding I was a big fan of the X Files...) I like to keep an open mind about non-traditional courses of treatment. A certain level of skepticism is warranted (and I'll grant a number of the points you reference above occurred to me as well). However, there is also something to be said about areas of care that perhaps not been thoroughly investigated (of course, you also have to wonder why- if the area has so much potential impact- it hasn't been plumbed before... again, skepticism can be healthy).

I'm currently of a mindset similar to how I view chiropracty (sp?). I'm sure there are definitely issues that can be addressed- but perhaps not as much as claimed. If I were an OD, I think I'd probably sign up to at least attend the courses and see for myself if there's anything there. I have no doubt regarding the sincerity of Dr. Feinberg- and I suspect she is on to something...

**Uilleann** · 05-25-2018, 04:51 PM

DrK nails it with a 10 lb sledge.

If there is any true clinical value to this course of treatment, it needs to be studied extensively. Tested, re-tested, and tested again. It needs to be peer reviewed. It needs to be double blind. It must be THOROUGHLY attempted to be debunked entirely. And if anything is still left standing, that's the path forward for further research.

It's called science folks. There is a proven methodology in place to save us from ourselves - to keep our own confirmation bias in check, and to verify fact from fiction and feelings. We should ALL be EXTREMELY skeptical of ANY new claims such as these, without proper (widely repeatable) scientific study to back them up. A certain Mr Jordan across the pond is feeling the sting now for failing these very basic principles. Not to say his chosen tact isn't beneficial per se - but there are proven ways to show that it is...or it isn't. And he hasn't satisfactorily met the basic scientific methodology. Same thing with the big, bad, blue light BS.

Be EXTREMELY skeptical. ALWAYS.

**Michael I. Davis** · 05-25-2018, 06:27 PM

Sigh, drk; first of all small amounts of vertical prism is not a panacea. Appropriate for the appropriate patient. As you know the strain comes not form just the phorias but with the compensating versions (or lack thereof). Double bind studies are expensive and time consuming, and by all means need to be done. Maybe some of the OD schools can start doing this research.

Dr. Fineberg has done what studies she can as a private practitioner and it is a good start. She has a protocol that is involved and appears well thought out. What is she supposed to do,not treat patients? This is a treatment with minimal cost to the patient, who has generally been to multiple practitioners with no relief and can help some. There are no adverse side effects to this treatment and I can not understand why you are so closed minded.

<Not all ODs are quacks, but we have a high proportion.>
You **** me off with this. How dare you!? Frankly this will lead me to pretty much doubt everything you may post. You must have a low opinion of yourself to stay in this profession if you feel it is full of quacks. Grrrt.

Post more later when my BP goes back down. OK one last thing, you have a right to your opinion, about anything, but be cognizant of how you express it, especially on a professional forum.

**King of the Lab** · 05-25-2018, 06:55 PM

**drk** · 05-28-2018, 12:06 PM

Are you, Mike:
1. a member of the College of Visual Development?
2. a member of the Optometric Extension Program?
3. a graduate of NEWENCO or SUNY (or even OSU)?

We certainly have our share of quacks. If you don't think so, you're flat out wrong. I know several, and I know you know a few, too. (P.S. you know who I am, BTW...every night's a party...) We knew and very much loved Merrill, and we know he couldn't defend his developmental optometry at all.

Vertical heterophorias matter, and everyone knows it. That's not what we're talking about.

**drk** · 05-28-2018, 12:07 PM

Oh, good gravy. I went to the site.

Not only are they scamming patients, they're scamming ODs to scam patients.

#sad.

(I will say they are good at it, though. Nice site.)

**drk** · 05-28-2018, 12:13 PM

Mike, you know, and I know, and everyone should know, that re-naming some kind or muscle paresis or heterophoria with a sexy-sounding diagnosis and prescribing some sexy-sounding prism (prism!) is a giant truck load of bull crap.

The diagnoses and treatments have been around since 1900.

**drk** · 05-28-2018, 12:21 PM

Drs. Mark Rosner and Debby Feinberg have done some remarkable work in helping patients with headaches and vertigo who were previously told there was no help for their debilitating problems. They didn’t do it with drugs, surgery, or VT. They did it with prism. Yes – eyeglass lenses with prism. And more often than not, they prescribed very, very small amounts of prism. So small in fact, that most doctors would swear, “There’s no way that minute of a correction could solve that big of a problem.”