Superior oblique palsy may cause double vision either vertically or diagonally. Diagonal
double vision is where both the vertical and horizontal are affected. Usually if the patient
has had superior oblique palsy since birth (congenital), a head tilt may be the only
symptom.

Symptoms of acquired superior oblique palsy can be dizziness, trouble reading, blurry
vision at distance and near, light sensitivity. An acquired superior oblique palsy can be
from head trauma, even mild head trauma such as a concussion can cause superior
oblique palsy. Motor vehicle accidents can cause superior oblique palsy.

Some patients who have a traumatic incident occur can have it spontaneously resolve
within 6 months. About 10-15% of patients experience persistent symptoms after 6
months. In this case, treatment with prism is highly effective – usually around 80%.

Dizziness when rising from sitting and dizziness when rolling over in bed can also be
signs of POTS (postural orthostatic tachycardia syndrome). An extensive neurovisual
exam will let us know if we need to incorporate both prism and a referral to cardiology to
rule out this condition.

There are also several conditions of the ear that can cause a patient to be dizzy, which
will also be ruled out during the neurovisual exam with Dr. Sarah. In this case, special
ear plugs can be used to reduce the symptoms, or a referral to an ENT will be advised
depending on the condition suspected. Most patients find that they have a significant
reduction in their dizziness with the use of prism.

Nausea is another symptom that can often be confused with dizziness when it comes to
binocular vision dysfunction and vertical misalignments. These patients will also have
difficulty walking without support, and will frequently use a cane or walker to get around.

Driving in the car can be difficult whether a passenger or a driver. The patient can
experience severe dizziness due to the moving vehicles beside them, and this can
trigger nausea/dizziness. Some even describe it as anxiety because they feel so unsafe
and uncomfortable driving.

Doctors that prescribe prism need to be certified and go through extensive training in
order to measure the prism correctly. If not done correctly, patients can be left with
dizziness, discomfort, anxiety symptoms or occasional double vision. Dr. Sarah has
been specially certified to prescribe prism for her patients.

The other aspect that is important is whether the lab that makes the prism frequently
calibrates their machines to accurately grind the prism into the lenses. If not done
correctly, the patient can end up more symptomatic than when they started.

The type of provider you are looking for if you need prism is a binocular vision specialist.
Specifically, a doctor that has completed Neurovisual Medicine Institute (NVMI) will be
able to prescribe smaller amounts of prism and more accurately.

When starting prism in your glasses, it is possible that over 6-12 weeks the eyes will
progressively relax and your prism will need to be adjusted at that time. This is very
common, since the eye muscles have been under strain and are still attempting to
compensate for the misalignment. Once the muscles get the help they need, the
symptoms can change and the prism may need to be adjusted.

Your doctor will likely be able to determine one cause, but some can be quite difficult to pinpoint. Around 85% of patients with dry eye have the type that involves meibomian gland dysfunction. The great news is that usually doctors can catch meibomian gland dysfunction before the patient becomes symptomatic or at the beginning stages. These cases are much more manageable with home-based therapeutics and supplements. Using drops alone for dry eye can help soothe the eye temporarily, but does not help the disease process. Most cases will continue to decline even with use of artificial tears and lubricants. 

At home dry eye therapies can help to temporarily reduce symptoms, but tend to not maintain as well as in-office treatments. The most effective in office treatments are ones that can liquify the meibum within the meibomian glands and get them flowing again. Some popular versions are Lipiflow, Tear Care, and Mibo Thermoflo. At our office, we use the Mibo Thermoflo, which requires no shields and is used with ultrasound gel over the eyelids. The patient is able to remain with their eyelids closed during the entire treatment. The Mibo Thermoflo treatment is 10 minutes per eye. In addition, the Mibo Thermoflo does not have any restrictions based on skin type or previous conditions. It is very safe.

Generally, the patient is seen for 3-4 sessions each 2 weeks apart. At your final session, the doctor can better assess whether there need to be more routine maintenance or if it can simply be repeated yearly. Patients usually state that their symptoms of dry eye feel better the day of or day after their initial treatment and results last longer and longer with each treatment. 

After reaching maintenance, the patient will be able to maintain at home with supplements such as Omega-3 fish oils or Heyedrate. These supplements help to maintain the effects of the treatment. In extreme cases of dry eye, the patient may need to have quarterly treatments if the dry eye is severe.

