Innovations in Binocular Vision Disorder Testing and Treatments: Interview with Denise Drace-Brownell, JD, MPH, and Jeffrey Cooper, MS, OD, FAAO

Dec 22, 2021
12 min read
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As Plato eloquently said, “Necessity is the mother of invention”—and it is also the mother of investigation, innovation, action, and advocacy. When confronted with unexplained fatigue, difficulty in reading, a drastic dip in prior focus, and balance issues, Denise Drace-Brownell, JD, MPH, began a personal journey that led to a diagnosis of binocular vision disorder, innovations in technology, and discovery of the many misconceptions around the disorder.

Subsequently, she has donated some of her company’s professional time and resources to educating both the eyecare community and general public on BV disorder.

According to Drace-Brownell: “This BV disorder issue became something I’ve worked on over the past few years. First, to develop the technology to help myself with a short-term vision issue and then to distribute information to assist others in finding their own diagnoses and treatments. I’m excited to have the opportunity to bring this information to the millions who need this help. This is a public health challenge we can solve.”

Drace-Brownell is an innovation and commercialization executive and the founder of DDB Technology, which has garnered awards for both business growth and IP innovation solutions. Within DDB Technology, her team created a holding company called Advanced OPTICA Sciences ™ furthers invention, development, and commercialization of breakthrough proprietary vision systems through advanced optical engineering.

A pivotal moment in her journey came when she was seen by a doctor who added her own experimentation to one of Drace-Brownell’s inventions, which Drace-Brownell had intended to donate. The doctor added the wrong strength of prisms and in the wrong direction. Drace-Brownell said, “I was left with a short-term disability. I couldn’t walk seven feet without falling. I fell and broke bones and ended up at the Lighthouse for the Blind, which was clearly a lighthouse of hope for me.“

The head of the organization recommended two doctors, one of whom was Jeffrey Cooper, MS, OD, FAAO. Through the improvements Drace-Brownell made in her own prism technology and vision therapy, such as that from Dr. Cooper’s practice, Drace-Brownell resolved her own condition; and today she no longer wears prism spectacles.

Dr. Cooper, a Professor Emeritus at the State University of New York, College of Optometry, holds a Master’s of Science in physiological optics and has done extensive training, research, and writing on BV disorder and vision therapy. He was also a principal investigator to the Convergence Insufficiency Treatment Trial (CITT), the most thorough and pivotal study on the treatment of binocular disorders to date.

What is binocular vision disorder?

Binocular Vision Disorder refers to a condition of the eyes caused by an inability to maintain comfortable sustained vision at near or distance (accommodation), or comfortable sustained alignment of images which are normally fused, to maintain single binocular vision (vergence). The most common types are amblyopia, strabismus, and convergence insufficiency.

Though it is known that inefficient neurological control of eye muscles results in BV disorder, the underlying cause is not clear. Risk factors include family history, sustained near work, extended use of computers and digital devices, head trauma, sports injuries, and aging, though BV disorder can affect people from infancy through old age.

Those suffering from BV disorder may experience a range of symptoms. Some of the most common are:

  • Fatigue
  • Double vision
  • Blurred vision
  • Trouble focusing
  • Vertigo/Dizziness
  • Car Sickness
  • Migraines/Headaches
  • Difficulty reading
  • Light sensitivity
  • Anxiety
  • Loss of concentration
  • Difficulty understanding formulas such as those in equations, chemical compositions, spreadsheets, and algorithms

A conservative estimate of the number of people affected is over 12% of the population in developed countries, with some studies showing upwards of 30%. With the time spent on computers and other digital devices steadily increasing, so will the incidence of BV disorder. According to Dr. Cooper, “The world has changed. We’re living in a near environment on computers and that requires a finer ability to both focus our eyes and maintain balance of convergence. The body often reacts and says, ‘I can’t do this.’ And that is when you get symptoms.”

Recognizing the severity of the problem, the US military requires a BV exam be performed on all applicants to its military academies as well as ROTC.

The impact of BV disorder on individuals can be devastating, ranging from difficulties in early education to missed opportunities, job loss, and deficiency in everyday function. “BV disorder really hampers people in their academic and workplace environment and actually just fundamental living,” said Dr. Cooper.