AREDS 2 vitamins include Vitamin C, Vitamin E, Copper, Zinc, Beta-carotene, Lutein and Zeaxanthin. They have to be formulated in certain concentrations to be effective. AREDs vitamins have ample availability at most drugstores. The trouble is that a lot of these companies do not have quality control, and so the vitamins are often not bioavailable. 

There are several companies that make a very high quality, professional grade macular supplement that is a great option for patients requiring the AREDS 2 formula. My favorites at the time that I’m writing this is Physician Recommended Nutraceuticals / PRN numaqula and Science Based Health Macular Complete. The Macular Complete formula also replaces a multivitamin. There is also some evidence that a high quality omega-3 can benefit macular health. Again, these formulations are known to help those who have intermediate ARMD or higher.

Options to protect against Macular Degeneration / ARMD: 

These companies also make formulations for those of us who have a gene for macular degeneration but don’t show signs of drusen yet OR have the mild version of macular degeneration. They DO have publications to back up these claims. Physician Recommended Nutriceuticals / PRN has the numaqula omega-3 formulation and Science Based Health has their Ocular Protect formula. The Ocular Protect formula also replaces a multivitamin.

I’ve noticed a few reasons why she has taken her glasses off that surprised me:

1. She was mad at me/dad/her siblings and this was her form of a tantrum
2. She sat in her carseat and the temples (arms) hit the seat pushing them forward
3. They got smudgy from oatmeal 
4. Someone at daycare tightened the strap too much
5. Someone at daycare loosened the strap too much
6. The strap twisted and was poking her in a weird way
7. She got a scratch on her nose and the nosepiece was poking her

So what do you do? Just try your best. Here are some tactics we have found to work most of the time:

1. Try not to react to your child removing the glasses because then it becomes a game that you do not want to play. 
2. Calmly replace them on their face.
3. Distract them from the glasses once you get them on.
4. No glasses? No ipad/TV/something they like. They will probably want to wear them while doing these activities anyway since their vision should be nice and sharp. 
5. Follow-through with any consequences, because kids are tricky and they will push the envelope. Just make sure the consequence is realistic and a natural one.

First timer? Here are some additional tricks getting used to them:

1. Start fresh in the morning. If you have the glasses dispensed to you in the afternoon, that evening might not go so well. Start the next morning right as they wake up so their eyes do not have a chance to compensate for their prescription.
2. Be encouraging. If mom or dad wears glasses it can help them understand that they need to wear them. There are a few books about wearing glasses and TV shows that address it.

Every 12 seconds, we are supposed to make a full and complete blink. This blink must include the two lids firmly pressing against each other to create suction and stimulate the glands to release oils. If the blink is incomplete – meaning the lids don’t actually touch or create suction – then the oil glands and lacrimal (water) glands do not release the tear film OR spread it over the surface of the eye. 

Imagine missing blinks ALL DAY. Your eyes would certainly dry out by lunchtime. Sometimes the dryness can be felt – that sandy, gritty, dry feeling. OR it can be seen by noticing your vision fluctuates and changes every time you blink. 

Imagine missing blinks consistently for YEARS. What happens to glands when they are not used as much? They get blocked and eventually they atrophy/die off. Many patients have been exhibiting loss of their meibomian glands, which cannot be regenerated once they completely atrophy. Hot compresses, nutraceuticals, blinking exercises, and some in-office procedures can be extremely effective to improve the glands over time. Remember, it takes years to get them to this point, so it can take some time to recover. And likely it can be a long-term management situation.

This is one of the more frustrating things to manage because part of it has to do with the lifestyle of ensuring you’re making complete and squeezing blinks to stimulate the production of tears. There can be some days that are good and some that are bad, but a general movement towards improvement is the most important. 

Chu CA, Rosenfield M, Portello JK. Blink patterns: reading from a computer screen versus hard copy. Optom Vis Sci. 2014 Mar;91(3):297-302. doi: 10.1097/OPX.0000000000000157. PMID: 24413278.

Your eyes need to converge or draw together in order to continue to be pointed at an object up close. There is a common condition called convergence insufficiency in which your eyes do not point at the object (i.e. a computer screen), instead they point past it. All day, your eyes are trying to compensate for this by readjusting and over-focusing. This leads to eye strain, headaches, blurred vision and uncomfortable vision.

Your doctor is able to use prism to correct this, but we have found over time that the prism makes the eyes do less work. This means that over time you would need more and more prism – it would never fully treat your condition. There are a few options when it comes to managing or treating convergence insufficiency:

1. Vision Therapy: usually a 12-18 session that occurs weekly and involves at-home therapies as well as in-office sessions. Maintenance sessions may also be needed . Usually this is not covered by insurance.
2. Neurolens: contoured prism for the treatment/management of migraines, eye strain, and is a quick-acting alternative that is added into your glasses prescription. If patients have accommodative insufficiency, neurolens can also be made into a bifocal to help treat this as well. 

Both options are great in my professional opinion, and I would say most people end up choosing Neurolens based on convenience and cost. I would argue that you could even do both together to improve your comfort short-term as well as long-term. Neither of them are typically covered by vision plans (VSP, Eyemed, Superior, Davis, Spectera, etc) or medical insurance plans. 

I have had some patients who were incorrectly diagnosed with dyslexia, ADHD, and other learning disabilities when in fact they have a binocular vision issue. I’ve also had some patients where they have dyslexia, ADHD, etc. AND a binocular vision issue. Once fitted with proper glasses, they were able to improve their reading scores and attention. 

The small oil glands that run up and down the eyelid called meibomian glands. These express meibum oils, which come out right behind your eyelashes onto the water line. This oil is so important for the tear film, and if you are getting styes then we have a dysfunction in this process. The oils become too thick to flow freely onto the surface of the eye. Meanwhile, bacteria is introduced into the gland, which leads to the localized infection. 

Bacteria tends to overgrow on the eyelashes, which is typically how it is introduced to the surface of the meibomian glands.

Hot to treat a new stye:

1. Hot compresses help to thin out the oil and get the blockage free from the gland. 
2. Gently massage the eyelid if it is not painful.
3. A visit to an eye doctor and the right antibiotics will quickly clear the stye

Never try to pop the stye, as this can spread the infection to the surrounding tissue and it can get serious. This condition is called cellulitis – the tissue becomes swollen, red, and painful. If left untreated it can spread to neighboring tissues and become widespread.

How can you prevent styes from forming in the future? If you have frequent styes, its likely that you have chronic meibomian gland dysfunction. Your eye doctor (optometrist or ophthalmologist) will be able to address this condition. A strong physician-strength omega-3 is effective at thinning the oils in the gland and have been proven to prevent the infections. A doctor-prescribed spray can help reduce the bacteria load on the eyelashes and the surface of the eye. 

In our office, we offer an in-office treatment system to reduce bacteria called ZEST. Then, this treatment can be maintained with Zocular / Zocushield products. 

Left untreated, a chalazion can form. Most patients describe it as a non-painful hard ball left behind after the infection has resolved. Sometimes it can drain over time, but the most common resolution is that a surgeon will remove it. The procedure is in-office and relatively quick. Recovery is minimal and most people can get back to work the next day or later that week.

Your doctor will likely be able to determine one cause, but some can be quite difficult to pinpoint. Around 85% of patients with dry eye have the type that involves meibomian gland dysfunction. The great news is that usually doctors can catch meibomian gland dysfunction before the patient becomes symptomatic or at the beginning stages. These cases are much more manageable with home-based therapeutics and supplements. Using drops alone for dry eye can help soothe the eye temporarily, but does not help the disease process. Most cases will continue to decline even with use of artificial tears and lubricants. 

At home dry eye therapies can help to temporarily reduce symptoms, but tend to not maintain as well as in-office treatments. The most effective in office treatments are ones that can liquify the meibum within the meibomian glands and get them flowing again. Some popular versions are Lipiflow, Tear Care, and Mibo Thermoflo. At our office, we use the Mibo Thermoflo, which requires no shields and is used with ultrasound gel over the eyelids. The patient is able to remain with their eyelids closed during the entire treatment. The Mibo Thermoflo treatment is 10 minutes per eye. In addition, the Mibo Thermoflo does not have any restrictions based on skin type or previous conditions. It is very safe.

Generally, the patient is seen for 3-4 sessions each 2 weeks apart. At your final session, the doctor can better assess whether there need to be more routine maintenance or if it can simply be repeated yearly. Patients usually state that their symptoms of dry eye feel better the day of or day after their initial treatment and results last longer and longer with each treatment. 

After reaching maintenance, the patient will be able to maintain at home with supplements such as Omega-3 fish oils or Heyedrate. These supplements help to maintain the effects of the treatment. In extreme cases of dry eye, the patient may need to have quarterly treatments if the dry eye is severe.