A patient’s perspective

For Drace-Brownell, the problems began in middle school and escalated into her mid-twenties. At that time, after receiving full funding to develop her cutting edge telecommunications program, she experienced extreme fatigue from working on the formulas and algorithms required to do the work. She thought she must be bored and left her program.

Drace-Brownell states: “We patients often don’t know these are vision issues. We may think instead that we are lazy, stupid, or bored. And years can pass before it is uncovered. There are also balance issues involved with this that are not often discussed. I used to wonder how I could test 20/20 with corrected vision in a doctor’s office, but I couldn’t navigate the doorway to get into the doctor’s examination room in the first place.“

Diagnosing BV disorder

The diagnosis of BV disorder is challenging for two primary reasons: diagnostic tools have not kept pace with society’s transformation into a digital age, and patients (and even some ODs) do not recognize the symptoms as an eye problem. “Patients often do not tell an eye doctor about their eye fatigue problems because previous doctors have told them there is nothing wrong with their eyes, and they do see 20/20,” stated Dr. Cooper.

To improve diagnosis Dr. Cooper offered this advice: “Eye doctors can diagnose the majority of these problems by performing three rapid tests: cover test for alignment, prism bar to measure fusional amplitudes, and a near point of convergence. These can be done in less than a minute. And eye professionals can add one simple historical question: ‘How long can you read or use a computer without getting tired, losing concentration, or just having your eyes bother you?’ ”

Drace-Brownell added: “We need to educate patients and the public regarding this issue so that they will discuss this with their doctors. We need to update testing protocols to reflect how we spend most of our time these days—with computers and digital devices and not with hard copies of documents. We need to make sure patients have the visual skills to use the tools necessary in today’s digital world, such as algorithms and computational graphs and formulas. Practically, this is rarely tested. And we need to make these exams more accessible. The tests can be done in minutes, not hours.”

The best binocular vision disorder treatments

For Drace-Brownell, the path to freedom from BV disorder began with the use of prisms. She said, “After eliminating all the other diagnoses, I finally decided it must be a vision issue. In 2009, I went to my contact lens doctor and told the poor man to fix it. Now! He did. He gave me prism glasses and that was life-changing for me. After that visit, I walked past Central Park. I was amazed to discover that Central Park has hills and wasn’t as flat as I had always seen it before. I will always remember that day.”

After the initial use of prisms, Drace-Brownell added vision therapy and eyewear of her own invention. Using this combination in tandem led to full recovery from all her symptoms.

With all BV disorder patients, each eye should be evaluated and the proper prescription applied before adding additional treatments. Vision therapy can assist with issues, including breaking suppression, coordination, focusing, depth perception, and eye movement and tracking. For severe eye misalignments, surgery may be indicated.

According to Dr. Cooper, “Prospective clinical randomized trials have taught us that the best single treatment of convergence insufficiency—a specific and very common BV disorder—is in-office therapy supplemented with home therapy (following the CITT protocol). While none of the other specific binocular anomalies has had this rigorous clinical evaluation, there have been decades of good studies. In practice we use all of the available modes of treatment: vision therapy (in-office or home); prisms and/or; plus (accommodative relaxing) lenses; and surgery.”

For those hesitant to commit to vision therapy, Dr. Cooper offers this solution:

“If in-office therapy is not practical (it is like having the benefits of a trainer in a great gym), then we set up a program at home using a home therapy computer program. If that is not going to happen, we prescribe prisms or other correcting lenses. We often combine therapy (ie.prisms, vision therapy and surgery.)”

The problem with prisms

Though prisms are an excellent treatment option and still a cornerstone of treatment, they should not be considered a permanent solution if possible, largely due to prism adaptation in many patients. According to Dr. Cooper, “Prisms clearly have their place. The biggest problem with prisms is that a lot of the people with eye muscle problems adapt to them. Their brain gets used to them. That happens with many patients, so they may not have a lasting effect.”

He elaborated, “I often use prisms to get a patient through the difficult time when we’re doing therapy. Prisms have a real place in the treatment, but they are not the only solution. Usually a better solution is obtained by altering the reflex in accommodation focusing and eye training through vision therapy and developing a lasting cure from that standpoint.”

Drace-Brownell added, “Modern optics innovation improves the overall wearability of today’s prism spectacles. I could not wear standard prisms, so I improved upon them. Prisms can be wonderful, but life without the need for prisms is even better.”

Cost to individuals, companies, and the nation

Undiagnosed and untreated, BV disorder has a far-reaching effect and negatively impacts not only individuals, but educational institutions, corporations, and the economy in general. Drace-Brownell estimates the annual economic damage in the US alone surpasses $200 billion.

The immediate losses include:

  • Losing individuals to other fields who would otherwise be going into STEM programs and science/technology careers
  • An overall increase in the disorder as the population ages, resulting in a reduction in our already struggling workforce, and losing valuable employee productivity
  • Costly mistakes made on the job by individuals with BV disorder
  • Costs from unnecessary medical treatments and the financial burdens on society from unemployment, increased crime, and substance abuse

Drace-Brownell related, “For instance, in my own case I missed a million dollar offer on a display board for my client. That was when I decided I better call a timeout and get to the bottom of it [BV disorder ].”

Finally, Drace-Brownell urges companies to assess the impact on profits.  With BV disorder worsening with aging and middle-age presbyopia, companies could lose top talent for whom they have spent time, money, and energy developing. There are some relatively low-cost ways to mitigate these impacts, and companies would benefit from simply identifying resources for education and testing for employees.

She adds, “The transition to a digital future demands improvements in BV disorder diagnosis, treatment, and therapeutic options.”

Personal experience leads to publishing a patient guide

In 2020, to give invaluable information and hope to the millions who struggle with BV disorder Drace-Brownell wrote a patient guide: Binocular Vision Disorder: A Patient’s Guide to a Life-Limiting, Often Underdiagnosed, Medical Condition. The book is published by Eliva Press and is available free as a digital download through DDB Technology.

On why she originally wrote the book, Drace-Brownell said, “I recognized there was confusion with jargon among patients and among many eyecare professionals, and that there needed to be clear explanations regarding useful diagnostic and treatment options.”

The future of BV disorder

As for the future of BV disorder, Dr. Cooper sees treatment moving toward automated programs relying on artificial intelligence (AI) and the principles of operant conditioning and/or gaming to present therapy in an augmented virtual reality setting. Drace-Brownell identified improved lens optics and the expansion of more digital vision therapy tools— in-office and at-home—used in combination, which will increase both accessibility and affordability.

According to Dr. Cooper:

“I think it behooves every eye doctor—optometrists and ophthalmologists alike—to be aware of these binocular problems and make the appropriate referrals if they cannot provide the resources to the patient.”

Denise Drace-Brownell plans to stay on the front lines of the broader implications for society’s digital transformation in the US and abroad. She stated, “My hope is that my pioneering work may help other children struggling against eminently treatable BV disorder, and may help companies to address unnecessary profitability losses from the disorder. This is one public health issue we can resolve. I am excited to be able to help the millions with this problem.”

If you have additional questions, please contact Denise Drace-Brownell, JD, MPH.  Phone: 212.899.5186  Email: denised@ddbtechnology.com

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About Donna Ison

Donna Ison is the Associate Editor of Eyes on Eyecare. Formerly, she served as editor-in-chief of MD-Update magazine, managing editor of skirt! Magazine Lexington, and a content/copy editor with BobVila.com. She is performance poet, playwright, and the author of two …

About Denise Drace-Brownell, JD, MPH

During her career as a science and technology innovation executive, Denise Drace-Brownell has created successful businesses and furthered breakthrough ideas for emerging growth, mid-sized, and Fortune 500 companies.

Denise holds a Bachelor of Science degree from the University of Illinois; …

About Jeffrey Cooper, MS, OD, FAAO

Jeffrey Cooper received his O.D from Pennsylvania College of Optometry in 1971 and an M.S. in Physiological Optics from State University of New York in 1978.  He completed a residency in Binocular Vision and Visual Perception in 1971 and subsequently …

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